Mental Health and Indian ClientsOriginally published in The GM Resource & Referral Directory 2000, 258-259.
By Laetitia Puthenpadath, with Philip Culbertson
The attainment of autonomy and emotional dependence from childhood attachments is a Western notion. In the Indian cultural context, personality development is a relational process. Maturation of the human person is attained through coming into harmony within social relationships. Self-identity is extended into a familiar self. This means fulfilling a complex system of obligations and responsibilities towards others throughout one's life cycle. Even beliefs concerning the nature of health and illness flow from such an extended sense of self. Disease is not just localised in the individual. Well-being is viewed as a balance or harmony of forces maintained by the proper observance of social obligations and other interpersonal behaviours.
CultureIndian culture is actually extremely diverse, so the mental health worker should not assume a sense of uniformity from one Indian client to the next. Yet all Indian clients tread the difficult line between individuality and a family-defined "we-self" which may strike the Westerner as completely paradoxical. While Indian clients have many ways of expressing their individualism, in the end they are extremely sensitive to family ties, societal conformity and group approval.
Traditional values include interpersonal harmony, filial piety, hierarchical family and social relations, and shame as a major behavioural influence, ideals of emotional restraint and self-control. Attainment of harmony both intrapsychic and interpersonal through negotiation between individual's needs and group needs is of high value. Indian culture normalises dependency. Experiencing helplessness is accepted as a basic fact of human existence.
Another significant cultural element is shame. The phenomenon of shame influences behavioural patterns in Indian culture. An Indian living in a Western culture, if unable to live according to the norms of the family, will suffer a sense of guilt and shame which colours his or her behaviour not only at home but in public intercourse as well. The implications of this shame-based emotional link between self-image and the image of others can be far reaching. Exploration of self-identity and fulfillment of self-esteem will have less meaning for an Indian client and may actually intensify guilt feelings, derived from the inability to subordinate his or her desire for autonomy, in order to live harmoniously with parents and peers. Western models of psychotherapy that call for clients to express themselves openly in healthy self-disclosure, especially concerning problems with parents or elders, may cause difficulties for an Indian client. The client may experience this as self-indulgence and against the values of loyalty and family obligation.
Culture Specific StressesDue to the paradoxical nature of Indian culture, stressors are extremely contextual. Predictable ones include the pressures and expectations which come with Indian culture's complex structuring according to caste, class, socio-economic influence, and race. In general, Indians feel caught between the influences of Western culture, and the patriarchal authority assumed by the indigenous cultures of the country.
Duty to parents and elders is a strong value in all Indian cultures, a duty which continues into adulthood. Because Indian children are raised in groups, by groups of caregivers, individualism remains a possibility where individuation is not. The norms of filial piety preclude any of the discussion or debate inside the family that ordinarily leads to individuation. Instead, Indian children are raised with an elevated awareness of the importance of pleasing their families in all things, and increasing the family's status in society.
Gender role divisions are rigid in these patrilineal and patriarchal cultures, and the status of women in most families is often quite low. Even arranged marriages are expected to succeed, primarily through subordination of women to their husbands.
Coping StrategiesCoping strategies of Indian clients are basically four. Clients may somatise, that is, express their psychic stresses in bodily disorders. Conversely, they are susceptible to conversion disorders, in which bodily ills are expressed through psychological maladjustment. In more extreme cases, clients may exhibit histrionic symptoms or compulsive behaviours.
Symptom PresentationsMany Indian clients may seem to be emotionally repressed; culturally one is expected to always subordinate the individual self to the needs of the group, in order to avoid disharmony and disruption. Symptom presentations often appear subconsciously calculated to restore a version of the client's childhood history which will maintain the integrity of the family's social status of choice.
In New Zealand, Indians experiencing acculturation conflict ordinarily pass through three distinct stages: (1) The individual conforms to parental values, and adopts a traditional stance. (2) The individual rebels against parental values and adopts an extreme affiliation with Western values. (3) The individual attains self-worth through developing a new Indian-New Zealander cultural heritage with mainstream Western values. Mental health workers need to measure carefully the development level of their Indian clients, in order to choose a therapeutic approach that will be appropriate.
Psychological Approaches To The TreatmentPsychotherapy and counselling are not usually familiar in the various Indian cultures; physicians, however, are held in very high regard, so most referrals for psychological support must originate with a GP for them to be taken seriously. The mental health worker should expect that a "quick magic fix" be requested, due to cultural expectations. Long term treatment plans are, therefore, rarely successful; when the Indian client does not see immediate results, he or she will usually terminate. For this reason, contractual brief-term therapies - solution oriented and designed for symptom relief - are the best options.
Indian clients expectations of mental health workers are strongly shaped by the traditional Indian expectation of a guru-disciple relationship. To therapists, this will feel like an unhealthy dependency, but should be recognized as an expression of cultural norms. Therapists may find themselves quickly idealized, and then the subject of the client's projected shadow as a test of the relationship. The client will often test the counsellor's personal integrity and spiritual depth as well, since Indian culture is still heavily affected by Hindu spiritual values. Mental health workers are cautioned to focus on their own personal integrity, and to let go of any desire to succeed or to see results.
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