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CBT

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:

Review: The Happiness Industry by William Davies

9781781688458-4171756f689401c14d3e2d09906a9e3fWatch out folks. There is a murky world lurking behind the scenes, a sinister cabal of policy-makers, psychologists, CEOs, advertizers and life-coaches, watching you, measuring you, nudging you, monitoring your every smile, all to try and make you happy. We must resist. This, broadly, is the message of sociologist William Davies’ book, The Happiness Industry: How Government and Big Business Sold Us Well-Being.

I opened Davies’ book expecting a historical critique of the so-called ‘politics of well-being’, a movement which arose in the last decade. Cognitive psychologists like Aaron Beck, Martin Seligman and Daniel Kahneman found ways to measure how our thoughts can make us miserable, and how cognitive behavioural interventions can help us to be wiser and happier.  The evidence-base they built up persuaded policy-makers – particularly in the UK, but increasingly around the world – that governments can and should try to measure and improve citizens’ well-being.

The science of flourishing became a way for policy-makers to move beyond the cultural relativism bequeathed us by Nietzsche, through a marriage of ancient wisdom (Buddhist, ancient Greek) and empirical science. Governments could then try and improve citizens’ ‘flourishing’ without being accused of imposing their version of the good life on every else. ‘It’s not our version’, they could say. ‘It’s science.’

The politics of well-being is still quite an undeveloped movement, but in England it’s led to specific policies, particularly to the collection of well-being data to guide policies; an on-going attempt to teach ‘well-being’ and ‘character’ in schools; and the expansion of free talking therapies on the NHS.

Davies has written well on this movement for the New Left Review. But what we get in this book is a much more sprawling narrative, which looks at the history of the attempt, in economics, psychology, statistics and neuroscience, to measure moods and emotions, and to use that data either to ‘nudge’ us towards policy-outcomes, or sell us things, or keep us working. The story meanders from Bentham to JB Watson via whiplash, social networks theory, the DSM, the history of management consultancy, the Chicago school, the history of stress and the Quantified Self movement. It risks becoming a history of everything, and could more coherently have concentrated on the last decade (although oddly he doesn’t mention Kahneman, or happiness economist Ed Diener, or the various attempts to teach well-being in schools, or Martin Seligman’s attempt to teach ‘resilience’ to the entire US Army).

The ‘enemy’ of his book seems to be an overly-mechanistic or behaviourist model of the mind, in which scientific experts measure our mood-machine and try to steer it without asking people what they mean or care about. Certainly, the politics of well-being can be anti-democratic and positivistic. When our government came up with a national definition of well-being, for example, it did so via a small panel of experts, entirely made up of economists and psychologists.

However, Davies’ story risks confusing the behaviourist with the cognitive behavioural. Much of the politics of well-being sprung from the success of Cognitive Behavioural Therapy, which arose in the 1960s as a critical response to behaviourism. In CBT, people’s beliefs, meanings and values are all-important, so it’s more humanistic and potentially more democratic. It’s true that CBT can ignore the impact of external circumstances like poverty on our emotions. But people are developing more collective forms which equip us to change our circumstances (like being in debt to loan sharks) as well as our inner lives.

Probably the biggest impact of the politics of well-being so far has been to increase public funding for talking therapies, and to put mental health on the political map – there is a new campaign in the UK for ‘parity of esteem’ between physical and mental health in the NHS. But Davies ignores this. Instead, he focuses on the possibility of therapy or life-coaching being forced onto benefit-claimants in England and Wales. The Department for Work and Pensions denies therapy is ever mandatory, although it may be on occasion, and this should be opposed as an ethical breach and a waste of tax-payer money. But we also need to vigorously defend and expand free therapy for those who need it and want it.  Davies doesn’t lift a finger in support.

Instead, he lays into corporate wellness programmes and the booming wellness industry, and slams the proliferation of ‘chief happiness officers’ and ‘happiness apps’ monitoring our every smile. Are they? Does your company have a chief happiness officer? Have you ever used a ‘happiness measuring app’? It’s true that a handful of companies are taking well-being seriously (a few, like Zappos, take it too seriously). On the whole I think this is a good thing, and could mean companies take employee satisfaction and corporate ethics more seriously as well. But at the moment, most companies’ well-being programmes amount to little more than a salad option at lunch, cheap gym membership, and one away-day a year for some wacky team-building and half-baked resilience-training. Hardly Brave New World.

The over-riding tone of Davies’ book is the hermeneutics of suspicion – he is constantly expressing ‘unease’, ‘disquiet’ and the need for ‘critical resistance’ to the ‘hidden agenda’ of the elite. This is left-wing academics’ favourite posture, but it’s not really radical in that it undermines people’s agency: the ‘well-being agenda’ in this narrative is always something the elite imposes, never something citizens develop for themselves (as is actually the case with the Quantified Self movement). And his ‘perpetual unease’ doesn’t change anything. What are you actually for?

It turns out Davies is for co-operatives, for co-owned companies in which decision-making is shared. Such companies make us happier, according to research. He’s also for local community mental health initiatives like therapeutic gardening, which research suggests make us happier. And he’s for more equal and less competitive societies, which some research suggests make us happier. So on the occasions he’s arguing for something positive, Davies turns to well-being data for support.

At the extreme of his argument, he says governments should ignore people’s moods and feelings altogether, and focus on the serious business of improving material circumstances. That’s exactly the argument successive governments have used to deprive mental health services of funding. Hopefully, this is finally changing, but Davies’ book does little to help the cause.