Lessons from India: Families and culture

by Patrick J. White
MB, BCh, BAO, DCH, Dip OBS, MRCPsych

I recently spent a month in India doing voluntary consulting work for a non-governmental organization in and around Madurai, a city of a half million inhabitants in the southern Indian state of Tamil Nadu.

My experience in India was one of extreme opulence but also one of extreme poverty. I found mental health issues in India echoed issues worldwide. The differences lie in their presentation, perhaps due to cultural and economic difficulties.

The crown jewel of India is its 1.2 billion people. They are resourceful, friendly, helpful and very supportive of each other. Nowhere is this kindness and support more evident than within families—particularly in my experience, families struggling with mental health problems.

However, this does not mean stigma doesn’t exist. Patients with psychiatric disorders have been stigmatized within the population and the public as a whole, and also within families.

In 2001 there was considerable dis-quiet in India when over 20 people with mental health problems were burned to death in a psychiatric institution in Tamil Nadu. It was revealed that up to 4,000 patients in this psychiatric facility were housed in a very restrained manner because of the system’s inability to look after them.

The resulting outcry in India contributed to changes in attitudes towards patients with mental health problems in the state of Tamil Nadu. Mental health issues are highlighted much more in the media. There are many articles about the health care system in general, but also an increasing number of articles specifically about the plight of the mentally ill. As in Canada, the stories are about service delivery and access to service. The difference is poverty. I personally witnessed one family who, due to poverty and lacking alternate strategies, kept a family member at home in restraints for seven years. Eventually the patient was seen in his home and prescribed medication. The psychosis resolved; he is now functioning well in a supportive family environment.

The degree to which families go to look after family members was a real eye-opener. Where government funding for mental health is lacking it is the families who fill the gap. I witnessed the significant empowerment of the family and saw them exercise a voice in how services could be delivered to their loved ones. Family members work and volunteer in the community mental health setting—a woman taught in her daughter’s school, a mother volunteered in the handicap unit where her two children resided, and patients and families worked along with staff in a small strip mall where they successfully built a small business and made a living out of it.

What can we learn from the people of India? Sometimes families have difficulties dealing with the stigma of mental illness. Often the nature of the illness and its symptoms arouse conflicting emotions within the family—they feel for the pain experienced by their loved ones, but react negatively to issues such as poor hygiene and socially unaccceptable behaviour.

In these times of difficulty, culture plays a critical role—either helping (as is the case in India) or hindering the family’s ability to support a family member suffering from mental illness. As physicians we are aware of the stressors families face. We are aware that negative emotions expressed toward the patient can increase the likelihood of relapse.

But are we aware of the need to foster cultural support within families? I am not sure we are.

As families struggle to deal with mental illness, it is essential that we work with them to address stigma within the family and its accompanying emotions. It can be difficult, but we all know that the prognosis is better with good treatment and supportive families.

When we travel we realize that we’re very fortunate to be living in a wonderful country such as Canada. Our standard of living is among the best in the world. Despite this high standard we struggle with issues of culture, stigma, family burden and service delivery. Working with families is a very important part of finding the solutions that will result in optimal care for patients.

Just as we need to expand how we work with families, we also need to expand how we work with the mental health community. I believe that we are in a time of great opportunity. Never before has mental health been discussed as much in the public domain. There are many province-wide initiatives and the Mental Health Commission of Canada has highlighted this issue nationally.

Of note is the recent federal budget announcement giving the Commission a one-time grant of $110 million. This grant is targeted towards innovative demonstration projects aimed at developing best practices to help homeless Canadians affected with mental illness.

I see this as a gesture of faith in the Commission and its mandate to lead the development of a national mental health strategy, to build a knowledge exchange centre, and to address stigma.

As physicians, we too can seize this time of opportunity and transform it into good service delivery for the chronically mentally ill. We would command the respect of colleagues, administrators and politicians if we take the initiative. Taking the initiative means we must form alliances with psychologists, social workers, occupational therapists and other disciplines. It would be better for us all to speak with one, organized voice. We must be open to affiliations and collaborations.

This strategy was highlighted by Dr. Ty Turner in his recent lecture to the Ontario Psychiatric Association in Toronto. He said the lack of human resources often drives us into alliances and affiliations, and forces us to work together for the common good of service delivery.

This also holds true for advocacy. Only by working in concert with all disciplines can we maximize our advocacy efforts.

© Copyright 2008. Canadian Psychiatry Aujourd'hui. All rights reserved.

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