“I was taken to hospital without my consent. They restrained me when I refused to be medicated, and gave me an injection to sedate me. I had a full-time job, supporting my mom, and yet I was ‘diagnosed’ as having Bipolar Affective Disorder without a proper clinical interview or case history being taken. I had just wanted to move out of home. I was heavily medicated and sedated for more than a month. The psychiatrist rarely spoke to me, and a junior doctor only asked me two questions each time he spoke to me. ‘Are you straight’? ‘Are you a Buddhist’?.
Shiromi*, 28.
Sri Lanka as a nation has come a long way from the days of Veerapuran Appu and Gongaale Godabanda. Wars have been fought, peace has been achieved, at least theoretically and we continue to be the resilient island we always were. However there are still issues that are pushed under the carpet, and mental health is one of them.
The dictionary definition of mental health does not fully take into account the impact of societal norms, cultural concepts, personal biases and prejudices that hinder an individual’s problems from achieving full potential, or from contributing effectively to his or her community. It certainly does not account for the crippling nature of systemic and personal stigma that surrounds individuals and families with mental health problems in Sri Lanka.
An individual’s mental health or the lack of it is only one part of his/her identity, but it often becomes the key attribute through which the individual is identified, and spoken about. Stigma can be systemic where communities, families and institutions perpetuate negative attitudes and stereotypes about people living with mental health difficulties. Systemic stigma often trickles down to cause personal stigma and this is influenced by beliefs about causation, and certain myths and misconceptions propagated by the media.
“I have been diagnosed with depression previously but medical professionals did not encourage me to go any further. I did not take medication because I knew my mental health was a symptom of something bigger. It turned out I had an autoimmune disorder that caused hypothyroidism which led to depression. It took other symptoms and two years of my own research to get a proper diagnosis. I felt like mental health professionals did not listen to me or really take the time to understand what I felt. While I displayed signs of systemic depression, most of them said I was being spoilt and that life is hard for everyone.’
Rushani* 30
Institutionalisation and stigma
We have moved forward from the days of pouring concoctions down people’s throats, whipping and beating, and the use of other inhumane methods to ‘treat’ mental illness towards more compassionate and scientific methods. However, institutionalising someone experiencing psychological difficulties contributes to the already existing stigma and discrimination surrounding mental illness.
Ward 59 at the National Hospital of Sri Lanka is one of the better known in-patient treatment facilities in the country. However, the dark wards with poor lighting, the condition of the washrooms, and most importantly, its location next to a garbage dump speaks a great deal about how physical spaces where mental health problems are treated contribute to negative attitudes and perceptions around mental illness.
It also indicates the level of priority mental health is given by the government. A visitor walking in to Ward 59 will mostly see heavily-drugged service users, bleak walls with peeling paint, and cold, clinical rooms. There is no warmth or comfort within those walls. One can feel the despair within Ward 59, and hear the echoes of convulsions induced on many a service user.
Another such example is the Office of the Judicial Medical Officer (JMO) of Colombo. Children and young people who have been victims of abuse, rape, and other heinous atrocities come to the JMO’s office for counselling and medical support. The counselling room is situated right opposite the mortuary. How can a child feel comfortable and safe in such an environment? The putrid stench of formaldehyde mixed with traumatic memories of abuse is far from healing.
The National Institute of Mental Health (NIMH), previously known as the Angoda Mental Hospital, is another pioneer institution catering to the needs of those with mental health problems from all around Sri Lanka. The stigma associated with being a service user at this institution is so strong that the previous administration had to take measures such as changing the name of the hospital to make it less stigmatising. They also opened out the institution for families to visit, and created user-friendly spaces for individuals to feel less restricted.
However, try telling a tuk tuk driver that you want to go to Angoda (not necessarily the hospital) or telling someone that you live in Angoda. The reactions are so telling of the negative attitudes and perceptions that exist around mental health problems in the country.
There have been improvements made to the infrastructure and facilities available within the hospital, but the care afforded to service users is something that requires evaluation. The service user-staff ratio is one of the largest in Sri Lanka, and there is so much that can be done to enhance the quality of life for service users seeking treatment.
Having walked around the hospital more times than I can remember, what I have often seen is a lack of enthusiasm and general apathy in the nursing and minor staff. I wonder whether they are also marginalised in their communities because they work with people who live with mental illness. I often think about whether that is a reason for them to appear so distant and disconnected from service users in their care. I believe that attempts at befriending, engaging service users in activities and interactions can really improve their outcomes far more than just prescribing medication and electro-convulsive therapy.
