The State of Mental Health in North- East India
AN UNTOLD CRISIS
28th December, 2020
Written by Nayomi Dave
Artwork by Ojaswi Kejriwal
The privilege that overwhelms our mental health infrastructures are stark and most evident in areas of conflict and seclusion such as the North East of India. The underdeveloped state of the region is largely due to its remoteness, poor means of communication, and most of all a lack of awareness. Although sparsely populated, the healthcare facilities lack trained professionals and are not evenly distributed in terms of region and socioeconomic status. If this is the condition of physical health care, one can only imagine how mental health care would be given, especially considering how it is not treated as equal to physical health in India, by any means.
About four years ago, I was teamed up for a class project with an Assamese classmate. Having lived in Silchar, Assam all his childhood, he had numerous stories and accounts of the happenings in the North East, from a perspective I’d never considered before. One such account that comes to mind is that of his cousin’s experience in a private rehabilitation center. I was walked through the heartbreaking story of the psychological disturbance and unethical behaviour that his cousin, a mentally ill opioid addict from a very young age was subject to. Despite being in a private center with a considerably high fee, he was mistreated by the psychiatrists and volunteers in the center. As opposed to rehabilitation, it felt like he was being punished. While the psychiatrists did have medical degrees and licenses, a few of the therapists did not have the RCI license and many were not experienced enough to deal with extremely ill people, let alone drug addicts looking to get rehabilitation and deep psychological help. This only goes to show the lack of concern and low prioritisation to mental health given in the North East, despite being in a centre for rehabilitation, and that too a private owned one. It goes without saying that such instances, in greater intensity, occur in government owned rehab centres and mental health organisations.
The national mental health survey conducted by NIMHANS in 2016 showed the existence of mental health issues in 12 states across India. The study’s aim was to determine what percentage of the sample size is suffering from mental health issues. Manipur ranked the first with a 14.1 percent closely followed by Madhya Pradesh with a 13.9 percent. Years of political violence, geographical isolation, substance abuse, ethnic clashes, human rights violations, poverty, etc have made mental health concerns the new normal among people in the seven sisters.
It is no secret that poverty and unemployment are major contributors to mental health decline.
Additionally, National Crime Records Bureau (NCRB, 2012), India reports that Sikkim and Tripura has one of the highest rates of suicides in the country. Mizoram is on the 7th position of the list. Even with such scathing data, there is not much done to help those who need it the most.
It is no secret that poverty and unemployment are major contributors to mental health decline. Not only does instability due to unemployment and poverty cause mental illness, but also becomes an obstacle when it comes to finding good treatment and medicines for the mental illness.
In Tripura, the highest rate of suicide is seen in tribal populations due to poverty and unemployment. Additionally, farmers in the north east have lost land to money lenders and there is a lot of competition among them. This has also contributed greatly to the poor mental health of farmers and their families, and also to the alarming suicide rates. The government facilities, policies and arrangements laid out for the healthcare of the poor are extremely limited, especially when it comes to psychological counselling and therapy.
Udisha Sarma, an RCI licensed Mental Health Professional from Guwahati, says mental health betterment for the poor is lacking. In most cases, private practitioners’ charges are exorbitant, and nowhere close to what an average North East inhabitant can think of spending, especially not ones belonging to a lower socioeconomic background, where mental illnesses are more prevalent.
While there are non-profits and organisations that cater to the mental healthcare needs of the poor, there are a lot of obstacles in achieving this goal. For starters the non profit managers are either unable or unwilling to invest in experienced and well trained mental health professionals. Inevitably, experienced and licensed professionals tend to charge more than unlicensed or inexperienced individuals. This is a risk non-profits are willing to take, and appoint the lesser experienced to deal with the more mentally damaged people of the region. As a result, the quality and rate of treatment they receive is very low, and they tend to opt out of the treatment or have bad notions about the practice of therapy that is passed onto people they know. This becomes a chain of incorrect and non factual bias against mental healthcare.
Lack of Infrastructure & Trained Professionals
The North-Eastern states remain untouched by the rest of the country. Factors such as problems with power supply, rampant violence and extortion make it less attractive for the private and public sector to invest in the States and create jobs for the mental health industry A low scope for career growth and employment opportunities drives away North East-born psychologists, let alone mental health professionals from the rest of the country.
