Indianization of psychiatry utilizing Indian mental concepts

Abstract

Most of the psychiatry practice in India is guided by the western concepts of mental health and illness, which have largely ignored the role of religion, family, eastern philosophy, and medicine in understanding and managing the psychiatric disorders. India comprises of diverse cultures, languages, ethnicities, and religious affiliations. However, besides these diversities, there are certain commonalities, which include Hinduism as a religion which is spread across the country, the traditional family system, ancient Indian system of medicine and emphasis on use of traditional methods like Yoga and Meditation for controlling mind. This article discusses as to how mind and mental health are understood from the point of view of Hinduism, Indian traditions and Indian systems of medicine. Further, the article focuses on as to how these Indian concepts can be incorporated in the practice of contemporary psychiatry.

INTRODUCTION

Most of the psychiatry practice in India and around the world is guided by the western (American and European) concepts of mental health and illness. These concepts of psychiatry which have dominated the field in the last century or so have mostly been developed for individuals with an internal locus of control (as in the west) and have largely ignored the role of religion, family, eastern philosophy and medicine in understanding and managing the psychiatric disorders. It has also been increasingly recognized that there is a significant difference between the east and the west in the distribution, phenomenology, treatment seeking behavior, and prognosis of people with mental illness. Hence, now there is an increasing focus on the role of Eastern concepts in understanding and managing psychiatric disorders. In recent times, there has been a greater emphasis on person-centered approach,[1] which emphasizes that treatment and care should be provided by health services by placing the sick person and their caregivers at the center of care. Practice of person-centered approach requires that the treating physician must have better understanding of the patient's socioeconomic, ethnic, cultural, religious, and spiritual beliefs, etc., When one tries to incorporate these aspects of the patient in psychiatric care, the currently practiced western models more often than not come in conflict with the needs of the patients.

India has a vast population comprising of diverse cultures, languages, ethnicities, and religious affiliations. Besides this, India has its traditional system of family. To a certain extent, the Indian families maintain until today, a great degree of cohesiveness and the members of the family show readiness to cooperate with one another on issues like taking care of sick relative, making career choice, marriage, etc., Given the differences between the Indian and western population, utilization of western psychiatric concepts for treatment of Indian patients is a largely myopic.

When somebody tries to understand what Indian traditions can offer to psychiatry or what is different in relation to Indian patients, one need to understand the traditional Indian systems and predominant religion in the country (Hinduism). These do shape the patient's reporting of the symptoms, reaction to stress and symptoms, help-seeking behavior, coping with distress, acceptance of suggested treatment, family's reaction and reaction of community in general. In this article, we first discuss how mind and mental health are understood from the point of view of Hinduism, Indian traditions and Indian systems of medicine. In the second half of the article, we discuss how some of these Indian concepts can be incorporated into the practice of contemporary psychiatry.

HINDUISM AND MIND

“Hinduism” is not the original name of Indian religion and those who followed the same since the ancient times never gave it any particular name except for “dharma,” which simply means “the eternal law that supports and sustains those who practice it.” The words “Hindu” and “Hinduism” were used by ancient Persians identifying people inhabiting the banks of river Sindhu (Indus). In the language of ancient Persians, the ‘S’ of Sanskrit became ‘H’ and this name has continued since then.[2]

The major scriptures of Hinduism are the Vedas, the Upanishad, and the Bhagwad Gita. Among these, Vedas are considered the oldest and the tenets and earliest concepts of Hinduism are recorded in the four Vedas viz., Rig Veda, Yajur Veda, Sama Veda, and Atharva Veda. The Vedas describe the worship of God in natural elements such as fire, water, wind, etc., This main purpose of worship was to express gratitude for survival of creatures. Over the years, this worship of God has taken many different forms, which include elaborate systems of rituals and sacrifices to please the Gods. When one tries to understand the concept of mind and mental illness from ancient Hindu knowledge - Rig Veda and Yajur Veda, it suggests that mention of prayer through mantras (rhymes) can lead to formation of noble thoughts in the mind which help in the prevention of mental pain (depression). The Rig Veda, also discusses about the speed of mind, curiosity for methods of mental happiness, prayers for mental happiness, methods of increasing intelligence and power of mind in healing.[2]

Yajur Veda and Atharva Veda conceptualize mind as the basis of consciousness, inner flame of knowledge, cite of knowledge, and an instrument of hypnotism. Different Vedas also provide detailed descriptions of preservation of will power, emotions, inspiration, and consciousness. The text also describes emotional states like grief, envy, pleasure, hostility, attachment, laziness, etc., There is also a description of Unmada (psychosis) as a deluded state of mind.

