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Inside Sri Lanka’s National Mental Health Institute: A Photostory

The day is humid, but overcast. We arrive an hour earlier than intended and stand outside the tall, white, colonial-style building. It looks every bit like an ordinary, government hospital ‒ and it is. Contrary to popular opinion fuelled by misconceptions of mental health, the National Institute of Mental Health (NIMH) located at Angoda is clean, calm, serene, and well organised. The 30 wards are spread over the area like a network of roots, at the centre of which this majestic colonial building stands.

In colloquial language, “Angoda” is often referred to when making a derogatory pass at a person’s mental health. While many shrug it off as merely a joke, what it reveals is an underlying, systemic insensitivity and callousness towards issues of mental health, an attitude carried forward from generation to generation and embedded in our everyday language and phrases.

Tree of life. The large tree in front of the hospital looms beautifully in early morning monsoon light. The tree, standing wide and strong, with big fat roots going deep into the ground, symbolises the safe haven the hospital provides for the patients. Image credit: Roar.lk/Christian Hutter

Perhaps the biggest tragedy you will see at the NIMH arises from the stigma associated with it. Because of poor mental health awareness, it isn’t unusual to hear of patients who have been abandoned by their families, left to grow old with the staff. Some have lived as many as 50 years within the walls of this institution. In some cases, families have admitted the patient to the hospital, provided a false address, and migrated from the country. As a result of the stigma associated with mental health, the patients are considered a burden and abandoned ‒ when, in fact, the successful recovery of a patient would be accelerated if there was a friendly family environment to return to, and a society that welcomes rather than shuns them. Therein lies the key and the NIMH’s biggest battle: as one of the nurses explained to us, community support is just as important as the services the hospital provides to the patients. If the system, which ostracises them, doesn’t realise that the patients, too, are part of our society, and need to be accommodated and integrated, then stories such as the ones we heard while visiting Ward 22, the long-term rehabilitation ward, will continue to be the norm.

A child patient sings a Sinhala song from his songbook for us. He was eager to share his talent with us. After singing, he also showed us some of his batting skills. He was extremely smart and eager to learn and explore. He easily understood how my camera worked and even knew which generation my mobile phone was. Image credit: Roar.lk/Christian Hutter

The adolescent ward is home to 12 – 18 years olds, some of whom are being treated for extreme cases of ADHD and bipolar disorders. There are six rooms in this ward, with two adolescent patients sharing a room. The walls are decorated with art. Here, art and music are therapy, and key tools in helping the children cope. Family members are also allowed to stay with the patients. Unfortunately, the children have little access to any formal schooling during their stay at the hospital, but there are plans in the pipeline to rectify this. During our tour of the ward, they either shied away from us, or followed us around. Although they were well looked after, and the nurses and members of staff were extremely friendly, there is always something sad about seeing children confined in hospitals.   

Art in all forms is used as a form of outlet and therapy by the patients. Some play instruments and sing while others paint and create. We witnessed some truly stunning art during our visit. Image credit: Roar.lk/Christian Hutter

The forensic psychiatric ward only stands out from the others because of one primary feature: it is constantly under lock and key. The patients here have been referred to by the Magistrate court for serious crimes, and are under treatment for various illnesses including schizophrenia and bipolar disorders. Some of the patients have anger management issues and no coping mechanisms, and have committed crimes as a result of their mental disorders.  Our guide explained to us that despite the nature under which these patients have been admitted to the hospital, the hospital staff don’t consider them criminals, but regard them as patients dealing with mental illness. The patients in this ward follow a daily activity plan. On Wednesdays, they attend an open school programme. Most of the patients lack education, and so the hospital has introduced programmes to increase literacy. After lunch on most days, they are encouraged to read books, and are given music, drama, kitchen, and play therapy, which includes sports like cricket and volleyball. In the recreation area of the ward, there is a bookshelf with books in various languages, and a gym with exercise machines.

“Things I Like”: the recreational area of the forensic ward is decorated with posters made by the patients. This one – the medical officer in charge tells us – was made by a group of patients as part of their occupational therapy and rehabilitation programme. It is a collage made up of newspaper cutouts of things the patients feel positively towards. Image credit: Roar.lk/Minaali Haputantri

A patient from the forensic psychiatric ward hides behind a folded newspaper. He showed me an article about cricket in one of the papers that he seemed to have an interest in. He had several other newspapers in his pockets too. After showing me his collection of newspapers, he offered me his tea and a seat in his chair. Most of the patients were happy to see us and were very welcoming. Image credit: Roar.lk/Christian Hutter

The wrinkled hand of an elderly patient in the forensic ward of the hospital. Image credit: Roar.lk/Christian Hutter

Two patients from the forensic ward are seen reading the papers at the reading station. Even though they can’t leave their ward, they have a connection to the outer world. They can read the papers and watch TV, and the whole place has massive windows that let in enough light and fresh air. Image credit: Roar.lk/Christian Hutter

Patients of the main and forensic psychiatric wards clean and wash their own clothes. Here, some of the clothes are hung out to dry. The hospital tries to make life in the wards as normal as possible. Image credit: Roar.lk/Christian Hutter

While most of the wards were spacious, the geriatric ward is perhaps the least comfortable looking ward on premises. When asked as to why this particular ward looks cramped in comparison (to put this in perspective, the general ward for women alone included an open ground area for patients to access), the nurse explained that this ward is a newer addition in comparison to other wards, therefore resulting in an allocation of limited space. Compared to the rest of the wards, this ward, in particular, looked wanting. In the male geriatric ward, an elderly patient stared at a TV screen that was barely functioning. All the patient could see was the middle section of the picture. The rest of the screen was obscured by static. Most wards had relatively decent looking TVs for the patients, but the TV in this ward was tiny and malfunctioning. The doctor in charge explained that while the government provided for the basic amenities, there were a few things, like adult diapers for instance, for which they relied entirely on donations. In the women’s geriatric ward, the doctor in charge explained that the biggest problem they were faced with were specialised beds suitable for geriatric patients. They had only five beds in the ward that met the required specifications, and as a result, the doctor explained, there were cases where the patient would fall, resulting in injuries and even death. Most patients here suffer from dementia and problems related to memory loss. Some don’t have families, or cannot find their families because they have forgotten, and as a result join the list of patients who while away their entire lives within the institute.

