Full transcript
0:04[music]
0:09[music]
0:16>> Hello everyone. I welcome you to my
0:18course introduction to medical
0:20humanities and today we are doing
0:22lecture 14 in which I am going to talk
0:25about mental health illness versus
0:28disease debate.
0:30Now
0:31before I begin with
0:33this particular topic, it's important to
0:35understand the difference between
0:38illness and disease and why in the
0:41context of mental health it's an
0:43important construct. Now when we think
0:46of health as an important component of
0:49well-being we do not exclude mental
0:52health. Now in fact WHO also defines
0:57mental health to be an important
0:59component of good health. Now in that
1:02sense mental health whether it is an
1:05illness or a disease is something that
1:07we are going to
1:09briefly touch upon in today's lecture.
1:12What is illness? What is disease? Now
1:15when we think of illness we are thinking
1:18from the patient's perspective. What is
1:21it that the patient is feeling? What are
1:23the symptoms? Things like that. But when
1:25it comes to mental health as disease, we
1:28think from the doctor's perspective.
1:30In case of disease, it's an objective
1:33data, but in case of illness, it's a
1:36subjective experience. So that is where
1:39we will try to navigate in today's
1:40lecture. Let us go from here.
1:43A brief overview. I will touch upon
1:45mental health. Why does it matter? Why
1:47is it important to discuss about mental
1:50health today? Move on to explaining the
1:53key terms.
1:55I discuss mental health as a disease,
1:57follow it up with mental health as an
1:59illness, and try to contextualize
2:02mental health in the Indian context and
2:05think of bridging the gap with the
2:07biopsychosocial model uh to sum it up.
2:12Now, when we think of mental health uh
2:16because of a different kind of
2:18lifestyle, very competitive, millennial
2:21kind of age that we are living in, the
2:24mental health issues have
2:27drastically increased.
2:30There are some researchers that also
2:32talk about it being reported.
2:35Now, considering that the stigma
2:38associated with mental health is kind of
2:40gradually reducing. So,
2:44let us go with the WHO definition, which
2:47says, and I'm on your screen,
2:49"Health is a state of complete physical,
2:52mental, and social well-being, and not
2:55mere the absence of disease or
2:57infirmity." So, just because you do not
3:00have any disease doesn't mean that you
3:03are
3:04completely healthy. In fact, a good
3:07health always makes a promise of being
3:11physically, mentally, and socially fit.
3:15Uh what is an individual then capable
3:18of? Mental, I highlight here because we
3:21are talking about mental health, and why
3:24this is important because sometimes
3:26there may be a case when a person looks
3:29or appears to be physically very fit,
3:32socially very active, and still dealing
3:36with mental health issues. In that case,
3:39what are the kind of
3:41symptoms or what are the kind of
3:44uh elements that we are thinking of when
3:47we think of mental health? What are the
3:49components? The first, we should be in a
3:52position to manage our emotions. Whether
3:55it is the emotion of fear, ecstasy,
3:59uh
4:00love, hate,
4:02uh ambition, we should be in control of
4:05it. And instead of they driving us, we
4:08should be driving them. Now, this in
4:11theory looks very easy, but I am sure it
4:14is not an easy exercise. But when you
4:16think of mental health component, this
4:19is one of the things we discuss.
4:21The second element that we discuss in
4:24the context of mental health is that you
4:27communicate positive actions.
4:30What do you mean by positive actions?
4:33This means that the when you think of
4:37different kind of action plan for you,
4:40you do not have a very negative approach
4:43towards it. That also constitutes. So,
4:46that is why, you know, when you come
4:48across your friend, somebody will say,
4:49"Oh, she's a very positive person. There
4:51is a positive vibe." In fact, when I
4:54discuss these issues with my students in
4:57B.Tech, they often talk about vibe. I
5:00have never seen what a vibe looks like,
5:02but they always talk about positive vibe
5:04and negative vibe. So, positive actions.
5:07Also feeling positive about oneself and
5:10others. So, in the last lecture, if you
5:12remember, I discussed how individual
5:16abilism also works. So, when somebody is
5:19having an issue with their mental
5:22health, they start doubting their own
5:25self-worth. Therefore, it's important
5:28that one feels positive about oneself.
5:32Human beings are social
5:34animal.
5:36I don't know if I should use the word
5:37animal, but we are all social person. Uh
5:40so, any kind of communication
5:43uh becomes a resort to how we maintain
5:47an effective relationship. And if you
5:50are a community person, you discuss with
5:53other people, you have a social life,
5:56usually that is said to be a good mental
5:59health condition.