The Upanishads provide descriptions of theories of perception, thought, consciousness, and memory. There is a description of prakritui, which can be considered as equivalent of personality in modern psychiatry. The Upnishads describe the different states of mind: waking state, dreaming state, deep sleep state, and Samadhi. The psychopathology of the mind was understood in terms of their trigunas and tridosas.[2]

The Bhagavad Gita provides a description of emotions and cognitive deviations. The Bhagwad Gita also gives beautiful description for gaining mastery over the vacillating mind and also describes the consequences of failure to attain such mastery. Essentially, The Gita shows a way out of worldly concerns and teaches that a person can be his/her own master.[2]

HINDU RELIGION AND INDIAN TRADITIONS

Important aspects of Hinduism include emphasis on spirituality and philosophies of introspection, idealism, Karma, Dharma, considering all life as sacred, and ancestor worship. Spirituality predominates both in life and the philosophy of living. Material welfare is never recognized as the only goal of human life. The introspective approach emphasizes evaluation of inner life and self of man rather than the external world of physical nature. The idealistic philosophy basically emphasizes the direction of monoistic idealism and the belief that reality is ultimately one and spiritual.[3]

As described by Wig,[3] the broad Hindu view of life can be summed up in four basics aims of life, i.e., Dharma, Kama, Artha, and Moksha. Dharma is understood a righteousness, virtue, or religious duty. It also means goodness of purpose and selflessness. The highest Dharma of a Hindu is to practice “Ahimsa” or non-violence.[4] “Kama” refers to the fulfillment of the biological needs or sensual pleasures. “Artha” refers to the fulfillment of social needs and includes material gain, acquisition of wealth and social recognition. “Moksha” means liberation or release from worldly bondage and union with the ultimate reality. Among these, “Dharma” is considered to be the central axis around which life revolves. If somebody tries to move away from dharma, it usually results in suffering, for example, if one just pursues “Kama” or “Artha” without “Dharma,” then in the long-term it will result in suffering for the individual and others around him.[4]

The Hindu ideally believes in one creator and a supreme reality which is the ground for one's divinity.[3] This divine reality is called as Atman, Brahma or self, which is seen to be present in all creatures, one and the same in everyone and not different from God.[5] This divine reality is considered to be beyond description and “pure” and makes the eyes see and the minds think. This divine power is changeless, holds everything together, creates, destroys, and recreates. This informing power or spirit, as God is recognized by many names and accordingly although there are multiples Gods, but they are the one and the same, named differently and are considered to be reincarnation in different time frames.[4]

Although Hindus believe that God is ever loving and purely benevolent, they also believe that people who feel guilty about their wrong doings may perceive God as punitive or punishing. Due to this fear, they may worship images of God that look angry and frightening. Hindus believe that God is there in all lives and manifests as love, truth, and light. Therefore, all lives are sacred, and have to be loved and respected. This belief gives rise to the concept of Ahimsa or non-violence.[4]

According to Hinduism, all deeds of a human being are called Karma and the law of Karma states that every event is both a cause and an effect and the basic philosophy is “as you sow, so shall you reap.” Every action will have its reaction and every cause will have its destiny determined in due course of time.[6] Accordingly Hindus believe that their suffering from mental illness is also due to Karma of the past. This law of Karma also states that we can change what happens to us by our awareness and efforts to change ourselves. Therefore, such beliefs can be used in the therapeutic situations to improve the motivation of the patient to change for betterment. Another concept which has significant importance in Hindu philosophy is the reincarnation, according to which soul is considered to be immortal and takes many different births until it is completely self-realized. The soul keeps on taking different births till it realizes self and unites with the creator. This is also called as Nirvana, meaning the stage when the soul ultimately finds spiritual knowledge and becomes realized and is liberated from the cycles of birth and death. Therefore, a Hindu's ultimate goal is to live a life by ways of conduct as described by Dharma. Such a life progresses in self-realization.[4]

