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Anxiety

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:

Anthony Seldon on venturing beyond happiness

Dr Anthony Seldon Sept 2006Sir Anthony Seldon is the former headmaster of Wellington College, one of the first schools to introduce well-being classes into its curriculum. He’s also a co-founder of Action for Happiness. In his new book, Beyond Happiness, he suggests we need to look beyond ‘workaday happiness’ to find something more non-rational and spiritual, which he calls joy or bliss. I interviewed him about this, as well as his thoughts on the ‘politics of well-being’ and his plans to create the first ‘positive university’.

Did you start out to write a book on happiness, and at some point decided you wanted to write one called Beyond Happiness?

Yes. I’d been quite prominent in Action for Happiness, and it occurred to me that we need to move beyond workaday happiness. Obviously that’s wonderful, particularly if you’ve had depression, but there are higher levels of being.

The book starts with a quote attributed to Edith Wharton: ‘If only we’d stop trying to be happy, we could have a pretty good time.’ That’s an unusual quote to begin a book on happiness by one of the founders of Action for Happiness!

Well, I just like that quote and find it funny. And the key word is ‘trying’. Trying too hard gets in the way, or rather, the ego gets in the way. Whenever I screw up my life, it’s because I’m trying too hard. I’m always trying. And then there are moments when you wake up from that. What I mean by ‘beyond happiness’ is going beyond the striving to gratify of the ego, to a place where there is a sublime effortlessness.

I have a theory that people interested in ethics and character education in later life were often quite rebellious and bad at school. It sounds like you were.

If_British_posterI was. In 1971, when I was studying at Tonbridge school, I was one of the ring-leaders of a rebellion against the Combined Cadet Force. We stormed onto the parade ground shouting about the Vietnam War, which in fact did finish shortly afterwards, although the Tonbridge CCF kept existing. The International Times covered it with a headline saying ‘A whiff of If’ – referring to the film about a rebellion at a private school made by a former Tonbridge pupil, Lindsay Anderson. All the ring-leaders were sent down, though I was allowed back to take my exams. So yes, I was rebellious, but I also had a sense of kindness and duty.

We have in common the fact that we both had a bad experience of drugs in our teens and then went to Worcester College, Oxford. Could you tell me about your bad drug experience.

It was in 1972, on a holiday in the Norfolk Broads. I smoked some dope and had a really frightening experience, I felt my mind was changing. It was so frightening I never tried a drug again, and developed a lifelong dislike of drugs.

Were you quite anxious as a teenager?

Very. I once made a list of all the things I was afraid of and it came to 29 things. I was afraid I might become anorexic, for example, or agoraphobic. One of my biggest fears is the fear of going to sleep, which I think is the fear of extinction. I’d have a huge panic attack to keep myself awake, and then I’d stay awake and be even more frightened the next night. It’s not a nice fear to have. That’s why I became so domineering – it was a way of trying to control my world.

Then you had some sort of depressive collapse in your mid-20s.

Yes. I think it was the amount of effort I spent trying to control my world. Also, two girlfriends had chucked me, and I felt abandoned by them. Then I was writing my doctorate at the LSE, which was a very lonely experience. After the collapse, I started to meditate, which helped me through. And I started going out with Joanna [now his wife], and she’s very centred and calm. And I knew she would never leave me, which miraculously she hasn’t.

You say that you moved from a personality based on restless hedonism, achievement and glamour to a more spiritual life based on acceptance. But you’re still a restless achiever – you’ve finished three books since Christmas!

I am two people, at least. There is a more spiritual or philosophical side to me, which is at peace with the world, and that side is more dominant now. But there is also a part of me which feels I need to make my mark in the world, which worries that I’ve never written anything that will survive, that whatever I’ve done in education will fade. There’s a bit of me that is highly self-critical, which trashes my previous experiences. Therefore I constantly need to keep going. I now find myself running a small university, for example.

And that restless desire to achieve and get recognized might come from being short – I say that as a 5 foot 7 anxious achiever!

I’d have given anything to be 5 foot 7! Yes, I’m sure our physical self-perception is a powerful force, and if we’re outliers, it gives us an impetus to want to compensate. I notice still that when I’m around other people I’m edging up on my heels.

So the new book brings together wisdom from Positive Psychology but also from religious mystics like Meister Eckhart or Sri Ramana Maharshi. Do you think Positive Psychology can be a secular substitute for religion?

51t8uL9MMvL._SY344_BO1,204,203,200_I’m sure for Alain de Botton and others it is. I’m sure some would like it to take the place of religion, which of course it won’t. But there are similar adjuncts. But when I talk about going beyond happiness, I’m talking about moving beyond workaday happiness to find joy, which is spiritual. For me, that’s about the divine, a blending of the ego into the Atman or Soul. It’s not about the vindication of the ego but the elimination of it. The ego is constantly interpreting and evaluating – only that which is beyond the ego is really awake, conscious, and in love with the whole of creation. But it has to be experienced, it can’t be debated or argued over.

So that means going beyond reason, I guess.

Reason has its place, but it only gets you so far – as far as Richard Dawkins or AC Grayling. We can go beyond reason, without abandoning it, and reach a much bigger view.  The ego tends to use rationality for its own goals.

A key part of transcendence in most religious traditions involves realizing that death is not the end, that something in us survives. Do you believe in an afterlife?

I don’t know. I want to move beyond belief. What I know is that when I’m still after meditating, I change. I’m more aware, more present. And then I come out of that state and I’m back in the world of ego-rationalizing. You know when you’re awake, but you don’t when you’re not. For much of my life, I’m egotistic, rationalistic, self-centred, and driven by external stimuli.

The idea of teaching well-being and character has tended to be championed by private school headmasters like you and Eton headmaster John Lewis. Does that give it a class problem – it can seem like private-school teachers bemoaning the lack of character education in state schools.

Well, class can be a problem. But if we go back to Aristotle and the virtues, he was around even before Eton College. There are eternal character values – honesty, kindness, perseverance, which I think schools should emphasize more. But many schools vacate that space because they’re afraid of it or because it’s not recognized by Ofsted. Many people who run education are quite immature and think it’s only about passing exams. I agree with Aristotle – it should be about flourishing.

Aristotle was tutor to Alexander the Great, and thought leaders should be educated in virtue so that they could encourage eudaimonia (or flourishing) in the citizens. You’ve written several political biographies, and have one about David Cameron coming out soon. Having seen political leaders up close, how virtuous would you say they are, and how capable of leading their societies to eudaimonia?

51Oz+FkMd5L._SY344_BO1,204,203,200_The leaders I have met and written about have mainly been extraordinarily capable and intelligent. The biggest thing they need is more solitary time in stillness, to get to know themselves and integrate themselves. Gordon Brown was an admirable person, but his greatest problem was he was very unintegrated. His self-image of himself was at variance with his very self-centred ego-driven approach. He needed to calm down and be more integrated. Blair too – he got carried away off himself. Both were good people, but in different ways they got carried away.

And finally, your next job is as vice-chancellor of the University of Buckingham, the first private university in the UK. How useful could well-being education be in higher education?

Very. I want to make the first positive university. That will include introducing mindfulness classes for all trainee doctors, to help them be more in the present moment in their dealing with patients.