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DIY therapy

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:

The Big Dream survey

Over 500 people filled in my survey about their dreams. The results suggest people have ‘big dreams’ which they find insightful and adaptive, but such dreams are rare, and usually in times of crisis. Big dreams sometimes involve a visit from a deceased loved one.

et-moon-560Colin Ludlow was a successful TV writer in his 50s, when he went into hospital to have a tumour removed from his bowel. After the operation, he contracted pneumonia and MSRA. He spent the next month in intensive care, close to death. During that time, he had a series of very vivid dreams. He never used to recall his dreams, but he can still remember these dreams today, and felt compelled to write a book about them, Twenty Four Dreams Before Dying.

The 24 dreams were quite cinematic, slightly flowery and romantic (several of the dreams involve medieval knights or World War II heroes), and often centre around a voyage (in one, he rides a tricycle to heaven), a great undertaking, a battle. In the last dreams in the series, the battle is won and he returns home, across the sea, to the land of the living. He’s not sure what to make of the dreams, but feels they helped him to face death, and that he’s less afraid of death, more open to the possibility of an afterlife, as a result. They helped prepare him for the journey, like a pre-flight safety video.

I went to the launch of Colin’s book, and was struck by his story. Personally, I rarely remember my dreams, or find them particularly significant, except for one period of my life, when I was traumatized and my psyche was quite dissociated (ie there were traumatic memories I struggled to integrate). I had a series of dreams in which I was pursued by a terrifying tramp-figure, who was trying to kill me. In the final dream, I was in a lorry with the tramp driving, and we crashed through the side of a barrier on a cliff. I manage to pull the tramp to safety just before the lorry crashes over. I feel those dreams helped me through a crisis, by helping me recognize and accept the dissociated parts of me, which is what I take the tramp to symbolize. I also think the dreams were prophetic – a few months later, I crashed through a barrier on a cliff, while skiing, and had a near-death experience which helped to heal me of PTSD.

At Colin’s book launch, I asked the neuroscientist Chris Frith (a friend of Colin’s) whether neuroscience presently believed there is any meaning to our dreams. He said no. In fact, this is not quite true. While the old, rigid psychoanalytic interpretation of dreams is not widely accepted anymore, there are several ‘dream labs’ in universities, who have arrived at various conclusions as to why we and other animals dream. They’re now considered a form of ‘threat rehearsal‘, and also a way of solving problems and consolidating memories – when I was taking my finals, I dreamt my essay plans were assault courses over which I had to clamber.

Big Dreams

I’m still curious about the phenomenon of ‘big dreams’. Carl Jung came up with the phrase. He wrote: ‘Unlike ordinary dreams, such a dream is highly impressive, numinous, and its imagery frequently makes use of motifs analagous to or even identical with mythology.’ And a big dream may not be just about you, it could be a ‘collective mythological dream’ for your tribe.

The ‘big dream’ fits with what was known in ancient culture as ephiphany dreams, in which a god or dead person visits you and tells you some important information. Epiphany dreams were rare, and the examples passed down to us usually occur to famous leaders, with gods telling them to invade a country or establish a city. But there was a democratic culture of epiohany dreams too – you could spend the night in a dream-cave to get advice from the god Aesculapius. Galen, the great medic, says he became a doctor after Aesculapius appeared to him and also to his father in a dream.

Sebastiano Ricci’s Dream of Aesculapius (1710)

However, the ancients and medieval Christians thought that most dreams were ‘mundane’, ie caused by the body and basically meaningless, and some could come from the ivory gate of false dreams. In any case, they were not considered easy to interpret, so dream interpretation manuals were always popular, like the Atharva Veda, which is full of such pearls of wisdom as ‘If, in a dream a flat-nosed, dark, naked monk urinates, there will be rain.’

Survey results

I thought it would be interesting to ask you about your dreams. I wanted to test the hypothesis (1) that there are ‘big dreams’, ie dreams that seem unusually vivid, significant, and insightful, (2) that such dreams are rare, and (3) that they particularly occur in times of crisis and transition – like Colin in intensive care, or me struggling with PTSD, when the psyche has a lot of work to do to adapt. I would suggest that in times of crisis, particularly confrontation with death, our subconscious ‘wakes up’ and communication with the dream-world becomes more vivid.