Hindus believe that ancestors watch over them and due to this they revere and worship their ancestors. Some Hindus feel that their ancestors give them guidance and positive thoughts while some feel that their ancestors are angry with them for failing to carry out their desired rituals after death.[4]

Jainism and Buddhism can be conceptualized as offshoots of Hindu philosophy. The Jain religion came into existence around the 6^th century BC, about the same time as Buddhism. Jainism shares several beliefs with Hinduism, including reincarnation, Karma, and non-violence. According to the Jains, the entire universe is alive. One should abstain, as much as is possible, from violence toward any living creature. Everything, including rocks and stones as well as plants and animals, is, in some sense alive. The idea of ahimsa, or non-violence, is heavily stressed by the Jains, having far-reaching implications for them. The ultimate objective is denial of the body and purification of the soul, as a necessary step to win the soul's release from matter. Buddhism too originated in India and Buddhists too believe in Karma and reincarnation. Buddhists reject the idea of the self or soul, believing it to be an illusion brought about by one's attachment to the worldly things. The Buddha taught that life is a stream in which no permanent self-endures. Individuals are composites of perception, feeling, volition, intelligence, and form, all subject to the law of Karma. Life is essentially suffering, desire is the cause of suffering, and the path to Nirvana (or salvation) involves the cessation of all desire. Non-attachment to food was generally practiced as one way of withdrawing from desire. Compassion for animals was also urged in recognition of the shared life of all creatures.

The concept of “Ahimsa” that is so predominant in Indian spiritual and philosophical systems also impacts lifestyle choices like diet. India has a large number of vegetarians and stems from abhorrence of violence in any form toward “living things.” From the 3^rd century AD onward, the use of beef was increasingly restricted. In the 4^th century, the Law of Manu again restricted meat-eating to sacrificial occasions. The life of Krishna was written down in the Bhagavad Purana during the 5^th century. Hindu vegetarianism received its strongest impress from the Krishna cult, from whom the revering of the sacred cow in Hinduism originated. This perspective persists until this day. It must be remembered that though vegetarianism is a way of life for millions of people, it does increase the risk of certain deficiencies like Vitamin B₁₂ if adequate dietary precautions are not taken and such deficiencies may lead to the development of psychiatric manifestations.

Indian system of medicine: Ayurveda, mental health and mental disorders

Ayurveda is the Indian method of medicine, which is based on the traditional texts of Vedas. Medical texts dating back to the 1^st and 2^nd century AD describe in detail the principles of Ayurveda. Of the various texts, Caraka Samhita deals with medical diagnoses and treatment. The Caraka described the human body as being an aggregate volume of cells where growth depends on Karma, Vayu (air or bioenergy) and Svabhava (personal nature). Life or AYU is described as a combination of Shareera (body), Indriya (senses), Satva (psyche) and Atma (soul). According to the Caraka, the mind provides direction to the senses, control of the self, reasoning, and deliberation. Further, the descriptions include the theory of Triguna or the theory of three inherent qualities or modes of nature. These three gunas or the three operational qualities of mind are: Sattva (variously translated as light, goodness or purity and includes self-control, self-knowledge and an ability to discriminate or make well thought out choices), Rajas (action, energy, passion and is indicative of violence, envy and authoritarianism) and Tamas (darkness, inertia which reflects dullness and inactivity). The theory of three gunas is also used to describe different types of personalities.[2,4] According to the various permutation combinations 21 different types of personalities are described. Ayurvedic texts also give description of insanity (Unmada) and spirit possession (Bhutonmada).[2]

Traditional methods of controlling mind: Yoga and meditation

Yoga is a discipline, which has evolved in India several thousand years ago with the basic aim of growth, development and evolution of mind. The ultimate goal of yoga is to control one's own body, to handle the bodily senses, and to tame seemingly endless internal demand.[7] It offers a world view, a lifestyle and a series of techniques by which changes in human awareness can be brought about which can help in realizing the human potential. There are various systems of yoga. However, all aim to achieve the same, i.e., bringing about altered states of consciousness, which is known as the cosmic consciousness, transcendental illumination, or samadhi. It is said that correct practice of yogic techniques gives rise to certain types of reactions within the person, which facilitate qualitative and quantitative changes in awareness.[1] It is considered that regular practice of yogic exercise reduces psychological tension, as well as reduces the decline in physical health.[7] In recent times, yoga and meditation have received wide acceptance and popularity all over the world.[2]

