Across the Borders
A comparative study of Mental Health Care in Saint John, and in DehraDun.
Contents
1. Introduction 1
Part One 2. Health Care Canada 4 3. The current Mental Health Care ‘System’ in New Brunswick 5 4. Mental Health Saint John 8 5. Historical development/foundations of Mental Health Care in Saint John 16 6. Centracare 17 7. Centracare changes its form 24 8. The history of the Mental Health Department Saint John 29 9. Current situation of Mental Health Care in Saint John 30
Part Two 10. Mental Health Care in DehraDun 34 11. The Official Position 34 12. Non-Governmental Health Care 37 13. Raphael: Ryder Cheshire International Centre 38 14. Karuna Vihar 48 15. Psychiatrists and General Physicians 54 16. Alternative Mental Health Approaches 57 17. The Ayurvedic System 60 18. An Analysis 62 19. In Conclusion 64
Page 1
Madness, insanity, mental disability, mental divergence, irrationality, possessions, cuckoo, nuts, mentally disturbed, lost, mystics, extremely godly, wizards, witches, ‘pagal’ are the phrases that different localities in the world have used to provide dissimilar names for similar phenomenon. These names, vastly divergent in their conceived meanings, are based upon the cultural and historical beliefs that dominate the mindset of the people living in the areas. Even within a particular social order people prescribe to divergent belief systems. This divergence within a society is also found to exist within the field of mental health. Due to these various, and conflicting belief systems, a mental condition of a particular individual can be looked upon in many different ways. Under the conditions where mental anomalies are viewed in a very heterogeneous manner, the predominant condition that is diagnosed often has more to do with the dominant belief system existent within the particular society of the time rather then the accuracy of the prognosis.
This essay looks at the Mental Health Care being provided within two social milieus:
Saint John in Canada, and DehraDun in India. My attempt is to ascertain the similarities and differences that exist within these two cities regarding the area of mental health. My original intention in choosing these areas was because of the obvious difference in the manner in which health care is practiced within the two localities. My research was based upon looking linearly at the Mental Health Care delivery model of Saint John as an integrative approach whereas the model in DehraDun corresponded more to an institutional approach. However as I progressed through this research I discovered my original assumptions to be highly simplistic and thus limiting. One could postulate that the mental health care practices prevalent in Saint John are more directed towards the integrated approach to Mental Health Care; thus mental health
Page 2 care in Saint John can be seen as corresponding to a ‘System‘. This analogy is easy to come about because one sees quite clearly a predominant direction in which mental health care finds itself positioned in Saint John. However in DehraDun, due to the sheer divergence of mental health care practices and underlying strong beliefs that propel them forward, it is incorrect to add the word ‘System’ to these practices. If one were to however find some kind of structure that underlies this area of study in DehraDun, it would have to correspond to one that is extremely open-ended and in western terms
Post-Modernist in its inclination.
Through my research I confirm that mental health practices are influenced by cultural and historical factors, and inversely history and culture are influenced by Mental Health
Care practices.
In DehraDun, my microcosm for Mental Health Care practices in India, due to the sheer diversity and size of the population, and the divergent social, political, religious, and economic factors, I believe it is impossible for a uniform Mental Health Care System to emerge that can incorporate all facets of thought existent within the society. Thus in
DehraDun there exist many avenues for providing divergent explanations for similar phenomenon. Whereas in Saint John, due to the relative homogeneity and smaller size of the population, wealthier infrastructure, and stronger and more efficient Government, there has developed a dominant Mental Health Care System that is upheld by a majority of the local population.
When I started this research paper I began by looking at the delivery model of the
Mental Health Department in Saint John as my epicenter from where I planned to research Mental Health Practices in Saint John. Similarly I looked upon Raphael
International in DehraDun as the epicenter of my research of Mental Health Practices in
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DehraDun.
In order to gather a detailed understanding of where mental health care stands in both areas I conducted a detailed and in depth research of the history behind the current status of Mental Health Care in both places. This research of the historical foundations of current Mental Health Care practices illustrates the manner in which current practices parallel the dominant beliefs of the localities. Through this research I have found that some DehraDun Mental Health care practices concur with the approach and practice of
Mental Health Care in Saint John; whereas other Mental Health Care practices in
DehraDun are clearly reminiscent of practices that were in existence in Saint John in the past. However it is important to know that whereas one can look upon Mental Health
Care practices in a developmental/evolutionary manner in Saint John, it will be a folly to look upon Mental Health Care practices in DehraDun in a similar fashion. The reason for this is that in India, Time is not looked upon in a progressive manner like it is in the
West: Time in India is generally believed to be cyclical. Therefore in India one finds within the Mental Health Care field a unique mixture of old and new Mental Health
Practices.
Incorporated in this paper are philosophical positions and current trends that are central to the delivery of Mental Health Care in Canada and India. In order to support my findings I used literature by noted authors such as Michel Foucault, Sudhir Kakar,
Erving Goffman, Thomas Szasz, and Michael Perlin. I have also incorporated information that I obtained from various pamphlets, brochures, and government periodicals. The Internet has been used extensively throughout this research to keep in touch with my contacts and also to tap into various online Mental
Health Care discussions. Through this research I interviewed people who are
Page 4 directly or indirectly involved with the delivery of Mental Health Care services. Due to the number and length of the interviews I have not been able to use them in their complete form. Instead this paper has incorporated parts of them at areas where I deem relevant. This paper will describe, in fiscal terms, the Government of Canada’s involvement with Health Care in Canada. This is followed by a picture of the present state of Mental Health Care Delivery in New Brunswick, which is followed by an in depth analysis of this picture.
Health Care Canada
One of the top priorities of the Government of Canada is Health Care. Canada has a very strong Federally funded Health Care Delivery System, and a large percentage of the Federal Budget is allotted towards maintaining, and upgrading this Health
Care Delivery System. In 2003 from Canada’s Gross Domestic Product of $958.7 billion
, $120 billion was spent on providing Health Care for Canada’s population of approximately 32.5 million people (Canadian Budget). According to the World Health
Report of the World Health Organization, the Canadian Government spends around 7% of its National Gross Domestic Product on providing its citizens with quality Health Care.
In Canada the total private funding for Health Care amounts to only 29.2% of all the health costs through the country, and the rest of the costs for Health care are provided for by the Government’s Health Care Plan. The Provincial and Territorial Governments in
Canada also give priority to Health Care. The Government of New Brunswick, for example, in 2004 allotted 28% of its budget towards Health Care costs. This figure amounts to $1.609 billion from which $56.4 million (3.04%) has been allotted to the
Mental Health Department for its effective functioning. (Canadian Budget)
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THE CURRENT Mental Health Care ‘system’ IN
New Brunswick.
The Government of New Brunswick’s Department of Mental Health Services Division primarily works to provide central leadership and accountability for the effective, efficient and equitable delivery of all forms of Mental Health Services to the Province of New
Brunswick. From time to time this division assesses the mental health needs of New
Brunswick’s population. Based upon their assessments and in conjunction with the
Provincial Mental Health Policy, the Mental Health Act, and the Mental Health Services
Act they allocate financial and human resources whilst monitoring their usage. Involved in their work is the direct management of thirteen Community Mental Health Centers that are situated around New Brunswick. Also they negotiate the effective delivery and purchase of service contracts with Hospital Corporations for in-patient services
(Psychiatric units and Hospitals) through out the Province.
The Structure of New Brunswick’s Provincial Mental Health Care
The Assistant Deputy Minister of Health and Wellness, who is a member of the
Department’s senior management team, heads the Mental Health Division. This senior management team helps deliver Mental Health Care Services through out the Province of New Brunswick. The management team works on providing services through the following four distinct operational sectors: y Community Mental Health Center’s y Psychiatric Units y Psychiatric Hospitals y Non-Profit Organizations and consumer and family groups with a primary mandate
Page 6 of serving people with Mental Health issues.
(Human Resources Development Canada, 2004)
Community Mental Health Centers
There are thirteen Community Mental Health Centers in New Brunswick. These centers are headed by directors who are responsible for the effective delivery of Mental Health
Services within their own area. The directors are also responsible for establishing mechanisms that ensure ongoing community, consumer, and family involvement. These centers are responsible for managing the following three core community-based program areas: y Acute Services y Child and Adolescent Services y Adult Long Term Services y Psychiatric Units y Psychiatric Hospitals
Acute Services
This community based program is meant for individuals of all age groups with mental or emotional problems that interfere with their functioning. Through this program the individuals with the problems are screened and assessed, and then directed to the
Mental Health Programs and the various Community Services that are appropriate for them.
Child and Adolescent Services
This program provides Mental Health Services to children and adolescents from birth to
Page 7 eighteen years of age. The services offered through this program include individualized assessments, treatment and evaluation services, and Crisis Intervention.
Adult Long-Term Services
This program caters to the needs of those adults who need treatment and rehabilitation.
Services are provided based upon a combination of diagnosis, duration of illness, and level of disability. A strong goal of this program is to ultimately facilitate the integration of these individuals within the community. Other aims of the program are to ensure that all clients/patients achieve an optimal quality of life, support themselves financially, and achieve some level of self-fulfillment. This program works towards maximizing the clients potential and resources.
