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|Year : 2017
: 59 | Issue : 4 | Page
|A magna carta in psychosocial rehabilitation: The long road traveled
VK Radhakrishnan, K Roy Abraham
Department of Psychiatry, CNK Hospital (P) Ltd., Kottayam; Department of Psychiatry, Pushpagiri Medical College, Thiruvalla, Kerala, India
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|Date of Web Publication||18-Jan-2018|
|How to cite this article:|
Radhakrishnan V K, Abraham K R. A magna carta in psychosocial rehabilitation: The long road traveled. Indian J Psychiatry 2017;59:407-10
We are living in a postcolonial era of political economy, where the role of financial capital is of vital importance. The economic theories compare only profit and loss in the final balance sheet. The social commitment of the individual and the protection of fundamental rights by governments are both in vain, on most economic platforms. Hence, rehabilitation is not of great consideration in economical planning, at the Ministry of Health and Family Welfare. When we consider society at large, psychosocial rehabilitation is not a major public health issue. The death rate of wandering mentally ill is lower than any other illness, and it is not a contagious illness. Once the person crosses over to the acute phase of the illness, it is more of a social issue than a health issue.
August 6, 2001, was a black day for mental health professionals in the country. The case in question was that of the Erwadi tragedy. Following that, the apex court rose to the occasion and sent notices to all states about implementation of Mental Health Act 1987. Few states were totally ignorant about the whole issue. In the state of Kerala, the government issued a notice for the registration of mental health facility under Mental Health Act 1987. The third chapter of the Mental Health Act 1987, mentions the registration criteria for nursing homes and psychiatric hospitals but does not have any separate criteria for rehabilitation centers. As such from the understanding and practice all over the world, rehabilitation centers are fundamentally different from mental hospitals. This impassionate debate obscures a basic problem, with the disease management scheme, which is that it presumes to know which comes first, the disease or rehabilitation. In general, mental health institutions grow stronger as a nation grows richer. India cannot expect to leapfrog up the development ladder, simply by purging deinstitutionalization from its system. Certainly, rehabilitation stands apart, as it bridges the hospital to the society.
Steger  has defined globalization as “a set of social processes that appear to transform our present social condition of weakening nationality into one of globality.” Globalization is the most accepted word around the world in economics, commerce, and social sciences. However, how far it has influenced psychiatry is questionable.
The waves of globalization touch every corner of the world from the cosmopolitan metro cities to the tribal villages where there is no electricity or road facility. Chomsky  opined that “globalization leads to exploitation, a cultural disenfranchisement and a new form of colonialism.” Genuine caregiving, to the mentally ill, will make a significant difference to recipients and reduce stigma for both patients and mental health professionals.
In India, majority of the people with mental illness are still cared for by their families. Sustainable development cannot be achieved without the inclusion of mental health, as a key global priority., Until recently, the international community had not mobilized the necessary attention, efforts, and resources for people with mental illness and disability. This is despite the knowledge that the economic cost of mental disorders is more than 4% of gross domestic product worldwide. Depression is a leading cause of disability, and more than eight lakh deaths occur by suicide every year. Many of them are preventable. The concept of sustainability has become a key concept in the rehabilitation movement and is indeed crucial. Hence, it is a great challenge of our times to create sustainable communities.
However, the government insisted to follow guidelines as per hospital or nursing homes. Most of the rehabilitation centers received notices to get registration or be closed down. It was then that the World Association for Psychosocial Rehabilitation Indian Chapter (WAPR IC) studied the matter and stood against the closure of these centers and encouraged them to form an association as Kerala Federation for the Care of Mentally Disabled (KFC MD) at Vazhavatta, Wayanad, on May 25, 2002. Due to repeated requests, the Mental Health Authority Secretary called for a meeting of those organizations at Thiruvananthapuram, which was chaired by the Health Minister. The minister assured them that the government was not taking any immediate action without studying the matter in detail. Again several meetings were conducted. Finally, due to the interest of the Health Minister, another meeting was called at Secretariat Conference Hall in the 1st week of August 2003. This was attended by the Health Minister, Mental Health Authority Secretary, Superintendent of Mental Health Centre, KFC MD office bearers, WAPR President and board members, Minister for Culture and Irrigation, Health Secretary, and Director of health services. The KFC MD president submitted a draft of the guidelines of the rehabilitation center to the Health Minister. The meeting discussed various aspects of mental health care and rehabilitation based on the draft submitted.
The meeting suggested that Dr. V. K. Radhakrishnan, the Board member WAPR IC and Dr. Jayaram S, then superintendent of Mental Health Centre, Trivandrum, study the draft guidelines submitted by KFC MD and make necessary modifications. The Health Minister also suggested to take necessary assistance from WAPR National President Dr. T. Murali and Mental Health Authority Nodal Officer of Tamil Nadu. The committee had various meetings in different places and discussed with various experts in psychiatry, law, and rehabilitation. They personally visited various rehabilitation centers in Tamil Nadu, Kerala, and Karnataka. The final report was prepared on the basis of these discussions and submitted to the Health Minister and Director of Health services. Due to an unforeseen political twist, the Health Minister resigned and again the process came to square one. Next year, there was a meeting with the Chief Minister along with social reformist and poetess Smt. Sugatha Kumari who is the founder of Abhaya Trust. The Chief Minister agreed in principle to start five model rehabilitation homes in Kerala, and link them with different Panchayats. During the process of further discussions, the Election Commission declared state election and things did not materialize.