I made a SurveyMonkey survey and sent it out via my newsletter, Facebook and Twitter, and to the members of the London Philosophy Club. I received 508 responses – thank you! Obviously there are methodological problems with this survey – the pool of respondents are probably mainly middle-class British and Americans in their 30s-70s. However, the results are still interesting.

Firstly, it’s clear that people do have dreams which they find significant and insightful (79.5% do), and that such dreams are rare – 27.8% have had less than 10 such dreams in their life, 18% said they’d had such dreams more than 10 but less than 100 times, and only 17% say they have such dreams very often.

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Secondly, as I hoped, such dreams particularly seem to occur at ‘crisis / transition / deep change’:

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And thirdly, 62% of people felt that these ‘big dreams’ had helped them adapt to that crisis:

Chart_Q3_151218What were the contents of these significant ‘big dreams’? Well, some of the replies suggest the sort of collective mythological content which Jung predicted (one lady dreamt she was a male martyr being impaled on a tree while vikings rode round her on bisons, which is…kind of mythological). A few of the ‘big dreams’ were about collective political situations – responding to the Paris attacks, for example. But not many. Most of the ‘big dreams’ people reported were about personal relationships, sometimes indicating subconscious feelings and bringing the insight that the relationship is not a goer:

Once in a relationship I was dissatisfied with, I had a dream it was the wedding day, I was at the end of the aisle with my dad about to walk down it, turned to him and said “I just can’t do it dad” and ran out of the church! Ended relationship soon after!

I would very often dream of my partner who had in the dreams the face of one of my male friends who has a more suited personality for me. It was like I couldn’t even be happy with my boyfriend in my dreams! I knew It had to stop… I broke up and immediately I felt a shift in my life and regained my joy and confidence.

Dreams about stressful work relationships and work crises were also quite common:

I was having issues at work with two people, I dreamt I was locked in a cell and they were throwing poo at me. Summed up the situation and scared me if I’m honest

Rather than the alchemical or mythological symbols Jung predicted, dreams seem to be pragmatic in their symbolism – they’ll use whatever metaphor or symbol seems to fit the situation.

In my dream I was operating on my boyfriend, taking his organs out one by one (like in operation game) and studying them to see what they told me about him. this was painful for him. when I woke up I realised this was what I was doing to him by asking questions I felt I needed the answer to (about previous relationships). I realised this was hurting him & that it wouldn’t tell me anything. this realisation enabled me to let go of this need – and helped save our relationship (for a while).

Dreams also seem to help people become aware of (and potentially change) their relationship to themselves. They will often use the metaphor of exploring a big house:

“I was in my house, and came across a door that led into a part of the house, with more rooms, that I hadn’t known was there. It was when my marriage was breaking down, and I was facing life as a single parent. I had the dream three or four times, and when I woke, it was with a sense of awareness that there were new places in my life to discover and live in, and where I would be safe and at home.”
“At times when I feel insecure, I often dream about my house being broken into. This is a recurring dream. Having done lots of research down the years, I understand that the house is symbolic, in that it represents the ‘mansion of the soul’ and or a play on words as has been my experience, where the question could be – ‘Is your house in order?'”

Another recurring metaphor is water / swimming pools / drowning / facing a storm or tsunami / crossing a river:

I dreamt I was trying to swim across the river Mersey with my friends with all my clothes on, so this made it difficult, my friends were helping he along. It was around the time I was going through an acrimonious divorce. I knew that everything would eventually turn out “all right” as my friends gave me support in my dreams and in real life.