Psychiatric Units
Both the Psychiatric Units and the Psychiatric Hospitals formally report to Regional
Hospital Corporations, but are funded by New Brunswick’s Mental Health Services
Division. The Psychiatric Units are responsible for providing, at the request of a
Physician or Community Mental Health Centers, hospital- based services. These services include both in-patient and daytime hospital care for voluntary and involuntary persons suffering from acute psychiatric disorders. Psychiatric Units also work in conjunction with other hospital medical/surgical units to provide consultation and educational programs for medical interns, nursing students and students in Occupational
Therapy, Social Work and Psychology.
Psychiatric Hospitals
Psychiatric Hospitals are responsible for providing specialized treatment and rehabilitative services for those patients with psychiatric problems who are difficult to manage, and/or are of a medium or long-term duration. These hospitals also serve as
Page 8 centers for evaluation, research, and training in the field of Mental Health.
Mental health Saint John
Saint John Community Health Services
The Saint John Community Health Services provide a wide range of services for children, adults, and seniors who are experiencing mental health problems. Services are offered on a 24-hour basis, are free of charge, and are confidential. The programs and services offered through this center are the following: y Adult Long-Term Program y Psychosocial Rehabilitation y Services to Families of those who have Someone with a Mental Disability y Services to People with both Mental Illnesses and Addiction/Substance Problems y Mental Health Court y Services to Seniors y Intake and Acute Team y Tele-Mental Health y Child and Adolescent Team
Motto found on the wall of Saint John’s Community Health Service Department
Adult Long-Term Program
This program strives to improve, restore, promote, and maintain the emotional and mental well being of people suffering from severe and persistent mental illnesses, older adults with Mental Health needs, and the families of mental patients. In Saint John the
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Community Mental Health Center conducts the assessment and evaluation of prospective patients and then refers them over to Centercare.
Front entrance to Centracare
The building in front contains Mental Clients
Centercare has an Outreach Program, Sustained Care Unit, Rehabilitation Unit, and a
Vocational Training Program. The Outreach Program provides a consultation service for assessment/treatment, and then gives recommendations to those individuals who require long-term care with local care providers.
The Sustained Care Unit provides care to those individuals who demonstrate a high- level of risk to themselves or to others within the community. This unit focuses upon providing clients with the type of care that works upon them maintaining their existing skills, and gears them towards getting a better quality of life.
The rehabilitation Unit provides care for people not exceeding 18 months. This unit provides psychosocial rehabilitation to only those individuals who have been admitted into the center. A focus of this program is to assist individuals to successfully reintegrate
Page 12 into the Community.
There are five Vocational Training Programs. These programs include teaching the clients those practical skills that can be used by them to become more self-reliant: clients in these programs learn carpentry, recycle paper, and ultimately sell their finished products within the market place.
Lobby of Mental Health Office
Psychosocial Rehabilitation
Rehabilitation is provided through a multi-disciplinary team in a manner that is consistent with the needs of the client. Clients in this program are supported through the
Page 13 interventions of physicians, nurses, social workers, psychologists, and Human Service
Counselors. This program also helps clients with their housing, recreational, and health care needs. Centercare is the main center for providing Psychosocial Rehabilitation in
Saint John.
Services to Families of those who have Someone with a Mental Disability
Families of people affected by mental illnesses are provided with counseling and educational help free of charge.
Services to People with both a Mental Illness and an Addiction/Substance
Problems.
Assessment and treatment in the form of medication, and/or group and individual therapy is offered to these individuals.
Mental Health Office’s front counter
Mental Health Court
The Saint John Mental Health Court deals with those people who have a mental illness or intellectual disability and are in conflict with the law. People due to their Mental
Disorders deemed unfit to stand trial, or who are deemed not criminally responsible for their behavior in a regular court of law, get sent to this court to be tried. The purpose for the creation of this court is to ultimately hold all people accountable for their behaviors.
Services to Seniors
The Adult Long-Term Team screens and accesses seniors who come looking for mental treatment. Based on recommendations from this team, Seniors get appropriate supports, treatment, and entitlements.
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Intake and Acute Team
Individuals facing emotional problems can avail of the services provided by this team.
Here an effort is made to build the self-esteem of these people by teaching then various coping mechanisms. The team of professionals that run this program include Social
Workers, Psychologists, Psychiatrists, and Nurses. At Saint John Regional Hospital, where a large part of the services are offered, the Acute Unit consists of the Inpatient
Acute Unit, Short Stay Unit, Emergency Mental Health Services, Mobile Mental Health
Crisis Service, Ambulatory Mental Health Services, and TeleMental Health.
The Inpatient Acute Unit at the Regional Hospital has 25 beds. It provides care that is directed towards the reduction of psychiatric symptoms.
Short Stay Unit has 4 beds and provides intensive treatment and crisis intervention that is focused on rapidly reducing acute psychiatric symptoms, and also upon stabilizing the precipitating factors.
Emergency Mental Health Services provides Psychiatric/Mental Health Services to those people who are referred to this Department. An assessment is then done on the person and the appropriate help is provided.
Mobile Mental Health Crisis Service is based through the Regional Hospital in Saint
John. This Service provides interdisciplinary crisis intervention for clients wherever they need it. Mobile nurses respond to some calls by making on-site visits within a 45-minute radius of the city.
Ambulatory Mental Health Services provide interdisciplinary care for patients and their families who need Psychiatric/Mental Health Services but do not require Hospitalization.
TeleMental Health Care
The purpose of this service is to enhance Mental Health Services through the usage
Page 16 of interactive real-time imaging and data solutions. Individuals are referred here from rural areas.
Child and Adolescent Team
The Child and Adolescent Services are aimed towards improving, maintaining, and promoting the mental health and emotional well being of children, adolescents, and their families and/or caregivers. The services provided by this team are geared towards promoting healthy approaches to mental health issues. The services available to children up to the age of 18 years, include crisis intervention, screening, mental health assessments, individual therapy, group therapy, family therapy, and play therapy. These services are also provided for under the Pediatric Program. The Pediatric Program is linked to Acute Mental Health Services and can be assessed through the Community
Mental Health Center. (Community Mental Health Services, 2004)
Historical development/foundations of
Mental Health Care in Saint John
In order to garner an understanding of current Mental Health Care practices in Saint
John, it is absolutely essential to explore their origins. According to my research, the point in history where a ‘solid’ structure emerged that was most influential towards the current shape/direction of Mental Health Care in Saint John, was when Centracare
(or the Provincial Lunatic Asylum as it was originally called) was built approximately one hundred and fifty years ago. In this section I describe the history of Centracare, from its former role as the sole dispenser of Mental Health Care Services in New Brunswick, to its current role as one of the extensions of Saint John Community Mental Health
Services. Through this section I incorporate information that has been gathered from my
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interviews with Mrs. Nora Gallager, the current Director of Centercare, Mrs. Dale Dorin, the former Director of Community Mental Health Services, Mrs. Armstrong, the present person in charge of Community Mental Health Services, and Mrs. Gogan, a former nurse at Centercare and the person in charge of the Mental Illness and an
Addiction/Substance Program at Community Mental Health Services.
Centracare
Before it opened up, the duties of taking care of insane citizens were placed on their family members. Each country dealt with the extreme and obviously ill ones under the Poor Laws System, so many were sent to jails or poorhouses with the other outcasts of society. Sometimes they were chained up in dark and dismal surroundings where they were able to catch diseases of all kinds. During the rapid increase in the population in the early 1800's, a facility was requested to house the insane. Thus New Brunswick established Canada's first Provincial Lunatic Asylum. A wooden building at the corner of Wentworth and Leinster streets was built in 1835 (Centracare, pg 7)
The above quote describes the first small temporary structure that was set up in Saint
John, to provide Mental Health Care. This structure, when it opened, had the capabilities of housing only about 20 inmates. Finally, due to the increasing cases of people facing mental illnesses in New Brunswick, a commission was set up in 1836 to request funds from the Government in England to create a large and permanent Provincial Lunatic
Hospital in Saint John. The following is a quote that was used in the commission’s report to justify the need for the creation of this Asylum:
Dr. Abercrombie says, that "an important rule in the moral management of the insane will be, to avoid every allusion to the subject of their hallucination, to remove from them every thing calculated by association to lead to it, and to separate them from scenes and persons likely to recall or keep up the erroneous impression. Hence, probably, in a great measure, arises the remarkable benefit of removing the insane from their usual residence, friends and attendants, and placing them in new scenes, and entirely under the care of strangers. The actual effect of this measure is
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familiar to every one, who is in any degree conversant with the management of the insane. That the measure may have its full effect, it appears to be of importance that the patient should not, for a considerable time, be visited by any friend or acquaintance: but should be separated from everything connected with his late erroneous associations“. (Centracare, pg 16)
Ultimately funding for a Provincial Lunatic Asylum were approved, and this created the first Mental Asylum in Canada. At the time the Provincial Lunatic Asylum was created in
Saint John, asylums were looked upon as the new, proactive and more humane option towards Mental Health treatment. Science was being increasingly used to understand mental disabilities, however it was quite absolutistic and positivistic. Even though religious morality still held the imagination of the populous, science was the ‘other’ option where the older antiquated practices of demonizing mental abnormalities could now be treated as conditions that were quite worldly and thus biological. However the underlying religious morality of good and bad ways of living were still what propelled this scientific flight of imagination. Foucault stated in his book ‘Madness & Civilization’ that “at the retreat (Asylum) one was at the grip of a positive operation that confined madness in a system of rewards and punishments, and included it in the movement of moral consciousness”(pg 250). Foucault stated that at this time the perceptions of madness were greatly influenced by the methods of Scipion Pinel (pg 251). Pinel according to Foucault had taken off where the famous Quaker Samuel Tuke had left off
(pg 251). Tuke’s method of treating the insane came along with a whole current of philanthropy that was reminiscent of the time. Madness was countered by instilling great fear within the minds of those who were prone towards transgressing the boundaries of sanity: the fear of punishment thus controlled the irrational. Under this method the patients were made responsible for their own actions; it was ultimately their own actions that decided whether they were to be punished or
Page 19 rewarded. Tuke was thus successful in establishing a connection between insanity and sanity where one before had not existed. The Asylum according to Foucault under Tuke was thus looked upon as a parental complex, and the patients were looked upon as its children who had to be taught how to live as ‘civilized’ human beings. Tuke’s idea of an
Asylum was directed towards creating a community where morality and religion were the over-arching structures under which mental patients recoveries were to be engineered
(pg 256).
