Anjali Mental Health Rights Organisation is a Kolkata based organisation that works on one of the most neglected areas of health.
Anjali works in partnership with the Government of West Bengal with an aim to provide full rehabilitation to people with mental illnesses and ensures their participation and consent in all decisions related to their lives. The organisation works in four mental hospitals in West Bengal, Pavlov Hospital, Lumbini Park Mental Hospital, Mental Hospital in Bahrampur and Institute of Mental Health Care, Purulia.
Ratnaboli Ray, a trained psychologist and mental health activist, is the founder and managing trustee of Anjali. She has more than twenty years of experience in the sphere of rehabilitation of persons with mental illness.
We, at FII, had the wonderful opportunity to speak with Ratnaboli Ray about her experiences of working in the field of mental health and her organisation Anjali.
SG: What was your motivation behind the genesis of Anjali?
RR: My initial drive came from my personal connect with mental illness. From a young age, I saw two of my aunts who suffered from mental illness and never saw them as a part of any family gatherings. It was as if they were in a state of forceful non-existence. My aunt, though an adult, was made to wear a frock, tie her hair in two plaits and sometimes even made to sit outside on the patio on a wooden chair. I can’t recall exactly, but I think on occasions, I even saw her leg shackled to the chair. These experiences left a deep impact on my young mind.
Another motivation came from my prior experiences of working in the development sector. When I joined Paripurnata, I heard my real calling. Now when I look back at the genesis of Anjali, I realise that my thinking was different from what I saw around me. The development sector and the social welfare organisations took up various issues for the marginalised population but they never really engaged with the State. I realised that organisations must delve into how to ensure that the State carries out its constitutional responsibilities to offer and include healthcare services to those who cannot normally afford it.
When we go inside the system and advocate, lobby with the government, only then do the necessary policy level and practical changes happen. So, Anjali made a conscious shift from a typical service-delivery mode and towards advocacy for the rights of people with mental illness/psycho-social disability.
SG: Did you face any challenges in Anjali’s inception?
RR: During Anjali’s inception, the challenges were just that the resources were limited and there was a complete lack of awareness. People had very poor ideas about how institutions operated. Back then, it was considered to be a hellhole and a punitive space. And so much has changed over the last seventeen years. From a filthy, dirty space to a relatively caring space; from complete ignorance of the personhood of the residents of mental hospitals to now considering and talking about their rights is a huge shift.
One initial challenge during Anjali’s inception was that I was being perceived as an outsider who had come to privatise the hospital. The looming threat of loss of employment made the staff members break our sign board, lock me inside a room etc. Over the years, it has transformed into a collaborative effort to make the hospital a better space.
The challenge now is how to be a persevering agent and advocate for the ‘patients’ and secure policies that are beneficial for them. How to move from a pro-state position to a position where you’ve earned the power to become a negotiator and be critical and oppositional to what the government thinks vis-a-vis mental health. I think that it’s a challenge as well as a privilege because the government has allowed us that space and we have allowed the government the same. The outcome of which has been a very mutually trusting relationship.
SG: We understand that there is gender disparity in the field of mental health, like in any other area concerning health issues. What gender biases do female mental health patients face in your experience? How does Anjali intend to overcome these biases?
RR: We decided we wanted to work with women because we were well aware of the redundant position of women in the society. There was very little attention paid to mental health conditions of women. So, marginalisation happened on both the levels of gender and of psychiatric illness. This when coupled with a resource poor background, leads to further marginalisation of women. We wanted to focus on women, initially, to bring them into the ambit of care, treatment and dignity. Gradually our work was extended to impact men as they too face gross stigmatisation and violation of rights.
