Evolving society and mental health

Numerous issues related to culture, occupation, gender, caste, and health, to name a few, have faced harshness of society from time immemorial. Reasons are debatable, ranging from somewhat understandable to completely unacceptable. There is no doubt that society is dynamic and it has changed its view on many of the issues with passing time. Mental health is one such issue which society has neglected for quite a long time. Even today, mental health and mentally ill people face stigma and discrimination in their family, society, and at their workplace. People do not feel comfortable talking about mental health, even if they know that there cannot be any health without a healthy mind. But, as Albert Einstein has said “learn from yesterday, live for today, and hope for tomorrow”, everything is not lost. The mentally ill patients who were once abandoned and left on their own have now started to get humane care and attention. This article discusses this very pertinent topic of changing society and mental health.

Defining society and explaining what constitutes it and how it functions can be a herculean task.While sometimes it is defined as "A body of individuals living as members of a community", [1] there are other definitions which speak about the functions and roles of the society.Thus, society can be defined as "A highly structured system of human organization for large scale community living that normally furnishes protection, continuity, security and identity for its members".[1] Another definition depicts the purpose of individuals living in a group, i.e. society is "An organized group of persons associated together for religious, benevolent, cultural, scientific, political, patriotic or other purposes".[1] Whether society is static, or it is continuous and evolving?Usually people think as a large organised group.Thus, attitudes and values that are prevalent in society are reflected.People living in a country or for that matter in a region represent society as well as their organisations and of course their way of life.Organisation of people having the same way of life is a society.[2]

Social paradigms of mental illnesses
Change is the law of nature.But what has changed?It is not possible to change the reality so better change the eyes which see reality.The mental aberrations are a reality, which have existed on earth ever since human beings are in existence.What has changed in the course of history is the eye with which society sees them.Mental illnesses were once viewed with the eyes of religion, spirits, and supernatural forces.This was quite understandable because there was no scientific knowledge at that time regarding these mental illnesses so everything which looked odd was supposedly done by supernatural forces.So naturally those patients were subjected to prayers, exorcism, segregation, and abandonment.[3] There have been other radical shifts in views, as mental illnesses were subsequently thought to be caused by dysfunction in the family or society.This view was in centre stage when the opponents of psychiatry were very vocal.According to them, it is not the patients who are abnormal but the society is such that they are forced to act in that way.[4] Many a times, mental illnesses are thought to be a problem of personal responsibility, and thus, the mentally ill patients are blamed for their condition, as they are thought to be weak and lacking in will power.[5] Of late, mental illnesses are being considered as a medical problem i.e. problem originating within the individual.However, inspite of this medical view, psychiatry has not been able to come out from the debate of mind-body dualism.[6] These issues have been present throughout the history of psychiatry.

India in the past
There are many descriptions of various mental illnesses in ancient Indian texts.Atharva-Veda, the latest among the four Hindu Vedas, conceptualises mental illness resulting from divine curses.There are some ancient evidences of segregation and alienation of mentally ill patients in Shahdaula's Chauhas in Gujarat and Punjab.King Asoka established one of the earliest hospitals for patients with mental illnesses.Mohd.Khilji (1436-1469), an ancient Indian ruler built asylums for the mentally ill people and references for the same are present.[7] OJPAS | Volume 7 | Issue 2 | July-December 2016

Modern mental hospitals and change of social response
The first modern mental hospitals were built in Islamic countries.In 872 A.D., a hospital was built in Cairo that catered to the mentally ill people.Similar hospital was started in Baghdad (Iraq) in eighth century A.D. itself.In Europe, the first and oldest institution for mental illnesses, 'Bethlehem Hospital' was set up in 1247 A.D. in London.[7] Building hospitals however, was not sufficient because mentally ill patients, by 18 th century A.D., got inhumane and ill treatment in those hospitals.They were allegedly chained, beaten, starved, and neglected.Ruling aristocracy showed no interest in mental health issues and thus, did not allot adequate fund for the care of the patients.Thus, society did not give what these patients needed most, i.e. care, affection, empathy, concern, and lack of discrimination.
Two persons contributed significantly towards humanitarian reforms in mental health.Philippe Pinel (1745-1826) was a French physician and psychiatrist who advocated 'moral treatment' .He removed the patients from chains and shackles, provided them sunny and ventilated rooms, and allowed them to exercise on the grounds.[8] William Tuke (1732-1822 A. D.), an English Quaker, did independent work on 'moral treatment' .He was appalled by seeing the squalid and inhumane conditions of the 'York asylum' and then, collected funds to open the "York Retreat" for the care of the insane.The mentally ill got more humane methods of treatment including removal of chains, housing in a pleasant environment, getting decent food, and a programme involving the therapeutic use of occupational tasks.[9] The decades of 1930s and 1950s are considered landmark and path breaking in the history of psychiatry and treatment of mental illnesses.The era of 1930s brought in convulsive therapy and the era of 1950s brought pharmacotherapy.But did medical advance bring about change in social response?Atleast now, the mental illnesses were considered to be treatable.