Foucault (1965) states that Pinel on the other hand took away the direct religious overtones that were characteristic of Tuke’s model and substituted them by a completely positivistic model. However Foucault believed that, Pinel reduced the ’iconographic forms, not the moral content of religion’ (pg 256). The asylum under Pinel was still a domain that worked to create ethical uniformity, however it was now being pushed forward as a medical institution. Foucault states the following about Pinel’s asylum:
The Asylum became in Pinel’s hands, an instrument of moral uniformity and of social denunciation... The operation.. was relatively complex: to effect moral syntheses, assuring an ethical continuity between the world of madness and the world of reason, but by practicing a social segregation that would guarantee bourgeois morality a universality of fact and permit it to be imposed as a law upon all forms of insanity (pg 258, 1965).
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Provincial Lunatic Asylum in Saint John 1800’s
Provincial Lunatic Asylum in Saint John 1900’s
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Man on the Asylum lawn late 1800’s
Painting of Asylum life in the early years of its creation
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Mental Patient having her meal in the Asylum
Another picture of Patient life.
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As science changed over the years the impressions that the public held about the
Provincial Lunatic Asylum also changed. Even as far back as the 1880’s, soft murmurs of disapproval were beginning to be heard which did not correspond to the official word that Asylums were places of emancipation for mental patients. In her book Mary Huestis
Pengilly, a former inmate of the Saint John’s Provincial Lunatic Asylum, compares it to a prison; where human dignity and freedom were constantly being trampled upon
(Pengilly, 1885). Asylums during this time were viewed by the intellectual community as overall success stories and voices of descent were treated as regrettable anomalies that were bound to occur in any large system that catered to more then the individual wishes of its patients. Finally in 1945 the government agreed to investigate the malpractices existent within the Asylum. The reason for this change in heart was due to the nature of the complaint. Based upon brutality stories at the Asylum being brought to the attention of the provincial newspaper, The Standard, decided to investigate by having one of its reporters go undercover as a worker in the Asylum. The enquiry was based upon the reporters damaging statements that were published in the newspaper. The following are excerpts from reporter Kenneth Johnstone’s allegations:
Excerpt:-"Standard"-Issue of January 27, 1945: “The Old Attic consists of two large rooms, a smaller room, an antechamber, and a toilet. The two larger rooms contain about 14 beds each, there are three beds in the smaller room and another bed in the antechamber. The place is unheated, the walls are filthy, a curious slime covers the floor, and rat holes are everywhere. I counted eight beds that possessed woolen blankets, the rest were equipped with one cotton under sheet and one thin flannelette sheet. Three of the patients were ankle strapped to their cots, the door of the small room was locked, and the door to the stairway was locked as Sid Phillips and I left the patients to their dreams. During the eight winter days that I spent at the Hospital, it was a constant source of amazement to me that no one collapsed of exposure in the Old Attic."
Excerpt:-"Standard" Issue of January 27, 1945: "Walking to my room that evening with Sid Phillips, I was shown the dungeons underground where unruly patients were formerly confined. Phillips was
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familiar with conditions at the hospital 20 years ago and was enthusiastic in his praise of the progressive work done under the present superintendent Dr. E. C. Menzies who has headed the Hospital for the last eight years. In his opinion, Menzies has turned an asylum into a hospital. He has replaced unsanitary wooden floors with stone floors that can be swabbed easily. He has brought in medical facilities like X-ray and each new patient is now given a thorough medical check up. He has abolished the straitjacket and the 'crib', which was a coffin like box, in which violent patients were formerly confined, taking their meals through the bars like beasts. Restraining straps and the ‘needles’ are the methods now used to deal with violent types." (Centercare, pg 19)
The commission answered to these allegations by calling them hearsay. Ultimately
Johnstone only had his own words and the words of former patients to go on. At the time, however, patients emerging from Asylums were not considered valid voices in governmental procedure. The commission ended up exonerating the institution and blaming the patients by making the following statement:
It must be remembered that in the care of the insane there is always a group of very difficult patients, and I refer to the group which is untidy, demented, denudative, destructive and restless because of the inroads of their disease. These patients, even under the best of conditions, would leave any hospital open to criticism by a critical observer. (Centercare, pg 42)
Centracare changes its form
By the 1960’s the clamor for closing down the Provincial Hospital - now called
Centracare - started getting louder. According to Mrs. Gogan, a former nurse at
Centracare and currently the head of Services for those who have both a mental illness and an addiction/substance problem, Centracare had to go because it had become such a negative symbol. In the community ’it was viewed as the symbol of the end‘ (Gogan, interview). The process of change was not sudden. For awhile according to Mrs. Gogan, the institution had been involved in downsizing. The result of this downsizing over a period of time resulted in an alternative service sector coming into place which could now incorporate the needs of the patients that were being discharged from the institution. Gogan states that due to actively downsizing Centracare, many ‘Special
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Care Homes developed’. In an interview that I had with the present Director of
Centracare (director of a new unit that houses less then fifty patients), Mrs. Nora
Gallagher I asked the following question about Centracare’s original closure:
Q. Was one of the reasons that they closed Centracare down, abuse of the ‘inmates’?
A. Yes, the reason that hospitals were closed in Saint John and across the country was because people did not feel that it was the right thing to lock people away. Years ago in Canada to have some one who was mentally ill or intellectually disabled was an embarrassment to the family - and the way of dealing with it was to lock, put people into the hospitals, to have them treated. So it was part of the culture: it was accepted. As more advocacy groups… and you know people started to talk about their experiences in hospitals, how they hated it, things started to change. Hospitals closed not because of rampant abuse, they closed because it wasn’t the right thing to do. And there were enough people coming forward to say that there is a better way of doing this... I am not suggesting that there were not any cases of abuse in Centracare. In the old days they had a different way of treating mental ailments. There was a nurse that talked about the practices within Centracare in the past. She spoke about coffins, and the most disturbed of these patients would be put into these Coffins and locked. Now that sounds like abuse today. That sounds almost like torture. However, have you ever seen a psychotic person having one of his/her psychotic episodes? It is really frightening. And the risk factor is quite high. These people in these conditions can kill others. Back then they did not have the type of medications that exist today. So they did the best that they could. Ultimately the patients themselves were in so much pain that something had to be done to alleviate their suffering. I had a person who said that without medication he had snakes crawling up his arms and all over his body. For this person this delusion was real, and was very frightening. I am not defending putting people into boxes, god forbid. But I guess I am saying it was the time. (Gallagher).
It is important to realize that re-integration within the community came out in a large part due to the developments made in the medications that were being provided to mental patients. The newer medications managed to work on select parts of the brain, whilst allowing the person to maintain ‘normal’ functioning in the other parts. This allowed mental patients to appear normal to the outside world, countering the fear of the
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‘unknown’ that existed in the community regarding the mentally disabled. This
‘normalizing’ of mental patients was necessary from the Government’s standpoint in order for the community to be willing to take these mentally divergent people back into their homes. Superficially it would appear that the move back to the homes was a move back into antiquated practices, after all it was because of the problems that occurred with mental patients in their homes that Asylums had originally sprung into existence.
However the crucial difference this time was that the mental patients were not just being released into the community with the onus upon the community for their upkeep. Now the Government was investing large sums of money into ensuring that the right kind of trained expertise was in place that could help these people live within a home situation.
Another crucial factor, which caused the eventual closure of Centracare, was the whole mood towards decentralization that was sweeping the whole of the Western World.