After the formation of the next government, there were repeated meetings with the Health Minister. One MLA took up this matter in the Assembly and the new Health Minister was unaware about the whole process. Then, the MLA put the copy of the draft on the table, and the Minister agreed to look into the matter. Again, a lot of water flowed under the bridge but nothing materialized. Then, WAPR (IC) and KFC MD held a combined meeting at Palai, by including the representatives of psychosocial rehabilitation centers in the state.
The meeting was inaugurated by the Law Minister Mr. K. M. Mani. The whole matter was presented to him by WAPR President Dr. V. K. Radhakrishnan. The Minister invited WAPR and KFCMD for a meeting in Trivandrum Secretariat Conference Hall on November 11, 2011. WAPR IC Office bearers with Members of KFC MD attended the meeting at the Secretariat. Dr. V. K. Radhakrishnan presented the matter, and others presented their opinions about it. The Law Minister Mr K. M. Mani, Joint Secretary of the Law Department, Additional Director of Social Welfare Department, and other officials attended the meeting. The Minister entrusted the officials to frame the rules based on the report submitted by Dr. Radhakrishnan and Dr. Jayaram. Another meeting was held at the conference hall of Law Ministers' official residence which was attended by Dr. Roy Abraham, office bearers of WAPR IC, KFC MD, and additional Law Secretary. The minimum standards were discussed in detail, and a consensus was reached.
The sincere efforts taken up by the High Court of Kerala, the Indian Psychiatric Society Kerala chapter, various committed nongovernmental organizations (NGOs), and Orphanage Control Board are to be specially mentioned. Honorable Justice Thottathil Radhakrishnan has conducted a special sitting at his chamber on World Mental Health Day, October 10, 2009 with Dr. V. K. Radhakrishnan and Dr. Thomas John. The work of WAPR (IC) was appreciated and was given important suggestions.
A meeting of all concerned Principal Secretaries was held under the chairmanship of Minister of Social Welfare on March 22, 2012, at Trivandrum. All the stakeholders attended the meeting including WAPR (IC) president and Indian Psychiatric Society representative. The meeting discussed various aspects of psychosocial rehabilitation and the importance of finding a shelter for the homeless mentally ill.
The Additional Director of Social Welfare Department conducted consultative meeting with NGOs, KFCMD members, Legal experts, WAPR (IC), International Political Sociology members, and Political leaders at Trivandrum, Ernakulam, and Kozhikode. The final draft tried to include all the relevant suggestions.
The evaluation by the National Human Rights Commission (NHRC) about 10 years after the quality assurance study points out some radical changes in certain areas such as a notable reduction in involuntary admission, better living conditions, greater budgetary allocation, and relatively more engagement with the community. However, human resource shortages, inadequate rehabilitation facilities, “closed wards” structures were persisting in some of the hospitals. Hospitals with continuous monitoring did significantly better than those that were not under the gaze of overseeing bodies in the state or by the NHRC. Here is ample evidence to prove that close monitoring and guidelines can improve the care and management of mentally ill.
SRO No. 543/2012 in exercise of the powers conferred by SubSection (1) read with SubSection (2) of Section 73 of the Persons With Disabilities (Equal opportunities, Protection of Rights and Full Participation) Act, 1995 (Central Act 1 of 1996), the Government of Kerala hereby make the following rules.
G.O (P) No. 45/2012/SWD Dated 24/07/2012 Thiruvananthapuram.
The rules contain nine chapters. Chapter I preliminary says about the title. These rules may be called “The Kerala Registration of Psychosocial Rehabilitation Centers of mentally ill persons Rules,” 2012; under definitions, “The Act” means the persons with disabilities and the competent authority means the authority appointed under Section 50 of the Act.
This chapter also defines about experienced nurse, psychiatric social worker, psychiatrist, occupational therapist, and relatives that include any persons related to the mentally ill person by blood, marriage, or adoption/guardianship.
Chapter II mentions about the registration of psychosocial rehabilitation centers. The application for the registration, by any person who wishes to establish a psychosocial rehabilitation center shall be submitted before the competent authority. The existing Centres should get a registration certificate within 6 months after the commencement of these rules by fulfilling all criteria laid down in the rules.
Chapter III lays down procedure for admission and discharge of inmates. 15. Admission. Sub section (1) Treated and controlled mentally ill persons after their discharge from a mental health centre including private institution shall be admitted. Sub Section (2). All admission into a psycho social rehabilitation centre of mentally ill persons, other than orphaned mentally ill persons shall be voluntary and made on the advice of a psychiatrist. The psychiatrist should certify that the referred as a mentally ill person requires only maintenance medication and rehabilitation measures.
