Parents use it against adult children, men against wives, in divorce, property and custody battles; families use it to ‘cure’ homosexuality and officials to get disabled beggars off the streets. The forced institutionalisation of mental-health patients is rampant despite a law to protect them
Bangalore: It was in the midst of her messy divorce in 2012 that Jhilmil Breckenridge, a Delhi-based mother of four, was forcibly admitted to a mental health hospital.
“I was still living in my marital home because of the custody case, as advised by my lawyer," she said. "I had just come home from the bank, and saw my father enter the gate with five-six policemen and policewomen. I didn’t protest. I knew what was coming and went calmly with them."
She was escorted by the police to a well-known mental health hospital in India’s capital city, where a nurse proceeded to inject her with a sedative. “My legs turned to jelly, but I was still made to walk and taken to the psychiatric ward,” she recounted.
Her father was a retired officer of the Indian Administrative Service (IAS). Her husband, an American, was influential too. The two appear to have colluded to have her incarcerated, a step she said worked to her husband’s favour in their custody battle. This wasn’t the first time either.
Back in 2007, only a year since giving birth to her fourth son and facing sexual abuse from her husband, they labelled her as suffering from bipolar disorder and ‘unmanageable’. For 46 days, she was kept in a mental-health institution, including two weeks in solitary confinement. Heavily sedated most of the time, she felt like a zombie for weeks after her release and lived in constant fear of being incarcerated again.
International advocacy group Human Rights Watch stated in a 2014 report that women and girls with psychosocial or intellectual disabilities in institutions in India are often abused and "treated worse than animals".
Jhilmil told Article 14, “When you are there, everything is forced. Nurses are always carrying a danda (baton).” She said the staff never struck her a second time — she was on her best behaviour. “But how will recovery happen if something is done against your consent?” This treatment only causes more distress, she said, and lengthens the time required to heal.
A 2015 report published in the British Journal of Medical Practitioners states that involuntary detention in an institution may cause anxiety or post-psychiatric depression. It could also lead to self-denigration, fear, and repression of anger due to coerced treatment. For Jhilmil, that resonates deeply.
The second time, in 2012, she was again forcibly medicated for the first three days of her institutional incarceration. But this time, human rights activists and journalists got a whiff of her case and arrived at the hospital. Afraid of the bad publicity that could ensue, she was released a week later.
The United Nations High Commissioner of Human Rights highlighted in a 2017 report the need ‘to put an end to involuntary treatment and institutionalisation and to create a legal and policy environment that is conducive to the realisation of the human rights of persons with mental health conditions and psychosocial disabilities.’ For Indian women with psychosocial disabilities, this is a distant dream.
Poor Implementation of Mental Healthcare Act
In India, the Mental Healthcare Act, 1987, was widely criticised as it did not consider the rights of persons with mental illness. This law remained in existence until the new Mental Healthcare Act (MHA) was enacted in 2017.
Arjun Kapoor, Programme Manager & Research Fellow, Centre for Mental Health Law & Policy, Pune, explained that before the MHA 2017, if a person wanted to get a family member with a mental health condition admitted, he/she had to get a reception order, an order or permission from a court magistrate for a mentally ill patient to be confined and treated in a mental health institution. “But a magistrate is not medically qualified, the process involved a lot of administrative work and the person is often made to feel like a criminal and stigmatized,” he said. Besides, many hospitals admitted patients without a reception order, as in Jhilmil’s case. This clause was discarded in the MHA 2017.
Under the new law, admission to a mental health facility occurs in two ways, voluntary and supported. According to Kapoor, for supported admissions, a nominated representative must apply for admission, and the case is forwarded to a psychiatrist and a mental health professional. Within seven days, each must conclude independently that the person needs to be admitted.
The criteria for supported admission include, among others, causing self-harm or harm to others, and inability to take care of oneself. Admission in such cases is seen as a last resort, to be used only if all other treatment options are exhausted.
The law also requires states to set up a Mental Health Review Board (MHRB) in each district, to oversee and review admissions, adjudicate matters of conflict, and conduct inspections.
Implementation of the new law has been uneven. Kapoor said some institutions continue to ask for a reception order. Also, the new requirements such as an admission recommendation by two independent psychiatrists are rarely followed.
In many states, the MHRB was never set up. There’s a lot of resistance by the psychiatry community, due to the belief that people with mental illness should be admitted and treated, Kapoor stated.
Jayna Kothari, co-founder of Centre for Law & Policy Research, Bengaluru, said MHA 2017 envisages that every person shall be deemed capable of making decisions about their mental health treatment. Still, patients are frequently admitted without their consent. “I know of parents who admit their adult children into mental health hospitals. If this person is brought kicking and screaming, who is going to ask for consent,” she pointed out.
The challenge is to create awareness among family members and mental care institutions about patient rights. A patient also may or may not know that they can refuse treatment. “Though in one instance, a young man with a history of mental illness sought our help to file a complaint against his parents who forced him into a mental health facility, where he was physically restrained and confined.” Although he later closed the case, the parents said they had done it in his best interest.
The MHA 2017 accords patients a charter of rights, including the right to information, the right against cruel or degrading treatment, the right to education and entertainment, the right to refuse or receive visitors, calls and emails and the right to confidentiality. Many of these are routinely violated everyday in public and private mental health institutions in India.
Deliberate Misuse Of The Law
There are cases of parents having their adult children institutionalised, imagining it to be in their best interest, or to control them. A Delhi-based mental health advocate who didn’t want to be named said there have been instances of influential parents forcibly admitting their children into mental health institutions when they don’t toe the line.