Indian psyche

When one tries to define Indian personality in general, it is proposed that the inner self of an average Indian is lodged in a “circle of intimacy” or the family.[8] Unlike the western man whose self-hood is confined to his own body, the Indian self diffuses into the intimate circle, with bond, bondship, and kinship becoming the fulfilling elements of life. Within these close ties, Indians can communicate without the fear of rejection, depend on sympathy, comfort, and support without considering them as charity. From childhood, social relationships in Indians are spread over several people like grandparents, uncles, aunts and siblings, and hence, parents are not the sole guardians or regulators of the child. With the growth of the individual, a series of similar relationships of varying intensity and duration develop and at no point of time do Indians assume full individual responsibility. Even marriage marks the development of a new set of relationship instead of independence. Hence, unlike the singularity, self-sufficiency and independence of western self-hood, the core Indian psyche is based on intimacy, family security, and stability.[7] Under these circumstances, the boundaries between “me” and “not-me” tend to get blurred, and for Indians, “we” rather than “I” becomes important.[9] As discussed earlier, Indian psyche is also influenced a lot by the Hindu philosophical beliefs of transmigration of soul, re-birth, and fatalism. The inner self of Indians has been enriched through the ages by the integration of different religions, languages and cultures, as the various invaders who came to India sooner or later mingled and became one with the Indians. Therefore, it was only at the time of British colonialism that the greatest challenge to the Indian self was posed by an “invader”, who, for the first time in Indian history, made no efforts to integrate with the ever expanding Indian psyche. Under these circumstances, instead of undergoing a radical change in the inner self, Indians sought to resolve the conflict by postponement and avoidance. Identity models were compartmentalized and behaviors conformed to the demands of the situation. The other model used to resolve the identity crisis was identification with the victor by internalizing them, in this case the western belief of self. However, the original Indian self-remained as before, making its presence felt time and again. Until date, this fragmented, multifaceted representation of the Indian self persists without creating any significant inner turmoil or crisis.[8] Understanding this dualism is useful not only in conceptualizing mental-health problems and their management in the Indian context but also to throw light upon the coping, resilience, attitude toward mental-illness, and treatment seeking behavior of Indians.

Indian family

Unlike the west, the Indian society is a collectivist society that emphasizes on family unity and integrity.[10] For an average Indian, his family is an integral part of himself as they are included in the “we” and “circle of intimacy.” As the family is almost inseparable from the individual, managing patients especially those with mental illness without taking the family into account is almost impossible. Given the available resources as well as the social paradigm, the family has to bear a greater responsibility than the state in caring for patients. Also, presence of family members is quintessential part of psychiatric treatment and they invariably accompany the patient during the hospital visits, aid in treatment decisions and facilitate the rehabilitation of the patient. It has been reported that in India, there is greater involvement of the family members in the treatment decision, career choice, and marriage of patients.[11] The families, especially the rural ones, are usually quite tolerant to persons with mental illness. It has been shown that the joint families help in dividing the burden of care for the mentally ill and this in turn results in better course and outcome of mental illness.[12–14] The concept of expressed emotions in the family set-up has received extensive research in the western world and it refers to the affective attitudes and behaviors of relatives toward a family member with psychiatric illness and has been closely tied with relapse in psychiatric disorders, especially schizophrenia. High expressed emotions among relatives of individuals with schizophrenia defined by the western operational criteria ranging from 67% in urban USA to 8% in rural India.[15,16] In the Indian set-up, over involvement is to be expected because the individual is part of the larger kinship group. Over involvement is intertwined and that warmth might act as a key protective factor.[10]

In the Indian family setup, males and females have clearly demarcated and different roles as well as different positions in the hierarchical system. Indian women are expected to be chiefly concerned with family and household issues while men are expected to be the chief decision makers and bear the financial responsibility for the household. Unfortunately, women in the Indian families lack autonomy, decision making power and access to independent income, and many other aspects of their lives and health will necessarily be outside their control.[17] This increases their levels of susceptibility and exposure to various kinds of health risks as compared with men and inevitably set limits on their opportunities for exercising control over the determinants of their mental health. Elucidating the defining characteristics of women's lives is a necessary precondition for any convincing, socially contextualized account of the gender specific risk factors for adverse mental health outcomes. Little education, early age at marriage, adolescent pregnancy, repeated pregnancies at short intervals due to lack of access to or the cultural unacceptability of family planning, son preference and less food being given to girls and women, all increase the likelihood of physical and psychological health problems. All are influenced if not caused by social and cultural, not biological forces.