The ageing patients at the hospital require adjustable beds with railings on them, but there aren’t enough to go around, resulting in a lot of falls, which lead to even worse conditions. A patient in the ward, who had just experienced such a fall, was full of hope that things would someday be okay – “God will provide,” she said. Image credit: Roar.lk/Minaali Haputantri

A patient in recovery following electroconvulsive therapy. The administering of ECT is a daily occurrence at the NIMH, as part of patients’ treatment. Image credit Roar.lk/Minaali Haputantri

Occupational Therapy plays an important role in the rehabilitation process. We spotted a patient sporting a guitar at the entrance. Inside, the nurse in charge explained that they identify patients suited to receiving occupational therapy, where they encourage patients to engage in activities and special programmes. Music, sports, ADL training, anger management, concentration, communication improvement are some of the areas they focus on. The staff assess past occupations of the patients and help them further develop their interests. There are special rooms dedicated to weaving, leather craft, painting, jewellery making and sewing.

A patient mends a cane chair as part of his occupational therapy. Much of the furniture sent here to be mended belong to the wards, and this is another example of the patients being trained to look after themselves. Image credit: Roar.lk/Minaali Haputantri

Patients at the hospital are encouraged to channel their energy into creative pursuits.The four patients in this room were making leather key tags, with one of them cutting the sheets of leather into shapes, the next drawing out the patterns, another outlining them, and the lady pictured here painting them in Image credit: Roar.lk/Minaali Haputantri

A patient in the occupational therapy unit colours in a picture. The art room in the occupational therapy building is decorated with pictures painted by the patients over the years, some of which are up for sale. Image credit: Roar.lk/Minaali Haputantri

A new-look ward: renovations are in progress to give the wards a facelift. Many of the existing wards – though well maintained – haven’t been upgraded in years, due largely to the lack of donations coming in. Image credit: Roar.lk/Minaali Haputantri

A nurse takes care of a patient’s baby in the perinatal unit of the Hospital. The perinatal ward feels very homey and cosy, to give the feel of a real home to the often young mothers and their children. Image credit: Roar.lk/Christian Hutter

Despite the range of wards on the hospital premises, what stood out was the fact that the staff, the doctors and the patients were exceptionally nice people, debunking all misconceptions about the kind of people who are normally found at the NIMH.

The silhouette of a patient in the general psychiatric ward is seen through a glass door. He was so kind to open the door for everyone passing through. When we were passing by a couple of hours later he was still manning the door. Image credit: Roar.lk/Christian Hutter

Apart from limited funding, however, the NIMH’s biggest battle is with stigma, and it isn’t only the patients who feel the brunt of it. Even the doctors, nurses and staff who work at the NIMH are treated with the same degree of reservation. One of the doctors noted that even after working at the NIMH for several years, his friends still make fun of his profession. Adding to the NIMH’s list of problems is the fact that they have fewer mental health professionals than the quota demands.  

Female patients converse with a nurse through the door that opens into their ward. Contrary to popular belief, most patients at the NIMH are active and full of life, and eager to converse with whoever visits them. Most of them asked us where we were from, and some of them even asked us to join them in a ball game. Image credit: Roar.lk/Minaali Haputantri

An elderly patient whiles away the time on a sewing machine. The patients at the NIMH are encouraged to maintain themselves to the best of their ability, and this includes mending their own clothes whenever possible. The lady in the picture was mending not only her own clothes, but clothes that belong to patients who are not able to do so for themselves. Image credit: Roar.lk/Minaali Haputantri

The nurse who took us on the tour explained that while there is a total of 71 male patients in the long term rehabilitation ward, there are 465 female patients in long-term rehabilitation for women. The stark difference in numbers is a result of the fact that the hospital has realised that reintegration into society for female patients is much harder than for male patients due to many social issues. For instance, in a conservative society like ours, it is more difficult for a woman to live by herself, especially if she has mental health issues. In addition to this, they are doubly vulnerable in comparison to their male counterparts, because of the unequal treatment women receive in society.

A patient in the forensic ward looks out at the garden. All the patients at the NIMH are encouraged to pursue some sort of creative activity, sometimes in the form of horticulture. Image credit Roar.lk/Minaali Haputantri

What it comes down to is our attitudes. Even the language we utilise, in most cases flippantly, only serves to deepen the many misunderstandings and misconceptions we have about mental health, conveying an attitude that makes it very clear that we’re referring to an “other”, when, in fact, mental health issues, including one’s own, should be everyone’s concern. The stigma associated with the NIMH and mental health, therefore, only serves to divert and diffuse the much-needed attention towards mental health and mental health issues, and exacerbates the situation for most patients. It is a reminder of how much sensitisation and awareness is required in Sri Lanka. Until mental health is given the same treatment and care as other illnesses, it is difficult to imagine a day when someone is able to mention the fact that they had once been admitted to the NIMH, without being ostracised and treated as lesser.

With contributions by Christian Hutter, Minaali Haputantri and Gazala Anver

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