A few years back, he said, a young woman who had been admitted to a mental health hospital reached out to him for help. He called the director of the hospital, a reputed institution, to enquire about her case. “The director openly told me that he was asked to diagnose her as bipolar as she wanted to be an actress, while the parents wanted to marry her off.”
In another instance, a couple who mistook the advocate to be working for a mental health institution, asked him to help institutionalise their son. The young man, a student at an Ivy league American university, was going through a rough patch while he adjusted to college life. The parents wanted him admitted so that he could be “normal” once again.
The law is also misused for property matters, marriage disputes and custody battles, the activist said. A 2018 news report featured the account of four people incarcerated by their family members for personal gain.
He said that people are ready to pay money to have their children/spouses incarcerated for their own benefit, unmindful of the harm this can cause. “It’s a rollicking business where money changes hands and the rot is deep,” he said.
For The Poor, There Is No Choice
On the other end of the spectrum are those who are unable to afford medical care.
Families who do not have the resources to take care of a member with a mental health condition or mental retardation have them admitted into government hospitals that provide free care.
Adrika Sengupta, Head of Programmes at Anjali Mental Health Rights Organisation, Kolkata, said many such individuals continue to reside in the hospitals “even decades after recovery” on account of being homeless, not having families, or because families are unwilling to take them home.
Sometimes, people who are lost or abandoned by their families are admitted by state authorities or police even though they do not have any mental illness. “In recent times, several physically disabled beggars were detained at railway stations and admitted without any history of mental illnesses. During the pandemic, several state-run general hospitals that were designated for COVID care only transferred many of their residents to Lumbini Park Mental Hospital, where they still continue to be incarcerated,” she added.
The National Human Rights Commission’s survey of government hospitals in 1999 found that 38% of mental health hospitals had ‘jail-like structures’ and inadequate lighting. There was overcrowding in large hospitals , many hospitals had overflowing toilets, eroded floors, shortage of staff and patient rights were violated.
Another survey conducted by NHRC in 2016 noted that while there were improvements in facilities and reduction in involuntary admissions, ‘priority to mental health was still low’.
‘Conversion Therapy’ For LGBTQ People
In May 2020, Anjana Harish, a 22-year-old bisexual student, died by suicide in Goa. Before she took her life, she had put out a video on Facebook describing how she had been placed in solitary confinement in a mental facility by her family and subjected to ‘conversion therapy’. The constant physical and mental abuse led her to take the extreme step, she said.
Conversion therapy is a harmful practice that proclaims to ‘cure’ homosexuality by changing sexual orientation through ECT (electroconvulsive therapy, a procedure where small doses of electric current are passed through the brain of a patient under anaesthesia, usually for the treatment of severe mental illness), hormonal injections or aversion techniques (a form of psychological conditioning where a person is made to give up a behaviour or action by associating it with something unpleasant).
Although ECT is considered to be safe, there are side effects such as short term memory loss, disorientation, loss of speech fluency and executive function. MHA 2017 bans the use of ECT without anesthesia, but studies suggest that prior to the ban, about half of all ECT use was done without anesthesia.
Mahesh Natarajan, co-founder of Innersight, a counselling and training center in Bengaluru, has counselled people from the LGBTQ community who underwent forced institutionalisation to overcome the trauma. He said, “Parents get them admitted because of heteronormative beliefs. Even though medical authorities and counsellors like myself have put out communication that this is wrong, it is frequently happening.” He said some hospitals even advertise that they can “cure homosexuality” though such cases are on the wane as awareness grows.
What Can Be Done
The need of the hour is for the MHA 2017 to be implemented and to create awareness about patients’ rights among people and authorities. Kothari of Bengaluru’s Center for Law and Policy Research said people who have been wrongfully admitted can take legal recourse or approach the MHRB. “But often, a person who is suffering from mental health issues may not have the resources or wherewithal to file a case,” she said.
Another option is for the person to make an ‘advanced directive’, she said. An advanced directive is a legal document that elucidates what treatment, if any, the person would like to receive in case his or her mental health deteriorates.
For the destitute who have been abandoned by their families, there is little hope. But organisations such as Anjali work to create awareness about patient rights and deinstitutionalise mental health care. Sengupta of the Kolkata-based organisation said Anjali establishes community-based care for persons with mental illnesses so that they would not need to go through institutionalisation against their will. “Anjali also conducts reintegrative efforts including, in some cases, limited economic support to ensure that the residents of these hospitals can go back into the society outside the hospitals and be able to lead a fulfilling life within the community.”
Jhilmil Breckenridge, who is currently in the UK pursuing a PhD , co-founded Bhor Foundation in 2017, an NGO that advocates a rights-based approach to mental care. “I was haunted by some of the traumatic things that were done to me — being dragged on the floor, forcibly injected, my agency and identity robbed in an instant. I wanted no one else to suffer as I had done.” That led her to undertake work on mental health advocacy and patient rights.
A rights-based approach gives agency to the person with mental illness to make their own decisions about treatment while ensuring quality and affordable mental healthcare. Among other things, Bhor Foundation provides people information about their rights, side effects of medication and helps them to create advanced directives.
“Although the road is long and fraught with obstacles,” she said, “I am determined to keep walking, with other survivors, activists and change makers, and make mental health and rights a reality for us all.”
(Deepa Padmanaban is a Bangalore-based freelance journalist with interests in healthcare, environment and conservation.)