I was amazed at the infrastructure of the place where women lived when I first entered the hospital. It wasn’t well-lit or airy. There was strict surveillance on women inside the hospital, which appalled me. If you look at the medical curriculum, there is very little thought on gender. If you look at the budget allocation, you’ll see a huge disparity. There is a glaring disparity between budget allocation for physical health and mental health, this is further widened by the disparity in the budget for men and women. Hospital diets too do not cater to gender specific needs, we know women suffer more from Anemia, yet there is no provision of a special diet for them. No provision for iron tablets and vitamins. Even discharge policies highlight similar discrepancies where it is much more strict for women than for men. The word ‘incarceration’ is applicable on many levels to women living inside mental hospitals.
If we talk about reproductive and sexual health, until some time back, there were no provisions for sanitary napkins. Even now there is no access to information on reproductive/sexual health in most mental hospitals. They are made to wear desexualised gowns and weren’t even given undergarments until recently.
When women are discharged from the hospital, the response towards a “recovered” woman is starkly different from the response towards a “recovered” man. A functional, recovered woman is made to stay at home still. They are rarely allowed to go out and do things they like, unlike men with similar conditions. A recovered man who has gone home is allowed to take some household decisions, while the woman who has completely recovered and has gone back to doing all the household chores is consistently deprived of this basic decision-making agency.
How Anjali intends to overcome these biases is a very pertinent question. Anjali, as an organisation, has embraced the gender lens. For every story, every incident, we choose to look at it from a gender lens instead of looking at it from a typical psychiatric lens. I feel it is an obligatory duty of civil society organisations like ours to constantly generate data, information and stories using multiple lenses and bringing about a new analysis for a sharper, more fine-tuned intervention.
This also meant we constantly fed information to women’s movement as well. I think that’s where Anjali made a leap. On one hand, we were working with the women inside the institution, on the other hand, I was also a part of the women’s movement. Hence, there was a constant information flow from one end to the other. And as stories of violation became more apparent with our presence inside the mental institution, we started trying to understand the mental health psychiatric problem through a human rights lens. And so, we got a new set of data, a new set of analysis. Integrating these different analyses into one, we designed our intervention and moved slowly from ‘therapy’ sessions to just sessions.
The language we use underwent a transformation too. There’s a change in how we communicate with the government, how we communicate with our fellow organisations and which has now lead to a very rich discussion with each other.
The change around me is tangible now with organisations rallying around for the cause of women with a psychosocial disability or mental illnesses. I’ve got incredible support from women’s movement in West Bengal. Even this interview shows that you think women with mental illness is a legitimate constituency, doesn’t it? This interview is also a way of us trying to overcome these biases together. Media advocacy is a very strong tool. I have written op-edit pieces for vernacular newspapers about women’s mental health and its impact. I can just recall an article that got published. It was about motherhood and women with mental illness. About how and why babies were being snatched away from women with mental illness or psychosocial disability and given away for adoption. What is the underlying presumption and why is the state allowing that?
Another strategy we are using to overcome the biases is to constantly build capacity and competency of people who have a mental illness. Only when more people come out and take charge can we challenge those biases. Alongside, Anjali works to build competency of the family members as well. We start at a very humble and benign level of allowing a woman to choose what to wear and then slowly move to showing them how decision making can build self-esteem. We show them how to include their wards into decisions about complex issues, like say financial transactions, about working and about livelihood.
But have all the biases gone? No. Because they are deep-rooted prejudices. It is important to state that women’s rights organisations, human rights organisations, other mental health organisations, are also collectively tirelessly fighting against these biases, not just us.
SG: Anjali works in cooperation with the government, and a government involvement can lead to a never-ending, tiresome process. What challenges did you face in getting the government to cooperate with Anjali’s projects? Were there often clashes between the government’s policies and Anjali’s aims?
RR: Anjali works in partnership with the government. We’ve been trying to define what a partnership with government means. Because partnership with government can mean that you are running an Out Patient Department for them. It can also mean you’re running a halfway home and you’re taking patients from the government’s mental hospital to work with them. However, the way we work is different and we’ve tried to understand this partnership in varied ways.