6:01Also, if you perform social roles. So,
6:05whatever role is assigned as a student,
6:07as a professor, as a person who is
6:10friend to somebody, as a brother, as a
6:12sister, you know, whatever role is
6:15assigned to you or you're born with, you
6:18do that in a good way, and that is where
6:21your mental health. So, all these
6:23elements decide your mental health. If
6:26you are doing all these things, it says
6:28that probably you are in good mental
6:30health state.
6:32Why does it matter?
6:33Why are we talking about mental health
6:35now?
6:37So,
6:38WHO estimated about 450 millions
6:42globally who suffer from mental health
6:44disorder.
6:46And 15% of adult Indians suffer from
6:49mental health issues.
6:51Now, that's a large number to even think
6:54of.
6:56In particular, in the context of India,
6:59if I can talk about, 70 to 92%
7:03of people with mental disorders did not
7:06even receive proper treatment. Now,
7:09there are several
7:10reasons why we can discuss that, and
7:13when we do the close reading, we will
7:15indeed talk about it. But for the time
7:18being,
7:19a very important government initiative
7:22came in 2017, and I will ask you to go
7:25to your screen, this particular act. The
7:282017 Act, the which says
7:33the Mental Healthcare Act 2017 replaced
7:36the outdated Mental Health Act of 1987,
7:41ensuring the right to mental health care
7:43and decriminalizing suicide. It was a
7:46very important intervention. In fact,
7:48earlier even attempt to suicide was
7:50considered to be a criminal activity.
7:54But this particular act said, "No,
7:57it's not a criminal activity. Maybe it's
7:59a mental health issue and probably that
8:02person is in need of some kind of
8:04therapy, some kind of counseling." And
8:07that is why it is a very revolutionary
8:09kind of change. Let us slightly map the
8:12government initiatives that have taken
8:14place.
8:16In 1982, we had National Mental Health
8:19Program and it was launched to integrate
8:22mental health into primary health care.
8:25So, this was probably according to the
8:29literature review that I have done,
8:31according to the data survey that I have
8:32done, this is the first of its kind
8:35initiative that happened because it
8:37recognized mental health also as an
8:40issue.
8:41The second turning point happened in
8:441996
8:45when we had District Mental Health
8:47Program introduced under NMHP
8:52to expand community mental health
8:55services. So, NMHP means National Mental
9:00Health Program. So, according to this,
9:03this program was expanded.
9:06From 2015 to 2016, you will find that
9:10there was a large amount of survey
9:12conducted. Now, when we think of
9:15the policy intervention, policies are
9:18not made in isolation. In fact, a lot of
9:21data comes from the public and therefore
9:25policy formation takes place. And this
9:28is where in fact, if you see the
9:30cinematic and literary narratives also
9:33come into play because what they do,
9:35they take up
9:37sometimes they influence the policies as
9:39well, but at other times they work in
9:44terms of disseminating
9:47the policy change that is mentioned in
9:50the policy document. So, after
9:532015-2016,
9:55we have the Mental Health Care Act and
9:58it is followed up by National Health
10:01Policy which recognized mental health as
10:05a priority and integrated [snorts]
10:07it into primary health care.
10:10This is followed up by the 2020 Rights
10:14of Person with Disability Act and this
10:17also came into full force enhancing
10:20rights and protections for individuals
10:23with mental illness. So, when I
10:25discussed the disability model, the
10:28medical and the social model, in the
10:30social model, you identify also this
10:34component as disability. In fact, if you
10:37notice, I also talked about legal
10:39changes where
10:41disability
10:43of certain kind was included in in the
10:45sense that mental health was also
10:47included as part of that 21 diseases
10:51that are identified as disabled in the
10:53disability act. Additionally, in 2020,
10:55we have Kiran Helpline which was
10:58launched to provide mental health
11:00support during COVID-19. Now, COVID-19
11:03was a tough time for all of us and at
11:06this point of time, there were so many
11:09people who faced mental distress, not
11:11necessarily in the mode of disease, but
11:14in the mode of illness and that is where
11:18this government initiative was launched
11:20and it became very helpful for a lot of
11:22people. The next program that we can
11:24talk about was launched in 2022. It's
11:28called National Tele Mental Health
11:30Program which is in short Tele-MANAS.
11:34MANAS is people. MANAS is a Hindi word.
11:37In English, it can be translated as
11:39person. So, Tele-MANAS. So, there is
11:43a very human quotient assigned to the
11:46naming of this particular scheme as
11:49well, which says that there is a person
11:52on the telephone. So, there is a person
11:54who will help you. So, despite knowing
11:56that it can it can also be, you know, a
11:59kind of a person with no face, uh still
12:03there was a meaning assigned. There was
12:05a personality assigned to this program.