Indian coping style

Indian culture has a fixed hierarchy in which God has a higher value as compared to individual responsibility. Hence, Indians seek sustenance from religion, visit temples and shrines and seek blessings of the Gods and Goddesses, when confronted with life stressors. They feel contented in handing over the responsibility to a higher authority, namely God, and thus relieving themselves from the burdensome responsibilities. This external locus of control, so integral and acceptable to Indians, is in stark contrast to the western world where the autonomous individual has to bear the responsibility of his own problems and seek their solution without depending on others.[18] Surprisingly, very few studies from India have evaluated the role of religious coping in dealing with stressful situations and mental illness. Only one study has attempted to study the relationship of religious coping and psychological wellbeing of caregivers of patients with schizophrenia.[19] It was noted that strength of religious belief plays an important role in helping family members to cope with the stress of caring for a mentally ill relative. Other studies, although have not evaluated use of religious coping in dealing with mental illness, but some of these suggest that level of religiosity has inverse relationship with hopelessness and suicidal intent in patients of depression.[20]

The close relationship between stress and psychological distress has been accepted with respect to almost all types of psychiatric disorders. Coping strategies are therefore, important predictors and modulators of mental illness. The ways of coping are in turn affected by the culture and the culture-specific buffers. Among the various coping strategies talked of in the literature, religious coping is very important from the perspective of Indian psyche and traditions.

In last 2-3 decades, studies across the world have started focusing on the religious coping in dealing with stress and symptoms of mental disorders. It is suggested that whenever religion is “available and accessible,” coping with challenges often incorporates a religious dimension.[21] In general, religious coping is considered as multidimensional concept covering a range of active to passive, problem-focused to emotion-focused, positive to negative, and cognitive behavioral to interpersonal and spiritual strategies.[22] For example, through religion, a person undergoing stress may define stressor as benevolent and potentially beneficial, or as a punishment from God for his sins, consider stressor as a work of devil, or believe himself to be helpless as that it is only God who can change the stressor. Other religious coping methods to deal with stress may include seeking control over the stressor through a partnership with God, engaging in solitary religious activities to shift focus from the stressors, going to religious gurus for guidance and strength to face the stressor, seeking comfort and reassurance through the love and care of religious congregation members, searching for spiritual meaning when encountering a stress, seeking a sense of connectedness with forces that transcend the individual.[22] Studies from the west which have evaluated patients with different illnesses have reported that 34.5-86.9% use religious activity to cope with problems.[23–26] Specifically in patients with psychiatric disorders, studies suggest that about three-fifth of the patients use religion to cope with their disorder and 30% reported an increase in religiousness since the onset of the disorder and about one-fifth of the patients reported that religion was the most important part of their lives.[27] Another study which evaluated the coping of patients with mental illnesses reported that more than 80% of the subjects used religious beliefs or activities to cope with daily difficulties or frustrations. This study also reported that majority of the patients devoted nearly half of their total coping time to religious practices with prayer being the most frequent activity. It was further seen that use of religious coping was associated with more severe symptoms, higher level of frustration, and higher impairment due to symptoms. It was also noted that those patients who devoted lesser time in religious coping reported higher severity of illness and higher level of frustration.[28] Another study evaluated the caregivers of dementia for frequency of attendance at religious services, meetings, and/or activities; the frequency of prayer or meditation; and the importance of religious faith/spirituality. It was seen that the various measures of religion were associated with less depressive symptoms in caregivers.[29]