The partnership that was there, say 15 years back, has obviously undergone change. Back then, the partnership was restricted to a level of giving permissions and allowing us to work. But now we get our ideas vetted by the government. Being called to meetings or being included in government groups is also an indication of how the partnership is working.
For instance, our inclusion in the patient welfare committee and in the diet committee straight away impacts the people we work with and for. This partnership entails both appreciation and providing critical feedback. If you critique constructively by writing letters, then they are more likely to be accepting of it and consider your ideas. But if you shame them openly, then the partnership can be impacted, adversely.
The partnership also depends on the strategies you use. It’s important to constantly keep them abreast with what is happening around the world, for example, what WHO is saying about quality rights, what the new Mental Health Act stresses on and such. I send the secretaries constant reminders and emails. Since they often don’t have the time, as an organisation working with the government, it becomes your responsibility to keep the information flowing.
The other important strategy to employ would be to tweak your language. Rarely does activist-oriented dialogue receives a response. One of the friendly secretaries told me that “While talking to the secretaries, you have to break it down and make it simple. Talk about the consequences, the impact and the reach.“
We have had challenges every now and then. Even just giving an idea and that idea getting adopted at the government level takes up a lot of time and in itself is a challenge. The government has a specific way of working and NGOs have a specific way of working and the key is to reach a negotiable point. We must also remember that if the government commits to something, it can never retreat. So, they take a lot of time to commit to a new idea or a project. The checks and balances that are there in the government is something to learn from.
I think clashes are really good because they keep both the parties interested. And I am not intellectualising it. In our program and our day to day interaction, we often talk about things which may seem like administrative issues. For example, we constantly pressure the government to do cleaning exercises. Because there are bugs infestations, maggot issues, lice epidemic. In the beginning, it was viewed as us interfering in the government’s administrative work. I still remember writing long notes to the secretary about how bent beds can impact the well-being of the patients. I think how you demonstrate to the government that admin decision is connected with the well-being, or the lack of it, of the residents who live in those institutions, is crucial.
For instance, when we are in the diet committee, we constantly talk about nutritious food, calories, taste, how food is going to be served, how we should get glasses and cups. So, our inclusion in the diet committee is important. Earlier there was no provision for serving roti and many residents of the hospital complained that they craved for roti. We questioned why they cannot be served chapattis. We have been partially successful in convincing the Government that food is about your identity building.
Anjali by nature is risk taking. But whilst collaborating with the government, can we afford to be so risk taking is also the question we ponder over internally.
SG: Mental health is a taboo topic in our country and persons suffering from mental health issues are often shunned from the society and hence, suffer several injustices. How does Anjali help mental health patients understand and gain access to their rights?
RR: I think mental illness is no longer a taboo topic, courtesy celebrities like Deepika Padukone. But the question is what is that nature of discourse in mental health? Are we making enough noise about the service delivery? Are we making enough noise about universal coverage? About the gender in mental health? About sexuality in mental health? Sexuality and mental health is a taboo topic!
It’s true that persons with mental health issues are often shunned from the society and they suffer several injustices. But the more we talk about mental health and its intersectionalities, the more will these injustices be addressed. Injustices are ingrained in the patriarchal nature of mental health system. Medical establishments are no exceptions. They are embedded in the very way the institution is organised.
The nature of these injustices is also changing. For example, ten years back, withdrawing food, withdrawing medicine, curtailing mobility and keeping them isolated were the big concerns and still are. But the injustices have become much more covert and much more impactful these days. Let’s take the example of abandonment of women in mental hospitals, which is a severe injustice. How and why does it happen? Mostly because the middle-class men want another wife and the easier way to shirk off responsibilities without any financial or legal hassle would be by getting an ‘insanity’ certificate and putting them in an institution.