Era of modern mental hospitals (19 th century)
In the later part of 19 th century to early 20 th century, the concept of asylums came in.But these mental hospitals were kept at a distance from the society, as society still did not show acceptance of mental health issues.The mentally ill people were segregated as if society was not for mentally ill people.These patients were considered dangerous for the society and the society was more concerned for its own care and protection rather than of mentally ill.[10] History of psychiatry in India and Pakistan LP Varma, first assistant superintendent of Indian Mental Hospital, Kanke (Ranchi) wrote a paper on the history of psychiatry in India and Pakistan in 1953.In this paper, he wrote that "though there have been brilliant psychiatrists in the past and they have tried their level best to ameliorate the conditions of the unfortunate mental patients, still their achievement, barring a few notable exceptions, have been practically nil.All their plans and ideas were either ignored or rejected by the then government".[11] He further mentions about a report on insanity among the Europeans in Bengal that was published in the first decade of 20 th century.He says "During the later period of the nineteenth century, the lunatics were considered to be horrible people.They were no better than wild animals that howled at night and disturbed the place and tranquillity of the minds of the officials and the government.They were atleast troublesome people and hence everyone was anxious to get rid of them.So they got rid of them by making high enclosures round any dilapidated buildings that could be easily available.If the Superintendent was a humanitarian, he racked his brain and made the best use of what he had.The patients were then comfortably looked after.On the other hand, if he was only a civil surgeon and an administrator with no interest in mental diseases, the treatment of the lunatics was left solely to the keepers.These keepers were illiterate and lazy people and had no sympathy for the unfortunate patients.They believed in the principle, "spare the rod and spoil the child"." [11] Early 20 th century: Mental hygiene Clifford Beers (1876-1943) was the founder of the movement called 'mental hygiene' .A former bipolar patient himself, he was institutionalised for three years, where he faced "torture and degrading treatment".He penned down his experiences of institutional care in his book "A mind that found itself ".He made efforts to improve institutional care, promote mental health, and fought against the stigma of mental illness.As a result, there was major change in attitudes of the authorities towards mental illness.Introduction of guidance counsellors in the United States (US) schools and the inclusion of evidence of a defendant's psychological state in law courts were the results of this change in attitude.[12]

Anti-psychiatry movement
The term 'anti-psychiatry' was first coined by David Cooper in 1967, a South African psychoanalyst.The movement started way back in 1950s when both biological and psychoanalytical psychiatry were struggling to take upper hand.However, in course of the time the attention has shifted from nonrecognition of psychiatric diagnosis to a movement focused on fighting against drug treatment, forceful hospitalisations, and other practices which hamper patient's rights.In 1960s this movement merged with other fights aimed at removing all forms of injustice such as racial and sexual.[4] Four seminal thinkers, Michel Foucault (France), RD Laing (the Great Britain), Thomas Szasz (US), and Franco Basaglia (Italy) contributed a lot in this movement.In "Madness and Civilization: A History of Insanity in the Age of Reason", Foucault opined that there were social, economical, and cultural interests behind mental illnesses.The insane, like criminals and the poor, were isolated because they were unable to engage in any kind of employment and were considered unwanted.In his book "The Divided self: An Existential Study in Sanity and Madness", Laing noted that schizophrenia could be cured through social remediation if it was merely an existential fight for personal freedom.Szasz believed that if schizophrenia had no demonstrable lesion, then its classification as a disease was conspiracy on part of organised psychiatry to gain power.L Ron Hubbard in 1969 wrote: "there is not one institutional psychiatrist alive who could not be arraigned and convicted of extortion, mayhem and murder".Kesey's 1962 novel, "One Flew Over the Cuckoo's Nest", popularised psychiatry's purported abuse of patients and contributed to reforms in mental health policy.[4] By 1980s with change in social paradigm, this movement started to fade as it was losing its broad-based support and also because there were numerous advances in the field of psychiatry such as, adoption of 'biopsychosocial model' of illnesses, neurotransmitter discoveries, and researches on the efficacy of neuroleptics.[4]

