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Mental illness: shedding the stigma around India’s big secret

From the 2016 movie Dear Zindagi, about a young woman seeking therapy for depression

Yesterday, I was at a panel on mental health in India, at a conference in Goa organized by UCL. One of the speakers – Ratnaboli Ray, who runs a mental health NGO called Anjali in West Bengal – asked for anyone in the audience who’d ever had mental illness or been on psychiatric drugs to raise their hands. For a few seconds, no one did. And then about 10 of us did, in a room of around 100.

It felt strange to me, raising my hand, in a way I’m not sure it would anymore in the UK – like I was risking my status, pushing against a wall of shame and secrecy. Like having had a mental illness was a big deal (which it isn’t). In fact, I only raised my hand because the lady next to me did first.

This is the paradox: that a culture with such a huge focus on health, well-being and spiritual wisdom should see mental illness as so taboo. If Prince Siddhartha hadn’t had a breakdown, India would have never given the world Buddhism, yet this is a country where mental illness is simply not discussed.

Why? My tentative initial answer is that India (like the UK) is a country obsessed with status and hierarchy. Mental illness is still seen as a terrible blot on one’s status, and therefore a risk to one’s career advancement, one’s marriage prospects, one’s place on the social scale, and to your family’s social prospects. India is the country that gave us Snakes and Ladders, and mental illness is seen as one big snake down to the bottom of the social hierarchy. (I might be wrong in this assessment – let me know in the comments!)

It’s also a threat to your rights. If you’re diagnosed with a mental illness, it can affect your ability to open a bank account, to get a driving license, to maintain custody of your children. Until 1976, it was accepted as grounds for divorce.

To protect the family status, the mentally ill are often abandoned in over-crowded psychiatric care facilities, where they can be ‘treated worse than animals’, according to a report by Human Rights Watch.

Mental illness is also hiding in plain sight in India. According to two recent surveys, between 130 million and 150 million Indians are suffering from a mental illness, including depression, anxiety and substance abuse. I’ve met successful young Indians on my travels who are clearly stressed, over-worked, and in need of support. But mental illness is seen as a terrible curse, not something that pretty much happens to everyone in varying degrees of intensity.

As the Buddha put it, life is suffering – having a mind means you sometimes experience mental distress, and there are techniques we can learn to mitigate that, both psychological and pharmaceutical. India invented many of these techniques – indeed, Buddhism is one of the major influences on Cognitive Behavioural Therapy, which the NHS has put over one billion pounds into providing.

Yet in India, 90% of those with mental illness receive no treatment at all. India has 0.3 psychiatrists per 100,000, one of the lowest figures in the world. And they’re almost entirely in big cities.

Even among the urban affluent, very few seek therapy because of the stigma attached. I sat next to one lady on a plane and said I wrote about mental health. She told me of her ex-husband, who refused to admit he had depression. I didn’t like to ask if they had divorced or he was one of the 250,000 Indians who kill themselves each year.

Soumitra Pathare, an academic who drafted a new Mental Health Act, says: ‘There is institutionalized discrimination against the mentally ill. If they were a caste or women, we would be doing something for them, but we do nothing.’

Things are finally beginning to change. The new Mental Health Act is due to be made law this parliament, and will legally guarantee Indians’ right to treatment, and also to refuse treatment if they don’t want it (many inmates are in asylums and given Electro-Shock Therapy without consent). There are new initiatives to train community health workers to give brief psychological therapies.

There are several new apps and websites that offer counseling and therapy online. In Chennai, India’s third biggest city, I saw adverts for private counsellors and a wall painted with a big sign: Depression Is Treatable. There’s even a sex therapist in Bangalore (something so unusual it was written up in the media).

There are signs of a new openness around mental illness – last year, there was even a Bollywood film, Dear Zindagi, about a young woman seeking therapy for depression from a hot therapist. Imagine if one of India’s cricket superheroes opened up about mental illness – something several western sports stars have begun to do.

At the UCL conference, I spoke to Vikram Patel, a Wellcome-funded psychiatrist from the London School of Hygiene and Tropical Medicine, who has pioneered training rural community care workers in India and Africa in the delivery of brief psychological therapies. He was voted one of Time magazine’s 100 most influential people in the world (he points out the leader of Boko Haram is also on the list).

Why are there so few psychiatrists in India?

There’s a bottleneck problem in training – only accredited teachers can train new psychiatrists and there are very few accredited teachers. There’s also a stigma around being a psychiatrist, compared to say a neuroscientist. And there’s a huge distribution problem too – most psychiatrists work privately in big cities. In rural India, there could be a region with 10 million inhabitants and no psychiatrists.

Your approach is to train community ‘health visitors’ to give brief therapy?