12:07It was launched to provide free 24/7
12:11tele-mental health support. So, in the
12:14same year, in the 2022,
12:17KIRAN helpline merged into Tele-MANAS.
12:20So, because Tele-MANAS was to running
12:2224/7, it kind of merged at that point of
12:26time.
12:272023 is also very important year because
12:30in this year, National Suicide
12:32Prevention Strategy was launched, and
12:35the aim of this program is to reduce
12:37suicide mortality by 10%
12:41uh say till about 2030.
12:44In 2024, Tele-MANAS expanded with more
12:48centers and video consultation, and
12:51the expansion of service means that more
12:54people can benefit through that. The
12:57in 2024, there was an app which was
13:00launched. Now, we have apps for so many
13:03things, uh even for mental health, this
13:06app was launched. And what did it do? It
13:08integrated self-care resources, stress
13:12management tools, and direct
13:14consultation services. So, in nutshell,
13:17this is the map that you can follow if
13:20you want to know how the mental health
13:22trajectory has taken place in the
13:24context of of
13:25Apart from that, broadly, I list out
13:28four programs here, but you can look at
13:31it in great detail. Uh this is very much
13:33available on the Ministry of Health and
13:35Family Welfare website, and uh maybe you
13:39can get some more recent data. Maybe,
13:41you know, before I found this data over
13:43there, but maybe there is some change
13:45that has happened because it's a crucial
13:47issue, and every day there is some other
13:49kind of tapping that is going on of this
13:51issue. So, what I'm trying to say is
13:53that this is an important concern in the
13:55context of India because
13:57mental health issues are surrounded by a
14:00lot of taboo, a lot of stigma.
14:02And therefore,
14:04government intervention is a must.
14:07Uh mental health, uh if you look at the
14:11definition and uh the characteristics of
14:14it, it's a conflicted side. Why? Because
14:17it's a ubiquitous kind of an concept
14:20pretty much everywhere. Uh
14:22on one hand, it's a biological problem.
14:25Uh on the other hand, it looks like it
14:29is
14:29uh something related to disease.
14:33Therefore,
14:34you you come across a
14:37space in which it is very difficult to
14:40do the diagnosis
14:42or
14:43to identify that probably there is some
14:45mental health issue or the person is not
14:49mentally
14:50fit.
14:51Because
14:52when you look at this
14:55issue of mental health,
14:57you will find that it can as well be
14:59around disease or it can be around
15:01illness. What is it? How does the
15:04bifurcation takes place? We will discuss
15:06it uh in due course of time.
15:10Now, when we talk about mental health
15:11issues, it's important that it is not
15:14something which is pertaining to one
15:16culture.
15:17It can be anywhere. So, the symptoms,
15:21the kind of uh anxiety people feel is a
15:25very universal
15:27thing.
15:28On the other hand,
15:30what escalates these phenomena is the
15:33socio-cultural construction. So, if the
15:36society is open to addressing the mental
15:38health issue, then it becomes easier for
15:41the person to deal with the mental
15:44health problem that is arising out of
15:47any of whether it is a disease or an
15:49illness, it is it is easier.
15:52But,
15:53in case of a country like India, where
15:55it is still a lot of taboo to deal with
15:58mental health, you
16:00find the role of culture being
16:02important. And not only in the case of
16:05India, many cultures do not
16:08discuss mental health issues as a
16:11prominent issue that can be discussed.
16:14Therefore,
16:15mental health is centered in mind and is
16:19culturally influenced. So,
16:21quite late people realize that there is
16:23an issue.
16:25And that has a lot to do with the kind
16:27of meaning construct of mental health
16:31that is happening in society.
16:33Mostly, you will find that people are
16:35judgmental of mental condition and bring
16:38personal desire, which is culturally
16:41embedded. So, what happens is that the
16:44culture is assigning a meaning to your
16:47mental capabilities, and that has a lot
16:49to do with ableism. You remember when I
16:52was defining ableism, I talked about how
16:55society creates a an able body. In that
16:58context, mental strength, a person with
17:01huge amount of mental strength, is also
17:05decided or decoded or labeled as uh
17:09abled. So, anything which is not that is
17:12a deviance.