SubSection (3), says that after examination, if the psychiatrist certifies the person referred as a chronic mentally ill person, who needs treatment in a hospital, he/she shall be dealt with under the provisions of the Mental Health Act, 1987 (Contract Act 14 of 1987). Section 16 separately mentions the terms for the admission of orphaned mentally ill persons.
Regarding the discharge of a patient. Subsection (1) Any discharge of a person admitted into a psychosocial rehabilitation center shall be made, in consultation with a psychiatrist. Death or escape of inmates shall be reported to the local authority and police within 24 h.
Chapter IV deals with the infrastructural facilities and services to be provided in psychosocial rehabilitation center. The building should be eco-friendly and user-friendly to the disabled with an open land area, of at least 30% of the plinth area of the building. Women shall be provided with separate accommodation, and they should be under the care of female staff only. Facility to be provided in training or work area should be with proper ventilation and lights. The training or work shall not be of a demeaning kind and its main aim should be helping the inmates to regain mental balance.
A strategy considered for improving the health of women and girls “… must be about promoting their well-being, an idea that is much misunderstood, well-being is not only happiness”… but also means life satisfaction and our sense of meaning or purpose.
Section 24 staff in psycho social rehabilitation centre shall be as follows, namely Sub Section (a) Every psychosocial rehabilitation centre should ensure the visit of a psychiatrist once in a month and shall be available on call to attend any emergencies, Subject to availability the superintendent of medical college/superintendent of govt. mental health centre or the district medical officer may assign any of the psychiatrists of each centre for this purpose. In their absence, the rehabilitation center shall make arrangements for the visit of psychiatrists from any private sector.
Section 25 mentions that as far as possible, all health services to the inmates shall be provided from government hospitals and a separate queue will be arranged for the inmates of rehabilitation centers. Every rehabilitation center should appoint a full time qualified nurse. The nurse inmate ratio shall be 1:50.
Chapter V deals with the protection of human rights of inmates of psychosocial rehabilitation centers. All the inmates in the rehabilitation center shall be treated without any type of human rights violation. No person shall be subjected, during his/her stay, to any indignity (whether physical or mental) or cruelty. The district legal service society representative may visit and provide free legal service to the inmates. Grievance redressal shall be addressed by the District Collector or the Deputy Collector.
Chapter VI explains organization and conduct of rehabilitation work. The social workers and psychologist shall ensure the rehabilitation plan with the help of occupational therapists. They should also maintain inventory, case records, establishment register, register for injury, escape and death of inmates and weight chart.
Chapter VII deals with the inspection of psychosocial rehabilitation center. The procedure for inspection is to be entrusted to a competent authority or an authority assigned by the government on its behalf, who may enter and inspect the psychosocial rehabilitation center and require the production of any records.
Chapter VIII comprises of NGO forum for psychosocial rehabilitation for mentally ill person and capacity building of the function areas. There shall be a separate NGO forum to assist and aid the state coordination committee specified under Section 18 of the Persons With Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995 (Central Act I of 1996), for coordinating activities of rehabilitation centers. They will develop best practice guidelines for rehabilitation centers. The forum will help state government; state and national level professional organization shall provide capacity building and training.
Chapter IX provides guidelines for monitoring and evaluation mechanism.
The State Level Advisory Committee comprises of 19 members which includes the Secretary of Social Welfare Department as the Chairman and the Director of Social Welfare as Member Convener. Other members of the committee includes Secretary of Health, Law, Local Self Government, the Legal Service Authority, Secretary of Mental Health Authority, Disability Commissioner, and Superintendent Mental Health Centre. Representatives of Indian Psychiatric Society and WAPR (IC) are permanent members of the Board.
It is a landmark achievement to get representation of professional bodies of psychiatry in a Government Forum. This envisages a meaningful involvement of the professionals in policy making and moves to improve the facilities for better care and management of people with psychiatric disorders. In the last 2 years, the World Association of Psychosocial Rehabilitation has been conducting a study to evaluate the improvement of the quality of care following the implementation of the new rules. The government of India has released National Mental Health Policy in 2014. This is the first Mental Health Policy in India. The strategic areas identified in this policy and action are promotion of mental health, prevention of mental disorders and suicide, universal access to mental health care, enhanced availability of human resources for mental health, community participation, research, monitoring, and evaluation.
The authors thankfully acknowledge the guidance and encouragement rendered by Prof. Dr. Murali Thyloth, Department of Psychiatry, M.S. Ramaiah Medical College, Bengaluru - 560 054, Karnataka, India for the framing of the draft rules.
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Dr. V K Radhakrishnan
CNK Hospital (P) Ltd., I. E. Nagar, P. O. Madukammoodu, Changanacherry, Kottayam - 686 106, Kerala
Source of Support: None, Conflict of Interest: None