Yes, we’ve trained health workers to give specific treatments for specific conditions. We found it worked very well when they were trained just for that, in controlled conditions. We now need to see how it works out in the field, in frontline primary care, where health workers treat not just mental but physical illness. The treatment of both in fact uses similar skills – lifestyle support, behavioural change support, the promotion of self-care.

And they give similar sorts of psychological therapies to western psychotherapy? Cognitive Behavioural Therapy, interpersonal counseling etc?

Yes, similar therapies, but briefer and simpler. The most profound discovery for me is that the theory of psychological mechanisms is universal. Cultural factors play a role in the metaphors you might use. Say you train people to use meditation and yoga in the treatment of anxiety. You could train them to breathe in, and then breathe out saying ‘om’, or a prayer to Jesus if they’re Christian. Those cultural factors make a difference because you’re tapping into hope, which is a very powerful healer.

Is depression and anxiety treated here?

Hardly at all. I thought the ‘worried well’ was a Western phenomenon but it exists here too. The majority could recover with some form of self-care, but some need more clinical interventions. But depression and anxiety are not even seen as illnesses. It’s just your social situation. It gets somatized, as fatigue or insomnia for example. And doctors would also not recognize they’re actually treating depression, they would treat it with painkillers or sleeping pills. People criticize me for medicalizing people’s experience, but these people are already in clinics, they’re just not getting the right treatment.

So nothing like the NHS’ psychotherapy service exists here?

Nothing remotely like it. We recently published a trial of psychotherapy in the Lancet- that was the first ever trial of psychotherapy in India. We don’t want to repeat the mistakes of the NHS’ therapy service, which was too professionalized. We want more self-care and community care – my dream is to be able to train someone off the street to treat someone else for depression.

Do you think computerized-CBT apps could be a way of getting therapy to more people?

Yes, I’m bullish on technology, it will transform healthcare in general. But there are limits on access to the internet, particularly for the poor and women. But we’re beginning to see things like Facebook pages for people with schizophrenia.

Are there charities and NGOs lobbying for improved mental healthcare?

There are, but they’re small, very local, and not yet working effectively together in the way we’ve seen, for example, in the treatment of HIV.

Could online media – blogs etc – play a role in opening up the conversation and getting rid of stigma?

Definitely. In fact, we’re launching a website in April which will encourage people to share their experiences online through various social media.

You can watch Vikram’s TED talk here:

James Mallinson, the sadhu-academic

Dr James Mallinson is unique among British academics. Not only is he a widely-respected Sansrkit scholar at the School of Oriental and Africa Studies in London, he’s also the only Westerner ever to become a mahant – a senior sadhu [ascetic holy man] in a sect of yogis, which he has spent time with since he was 18. He’s recently co-authored (with Mark Singleton) a book called The Roots of Yoga, which is the first academic book to investigate the historical roots of yoga.I met him at the Jaipur Literature Festival and asked him about his journey.