17:14Uh Uh, like I said, I will talk about
17:17mental health in two categories. One as
17:19a disease, the other as illness. When I
17:23think of mental health
17:25as disease, I will go ahead and talk
17:27about it from the doctor's perspective,
17:31from the data-oriented perspective, from
17:34the symptom-oriented perspective, and
17:36also to certain extent, what you can
17:38call the bio perspective. So, if you
17:42look at mental health issue as a debate,
17:45you find that in biological or the
17:47medical model, it is a deviation from
17:50the normal brain system. So, there are
17:53certain signs that are identified, and
17:56it has to be taken care. So, it is
17:58purely physical is what is believed by
18:02the doctors, and they say that it is
18:04caused by neurological defects. Now,
18:08what do the doctors do? The clinicians
18:11treat it by observing the mental systems
18:14that are manifest fested in behavior.
18:16So, maybe you know, somebody is severely
18:18depressed, schizophrenic, or there is a
18:21bipolar disorder. Maybe any of these
18:24symptoms or more is happening, and they
18:27try to
18:29cure uh,
18:30these mental symptoms. Now, these mental
18:34symptoms are related to social context
18:36in the same way the bodily symptoms are
18:39tied to anatomical
18:41and genetic context. What does this
18:44mean? This means that just the way we
18:47assign meaning to different other kinds
18:50of disease, even mental health finds its
18:53construct of meaning within the society.
18:56And therefore, if somebody is
18:59schizophrenic, uh, maybe, you know,
19:02depending on the culture, maybe it's a
19:04tragedy, maybe some trauma has happened,
19:07or maybe, uh, you know, uh,
19:10I mean, sometimes if you go, uh, to some
19:12of uh, the very remote areas in
19:17some places, you also come across which
19:20which hunt practices assigned to
19:22schizophrenia and not being diagnosed.
19:24And therefore, it becomes the
19:26philosophical idea of the duality
19:29between mind and body. So there is a
19:31conflict between the mind and body that
19:34is going on. And
19:36a very important field of study in this
19:39regard is psychiatry. So psychiatry
19:41usually
19:43treats the mental health diseases and
19:46they are the designated branch. And uh
19:50there is a diagnostic and statistic
19:53manual
19:54which is used to diagnose. So there are
19:56certain parameters you will come across.
19:59You can just quickly Google it and you
20:01will find out. I refrain from speaking
20:03about it because I'm not a doctor, but I
20:05know that there is a manual that decides
20:09whether
20:10mental health is a disease or not. So
20:13usually this standardization takes place
20:16by the clinician who are psychiatrists.
20:19When we think of mental health as an
20:21illness, like I said, it prioritizes the
20:25perspective of the patient.
20:27What is the patient feeling? And this
20:31can be from a simple distress to extreme
20:35anxiety.
20:36Uh and all is
20:39categorized as mental health issue. Now,
20:42mental health
20:44is manifested in specific social world
20:48within a specific network of relations.
20:51What does this mean that
20:53when you think of the
20:56social model, only then you will be able
21:00to define mental health as also illness.
21:03If you
21:04bring it or if you try to homogenize it
21:09with only the disease model or the
21:11medical model, probably this kind of
21:16nuanced understanding of mental health
21:19issues will not be possible. And
21:21therefore, this debate, mental health is
21:25an illness or mental health is a
21:27disease, is crucial to medical
21:30humanities. Because medical humanities
21:34emphasizes that each patient with same
21:38or similar disease can have a different
21:41trajectory of lived experience. And each
21:44experience is to be valued. Therefore,
21:47when we come across
21:49mental health as an illness, the medical
21:52model does not necessarily cater to what
21:55we are talking about. So, what happens
21:57if you look at your screen? Mental
22:00illness caters to patient's subjective
22:02and
22:03socio-psychological happenings. So, in
22:06this particular model,
22:08subjective,
22:10socio- psychological, these three
22:14becomes important. And
22:16there is where we formulate mental
22:19health as illness. There can be, you
22:22know,
22:23different kind of symptoms like stress,
22:27anxiety,
22:29chronic hostility, vengefulness, all
22:32these are indicators of how mental
22:36health issues function as illness.
22:39So, what you can call as recovery model
22:42of mental illness. And uh
22:45whether it is a disease or an illness,
22:49in both this uh
22:53I mean, no matter how you kind of uh
22:56categorize it, you find this model
22:59extremely
23:01essential to the understanding of mental
23:03health. Now,
23:06in either of the case, whether mental
23:08health is a disease or mental health is
23:10an illness, the living conditions decide
23:13how a person will respond to and be
23:17resilient towards mental health
23:19issues. Now, according to SARS, mental
23:23illness is a problem of living, not a
23:26disease. This means that
23:29be any kind of feature, if the living
23:32conditions are sorted, then probably the
23:36mental health will be taken care of. So,
23:38what is this living condition? It
23:41primarily means a good support system.