Community mental health: Improvement of mental health care in India
The Bhore committee report in 1946 put substantive emphasis on issues of mental health.Within the limitations of that period, it laid the foundation for the community health movement in India and combined the 'top down' and the 'bottom up' approaches.Three apex institutions were opened up in the country by 'top down approach' while provisions of primary healthcare were made by 'bottom up approach' .The report brought the movement of preventive and social medicine, including the development of academic departments in the medical colleges.[13] The development of the field of community health has become possible because of institutional care being too expensive, 'institutionalization syndrome' , shortage of qualified professionals, and training of general health workers.Community medicine has evolved over time-from exclusive medical model to larger concepts of health and the need for working across different sectors.The community psychiatry initiatives in the 1960s and 1970s led to development of the National Mental Health Programme (NMHP).The major guiding principle has been 'reaching the unreached' .This concept of community mental health is governed by socialist ideology.[13]

Public mental health: Involvement of society at large
Public mental health model is a concept way beyond that of community mental health.It incorporates the prevention and promotion aspects, involves different sectors and other applied sciences, focuses on millions, leads to policy making which culminates into health programmes, inputs from public participation, and also gives attention to social issues (poverty, violence), as well as special groups (homeless, refugees).[13] 'Health for All' (1981): Alma Ata Declaration After going through the phases of disease control (1880-1920), health promotion , and social engineering , the field of public health has now entered the fourth phase, known as health for all phase (1981 onwards).This latest phase also known as 'the new public health' followed research showing benefits of behaviour modification and environmental change on health improvement.Mental health services are no longer driven by a policy of illness containment.It has now been increasingly understood that the place of rehabilitation of mentally ill people is in the community itself.This understanding itself has led to diminution of social stigma regarding mental illnesses.The mentally ill people isolated from the society earlier are now gradually starting to get integrated in the community.[13]

Positive mental health and health promotion
The World Health Organization (WHO), long back in 1948, defined health as "a state of complete physical, mental and social wellbeing and not merely absence of disease or infirmity".[14] So naturally, mental health is assumed as being 'free from mental illnesses' .However, this is not the case and measures of mental illness and measures of mental health are two distinct concepts.It has been observed that only a small proportion of those otherwise free of a common mental disorder are mentally healthy (flourishing).The aim of 'positive mental health' is to promote flourishing in individuals otherwise free of mental illness but not mentally healthy."Completely mentally healthy (free of a 12 months mental disorder) and flourishing report fewest missed days of work, fewest half-day or greater work cutbacks, healthiest psychosocial functioning (i.e.low helplessness, clear goals in life, high resilience, and high intimacy), the lowest risk of cardiovascular disease, lowest number of chronic physical diseases with age, fewest health limitations of activities of daily living, and lower health care utilization."[15] The dimensions of flourishing are related to emotional, psychological, and social wellbeing and are: Positive affect, avowed quality of life, self-acceptance, personal growth, purpose in life, environmental mastery, autonomy, positive relations with others, social acceptance, social actualisation, social contribution, social coherence, and social integration.There is very low prevalence (20%) of flourishing in adult population.[15]

National Mental Health Policy
Government of India on 10 October, 2014 launched its first National Mental Health Policy with a goal to provide "Universal access to mental health care".Provisions will be made to expand the existing hospital network, as well as primary care centres.The policy is backed by a "Mental Health Action Plan 365", which assigns specific roles to the concerned authorities ranging from the centre, states, local bodies, and civil societies.In order to insure smooth functioning and collaboration this policy will be articulated into the National Health Policy and National Health Assurance Mission (NHAM).It has also been decided to observe October 10, as National Mental Health day like World Mental Health day.[16]