With decentralization came the change from large governmental structures to smaller private ownerships that were responsible for carrying out the same functions. It was believed that with governmental handling of public property came inefficiency, and corruption. The new private establishments that were emerging and replacing the governmental Mental Health Delivery apparatus were geared towards maximum efficiency and cost-effectiveness. Now slowly but steadily Mental Health Care in Canada started to come into the hands of the private sector, however the overall management of these services still rested with the government. Mrs. Gallagher supports this trend in governmental policy by stating that ‘Institutions cost a lot of money to run. If you could transfer this money into the community it would save on money and provide better service‘. The following is an excerpt from my interview with Mrs. Gogan a Mental Health
Nurse that describes this change over period and the problems that arose with it:
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Q. How has changing the management of Health Care delivery from public hands to private hands changed the delivery of Mental Health Care to the community?
Gogan - I think that over time the skill level of the people working within Special Care Homes has definitely increased. The residential services nearly all require people trained in the Human Service Counseling Programs - that are acquired through the Community College System. So that is one of the things that have happened. In order to branch out into the community, an Education System was set up that would enable the community to have skilled workers. One of the things I believe is that one can’t necessarily take staff that has been working in a hospital (big institution), and put them in-between and expect them to do a good job. This can not occur because these staff are institutionalized themselves. So the move into the community and of the thought that people became a part of the community was too big for some people. Some people did the move/change extremely well; but for others it was harder as they wanted to maintain the institutional way of doing things. This conflicted with the new approach - as making a home into the community requires giving up the Institutional life. The staff had to now view the person not as a patient but as a person who lived in the house, in the neighborhood, in the Community.
The move into its new complex for Centracare, according to the Health minister of the time G. W. N. Cockburn, was a move into a ‘community type’ situation which resembled a little village with ‘services and smaller quarters making it much more natural to live in’
(Centercare, pg 22)). The older building which had housed patients for over 150 years lay abandoned for many years until it was finally torn down in 1991 by its new private owner - the multi- million dollar industrial giant Irving.
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The demolition begins...
There was some opposition from the community towards this demolition as to many people it was part of their cultural heritage
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An empty space now. The white flag is the Irving Flag
The History of the Mental Health Department
Saint John
The following is gathered from my interview with the Past Director and also the current person in charge of the Mental Health Department in Saint John, Mrs. Dale Dorin and
Mrs. Armstrong respectively.
Prior to 1988 there was a small mental health clinic in Saint John. There was a doctor, a nurse, and a couple of other Mental Health Clinicians who would provide services to those people who would walk in with Mental Health issues. At the time Centracare housed around 325 people, and there was an Acute Psych. Unit at the Regional Hospital. The Psychiatry Unit at the Hospital was really for the walking well. It was for people who were more affluent and thus could get similar services as provided in Centracare, without having the stigma of going to Centracare attached to them.
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In 1988 the Government of New Brunswick developed what was then called the 10-Year Plan for the reform of Mental Health Services. As part of this reform The Mental Health Commission was created. The head of the Mental Health Commission reported directly to the Health Minister. During the time between 1988 and 1996 the Ten Year Plan was implemented. Within this time occurred an active down sizing process at Centracare. In Mrs. Dorins words what was happening was ‘a re-balancing of services’. Due to this re-balancing of services the Regional Hospital had to increase the size of its operations in order to accommodate many of the people who had been moved out of Centracare. Meanwhile staff that was no longer working at Centracare because of the reductions to Centracare’s services began being transferred into the community. All these various changes had to be managed by a central service component. The onus of this central responsibility fell upon the Community Health Center. All of a sudden the Community Health Center (or the Mental Health Clinic as it was formerly called) was at the helm of the occurring change, and to effectively deal with its newly-added responsibilities the Center was forced to expand its space and powers of operation. There were 13 such Community Mental Health Centers developed in the Province of New Brunswick. The one center in Saint John was the biggest Mental Health Center in the Province: as it had Centracare in its backyard, and thus had to take the bulk of the discharged patients from Centracare. In order to make a smooth transition of Mental Health Services there was some bridging Funding put in place by the Government to ensure that there were services available in the community prior to the patients coming out. During this time the Case Managers from the Community Mental Health Center would go in sometimes on a daily basis and engage with the folks at Centracare; bringing them out into the community, helping develop individual service plans with them, and getting living arrangements set up for them. The Government’s money thus followed the clients, and the staff (trained personnel) followed (the money) these clients as well. The new Centracare opened in 1998. In order to have a power of authority that represented all the sectors of Government involved in Mental Health Services the Regional Management Team was established. All of the Middle and Senior level Managers in Mental Health Services were on this Regional Management Team. This Team overlooked the whole Health Service Operation.
Current Situation of Mental health Care in Saint John
From my interviews with people in positions of authority and from my own literature review people view the current Mental Health Care situation in Saint John as an
Page 31 improvement from the way it was in the past, There, however, appears to be growing concern amongst professionals and the general layman that something in the current approach is just not working. There appears to be agreement amongst Saint John’s people that there is an over-reliance placed upon medication as the cure for all mental anomalies. This over-reliance upon medication has the propensity of clashing with the ideals of holistic treatment proposed for all Citizens of Canada under the Health Care plan. Mrs. Nora Gallagher, Director of Centracare, states ‘I do agree... we way over medicate people in mental health...these are the people who are not spending time in institutions and are suffering from depression and anxiety and are being definitely well over medicated”. Mrs. Dorin also states similar sentiments concerning the over- medication occurring within Saint John’s Mental Health Care Model. She states “we are a drug-focused society. We have huge pharmaceutical companies who spend a lot of money on dancing with doctors, and getting doctors to prescribe lots of drugs, and yes there is a general sentiment that the pills can solve everything”.
In Saint John there is also general concern that the funding cutbacks that are being made by the Provincial Government are already starting to have an impact upon the
Mental Health Care Field.
In Saint John there is also a trend towards all governmental services being placed under one roof. The one roof that is being erected for The Department of Health in New
Brunswick is called the Regional Health Authority. The creation of this new power structure is resulting in many of the heads of the older structure being effectively cut off.
Directors like Dale Dorin, whom I interviewed, have lost their job positions. My interview with Mrs. Dorin was conducted in the last few days of her tenure as the Director of
Mental Health services in Saint John. Centracare on the other hand has not received
Page 32 any direct senior management cutbacks yet. Mrs. Gallagher, however, expresses her concern about the current trends by stating that today we ‘need more services, not more cutbacks’.
After describing Saint John’s continuing struggles with Mental Health through the ages one gets to witness a lot of good intentions, but not many success stories. Saint John’s society still continues to struggle with Mental Health issues. No approach has emerged yet that can be categorized as ideal towards balancing health care with personal liberties. Mental health problems are on the rise in Saint John and the government’s answer to this is to cut back its resources for this sector. Maybe ultimately no approach has worked in curing mental illness in Saint John, because what we are dealing with is not something that can be ‘cured‘. On this note I am reminded of Foucault’s following words:
In the serene world of mental illness, modern man no longer communicates with the madman: on one hand, the man of reason delegates the Physician to madness, thereby authorizing a relation only through the abstract universality of disease; on the other, the man of madness communicates with society only by the intermediary of an equally abstract reason which is order, physical and moral constraints, the anonymous pressure of the group, the requirements of conformity. As for a common language there is no such thing; or rather, there is no such thing any longer; the constitution of madness as a mental illness, at the end of the eighteenth century, affords the evidence of a broken dialogue, posits the separations already effected, and thrusts into oblivion all those stammered, imperfect words without fixed syntax in which the exchange between madness and reason was made. The language of psychiatry which is a monologue of reason about madness, has been established only on the basis of such a silence. (Foucault, 1965)
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Does Joe in Saint John need us/want us to help him from himself?
The following section of this paper will provide a picture of private and governmental approaches towards Mental Health Care that are practiced in DehraDun, India. This section incorporates the vastly divergent culture that exists in DehraDun from the one that I have described in Saint John.
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Mental Health Care in DehraDun
While describing DehraDun’s Mental Health Care sector much of the terminology used has now been discredited and is no longer used by mental practitioners, and mental health literature found in Canada. My reasons for still using this terminology are not an attempt to be insensitive to people facing mental divergences, or an attempt to be apathetic towards the direction Western Mental Health Care has gone. Instead, it is an attempt to be exact to the details of this section of my research that are based from
India: I have used terminology that is currently in use in India. I begin this section by providing a brief synopsis of the Central Government of India’s attitude towards Mental
Health Care. This is followed by a description of the Official Governmental position of the
State Government of Uttaranchal (of which DehraDun is the capital). My reason for starting this analysis through first stating the Official Governmental Mental Health Care position is to provide the reader with an understanding of the direction/or lack of direction provided by the government towards Mental Health Care in DehraDun. Through an analysis of this Governmental position I manage to describe better the reasons for the existence of Private Mental Health Care Centers, and for the existence of Alternate
Health Care approaches towards treating mental health conditions existent in DehraDun.
The official position
During 1990-91, a survey conducted by the Government of India estimated that 16.15 million (about 1.9 percent of the total population of the country) people in India suffer from physical or sensory disabilities. In another survey of children between 0-14 years with delayed mental development in India, it was discovered that 29 out of 1000 children in rural areas have developmental delays usually associated with mental retardation
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(Mohan). ‘The rehabilitation and empowerment of disabled people in India is a statutory responsibility of the government’ as stated in the Persons with Disabilities Act, 1995
(chopra, Interview). The Persons with Disabilities Act promises free education, with a focus on integration within regular schools, for all disabled children till they are of the age of 18 years. The total money the government is currently spending for this sector is
Rupees 1446.00 Crores (approximately $ 498 Million). This money is to be spent during the next 10 years. Divided equally per year for the next ten years this allotted amount breaks down to $ 49.8 million yearly for the 16.15 million living in India with disabilities.