Religion, traditions, Indian psyche and psychopathology

The religious background and practices can color the reporting of the psychopathology. Studies in patients with delusions from the west have shown that the delusional themes of the patients are usually based on the myths according to the ancient culture. Such themes have been termed as mythologems.[30] Similarly, some of the perceptions, which may be considered to be standard in the patient's religious background may be interpreted as part of the psychopathology. Hence, ignorance about the patient's religious background may lead to an incorrect diagnosis. At other times, the psychotic patients may interpret the religious teaching literally and act accordingly with harmful consequences for them or people around them. Studies from India suggest that delusions and hallucinations are often colored by cultural influences in terms of paranormal phenomena, irrespective of the educational and residential backgrounds of patients and caregivers.[31]

Studies from India also suggest that many patients attribute their symptoms to supernatural causes. Others may consider their symptoms as some kind of punishment from God and resultantly decide that they do not deserve to be relieved of their suffering, or they may refuse to take treatment and assert that the illness can be cured by prayers only. It is also suggested that ideas of guilt in depression when present are often attributed to Karma or to the deeds of a previous birth, which in turn may render them less distressing.[9] The same influences may explain more common delusions of persecution and reference in Indian patients than hypochondriacal, guilt, and nihilistic delusions.[32]

An interesting aspect of neurosis in India is higher prevalence of possession states, trance states, fugues and hysterical fits compared to the west. On the other hand, multiple personality disorders, a common problem in the west, is rarely seen in our patients.[33–38] It has been hypothesized that religious beliefs in polytheism and reincarnation contribute to the documented high prevalence of hysterical possession in India, while the social approval of role playing in the west has led to higher prevalence of multiple personality disorder in these parts.[35] Similarly, pseudoseizures and other motor manifestations of dissociation are also more common,[39] while dissociative amnesia, fugue, and depersonalization-derealization syndrome are rarely seen in India. Sociodemographic variables can have a pathoplastic effect on content of psychopathology, for example, in Indian setting, “Suchibai Syndrome” is obsessive compulsive syndrome recognized in Bengali widows (characterized by repeated washing and purity rituals).[40] In the realm of sexual disorders, many young males present with hypochondriacal, anxiety and depressive symptoms under the major visible “pathology” of semen loss and it is termed as “Dhat syndrome.” The syndrome arises in the background of the teaching of Ayurveda, which teaches the physiology of the production of semen, based on the central idea that there are seven essential constituents of the body (the seven Dhatus: chyle, bile, blood, flesh, fat, bone marrow, and semen) produced through a cycle of successive internal cooking and transformations. After ultimate distilling, the most concentrated and hence the most precious elixir among the constituents of the body is semen (dhatu). In Charak Samhita, disorders of dhatus have been elaborated and a syndrome resembling modern day Dhat syndrome by the name of sukrameha (shukra = sperm + meha = passage in urine) finds a prominent place. In Susruta Samhita and in Ayurveda, loss of semen in any form leads to a draining of physical and mental energy and vitality. This is further reinforced by the belief enshrined in religious scriptures according to which 40 meals produce one drop of blood, 40 drops of blood make one drop of bone marrow and 40 drops of bone marrow form one drop of semen.[41]

Attitude towards mental illness and treatment seeking

The traditional Indian family values consider family members capable of solving all problems and seeking help from “outsiders” as unnecessary and shameful. When they need to turn to outsiders for help for any ailment (especially mental illness), the religious bend of the average Indian mind leads them first to the temples and religious leaders. The belief in the supernatural causation, the curse of God or evil spirits, is even more predominant in mental illness as compared to physical illness. Indians believe in magical cure resulting from eradication of these evils through the goodwill of the Almighty. Magico-religious healers employ various methods of healing like facilitating improvement of interpersonal relationship and encouraging adherence to social norms.[42] In addition, these healers also practice alternative systems of medicine. There are a large number of reports stating that a good proportion of individuals do believe that these visits have helped them.[43] It is important that psychiatrists be aware of the role of such healers in the community. A large proportion of people also tend to attribute their psychiatric ailments to physical problems and consequently, visit the general physicians before reaching the mental health professionals. Hence, most of our patients seek psychiatric consultation only after exhausting all these options. It is not surprising that patients and their family members continue to visit magico-religious healers even after contact with the medical fraternity.[44]

Indianization of psychiatry utilizing Indian mental concepts

After reviewing the broad Indian concepts, now let's turn to how these could be utilized in the treatment setting and current practice of psychiatry. The knowledge of these concepts can help in better understanding of the patients, can help in formulating or tailoring the treatment offered and overall improving the outcome. In this section, we would briefly discuss some of these issues.

