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RATNABOLI RAY

India,

A trained psychologist and mental health activist, Ratnaboli Ray is working to transform India's state mental institutions, which are little more than holding cells, into centers of modern, high-quality professional care. She also wants to create a system for reintegrating released patients into their home communities.

This profile below was prepared when Ratnaboli Ray was elected to the Ashoka Fellowship in 1999.

INTRODUCTION

A trained psychologist and mental health activist, Ratnaboli Ray is working to transform India's state mental institutions, which are little more than holding cells, into centers of modern, high-quality professional care. She also wants to create a system for reintegrating released patients into their home communities.




THE NEW IDEA

While Indian law permits the police to take the mentally ill into forced custody at any time, the state institutions where these patients are held generally do not provide rehabilitative care. Nor is there political will to integrate cured inmates back into their communities. As a result, thousands of recovered patients, Non Criminal Lunatics (NCLs), and the mentally unfit overcrowd custodial care institutions and maximize their space, personnel, resources, and services.

Ratnaboli Ray has created an approach that co-opts the institutions as partners in change. She is opening the doors of state institutions to a broad array of professionals - counselors, human rights activists, psychiatrists, therapists, community workers, and others - whose expertise will dramatically modernize treatment. These professionals will train medical and care-giving staff to move patients with different levels of mental illness into appropriate paths of treatment and introduce modern rehabilitation techniques, community psychiatry, and mental health practices.

Ratnaboli and her allies will also be demonstrating how to integrate recovered patients into their original communities, by building awareness and acceptance for them and by establishing healing zones within those communities. She and her team will design a model and build legitimacy for this as a generally accepted practice within mental health institutions.




THE PROBLEM

The field of mental health is perhaps the most neglected aspect of healthcare in India. The Mental Health Act of 1987 revised the Indian Lunacy Act of 1912 but retained the myopia of the past. It empowers the judiciary and the police to take mentally ill persons into custody and remand them to a custodial hospital, but forbids the mentally ill from using the services of the psychiatric wards of general hospitals, psychiatric day hospitals, or community care. Patients are herded from prisons to hospitals to homes for vagrants. The law makes no provision for the integration of patients after the stipulated 30 days of treatment. Almost always, patients are rejected by their families for the stigma of being in a mental hospital. The law also does not commit to the mainstreaming of those who are cured over a period of time or to the upgrading of mental health practices.

Owing to an historical allocation bias toward physical health over mental health, the demand for infrastructure and services far outbalances the supply. In a country where more than 20 million people require active mental health care, there were, in the mid 1990s, as few as 50 mental hospitals nationwide, with a capacity to serve no more than 75,000 patients. There are as few as 1,000 trained psychiatrists throughout the country, and approximately the same number of nurses, to attend to the burgeoning numbers of patients in institutions. Inmates of mental hospitals and other state custodial agencies are herded together with no recreation, creative activity, or social contact. Sexual abuse, violence, and neglect mark their lives.

Medical services are outdated and professionally inadequate. The nation's medical colleges devote two weeks to psychiatric training out of a five-and-a-half year curriculum of general training. There are only 42 training hospitals in the country, with few seats for those who wish to specialize in the field. All psychiatric patients receive the same drugs and therapeutic interventions regardless of their condition: the recovered, the curable, and the chronically ill.

Reform in custodial institutions is new in India and has been attempted mainly by charitable institutions and citizen organizations, who have worked outside the system. Sporadic investigative journalism has led to public interest litigation, but cases have rarely moved beyond the courtroom. State institutions have remained closed and resistant to outside scrutiny. Protocol and red tape have stifled every attempt to sustain progressive efforts within the system.




THE STRATEGY

Ratnaboli has decided to launch her reform at the Pavlov Mental Hospital in Calcutta, West Bengal, where it has been sanctioned by the State Health Minister and the Head of he State Human Rights Commission. Extensive research has documented that custodial institutions for the mentally ill in West Bengal are the worst in the country. The project will focus on incarcerated mentally ill women, who face severe psychosocial challenges when they attempt to reintegrate into their home communities. Such women may have slim chances of ever stepping out of prison.