One just has to look at the figures quoted for India’s Health Sector by the World Health
Report of the World Health Organization (WHO) to realize how inadequately funded health coverage in India really is. India’s Gross Domestic Product (GDP) of $ 3.033 trillion is one of the largest GDP’s in the world (India Shining). From this GDP the Indian
Government spends only .9% on its Health Sector. The WHO report goes on to state that the Government of India’s contribution towards all the money spent on Health Care in India is only 17.9%, or $80 per capita. Private capital thus amounts for 82.1% of the spending on Heath Care; making India’s delivery of health care one of the most privatized in the world. Privatization of health services does not benefit the approximately 300 million Indian people who live below the poverty level, because they lack the funds to pay for Private Health Care. These people thus are forced to rely upon the Government’s highly under funded and insufficient health care services. The picture gets worse for the field of Mental Health Care. According to the World Health
Organization’s analysis of the latest budget in India, Mental Health Care has only been allotted .83% of all the funds prescribed towards the care of Health in India (World
Health Report).
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This makes Mental Health Care the lowest priority on the list of the Health Department of
India. This dismal picture carries on to the level of the State Governments. In
Uttaranchal (of which DehraDun is the Capital), the Government’s latest budget totals
$ 2.09 Billion (2004), of which .0004% (or $ 1.25 million) has been allotted towards
Health care (Uttaranchal, 2004). From this small amount for Health Care in Uttaranchal an insignificant amount has been allocated towards Mental Health Care.
Under a law passed by the Supreme Court of India every State must have a Mental
Hospital to take care of the mental needs of the people living within its boundaries. The
State of Uttaranchal, because it has only just been created, lacks such a facility.
Presently all the people wanting mental treatment at a hospital in Uttaranchal have to go to a Hospital in some other State. In an interview with Dr. Sayana, the current Assistant
Director of Health in Uttaranchal, he spoke about the possibility of such a facility emerging in Uttaranchal. He also spoke about all the other initiatives that are being currently carried out for/by the Mental Health field in Uttaranchal.
In Sillaque near Dehradun we are making a 30 bed hospital - 30 bed Mental Hospital. The Government is also giving 60 Lakh’s (approximately $175, 000) for this project. We are also starting a Mental Society - Government has made this society which is the Mental Authority for the State of Uttaranchal. Involved with this Mental Authority are the Health Minister of Uttaranchal, Uttaranchal Medical Board members, a Clinical Psychologist, and also a chief Medical Psychiatrist. This Authority will discuss issues relating to Mental Health Care in Uttaranchal.
I asked Dr Sayana how such a small facility of 30 beds would be able to take care of all the needs of a population size that is in the millions. He informed me that 30 beds would be adequate, as ‘there is not much demand in the region’. This conflicts with the following statement made by a prominent Psychiatrist of DehraDun, Dr Nand Kishore. Dr
Kishore states that “in large about 5% of the population is suffering from major
Psychiatric disorders and 20% are suffering from mental problems of a minor
Page 37 magnitude” (Kishore). The discrepancy portrayed through Doctor Kishore’s accurate statement clearly shows that Mental Health Care is not one of the priorities of the State
Government of Uttaranchal.
Dr. Sayana also mentioned that this hospital facility would be for short-term care only.
(1-30 days). When asked about what would happen for the people with Special Needs, who require long-term care, he replied that there wasn’t such a need. According to him patients usually stay on in hospitals for long-periods of time only because they are left there (abandoned) by their relatives. Dr Sayana stated that all people with special needs are short- term patients primarily because they are all cured in a short time.
Dr. Sayana’s comments sum up the official governmental position regarding Mental
Health Care in Uttaranchal. Presently this proposed Mental Hospital is not in place. At this time all people in Uttaranchal with mental problems have to come to Doon Hospital
(the one Government Hospital in DehraDun) where the Government has provided one
Psychiatrist, or they have to seek help outside Uttaranchal.
The lack of governmental service for mental patients leaves the onus of Mental Health
Care delivery in Dehradun upon the private sector, religious organizations, and faith healers.
Non- Governmental Mental Health Care
In DehraDun besides the meager mental health facilities offered by the Government the other avenues that are open to the public are: Raphael International Center, Karuna
Vihar, private psychiatrists and general physicians, and a number of alternative methods towards treating mental health conditions. Due to limited time I have managed to interview only certain people from each of these categories. The information obtained
Page 38 from these interviews has been added to research conducted on pertinent literature.
Raphael: Ryder Cheshire International Centre
The Secretary of Social Justice and Empowerment of India monitors the Mental Health
Sector of India. A big portion of the budgetary allocation for this sector is invested within the Non-Governmental Organizations (NGO) under various schemes. Select NGO’s receive monetary assistance and in return they have to provide a detailed income and expenditure balance sheet at the end of the year. In DehraDun the only NGO to receive funds last year was Raphael, and it received a sum of approximately $ 70,000 for the year (Publications of Industrial Development, July 2004)
The Raphael Ryder Cheshire International Centre, or Raphael as its more popularly known, was established in April 1959 by Group Captain Leonard Cheshire, a British Air
Force officer, and his wife Lady Sue Ryder: both renowned all over the world for their various humanitarian activities. After a distinguished career with the Royal Air Force,
Lord Cheshire in 1948 set up the first Cheshire Home for the Physically Challenged.
Today, the Leonard Cheshire Foundation operates over 170 homes in 34 countries caring for the physically and Mentally Challenged (Raphael, 2004)
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The Two founders
Currently Raphael in DehraDun provides care to over 300 people. The large Raphael complex was leased from the State Forest Reserve department in 1974. Now this land hosts a Tuberculosis hospital (TB is still quite rampant in India), a Leprosy Village (many of the leprosy patients that live in this village are employed within Raphael), Little White
House (a hostel for Mentally Challenged Children), Ava Vihar- Residential (Hostel for the
Adult Mentally Challenged), and Ava Vihar- Day Care (a care facility for local mentally challenged children; it includes a primary school). Raphael also offers many Certification
Programs through its facilities. :
Raphael is not an Asylum; it is a Rehabilitation Center for the treatment of people with mild to moderate handicaps. Approximately 160 people are full-time residents. The other residents come in to use the facility during the daytime. Services are provided free of cost for the residents. General Bakshi the current Chairman of Raphael informed me that Raphael provides free services to its residents because of donations from around
Page 40 the world. However according to him, donations from overseas have dramatically reduced since the demise of Raphael’s founder, Lord Cheshire. To make up for this financial shortfall Raphael has had to concentrate more of its energies upon getting funding from within India. A certain portion of Raphael’s cost for operations now come from the Government of India. This according to General Bakshi has only come about since he made it clear to the Government that Raphael was not an organization that was affiliated in any form or manner with the Church or any other religious organization.
The cost for maintaining one resident within the facility is Rupees 62 ($ 2) a day. The yearly budget for running Raphael is a little over one Crore Rupees (approximately 300 thousand dollars).
On the following pages are my pictorial and written observations from the various activities that I watched being carried out in Raphael during my time there.
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Young children are taught how to work with their hands in an exercise that involves folding and cutting of papers. This type of exercise works on the fine motor skills. An attempt is made in these classes to have them resemble the workings within any
‘normal’ class room structure. This is done so that on a later date these children can easily fit into the mainstream. A high percentage of the students pictured here are mild autistics. There are four classrooms in the school. Children in these classrooms are taught in an atmosphere that is congenial towards imparting learning. Positive attitudes are constantly re-enforced by the teachers setting an appropriate example. The children are encouraged in the strongest terms for all the things they do successfully, and not made to feel bad about all their temporary failures. Children are taught the Hindi
Page 42 alphabets in an attempt to make them literate. There are approximately five to seven children per class/teacher. Outside the class waits a ‘Ayah’, who leads the children to the bathroom if they ever desire to go. The Ayah toilet trains the children.
The teacher here is encouraging the children to work with their hands at beading strings.
Class times are from ten in the morning up to one in the afternoon, then from one thirty up to three in the afternoon. A strong focus in this education forum is placed upon music. Children are encouraged to spend much time playing with various musical instruments; that are placed in one of the classrooms. The teachers also during their instruction time use a form of speech that undulates up and down like musical harmony.
This type of animated style of teaching keeps the interest of the children focused upon the task at hand.
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In the above picture children are shown coming back from lunch for their afternoon classes. The doors in the center of the picture host the various classes held within the school. The ratio of teachers to students in these classes is approximately 1:6 . The students are taught with the objective that they will one day be a part of a ’normal’ school situation.
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Vocational training for the older students (over the ages of eighteen) is encouraged.
These children work with paints, making Batik (patterns on cloth), or print designs on cloths. These clothing items are ultimately set up for sale or usage within the center.