Indian psyche is also influenced a lot by the Hindu philosophical beliefs.

Assessment and understanding of patient

Patient's history, phenomenology and his or her own understanding of illness should always be considered in light of his/her socio-cultural milieu and belief system. Even the physical examination of the patient is not exempt from this consideration, as the body of the individual can demonstrate religious beliefs (through tattoos and other stigmata), and the general nutritional status of the person, which is important given the predominantly vegetarian diet followed by many Indians. Further, physical examination strengthens the medical model of help seeking, even though the symptoms are purely psychological.

It is suggested that the practicing psychiatrist should have adequate knowledge about the cultural background of their patients. While dealing with patients with specific religious background, it is suggested that the therapist must be as empathetic as possible to the patient's belief system and to do so, they must be well informed about the patient's religious views. Depending on the situation, the therapists can encourage the patient to re-prioritize their religious practices, keeping recovery from illness in mind.

Understanding the needs of patients and their families

As Indians are a diverse group of people, it must be understood that treatment should be tailored according to the needs of individuals and their families and the idea that “one size fits all” should be abandoned. In addition to keeping a psychosocial bent of mind, the psychiatrist should also remember the physical or medical concept of mental illness prevalent among Indian patients. It not only influences the expression of mental illness but also leads to an expectation that the therapist would follow a medical rather than a psychological approach toward the management of their problems. Hence, it is important to remember that only advising psychological treatment without a pill may be a difficult proposition. In situations, which require only psychological interventions, it is important that the psychiatrist pays enough importance to the expectation of the patient and the family with respect to the treatment modality. In clinical situations which do not require medications, the psychiatrists should spend enough time in addressing this issue before proceeding with the advice of only psychological treatment.

Coping with stress

As discussed earlier, religious coping does play an important role in dealing with symptoms of mental illnesses. Hence, the clinicians should always enquire from their patients about the religious practices and how they use the same to deal with the stress. It is suggested that just asking about the same, acknowledging the same and respecting the same can be very useful from many perspectives. First, it can help the clinician understand as to how the patient gives meaning to and understands the illness (both its causes and consequences). A very religious person may use faith to give meaning and purpose to negative events that happen to them. The faith may help to shape the meaning of the event and aid in integration and processing of the event. Further, if somebody is using prayers and/or visiting religious places to cope with mental illness, just encouraging and supporting the same would enhance this form of coping particularly if the religious practices are not contributing to worsening of the emotional/mental condition. Acknowledging and respecting the religious practice may help in improving the rapport between patient and the therapist as patient may perceive the therapist as a complete person, one who tries to address the mind, body, and spirit.[22]

Utilization of family support

Mental ill health is not only biologically mediated, it has psychosocial components as well. A review of studies reveals that psychoneurotic and depressed patients are overrepresented in the unitary and small-sized families, whereas hysteria is observed more commonly in females from joint families.[10] The reason being that in a unitary family there is lesser dilution and fewer opportunities for sharing of emotion, particularly in times of stress, which leads to swelling of emotions, in turn leading to formation of a nidus for subsequent precipitation in the form of depression. On the other hand, in the “restrictive” environment of the joint family, women are expected to observe more restraint, all must be subject to command of the “elders,” which leads to interpersonal maladjustment. Hysterical manifestations may arise or may get perpetuated because of easy availability of a secondary gain. Hence, it is important to understand the interplay of the dynamics of family and individual psychology in the adequate management of patients. The important role played by the family in the Indian context has led to the success of family interventions in the management of severe mental illnesses like schizophrenia. Group meetings of caretakers of patients with schizophrenia and bipolar mood disorders have been demonstrated to improve the monitoring of the functional status of individuals, reduce subjective family burden and family distress, provide a better support system with adequate coping skills and good compliance with the treatment program.[45] In alcohol dependence too, family intervention therapy has been seen to significantly reduce the severity of alcohol intake, improve the motivation for abstinence and change the locus of control from external to internal in the patients as compared to controls.[46]