I watched the BBC documentary West Meets East, in which you and your friend the actor Dominic West went to the Kumbh Mela, the enormous gathering of sadhus that happens every three years. It was a fascinating insider look at that world – how 120 million people gather in one place and organize themselves, how the different sadhus distribute money to each other, and also the rivalry between different sects, which sometimes descends into fist-fights. Did that gang-war aspect of this huge spiritual gathering disillusion you?
I still find it hard to understand, but the sadhus don’t see it as a big deal. There’s a clear split between the yogis and the fighters. There was one incident, about 20 years ago, when my guru and another sadhu ended up fighting over me. I was lying back, having been drinking bhang [marijuana] all day, and it suddenly kicked off. It didn’t last very long, some other yogis jumped on the other guy, but some people asked me ‘why didn’t you jump in too?’ And my guru said, ‘he’s a scholar, he doesn’t fight’. I was quite relieved by that.
What have you got from your yoga practice over all these years?
A lot of it is just being part of this tradition, hanging out with the sadhus. As for the physical practices, I’ve only started practicing them more assiduously 10 years ago when I was working more as an academic and I started to get a stiff back. Since then I’ve become more religious, as it were, about doing it every day. I still sit down and meditate occasionally. It makes me feel good, happy, balanced. In this day and age, just sitting quietly and not reaching for your smartphone every minute is a good thing.
What do you like about the sadhu community in which you’ve spent so much time?
My guru never ceases to amaze me with his energy, his ability to be on it, despite hardly ever eating or sleeping, he’s always happy, never perturbed. As for the wider community, although they’re joyful and happy, deep down they see the material world as pointless. They don’t want to be a part of the world outside their religious round, their whole lives are predicated on being dissociated from it.
Do you find that detachment refreshing?
Yes. It’s got to be good for one’s mental level of happiness to completely experience a totally different way of life. You can go back to your life [working as an academic and living with his wife and two children in the UK]and realize some of the things you get wrapped up in aren’t that important.
Do you think your attraction to that world was partly a rejection of your background, growing up in England and going to a stuffy boarding-school?
It might have helped – I found myself once again in an all-male community governed by arcane rules.
Do you feel there is a lack of spiritual options in the West today, like the option to be a complete renunciate and for that to be an accepted social choice?
Yes I do. Just the other day I was speaking to a rather annoying young sadhu who was desperate for me to take him back to the UK so he could get followers. My guru has no interest in that, because he knows people just wouldn’t understand the life of renunciation. I suppose one option is to go and live in a monastery, but that’s not the same enjoyable, colourful life as at the Kumbh Mela.
But of course a lot of Indian gurus have gone to the West and become rock-star gurus. What do you think of them?
It doesn’t really rock my boat. The sadhus in the tradition I belong to explicitly shun that behavior. Some do public teachings, but I was told that if they’d done that 30 or 40 years ago they’d have been beaten up. Because it’s meant to be complete renunciation. The irony is, the more you renunciate, the more people give you material possessions. But the sadhus never build up a big storehouse of wealth, they tend to give it away. So those rock-star gurus like Osho, who accrued 95 Rolls Royces, that’s a different world.
But sadly those gurus who want to become rock-stars tend to be the most visible and famous. I suppose they’re not part of a tradition – they’re freelance gurus, with no one to answer to.
Those big-shots think they should get a big tent at the Kumbh Mela. But they can’t get a good spot, they have to camp out right at the outskirts, unless they pay a lot of money. They’re not respected by sadhus. Quite the opposite. My own guru couldn’t care less about publicity. I showed him the BBC documentary we made about my initiation at the Kumbh Mela, and after two minutes he stopped watching. He wasn’t interested at all, which is the perfect response.
What does a day at the Kumbh Mela look like in your community of sadhus?
You get up in the morning, do your ablutions, bathe – there’s a lot of bathing – then sit down and maybe start smoking, drinking chai. The ultimate behavior for a sadhu is to sit around and chat for hours and hours. Talking, chatting, gossiping, telling stories. There’s not much philosophical discussion.
Tell me about the new book, The Roots of Yoga.
It’s a relief it’s over. It was five years hard work, involving the translation of over 100 texts, in 12 different languages. It’s the book I wish existed when I started exploring yoga. Nothing like it previously existed. A few books would have translations of a handful of texts but they wouldn’t be dated correctly and there was no understanding of how texts related to each other.
How does it change our understanding of the historical roots of yoga?
The conventional history is that yoga begins with Patanjali in the fourth century CE. That’s what most practitioners of modern yoga learn. My co-author Mark Singleton has written about how 95% of modern yoga is not from that. Much of it is more recent – many popular modern postures, like the sun salute, are only around 100 years old, and grew out of a number of influences, including Swedish gymnastics. In Patanjali, there’s almost nothing on physical postures, and it’s mainly 12 sitting postures to prepare you for meditation and breathing exercises. And there’s stuff on yoga earlier than that – Buddhist texts, Jain texts, some writing in the Mahabharata which has been almost entirely ignored, and some writing in the Upanishads. Yoga was practiced in a wide range of traditions with many different viewpoints. They all agree that ‘yoga works’.
But what does that mean, ‘work’? That it makes you healthy, or brings longevity, or grants enlightenment, or magical powers?
There are different interpretations, including of the word yoga or yuj itself. It can mean to concentrate or to unite. There’s a passage I often quote from one ancient text, which says, ‘whether you are a brahman, an ascetic, a Buddhist, a Jain, or even an atheist, if you practice yoga assiduously, it will work, you will attain siddhi’ – that can be translated as success or magical powers.
What do you think of the huge popularity of yoga in the West, and increasingly in India?
From a mercenary level it’s good for me. It means it’s easier for me to get funding. It’s nice to have a wider audience for your work. Is it a good thing in general? I think it probably is. One valid criticism is that it’s quite selfish. People do it for personal reasons. But even there, it’s beginning to mature. In the US, there are people trying to bring more social awareness back into yoga. People are also becoming more critically aware, they won’t accept from their guru that the asanas they practice are 5000 years old.
But that critical awareness hasn’t undermined your enthusiasm for the practice itself?
No – I’ve come across practices from the past that I try out. And I still begin with the sun salutation, even though I know it’s a modern innovation. It still feels good.
Finally, yoga is obviously being promoted by the Indian government, which has some ties to Hindu nationalism. Has it been at all controversial for you to decide that the earliest written texts on yoga are actually Buddhist?
No one’s noticed. We were nervous. But I don’t think they’re that interested in our scholarship.

 

You can buy The Roots of Yoga here.