As for how we address the accessibility and securing of rights, it’s based on the curriculum we have developed at Anjali. On one hand, we enhance capacity and competency of the people to be aware of their rights and on the other, we constantly attempt to create an environment where people with mental illness can access their rights. I remember we were once helping a person to file voluntary discharge petition as he was well and wanted a discharge from the hospital but didn’t have a family to discharge him. The process for voluntary discharge itself took us two and a half years. Because how can a “mad” person appeal for a voluntary discharge? His file was being kept and got dumped. On his file, it was written “pagal ka file”.
Anjali also has a legal team so legal resources are available to people. We are currently fighting the case of a woman whose children were taken away and visitation was curtailed. Our law officer has managed to get a good order where visitation has been increased.
SG: Anjali encourages the indulgence of its patients in art forms like paintings and theatre as a medium of therapy. What role has art played in helping Anjali achieve its goals and empowering Anjali’s mental health patients?
RR: As I have said earlier, I honestly don’t know whether art is a medium of therapy or not, but I definitely believe it’s a medium of expression. When I see the residents enjoying, feeling important, proud and incredulous of their own work, it gives me lot of joy.
Why does everything have to be therapeutic? Why can’t things just be pleasurable? There is no coercion in any of our sessions. We don’t believe in it. I think what is interesting and equally inspiring is their spontaneity; in terms of colours and the subjects of their paintings. It is their world vision and their politics.
SG: Anjali recently organised a two-day conference on “Sexuality, Rights and Persons with Psychosocial Disability” in association with The Asian-Pacific Resource and Research Centre for Women (ARROW). What prompted you to organise this conference? What, in your opinion, are the barriers that exist in regards to mental health and sexuality?
RR: As an organisation, we wanted to highlight the sexual rights of people. For a very long time, sexuality and any form of sexual expression have been attributed a pathological connotation of being either “hypersexual” or “over-sexual”. If you look at the research and literature available, there’s very little acknowledgement and encouragement of sexual desires and affirmative sexual rights. It’s always about the disorder. If you can’t reach an orgasm, it’s an Orgasmia. If you can’t participate in a sexual act, it’s sexual frigidity. We needed to discuss these things and bring about a more reasonable conversation. It is relatively easy to talk about reproductive and sexual health but far tougher to talk about affirmative sexuality or sexual expression. However, it was very heartening to see the participation at the conference. We held several Focus Group Discussions as part of Closing the Gap initiative that we ran for a year and a half. And now, we’re in the process of bringing out a work book on Sexuality.
Our endeavour intended to bring practitioners like us, psychiatrists and the social activists together in a space where all of us can talk about sexuality and mental health together. Because sexuality is about mind and society. Sexuality has been regulated by society for so long. There’s also rampant moral and medical gatekeeping. One of our residents once asked us if she could get married. She had received a different kind of response from her psychiatrist and us. Why was it so? Why should a psychiatrist or even an NGO like us be able to comment on the person’s personal choices, like marriage? In institutions there is no provision of private space to address any sexual need and the larger conversation is that they lack the capacity to make a decision regarding their sexuality or grooming or even becoming a mother.
SG: Please tell us about Anjali’s achievements. How have they benefited mental health patients?
RR: Anjali currently has two Livelihood Projects running, where women and men are earning money according to the basic wages Act of Govt of West Bengal. The participant/workers each have a bank account with several thousand rupees as their balance. Our work has spread out to four hospitals since we first began in 2000 voluntarily in one hospital. What’s rewarding is despite being critical, we were invited by the government to expand in three other hospitals. There must have been something that we did right for the government to ‘invite’ us. We pride on being able to gain a consultative status with the government.
SG: What would you say are Anjali’s immediate and long-term agendas for the betterment of mental health patients?
RR: We are planning an academic institute on sexuality and mental health. We also plan to reach out to the community in more interior and rural spaces through our Community Mental Health Project. We also plan to make films as resources on sexuality, mental health, domestic violence, bullying, suicide and such. Our long term strategy will also focus on how to exit from directly providing services to getting them adopted by the government. That’s what we hope to achieve and live by.
All images courtesy Anjali’s Facebook page. Visit their website here.