Use of yoga and meditation in management of psychiatric disorders

With the worldwide recognition of yoga in management of stress and positive mental-health, studies from India and the west have evaluated its usefulness in various psychiatric disorders. A recent meta-analysis included studies which have evaluated Hatha yoga, Iyengar's yoga, Sudarshan Kriya yoga, and different types of meditative yoga for management of various psychiatric disorders. This meta-analysis demonstrated that yoga therapy is an effective adjunct treatment for depression, anxiety, PTSD, and schizophrenia, with a significant pooled mean effect size of 3.25 (P = 0.002).[47] Yoga-based practices may provide relief for symptoms left untreated through common treatments such as psychopharmacology and psychotherapy. Yoga breathing can be extremely useful in the treatment of anxiety and PTSD. Considering the usefulness of yoga and acceptance of the same by many patients, advising the patients to practice the same under the guidance of an expert may be very useful as an adjunct to other modalities of treatment.

PSYCHOTHERAPY IN INDIAN CONTEXT

Psychotherapy is a specialized form of communication where a therapist adopts specific roles such as teacher, redemptive listener, a guide through the healing process, motivational speaker and persuader, and engages in different types of interactions.[48] The unique nature of Indian psyche renders the western model of individual psychoanalytic based psychotherapy difficult. The Indian patients expect the therapist to play an active and authoritarian role, making difficult the maintenance of “therapeutic neutrality,” an important part of western practice of psychotherapy.[49] The western models of psychotherapy encouraging independence are redundant in the Indian population as dependency is a social norm among Indians.[50] The Hindu philosophical beliefs of transmigration of the soul, re-birth and fatalism, the different nature and quantum of guilt feeling in the Indian culture, and the differences in the need for confidentiality and inactivity exercised by the therapist, especially with regard to decision-making for the patient, and environmental manipulation render Indian psychotherapy vastly different from the western model. Therefore, modifications in the form of face-to-face seating arrangement, playing a more active role than in the western model with use of suggestions, sympathy and manipulation of the environment along with teaching and reassurances should be used more frequently. Even within India, diversity across cultures suggests the need to adapt psychotherapeutic models to match patients with their contexts. Matching of therapist and patient characteristics (for example, ethnicity) has been suggested to better understand the patient. However, strict matching is not practically possible given the paucity of trained psychiatrists and psychologists, the heterogeneity within cultural groups and the many differences in social class, educational status, language and dialects. Therapists, however, should be aware of the local cultural organization, world views and values, etic-emic differences, linguistic concepts and idioms of distress.

Effective therapists are able to employ and adapt their psychotherapeutic models to provide structure while exploring the patient's issues, stress, personality, coping, context, and culture. The psychotherapeutic interventions have been suggested to be short term, crisis oriented, supportive, flexible, eclectic and tuned to the cultural and social conditions.[51] Therapists have also sought refuge in the psychotherapeutic paradigm illustrated in the Bhagvad Gita.[52,53] and in the guru–chela relationship.[50,54] Anecdotes from the ancient mythology and religious texts can be used to highlight psychiatric symptoms, psychological principles, unconscious conflicts, defense mechanisms, automatic thoughts and cognitive errors.[55–58] Ancient texts and myths, widely known to many in the population, contain therapeutic wisdom and are easy to understand and to identify with. Many therapists practicing in multicultural settings employ pragmatic and eclectic approaches and manage diverse problems. While purists often frown upon eclecticism, its usefulness in clinical practice maintains its popularity. Shamsundar[59] proposed an integrated approach, including experimentation with actual clinical circumstances and innovations dictated by cultural and individual specificities along with incorporation of traditional cultural concepts into the framework.

CONCLUSION

India, as a country is fast developing, in sync with the modern day economics. At the same time, it still values and holds on to its rich history, traditions and philosophies. An average Indian is multidimensional and vastly different from the generic American and European, hence, has different ideologies, needs and support systems. To blindly follow western concepts in psychiatric care would therefore be extremely short-sighted and unproductive. We, as Indian psychiatrists should therefore be open to the incorporation of Indian concepts in our practice, despite our training in contemporary western schools of psychiatry. In addition, we should also vigorously test the applicability of methods like yoga and Indian models of psychotherapy to validate our age-old principles and philosophies and not label them as third world superstitions. As a country, we have established ourselves as an evolving superpower and we should acknowledge our uniqueness, nurture our traditions and embrace them, making them an integral part of our care.