The stench of urine and feces is what you are immediately confronted with when you enter the geriatric ward at NIMH. What does that do to service users and their families, at least those families who don’t abandon the elderly? Service users often are seen staring into space, and the staff having a nice cozy chat between themselves. I often wonder whether the elderly are seen as hopeless cases, that the stigma seeped into every nook and cranny of the hospital.
Shan*, 25 was admitted to a renowned hospital in Colombo following a suicide attempt. The doctor who was managing his liver had repeatedly interrogated and humiliated him before the nursing staff. People at his workplace knew about the incident and questioned him when he returned, because one of the junior doctors who treated him was a good friend of one of his colleagues. There was absolutely no confidentiality.
Do service providers and institutions contribute to perpetuating the stigma we are fighting hard against, the stigma we all talk of wanting to end? The stories shared with me, for the purpose of writing this article, and from what I have seen and experienced as a mental health professional in Sri Lanka, all suggest that there is so much work to be done in this regard. As much as we boast of literacy and top class educational facilities, we also need to improve on our mental health literacy.
Stigma and the family
The family unit bears the brunt of caring for those with mental health problems, due to the lack of adequate services and professionals in most parts of the country. They are tasked with the enormous responsibility of providing care for those struggling with their mental health. However, there are legitimate concerns that most families of individuals with mental health difficulties face in Sri Lanka;
“How will I get my daughter married, if people find out that my son is mentally ill?”.
“What will people say”?
“Will my son get bullied in school because my husband is mentally unwell?”
There is a sense of isolation and disconnection from the community, a ‘wall of silence’ is built around the family and their home, especially after a death by suicide. Funerals houses are generally empty, and it’s the family alone that cremates or buries their loved one. The stigma can be so dehumanizing that it causes families to shield members with mental illnesses from society completely, and can cause families to rip apart.
Stigma and the media
This is an institution that I always struggle with as a mental health professional, because there is a serious lack of ethical reporting practices for mental health problems and suicide. The media has been criticised for glorifying and sensationalising suicide and self-harm, and also for their apparent lack of respect for privacy and confidentiality. Negative stereotypes about mental health or mental illness are often portrayed in both mainstream and social media. The information given out can elevate stigma and also cause people to receive wrong information that can be harmful. Guidelines have been developed for the media on ethical reporting by the World Health Organization, but it is always a struggle to engage with the media so that they follow the guidelines.
Not only can following ethical reporting guidelines prevent mental health concerns from being perceived in a negative light, they can also promote positive health practices and most importantly help-seeking behaviour. Including helpline numbers in an article published about mental health or psychosocial issues can go a long way in helping people access support when required. Collaborating with competent mental health professionals can also a be a useful way of providing appropriate information to the public.
Stigma and discrimination takes many shapes and sizes, and it is one of the key factors that prevent people from recovering from mental health problems and often leads to poor outcomes in health and well-being. However, there are steps that we as citizens of this nation can take to promote better understanding and knowledge around mental health and also to prevent those living with mental health problems from being discriminated and ostracised in their families, schools, workplaces and communities.
It is sometimes convenient for us to blame ‘society’ for all its prejudices, and stereotypes. However, you, the reader and I, the writer – we are also part of society. Hence, it is important that we constantly reflect on our prejudices and biases and be aware of how we ourselves perpetuate stigma. We need to start having conversations about our mental health, and also create safe spaces where other people can talk about their mental health openly. I believe that medical professionals (not just those working in mental health) need to be trained to deliver services sensitively and proactively. You and I cannot do this alone – we need our government to support us. Those responsible for the health and well-being of our nation need to step up and take steps to work towards better mental health and psychosocial well-being for the entire country, starting from appropriate budget allocation and campaigning for mental health literacy.
We are in this together, you, me, policy-makers, law-makers, everyone. The onus is on us to advocate for and perpetuate less stigma and promote more understanding. The road is long, with curves and bumps, but as long as we chase after what’s right, together, there is always victory to be achieved.
Editor’s Note: Also read “The Reality of Suicide in Sri Lanka: Need for data-driven analysis” and “From isolation to integration: Addressing stigma on World Mental Health Day.“
*Names and identifying details have been changed to protect the privacy of individuals.
If the content of this article caused any distress, please seek help by calling the following helplines. 0112696666, Sumithrayo, 1333, CCC Line, 0717639898, Shanthi Maargam.