The atmosphere in this classroom is very congenial, and the children obviously enjoy being here.
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In the Custodial Class people from ages 16 upon 60 are present. In this class the people are busy cleaning the candles that are made in the Candle Making Center within the
Raphael Campus. There are approximately 15 people per class, who range from mildly retarded to moderately retarded. Within these classes there is present a professional lady tailor who is constantly busy mending and stitching the clothes of the residents of
Raphael. The atmosphere in these classrooms appears not as positive as the one which hosts the younger people, however this may have to do more with the divergence in ages between the two groups, then with anything else.
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Near the Gym are the Candle Making and Carpet Making Centers. Here goods are made by local residents, which then are either used within the Center or sold outside in the local market.
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Within the campus gymnasium is taught a Psychotherapy class. Also within this gymnasium an expert teaches Martial Art Skills to the residents: so that they can defend themselves should the need ever arise.
Working within Ava Vihar and the Craft Making Units are approximately 28 specialist staff employed by Raphael at all times. Raphael’s staff receives their training before they begin work from government institutes set up in neighboring areas.
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Karuna Vihar
The founder of Karuna Vihar, Mrs. Jo Chopra, an American citizen, got the idea of opening her own school for children with mental disorders while working for the Latika
Roy Foundation. Latika Roy Foundation is involved in the promotion of creative education through out India.
Mrs. Jo Chopra
Karuna Vihar, a project of the Latika Roy Memorial Foundation, was opened in a rented building in Dehradun in 1996. At the time there was only one full-time worker, a handful of volunteers and two students. Today the school has thirty children, and many trained staff employed.
The children, whom Karuna Vihar cannot take, due to limitation of space and funds, are
Page 49 offered a place in Karuna Vihar’s Home Management Program. The Home Management
Program meets once a month and provides parents with the advice and the support of a professional team. The school employs a Speech Therapist, a Developmental
Pediatrician, and many Special Educators. Activity is the school's mantra, and children are grouped on the basis of their abilities rather than their age. As far as possible
Individual Learning Programs are drawn up to cater to each child's unique requirements.
Karuna Vihar
Karuna Vihar does not admit children with major mental disorders; the school only
admits those children who have mild to moderate disorders. Presently, Karuna Vihar is a
day school, which takes children from the ages of four to eighteen years of age. The
Management Team for Karuna Vihar strongly encourages parents to admit their children
Page 50 when they are just a few months old. Admitting children at an early age is done with the hope that the earlier the children learn the necessary tools for their survival the better chances they will have of being re-habilitated within the community. Since most of the students come from poor families, the fee per child has been fixed at about 2 per cent of the parents gross earnings. Due to the poor socio/economic status of majority of the parents the money that comes from them in terms of the children’s fees is not sufficient for the schools effective functioning. The main chunk of the money needed to run the school comes in from the grants procured from private agencies like Sir Ratan Tata
Trust, and the ONGC (Oil National Gas Corporation).
Currently attempts are being made to get Karuna Vihar a bigger campus that will enable it to host approximately one hundred students.
Karuna Vihar works on the premise that no two children are alike; thus individual programs have been designed for each child to draw on their own potential. The key word at Karuna Vihar is ‘Fun‘. To make school fun for the children the administration provides education that is activity-based. Equally central to Karuna Vihar’s philosophy is the inculcation of the children’s family within the support structure needed for the their healthy growth. The children’s families are involved not only with their own child but also with the process involved in the development of each and every child registered within the school.
The Home Management Program is also designed for children who live far away from the school, or who are too young to be admitted within the school. Individual Programs are drawn up for each of these children after their assessments are conducted, and their parents provided with the appropriate training in Physiotherapy, Speech and Language
Therapy, Sensory Stimulation and Early Literacy Activities.
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Karuna Vihar also hosts an Early Childhood Intervention Center.
The following is a excerpt from my Interview with Mrs. Jo Chopra, the Founder and
Current Director of Karuna Vihar, Latika Vihar, and the Early Childhood Intervention
Center in DehraDun:
Q. What types of trades/skills do children learn at your school that enable them to take on a job later on in their lives? Ans. We are looking at a number of things. Horticulture however is our big focus. We basically try to provide the children with some skills that their parents can work with.
Q. What socio/economic status children are we looking at here? Ans. We have a range from high to low to very low-income children. The bulk of the kids are however from the lower middle class.
Q. Do you have dealings with a psychiatrist? Ans. No we do not have a psychiatrist.
Q. How long have you been in operation now?
Page 52 Ans. 7 years.
Q. Don’t you find it frustrating that the Government here is putting in so very little money in the Mental Health Field? Ans. Not really. We get our money from private donations. We are so wary about getting involved with the Government that I have not even applied for any Government grants/loans. I/we find their bureaucracy (red tape) so very frustrating. You know because of the corruption inherent within Government there is no reliability. In this line of work, where one has to look after children, one has to be very reliable. The Government has the money. I am not saying that it (the Government) is not committed to spending it, however, there are people in between who make life difficult for everyone like us.
Q. What do you think needs to happen more in this field? Ans. We need a lot more people in our field prepared to stay. Some of the best people leave. And that is a really big problem. It is a field that not many people are even aware of, thus not many venture in. There are also not that many good training centers. The ones that are good produce graduates who when they get a chance end up moving to the Gulf or the US - because things are more developed there, there they get to work in what they desire, and there they get paid better for their work. Fewer people do this line of work here because it is very time consuming and can thus become frustrating. I would like to see here some really high-quality and professional training facilities available for the teaching of people involved within this field. I particularly direct this statement at Pediatrics. Also all of the Speech Therapy that is imparted here is for adults; for children there is very little. For children with disabilities there is almost nothing. The current therapy available is directed more towards people who have had accidents or strokes injuries- that kind of stuff. The second thing I would like to see happen here is ‘inclusion‘. I think the only way the current mindset of the people in this country is going to change regarding disabilities is if they see more disabled people included into the mainstream. Once disabled people are in the mainstream their needs will become more apparent and the ways to address these needs will also become easier to figure out. As long as these people are being hidden in their homes it will remain hard to really know what needs to be done and how one needs to go about providing it.
Q. Is this push towards inclusion financially based? Ans. No. I think the family is really the ideal place for most children. They are situations however where the disability is so severe that families cannot manage the person by themselves, or situations where families are just too poor, or where they do not have the available human resources to look after the child, in these cases the child needs institutional care. In majority of situations, however that a child is put into institution care the parents lack an alternative choice; were this choice available I am quite certain these parents would not like to put their child into this type of care. My belief is that when you put a bunch of people together who have severe disabilities it becomes harder to see them as individuals - you end up seeing them as mouths to feed, and bodies that need to be washed. On the other hand when there is only one person to look after it becomes easier to give him/her concentrated care. So we feel that children do better in their own home where they can receive this concentrated care, and that parents of disabled children need all the support that the community can provide to enable them to provide this sort of care.
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Q. Over all is this field very poorly paid? Ans. Yes.
Q. Due to poor pay do you find the commitment to work is poor?
Ans. No, our staff is paid very well. In general however around this area people working in this field are not paid well. I have heard of people getting salaries in the range of 700 to 900 a month (20 - 30 Dollars) for a very hard day of work. We pay in the range of 4000 to 5000 rupees (150 - 175 Dollars) a month.
Q. How do you differ from a place like Raphael? Ans. For one thing they are residential. Due to this they face a whole bunch of problems that we do not -they really have their hands full. Secondly, their approach is a bit different from ours. Thirdly, the government funds them - and that comes with its own set of expectations.
Q. In your estimation what do you think can people working in this field in DehraDun learn from the manner in which Mental Health Care is practiced in the West? Visa versa, what can the people working in the West in this field learn from how things are done here in DehraDun in the Mental Health Field? Ans. My experience as a mother (of a severe mentally challenged child) over the years in both India and the West is extremely positive. People in the West were really upbeat about what ever they were trying to do for her. There are such wonderful people working there in this field - so knowledgeable and excited. I think we need more of that here. I think there is more of an acceptance in the West about human weakness; the realization among people is there that even they at some point in their lives will need some sort of Special Care. In India this is not the case. We do not see a lot of caring happening within public visibility. I believe to counter the current apathy there needs to be a stronger public awareness campaign carried out. On the other hand the human element that exists here in India in the Mental Health Field is what I find is lacking in the West. In India because majority of families cannot afford Special Helpers, they end up having to rely more on their own families and neighbors. This I believe creates the existing human element. I do not want to say that the people/professionals in the West are not humane about their interactions with disabled people. What I am trying to say is that in general terms one needs more day to day help in the West and here in India one needs more trained professional knowledge.