As compared to the population, mental health professionals including psychologists and medical psychiatrists are extremely low. In a 2017 report by researchers at Indian Psychiatric Society, Assam State Branch, it was stated that Assam, with a population of 2.7 million had only about 140 mental health professionals, making it the highest in terms of the number of mental health professionals. At the lowest was Meghalaya, with a population of 2.3 million and just 7 mental health professionals. This number is inclusive of Psychiatrists, Clinical Psychologists, Psychiatric Nurses and Psychiatric Social Workers, which only goes to show that the actual number of people licensed to give therapy is troublingly low. The LGB Regional Institute of Mental Health is the only mental health hospital in the whole of North East India and at any given point is overcrowded, understaffed, and seriously lacking beds.
A lack of mental health awareness, and awareness regarding the qualifications of mental health professionals are also major contributors to the absence of enough mental health care. When we want to get ourselves treated for a physical illness, we know exactly what kind of a doctor we want. We know they should have done an MD or MCh in a particular specialisation in order to be fit to treat us, but how many of us know about the necessary qualifications a therapist or psychiatrist should have?
Sarma talked about the prevalence of a lot of unethical practice and malpractices under the pretext of giving therapy, which goes undetected because the prospective clients and therapy seekers are not aware of the standards a therapist should meet. She talked of how there are many instances of people attending short term certificate courses in a particular therapeutic approach such as CBT, and using it as proof of their ability to give therapy. People unaware of the educational qualifications their therapist should have, end up visiting such ‘therapists’ and inevitably receive low quality or ineffective treatment. This not only worsens their mental health but also leads to an increase in the stigmatization of therapy and mental illnesses.
When we want to get ourselves treated for a physical illness, we know exactly what kind of a doctor we want...but how many of us know about the necessary qualifications a therapist or psychiatrist should have?
People of the North East, or anywhere for that matter should be encouraged to ask a therapist their qualifications before or during the sessions. An RCI certificate from the Rehabilitation Council of India is a must to practice as a clinical psychologist in India. As per the Mental Healthcare Act (2017), an MPhil degree is the minimum one needs to be eligible for the RCI licence. According to Sarma, most people, seeking therapy or otherwise, are not aware of the existence of this rule or the RCI. They fall prey to malpractices and are charged heavily for unethical and fraudulent services rendered by individuals claiming to be trained mental health professionals while just having a diploma, a bachelor’s, or sometimes even just a course completion certificate. Asking a mental health professional regarding their qualifications before availing treatment can go a long way in improving the quality of available mental health care in the North East. Not only is the distinction between a genuine and fraudulent mental health professional important to know about, but also that between the different specialities under psychology. Sarma talked about how people, especially laymen but also including those who want to start mental health initiatives are unaware of the fact that someone with a School Psychology, for example, is not eligible to give talk therapy to anyone but schoolchildren, that they are not eligible for or trained to deal with, say, an anxiety disorder.
In her experience at an Autism foundation for children, Sarma saw that the presence of trained professionals to help the children suffering from a specific mental health illness is very low. Even those aiming to help children with a mental illness are unaware of the special needs and qualifications one needs to have in order to teach and mentor these children or even to be a volunteer with the organisation. As a result of this, untrained and underqualified people are taken on as teachers and helpers to these children, often slowing their healing process.
The lack of infrastructure is also a huge problem in North East India. Sarma recalls an instance where her friend, a school psychologist, was appointed to counsel children at a school in Assam but was not given any office to do so, and had to eventually use a cleared up storeroom. This proves how mental health is treated as an afterthought and not a priority in the agenda of school administrators. The fact that the environment of the room where the therapy session is being conducted has an impact on the child is either unbeknownst to or simply neglected by the management. It is things like these that deter people from practising psychology in the North East. The dearth of jobs and awareness in this field leads to lesser chances of earning a living as a psychologist or any kind of mental health professional, causing them to emigrate to other states and cities to practice. This only further worsens the mental health professional to population ratio and in turn the mental health of the people.