Dreams, death and bereavement

One of the most common types of ‘big dreams’ people remembered involved meeting loved ones who have passed away –  43% of respondents said they’d met a deceased loved one in a dream, of which two thirds think this was their memory, and one third believed this was the actual loved one’s spirit visiting them:

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These spirit visitations helped people adapt to the crisis of bereavement

my father had died and I vividly met him in a dream where I felt that he was acknowledging me as a person and showing his acceptance and deep love for me 🙂

Or to adapt to an upcoming bereavement:

When my toddler nephew was dying, I had a dream of him as an infant, and there was a group of relatives / ancesters standing along a river some on one side and me and others one the other side of this very nerrow river maybe stream. On my side of the river we passed infant Mike down the row of relatives till he came to me I then gave Mikey to an ancester on the other side of this river with the understanding he was “with us now, and we will take care of him.” I woke up and I heard a disembodied voice saying “he is no longer of this earth and will be at peace now.” I knew then he wasn’t going to make it through his cancer treatment and would die. He died one or two days later.

Or sometimes the visit was simply an ancestor spirit offering support in a later crisis:

my late dad giving me a hug & telling me everything would be alright because i’m strong. This was a very bad time as i had just been diagnosed with ms. the dream was very vivid – i could see, hear & sense my dad very clearly & it left me feeling calm & comforted.

The anthropologist Edward Burnett Tylor thought that dreams were the origin of religion and belief in the soul – because it feels like the soul leaves the body (33% of you say you’ve had an out of body experience while dreaming), meets the dead, and receives messages from some other dimension. People are more secular in their interpretation of dreams today, but interestingly, 47% of respondents still believed that some dreams come from God or a higher spirit:

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I also asked people if they’d ever had ‘prophetic dreams’, ie dreams about events which subsequently happened. I only thought of this question after the initial release of the survey, so the data pool is smaller (138 people), but the results are still interesting – 38.2% said they’d experienced prophetic dreams, also often about relationships:

“Soon after a new man came into my life I had a series of vivid dreams with a common theme: he was driving to pick me up and I noticed someone sitting in the rear of the car; we were in his flat and he wouldn’t listen when I said I thought someone was in the kitchen…reader, he was married and playing away from home. My dreams quite often warn me of things that I don’t want to admit consciously”

“I kept on dreaming my partner was cheating (he was)”

“Dreamt would be broken into over Christmas. Was so vivid could see their faces. Put extra locks on front door. Got robbed anyway.”

“I dreamed my late father told me I was pregnant. I took a test the following day and I was!”

“I have twice dreamt the result of a sports event, taking place the following day. One was a 5-4 win in a football penalty shootout and the other a Six Nations game. Both were correct and I won money on the second one!”

Before you jump out of bed and accuse your partner of infidelity or put £100 on Manchester City, remember the warning of the ancients – it may be a false dream from the gate of ivory!

Lucid dreaming experiences were common among respondents:

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And clearly we’re not embarrassed to discuss our dreams with others:

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Around 30% of respondents said they had some sort of ‘dream practice’ – usually trying to remember their dreams in the morning, often writing them down in a journal, and sometimes discussing them with a therapist. One person with tinnitus says she uses her dreams to manage her physical condition, while another said they can tell from their dreams when their iron level is getting too low!

What about sex? Well, Freud would say all your dreams are about sex (Jung would say they’re all about alchemy). That doesn’t seem to be the case. But there’s some transgressive sex in there – 50% of you who describe yourself as either heterosexual or homosexual said you’d dreamt of a sex experience contrary to your usual preference, which makes me wonder if we’re all bisexual or trisexual in our subconscious self. We’re not that faithful in our dreams either – according to the Montreal dream lab, women only dream of having sex with their partner 25% of the time, the rest of the time it’s sex with someone else; with men, only one sixth of their sex dreams involve their partner.

Conclusion

So, to return to my initial hypothesis, it does seem that people have ‘big dreams’ which strike them as unusually significant and insightful. Such dreams are not common for most people. They usually happen in moments of crisis and transition. They are pragmatic in their use of metaphor and symbol, using symbols that fit your situation, although there are symbols and metaphors that reoccur quite often. People find them relatively transparent in their meaning. They seem to help people adapt to the crisis. They particularly give people insights into relationships – to oneself, to loved ones, to people at work. And they quite often involve a visit from a dead loved one, which helps people adapt to loss and bereavement. Hooray for dreams!

Here, by the by, is a New York Times article looking at how dream-labs are now studying such ‘big dreams’, particularly dreams of visits by dead loved ones.