23:44That is
23:46an extreme kind of requirement that
23:48recovery model talks about. In fact,
23:51K.S. Jacob talks about recovery model of
23:54mental illness instead of symptoms and
23:57emphasizes on resilience and control
24:00over problems in life. So,
24:03lifestyle change, community support,
24:06individual behavioral change, all these
24:10are aspects of how you think of recovery
24:14model when it comes to the mental health
24:17campaigns. Uh so, mental health, whether
24:20it is illness or whether it is disease,
24:22they always say that it is a treatable
24:25uh kind of an issue, and therefore a
24:28strong medical and social support system
24:32can help one
24:34regain a meaningful life, whether it is
24:37a disease or
24:39if even it is an illness. Surely, in the
24:42case of illness, sometimes also in the
24:45case of disease.
24:46Uh when we think of uh medical health in
24:50India, we think that uh
24:52in India, uh if you leave aside the
24:56taboo that is associated with mental
24:58illness. We are a collectivist country
25:00and therefore the community support is
25:02something that we can bank on.
25:04Therefore,
25:06it is an issue that can be tackled in a
25:08good way.
25:09This aspect of community also becomes a
25:12problem.
25:14If there is a positive side to it, there
25:16is also a negative side to it that we
25:18always look for our identity, meaning of
25:22our life in tandem with what society is
25:25thinking of us. And therefore, some
25:28mental health issues are pathologized
25:31for failure to confirm the cultural
25:33norms. So, if you're not marrying at a
25:34particular time, if you're not
25:36performing at a at a particular pace, if
25:39you are not having child at a particular
25:41given time, so so many
25:44things that you can think of. Probably,
25:46this will be a deviation from
25:48your assigned role and then that can
25:51also lead to mental health issues.
25:54In terms of mental health, it is highly
25:57stigmatized and therefore cultural
25:59influences intervene in interpreting a
26:03medical disorder. I spoke about
26:05witchcraft. So, delusion is
26:08supposedly taken as witchcraft or evil
26:11spirit that has come. There is a
26:14supernatural visitation. And
26:17if something like this happens, which is
26:19not visible, which is not physical, then
26:22they say that probably it is your karma
26:24that is punishing you. Now, all this put
26:27together is a problematic state of mind
26:31and that has been taken care of
26:33immensely. What Mental Health Care Act
26:36does is it protects the human right of
26:39mentally health patient. Again, we move
26:41on to the right-based model, which
26:44prioritizes
26:45human beings at any cost under any
26:49circumstances. On that note, we come to
26:52the end of illness disease debate in
26:55India when it comes to mental health
26:57where
26:58family plays an important role in
27:01diagnosis and treatment. So it is the
27:04because we are in a community living, we
27:06identify that it is the community who
27:09sees the symptoms for the first time and
27:12therefore the diagnosis is not just from
27:16the doctor side, but it is from the
27:18patient side as well. And depends on a
27:20lot of other factors like
27:24class, income, job, all those things for
27:27example.
27:28The conflict is visible in a case study
27:31by Veena Das where you know doctors feel
27:34that maybe there is a mental health
27:36issue, but because there is a no
27:38resource possible, so
27:40they take into account that aspect also
27:43is something that Veena Das talks about.
27:46And this is where the mental health care
27:48act 2017 becomes important because it
27:51protects the human right of
27:53each one of us
27:55irrespective of what mental health
27:58issue is
28:00and that is why probably contextualizing
28:03mental health in the context of India is
28:05extremely important. Finally, when we
28:08think of mental health, the
28:09biopsychosocial model
28:12proposed by George L. Engel is one that
28:16we can take into account because what it
28:18does is it bridges the gap between the
28:21disease illness when it comes to mental
28:24health. One of the examples that I can
28:26take up is the schizophrenia
28:28in which unless the patient's thoughts,
28:31feelings and cultural context is
28:33analyzed just relying on what are the
28:36symptoms may not work. And that is why
28:39you know you talk about living
28:40conditions when you think of mental
28:42health issue. Similarly, the role of
28:45physician cannot be undervalued because
28:47it is of immense value. The whole
28:49rapport that gets created, the
28:51patient-doctor space that gets created
28:54within the space of mental health is
28:58important in the understanding of how
29:00you perceive
29:02or see the trajectory of going forward
29:06uh in the way of life of a person who is
29:08dealing with mental health issues. This
29:10is where I will pause and deal with
29:12trauma narratives in the next slide.
29:15Thank you.