Ratnaboli has assembled a team of occupational therapists, creative therapists, counselors, rehabilitation experts, and other experts to move into the Pavlov Mental Hospital with planned interventions. The team will work at three levels: with the mentally ill, with institutional personnel, and with the surrounding community. Ratnaboli and her colleagues will develop occupational, creative, recreational, and rights-awareness therapies to rehabilitate patients and provide them with informed, professional medical care. They will focus on democratizing the environment of care. Alongside dialogues and sensitization programs for doctors and decision-makers, they will provide the nursing staff with comprehensive training about rehabilitation techniques. They will devise solutions to personnel management concerns such as the high burnout rate, protection from violent patients, and professional acknowledgment, and create channels of communication between institutional heads and the nursing staff. At a later stage they will offer perhaps the most critical services: judicial assistance to institutions (through public interest litigation) and legal aid to recovered patients to accelerate their release and integration into their communities.

Rather than try to create a whole new organization, Ratnaboli is identifying colleagues from the mental health movement of West Bengal, in which she is a key player. She views the network of mental health activists as her primary lever for professional resources, strategic alliances, and national visibility. She is also building credibility for her idea within the upper echelon of the state's bureaucracy, to prevent resistance to her work once it is integrated into institutions.

The broader thrust of generating awareness and acceptance of recovered patients in their local communities invigorates Ratnaboli. She feels that this approach has enormous potential for generating broad citizen support for her idea.Through a creative combination of the media and information activism, Ratnaboli aims to convert local leaders, religious heads, and community elders to ease a client's integration. During the first year, Ratnaboli will integrate fifteen women back into their communities - an adequate sample to demonstrate the viability of her model.

Simultaneously, Ratnaboli will be developing the capacity of organizations and activists who are already working in other custodial care institutions, such as the Soroptomists, who are active in the Presidency Jail in Calcutta, and Sevak, which has been working in a home for vagrants in the city. These organizations will design models of professional medical intervention and human rights protection for the incarcerated mentally ill. As models are tested in a range of institutions, honed, and intensively documented, Ratnaboli will disseminate them among partners in the mental health field, as well as through linkages she is building with premier institutions such as NIMHANS in Bangalore, SCARF in Chennai, and the National Commission of Women in Delhi. Ratnaboli hopes to grow the model beyond national borders - for example, to neighboring Bangladesh.




THE PERSON

Ratnaboli Ray was born into a family of committed social activists. Her mother and grandmother were active in several of Calcutta's charitable institutions. The experience of meeting national leaders of the women's movement and organizing rummage sales and charity shows deeply impressed her young mind. Ratnaboli's decision to study psychology was prompted by her need to explore the psychic landscape of the underprivileged. Most importantly, she remembers the plight of her two mentally ill aunts, whom her parental families have yet to bring back from state institutions. She pursued postgraduate studies and thereafter worked extensively with drug users and their families in the shantytowns of Calcutta. She moved on to pioneer the first daycare center and short-stay home for the children of sex workers in Calcutta - today a thriving enterprise that has drawn much media and developmental attention.

Ratnaboli heard her real call in 1993, when she joined Paripurnata, the first half-way home for the mentally ill in West Bengal. Paripurnata was a fledgling organization then, when a Supreme Court order released recovered Non Criminal Lunatics from the Presidency Jail in Calcutta. Rather than see them herded into homes for the destitute, Ratnaboli stepped in and trained a team and designed a new program of "planned stay" and rehabilitation. Her first experience of working inside a prison gave her an up-close view of the system-induced misery that inmates suffer. Under her leadership, 23 women were integrated back into their communities and a 19 year-old Bangladeshi girl was repatriated.

The highlight of Ratnaboli's work came when local communities accepted both Paripurnata and the issue of reintegrating the mentally ill. She worked tirelessly with local youth clubs and the political and religious leaders of a poor neighborhood to spread awareness and build a positive public opinion about mentally ill persons. As a result, the local maulvis (Muslim religious leaders) would conduct awareness sessions on mental health inside the mosque after the Friday prayers, and refer problem cases to Paripurnata. The intensive experiences of working with institutions and communities firmed Ratnaboli's resolve to aim for a paradigm shift in government institutions.

Ratnaboli has also been a full-time volunteer coordinator for the Forum for Mental Health Movement, which under her leadership has attracted several key organizations and activists from the northeast and eastern parts of India. Most carry impressive credentials in the fields of mental health and action against state custodial violence. The organization is West Bengal's first really multidisciplinary consortium.




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