Over the years, the North-Eastern states have been exposed to an environment of violence and rampant drug use contributing to the deterioration of their mental health. Tripura also has an open border with Bangladesh through which drugs are trafficked at a large scale and have made their way into the drug markets of the North East. In fact, most states sharing borders with Myanmar and Bangladesh have reported a massive inflow of illegal drugs into the country. The forest-covered roads connecting the borders have become a convenient cover for vehicles trafficking drugs. Myanmar is the world’s largest producer of ‘WY’ tablets whose primary constituent is methamphetamine, followed by some amount of caffeine.
Apart from illegal drugs, prescription drugs such as Propoxyphene and Spasmoproxyvon (Opioids) are also abused by the youth of the Northeast, owing to their easier availability and cheaper price. Not only does such drug use lead to physiological and psychological problems, but it has also lead to a rise in crimes such as chain snatching, petty thefts, and even murder by drug-addicted youths.
Despite Nagaland, Manipur and Mizoram being dry states, illegal home-brewing of ‘desi’ alcohol is an extremely common practice in these states. Apart from this, illegal liquor stores and bars are also common and functional in these states. Consumption of alcohol is very common among the youth due to its easy availability and cheap price. Additionally, the government has been largely unsuccessful in keeping these practices under check, despite everyone knowing about these occurrences.
Cannabis (commonly referred to as weed) grows in nearly every part of the North East. Regular use of cannabis is very common in these states, and it is not even looked at or considered as a drug.
Drugs are rampantly trafficked, easily available and very cheap. They can be orally taken, snorted or injected and are extremely harmful to the central nervous and cardiovascular systems. The constituents of any class of drugs - be it a stimulant, depressant, or hallucinogen, can lead to addiction and mood swings, and in severe cases can lead to depression and anxiety among other mental illnesses. Liver and kidney diseases faced by loved ones due to rampant drug abuse also indirectly becomes a cause of poor mental health among members of the family.
While many rehabilitation centers do exist, the government run centres are usually overcrowded and understaffed while the private centres are not within the budget of most drug addicted people of the North East. The inability to find good treatment for the drug addiction increases the psychological disturbance of the users and their family.
While most of us assume that drug and alcohol abuse is something rampant only or majorly among the youngsters, this is not the case in the North East. Sarma says that the normalisation of drug use in youngsters comes from them seeing their elders and family members using it regularly since childhood. As a result, it is not viewed as a harmful substance.
Schools and colleges are aware of the fact that children grow up in an environment of substance use and are likely to become abusers themselves. Despite this, Sarma says there are extremely few camps or awareness initiatives held in schools, colleges, or otherwise in order to educate North-Easterners of influential age about the hazards of substance use. While interning at a Rehabilitation Center, Sarma saw that youngsters do not voluntarily come in seeking help and are in a state of denial regarding their addiction. They are brought into rehab, often against their will, by members of their family who are aware of the repercussions of substance abuse.
In conclusion, while there will always be barriers to mental health betterment in the North East, mental health activists as well as professionals must try to overcome these by doing our bit. Private practitioners, by offering services on a sliding scale of payment, or by volunteering some of their time to a mental health non profit, can go a very long way in improving the mental health of the poor and their families in the North East. Apart from this, the biggest barrier to overcome is the lack of awareness. People, be it therapy seekers, mental health activists, or any average person, should know and educate others regarding the necessary qualifications of a therapist, they should unapologetically ask mental health practitioners their credentials before seeking therapy from them. Awareness initiatives regarding mental health and substance use started from an early age can prevent numerous cases of addiction and psychological illness in the adults of tomorrow.
*Udisha Sarma is an RCI licensed Clinical Psychologist from Guwahati, India. Udisha Sarma works at Apollo Hospitals in Guwahati, Assam and has completed her M.Phil in Clinical Psychology from Sweekaar Academy of Rehabilitation Sciences, Secunderabad in 2018. She has been associated with the field for more than a decade and with 5 years of work experience in Delhi, Bangalore, Hyderabad and Guwahati. At present, she works with clients from all age groups dealing with various psychological disorders and she specialises in Cognitive Behaviour Therapy. Her work mostly includes providing Psychotherapy, Psychological guidance and counseling and conducting Psychological Assessments.