Q. India is a land where people say mysticism blooms. Keeping this analogy in mind there may be people in India who look upon mental disabilities from another perspective. How do you, coming from the West, having a daughter who is mentally divergent, and now working within this society in this field look upon people who have these conditions? Ans. You know there are people who would look at Mental Disabilities as some sort of spiritual kind of thing. Many people in India revere a child like mine, thinking she is holy. They think she is some sort of incarnation. At one level I say “oh god please do not - not my child”, on another level I can see that there is some kind of a purity in her because she is so oblivious to all the things that we think are important - she has no idea about consumerism, about professions, about attachments. Maybe there is an unconscious
Page 54 spirituality existent within her, however, it is not something she has had to strive for. I am a very religious person and I think about these things all the time, but I cannot make up my mind what to say. It’s a hard thing, because if you accept this way (spiritual beings) of looking at these individuals you could end up ignoring the human part of the person. My child is a happy person, which however is the nature of her disability. But this is not the case with all disabled people/children. Some of them have very harsh disabilities, which are quite unpleasant to manage. As parents of disabled children we have to always think about practical and very obvious truths - such as what is our child going to do after we are gone. We have to look at the practical aspects of helping these individuals survive in a world that will not necessarily cater to their uniqueness. So spirituality is great but survival in a practical manner is quite another thing.
Psychiatrists and general physicians.
Psychiatry even through it has been practiced in DehraDun for many years is still a relative new comer into the Mental Health Care field. There are eight private psychiatrists that are currently practicing in DehraDun. Due to limited time I only managed to interview one of these psychiatrists. However Dr. Nand Kishore is the most popular and prominent of DehraDun’s practicing psychiatrists. Dr. Kishore informed me about the relationship between various sectors of mental health delivery in DehraDun, the limited resources available for treating mental health conditions, and the important issues existent in DehraDun that affect the treatment of people facing mental disorders.
Dr. Kishore informed me that initially when he started his practice over twenty years ago it was hard to break through the cultural barriers that existed. These cultural barrier’s tend to view Psychiatry as a western and alien form of medicine. However through information camps, word of mouth, and time he now attracts in a large number of patients.
Generally according to Dr. Kishore patients tend to come along with their whole village.
He however states that even today it is only when the villagers have tried all forms of cures on mentally disturbed individuals that they finally collectively decide to bring the person to one of the practicing psychiatrists. Dr. Kishore says that more and more
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General Practitioners are starting to send those patients they see who are with mental disorders to Psychiatrists. However the situation is by no means ideal. Dr. Kishore has to deal with majority of people relying upon traditional faith healers before they come to ask him for his assistance. Also the apathy shown by the State government towards
Mental health care leaves nearly all the effort of changing the minds of people on his limited hands.
In a situation where there is no central push towards providing a medicated approach to
Mental Health Care, and where faith and religious healers are still so popular and widely used through out Uttaranchal and DehraDun, Dr Kishore describes how he continues to make a living through his Psychiatric profession.
In India and Uttaranchal particularly many go to the Faith Healers (religious healers)...You know there are religious and cultural beliefs which cannot be removed. So in order to function as a Psychiatrists one has to let people believe in what they believe, but then conduct some form of modern intervention in the form of medication, and/or other Psycho and Socio interventions. It is however difficult to incorporate a medical model with the alternative local Mental Health Cures because some rituals that take place before the people come to see me end up wasting 15- 20 days of treatment time. My solution is however not to contradict the faith healers, and have enmity with them, but rather to sensitize them to use a Psychiatrist soon after they are done their ritual treatments. They should all be sensitized and trained about what they need to do in a treatment that includes all facets of care. Visa Versa let me admit for situations that involve family tensions they can sometimes be better handled by religious/ faith healers - as they have a better idea about their cultural and family mores then me Dr Nand Kishore who has absolutely no idea about their cultural/family mores. So for the minor family tensions one cannot reject those other forms of practices. However what they (the people and the healers) have to be sensitized to is sending people facing more severe mental problems to a proper trained mental practitioner at the earliest (Kishore Interview).
Doctor Kishore declares that even though in DehraDun there is hardly any money being provided by the State government towards providing Mental health care, help can be provided through the private sector for a very minimal cost. Unfortunately according to him none of the NGO’s are interested in taking up his proposed solution to help the
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most desperate of the mental health patients. He state the following about his proposed solution:
All the NGO’s (in DehraDun) are interested in setting up street camps to showcase a lot of treatments for medical conditions but no one has shown the slightest interest in providing assistance to the destitute and miserable looking street lunatics (and there are quite a few around). Believe me if there was someone to pick these people up, clean them and provide them with shelter and food at the cost of just three rupees a day (9 cents) they may be treated. Medicines would change their lives totally, from being crazy and shabby they would become almost like you and me. However majority of NGO’s are not willing to take the extra pains associated with this sort of treatment for the betterment of street lunatics. All the NGO’s are busy working on highlighting their own performances without doing anything substantial.
A Street Lunatic
The nine-cent treatment that Dr. Kishore alludes to corresponds to those people in the highly disabled category in DehraDun who are suffering from chronic schizophrenia.
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This cheap treatment includes providing these people with a 5-mg tablet of
Trifluoperazine (Eskazine), which is administered three times a day, and a 2-mg tablet of
Trihexiphenidyl (Pacitane) which is administered three times a day. Unfortunately, according to Dr. Nand Kishore, even though this treatment is so cheap, no NGO is willing to administer it because no funding agency is willing to cover the costs of the operation.
Alternative Mental health Approaches
Psychiatry and the whole Medical Approach towards understanding and ‘curing’ the psyche are relative newcomers amongst India’s many diverse healing systems. Some of the older and widely used systems of healing that exist through out India, exist in many parts of Uttaranchal as well. Some of the most noted amongst these healing practices are Tantric healing, Ayurvedic healing, Saintly healing, and amongst the Muslims the Pir culture.
Sudhir Kakar a noted Indian Psychiatrist in his book ‘Shamans, Mystics and Doctors’ compares and contrasts the manner in which Mental problems are treated by India’s diverse Faith Systems to the manner in which they are treated by Modern Therapeutic
Medication. He states:
A line of cleavage in the healing professions and amongst different healers is not simply a cleavage between ‘traditional’ and ‘modern’, or between ‘Western’ and ‘Asian’, or between healers belonging to different cultures. The real cleavage, cutting across cultures and historical eras, seems to be between those whose ideological orientation is more towards the Biomedical Paradigm of illness; who strictly insist on empiricism and rational therapeutics, whose self- image is closer to that of a technician, and others whose paradigm of illness is Metaphysical; who accord a greater recognition to irrationality, and in their therapeutics seeing themselves (and are seen by others) as nearer to the Priest. (pg 30)
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A follower of Tantra
A Faith healer at work
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Belief in the metaphysical has made the man on the left keep his hand held up non-stop for 15 years. The worshipping woman on the right epitomizes the influence religion has upon the majority of the masses in India.
All the other healing systems in India include the realm of the metaphysical within their healing practices. Their treatments in general involve attempts that are made by
‘healers’ (experts) to communicate with the ‘other side’ in order to draw out the troubling spirit that is involved in disturbing or possessing the soul of the human recipient. These forms of treatment are similar to what used to be the dominant manner of treating mental illnesses in the West up till the Middle Ages. Where as in the West these practices of exorcism and other spiritual healing practices have all but disappeared, in India maybe because of the lack of interest shown by the Central Government towards the Medical
Model, or because of the entrenched and widespread belief in the metaphysical realm, these practices continue to speak loudly to the local populous.
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Another reason that the metaphysical realm continues to thrive with India’s population in respect to them treating mental divergences could be the level of illiteracy amongst the population. It is common knowledge that wherever illiteracy is rampant in the world, the attempts made by people to understand life tend to point towards organized religion with a focus on the metaphysical realm.
Education, which incorporates the ideals of literacy, generally tends to correspond towards engineering a rational understanding to life. Maybe in India due to the lack of this sort of ‘non-metaphysical education’ the metaphysical paradigm has been allowed to flourish. Ultimately even though the approach towards understanding ‘strange behavior’ may differ between healing practices, the objective of ‘normalizing’ the behavior or making the behavior concur with that of the status quo is a common trend amongst them all. In the Western Bio-Medical approach drugs are used to make mental patients ‘fit’ into the larger society. Visa Versa with the traditional therapeutic methods found in India a similar attempt is made to ‘normalize’ people, however, the methods and the understanding of the causes are divergent. Sudhir Kakar’s following statement about traditional temple healing can also be used in general terms towards understanding the goals that healing practices attempt to achieve in their treatment of mental ‘disabilities’ in the West:
The underlying values of the traditional temple healing, stress that faith and surrender to a power beyond the individual are better than individual effort and struggle, and that the source of human strengths lies in a harmonious integration with one’s group: in the individual’s affirmation of the community’s values and its given order, in his obedience to the community’s gods, and in his cherishing of its tradition (pg 88)
The Ayurvedic System
The Indian Ayurvedic System is a bit different from these other demon-exorcising traditions. The Ancient Ayurvedic System although it acknowledges the metaphysical,
Page 61 and treats the individual keeping this realm in mind, would be the closest to a medical model that Indian healing traditions have come. The philosophical emphasis on the wholeness of the person is reflected in the comprehensiveness of the diagnostic examination prescribed by the Ayurvedic physician. The doctor before making his/her diagnosis finds out where the patient comes from, the habits of the person, the social and cultural make up of the region, and the health conditions of the local inhabitants.
After evaluating all these factors a diagnosis is passed.
