The Lost Keys: On Social Recovery in Long Stay Mental Institutions

Mental health has perennially struggled to find its balance between the biomedical and the social model. Theorists and practitioners of the latter often talk about social recovery and how it is a far more humane way of looking at mental distress. But to the uninitiated, what is social recovery? There are two basic tenets of this model - i) that recovery from mental health conditions is possible and ii) effective, long-lasting recovery is possible when the person affected directs the course of recovery.

The biomedical model posits that mental health conditions are a physiological anomaly and its management should therefore be based on medication and large-scale, homogenous empirical evidence. The social recovery model, on the other hand, relies on a sense of community, participation, and respecting the agency of an individual to define how they want to recover. For the longest time these two schools of thought were polarised with one rejecting the other. The advent of increased awareness, progressive civil society discourse, praxis, and advocacy have played a crucial role in bridging the twain.

Much research that is rooted in lived experience shows that a holistic method for addressing mental health is a combination of both models and not necessarily either/or. Poverty, unemployment, caste based discrimination, and gender based violence are all contributing factors to distress and even illness. A holistic, psychosocial approach therefore would be concerned with alleviating these factors as well as employing biomedical methods to manage symptoms as required.

How can one apply the principles of social recovery to long-stay mental health institutions? There is no one answer, and to attempt an adequate one, we need to understand what attitudes and systems these institutions are built on. Systems are not inexorable; they are dynamic, built on values and practices. Society has, through generations, been conditioned to fear and hate ‘madness’. Literature and history record instances where people were not only shunned but also cruelly punished for not having normative thoughts and behaviours.

Conversations on what is ‘normative’ and who decides on it have certainly made things better but much remains the same. Here, it would help to imagine what a mental health establishment more often than not looks like. Dreary walls, high iron gates to prevent the inside and outside from colluding, a few bare trees and unkempt grass leading into long, cold corridors that are guarded by rusted, creaking grilled doors whose keys have long been lost. Inside these corridors are people who have been alienated from all fundamental rights. There is scattered filth, the stench of rotten food, and old-generation drugs.

It is easy to presume that symptoms of mental illness cause such a scenario. But it is crucial to realise that squalor and dearth are not indicative of symptoms but a system signifying poverty of care and gross neglect. This infrastructural description does not hold true for all long-stay mental institutions; there certainly are many that provide quality services. However, there is enough literature in the form of research and on ground work that speaks to the systemic oppression a person faces once they are diagnosed and admitted into a mental health institution.

The keys that get lost in this system are freedom, autonomy, liberty, participation, and self-determination. Often, these institutions reflect the punitive system, with similar language employed, such as ‘parole’ to describe a resident going to visit their family, and ‘escaped’ if one voluntarily leaves the hospital, severe verbal and physical abuse if subservience is not maintained. This is telling of the public mental health system that views people with mental illness living in institutions as deserving of imprisonment. It also indicates why there is such poor social welfare and lack of any attempts at community inclusion. They are a forgotten constituency — morally, socially, and even constitutionally. Long-stay institutions can see people living in them for anywhere from five to twenty years, even to the natural end of their lives.

On the bright side, there is finally a powerful mental health discourse in the country that attempts to bridge the gap between social recovery and the medical model. Proponents of this discourse see the role of trained mental health professionals — psychiatrists, clinical psychologists, and psychotherapists — as much more than treating symptoms. Their responsibility goes beyond writing out prescriptions and conducting talk therapies that aim to fit the person back to ‘normal’.

Given that part of every condition owes itself to the sociocultural and political milieu of a person’s life, these factors play a pivotal role in the recovery process. A person’s context is not inalienable from their mental health. Therefore, mental health professionals must also address discrimination and marginalisation of people with mental health conditions because is there really any recovery if one manages symptoms but is ostracised from social events, from voting rights, and from employment?

The moment has passed, unfortunately, of conveniently compartmentalising the responsibilities of the activist and the professional. A psychiatrist must practice responsible diagnosing, ensure the person has access to information about their condition and its prognosis, and, in consultation with the person concerned, recommend suitable practitioners of social recovery, alternative therapeutic praxis, and facilitate connections with state departments for civic entitlements.

Non-biomedical mental health professionals might do well to focus resources on building safety nets and responsive communities, ensure inclusion and self-determination of persons with mental distress and/or illness, help assert legal capacity, and propagate implementation of progressive laws and policies that are person-centric within the medical, legal, and judicial fraternities.

Long-stay mental institutions are a product of the public mental health system, and while it could always do with more funding and resources, there is much that can improve even as things stand. It must begin with increased sensitivity of care staff, no-tolerance policy for violations, access to legal recourse, redressal mechanisms for violations and an intrinsic value shift where care and treatment are about service-users foremost. Caregivers and other stakeholders in these establishments should undergo capacity building on mental health practice, legality, ethics and intersectoral issues.

Different governmental departments must liaise with each other and develop welfare services for those abandoned in these institutions. Civil society organisations must also share their knowledge and resources with governments for optimal reach and sustainable interventions. These are some keys needed to throw open those gates to freedom and rights. Of course, it would be good to first polish these with empathy, compassion, mindfulness, and equity.

Adrika Sengupta is the Head of Programmes at Anjali, an NGO working in the areas of mental health, disability, development, and human rights in state mental health establishments and semi-rural communities in West Bengal.

Curated by Centre for Mental Health Law and Policy