According to the Ayurvedic philosophy the human body occupies in creation a unique position, as it is the only object that is part of both our inner and outer worlds. The
Ayurvedic System singles out desire and revulsion as the twin causes for mental disturbances amongst persons. In this system the roots of desire and revulsion go further back then the birth of the individual. The Ayurvedic System states that the unfulfilled longings of the mother are transferred to the child, and this process is repeated on towards the next generation. The Ayurvedic System treats these disturbances through Purification, Pacification, and/or the Removal of the Cause. Under
‘Purification’ the Ayurvedic doctor uses treatments like purges, enemas, and bleeding.
The treatment associated with Pacification sees the doctor administer drugs that are made from various plants, and metals. Finally, if needed, the doctor or Vaid, as the
Page 62 trained Physician is called in the Ayurvedic System, attempts to remove the cause of the disturbance. The Vaid endeavors to inculcate within the patient’s life a respect for proper conduct. This hand on approach involves the Vaid spending a lot of his time with the patient, and through active communication changing the behavior of the patient. A noted
Vaid in India states the following about the Western Medicine based approach:
In your tradition, Largactyl (A major tranquilizer prescribed in cases of Schizophrenia and often called “the chemical equivalent of a straitjacket“) is given and the patient made to sleep. As long as he is asleep he doesn’t trouble anyone. The patient’s family is satisfied and so is the doctor. As far as the patient is concerned, well he is too drugged to complain. How convenient for everyone. (Kalam)
An attempt however towards creating balance, that is characteristic of the Ayurvedic system, is also characteristic of majority of the other Indian therapeutic approaches and of the Western Bio-Medical approach towards healing Mental Illness. I have shown through this paper that this attempt at achieving mental balance is influenced by cultural, historical, and political factors, and also by the dominant belief systems. Also I have shown, that the way Mental Health Care is promoted and practiced also has a profound impact upon the way cultures are allowed to remain unchanged (as in DehraDun), or are changed over time (as in Saint John).
An Analysis
The haphazard and apparently disjointed nature of my description of Mental Health Care in DehraDun is purposely done, as it mirrors the reality on the ground. The truth is that
Mental Health Care in DehraDun is provided through various pockets of delivery that are quite independent of each another. I believe this disjointed character of DehraDun’s
Mental Health Care Delivery is because it lacks a center.
A center to DehraDun’s Mental Health Care delivery is lacking because the one source
Page 63 with the capabilities of taking on this responsibility, the Local Government, has not taken on this responsibility seriously so far. The State Government does have a plan for the
Mentally Disabled (which after ten minutes of lax searching is pulled out of the
Governments chaotic filling system), however, this plan does not even superficially fulfill some of the basic needs of the local populous. To make matters worse the inbuilt corruption, and the stifling governmental bureaucracy have made it absolutely impossible for any one else to take advantage of the Governmental Services that are available for the Mentally Disabled.
In an interview I had with Mr. Dharmvir Singh Dahiya, who currently has a proposal with the Government laying out the plans for the opening and the operation of another Mental
Health Care Center in DehraDun, he stated the following about his experience dealing with the State Government:
The State Government of Uttaranchal has shown its willingness to provide funds for this center, however the process has ground to a halt at the level of the petty bureaucrat. Due to corruption inherent every move forward has to be acquired with money that is dispelled underneath the table.
Mr. Dahiya further states that in the present situation those institutions that have the clout to garner private or public donations are the only ones that are managing to provide minimal services to the local people. Institutions like Raphael, for example, have managed to gather funds from the government because the people running the show within Raphael have belonged in the past to the top ranks of governmental bureaucracy.
This privileged position allows them access to the top echelons of governmental structure; thus effectively by-passing the problems associated with petty bureaucrats.
Similarly the people running Karuna Vihar, also due to their privileged socio/economic status, manage to interest big private companies like Tata to invest into their Centers.
The stark truth is that even with the much-needed services that both these Centers
Page 64 provide, they only manage to serve a very minute section of the disabled people in
DehraDun. The people that are looked after by these Centers amount to only about 400 people, and because both the Centers are geared towards rehabilitation they only end up taking in those people who can be rehabilitated. One of the reasons according to Mr.
Dahiya, for people venturing into the Mental Rehabilitation field in India is due to the nature of funding agencies. Money is only provided based upon Institutions generating results that are financially sound. In other words people who can be rehabilitated can guarantee financial benefits (in terms of the mental patients being able to join the labor force at a later date) thus funding agencies are more willing to provide money when they see these short-term benefits. This form of logic sees the seriously mentally ill people being left out of this Medical-based Mental Delivery Model. In light of such pathetic governmental and private business involvement in the Mental Health Care sector for the vast majority of people in DehraDun the alternate and much older models of Mental
Health care still continue to speak more loudly primarily because they are easily accessible, and because they are familiar
.
IN Conclusion
In conclusion Madness, Insanity, Mental Disability, Mental Divergence, Irrationality,
Possessions, Cuckoo, Nuts, Mentally Disturbed, Lost, Mystics, Extremely Godly,
Wizards, Witches, and ‘Pagal‘, all these divergent terms have one stark similarity: when attributed to a person they portray him/her as the ‘other’: i.e. not part of the mainstream.
When one is not part of the mainstream the common reaction shown by both the society’s to the anomalous entity is an attempt to control its divergence by bringing it back to state of ’normality’.
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In civilized societies social control of the masses is of paramount importance towards maintaining the smooth functioning of wheels of progress. My essay shows that both the cultures researched use Mental Health Care Practices that serve the social function of controlling the Mentally divergent within their populations. My essay thus highlights the fact that in Mental Health Care the social control aspect of this field ends up trumping its endearing aspect. I postulate that attempts made in this field to empathize with mentally divergent people are thus in actuality attempts made to encapsulate them within our own understanding of life.
From the results accrued from this paper it is quite clear that when one looks at the case of India that Health Care is not one of the priorities of the Central Government. In the case of Canada however Health Care is one of the top priorities of the Central
Government. Due to the lacking focus of the Central Governmental of India towards the field of Mental Health Care the onus of the Health care responsibility has fallen upon the shoulders of the private sector, and religious organizations. My paper shows that in
Uttaranchal a very marginal number of the populous are being treated for their Mental
Health Care needs through governmental support structures. The end result of this governmental apathy is that the majority of Uttaranchal’s population with Mental Health
Care needs are still going to faith healers, and religious organizations to get themselves treated.
In Canada due to the economic slowdown, the government is continuing to move further towards decentralization. This is having a direct affect upon the Mental Health Services in Saint john; they are ending up losing much off their governmental finances and governmental Mental Health workers. The end result of this clear focus towards decentralization and privatization of Governmental Resources is that Mental Health
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patients in Saint John are being increasingly looked upon in financial terms. This financial focus to the Mental Health field of Saint John has the potential of creating within
Saint John a similar type of situation as the one that exists in DehraDun: only those people who possess a possibility of becoming contributing members of the job market could get ’rehabilitated’. The people with Major Special Needs are thus increasingly falling short off the Mental Health Care Governmental models in both countries. The only obvious difference between the way the two cultures treat their severely mentally
‘different’ people is that in DehraDun’s case these people are left to wander around dirty and ignored, picking scraps from garbage can, having their ‘demons’ as their best friends, whereas in Saint John’s case they are left to wander around dirty and ignored, picking up scraps from garbage cans, having the pill as their best friend. It appears quite clear that because in today’s world social function is evaluated on the basis of financial accruements, using Albert Spencer's phrase, those who just are not fit enough to survive are basically being relegated to the garbage cans of society. At the end of my paper it is clear that the prime method of treating mental anomalies in Canada is to medicate them away, whereas in India the prime method is to exorcize them away.
From the parents who send their children to institutions such as Raphael, and Karuna
Vihar to have them ‘rehabilitated‘, to the people running Mental Health Care Services in
Saint John who believe that medicating people helps control their symptoms and not the individual, are people who generally speaking have the best interest of the individual in their hearts. Metaphorically speaking, their attempts to change the colors of those who either lack the biological ability to change their own color, or refuse to do so, could either
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end up making them into chameleons like us, or could end up changing their natures so fundamentally that they end up becoming totally and permanently another color. By studying the manner in which Mentally Divergent people are treated one has to wonder about the extent to which we change ourselves to fit into an existing and dominating social paradigm. One also wonders if the one big difference between the people with
Special Needs and ourselves is that we have the ability to hide better then them? The answers to these questions are not simple, as they question the whole basis of our own identity. Ultimately we can only progress as a people if we critically look at ourselves, our cultures, and our societies.
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Pertinent Interviews
Mrs. Gogan. Mental Health Nurse Mrs. Armstrong. Current person in charge of Saint John Mental Health Services Mrs. Nora Gallager. Director Centracare Mrs. Dale Dorin. Past Director of Mental health Services, Saint John Mr. Wes Hall. Past Inmate of Centercare General Bakshi. Director Raphael Mrs. Priyo Lal Manager of the Mentally disabled children at Raphael. Mrs. Jo Chopra Director Of Karuna Vihar Dr. Sayana. Assistant Director of Health Uttaranchal Mr. Dharmvir Dayia. Mental Health Worker, DehraDun Dr. Nand Kishore. Psychiatrist in DehraDun
.