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Stigma

Translating therapy

Depression is the leading cause of ill-health worldwide, but therapy is little known or practiced outside the West. If psychotherapy is going to become more popular in the non-western world, it needs to build bridges and find cultural parallels in local spiritual traditions. This is totally doable. 

The UK has had a good last decade when it comes to mental health awareness. The Brits don’t talk about our emotions? We never shut up about them these days! Not a week goes by without some official or celebrity – Theresa May, Prince Harry, Rio Ferdinand – saying we need to talk more about mental health. That’s a good thing. It’s good to talk, though it’s even better when that talk is backed up by increases in government spending on mental health services.

The situation is a lot worse elsewhere. As the World Health Organization highlights this Friday in its World Health Day campaign, depression is now the leading cause of ill health and disability worldwide, affecting more than 300 million people. While only around 50% of people with depression get therapy or medication in high income countries, in middle and low income countries, the percentage is closer to zero.

In half the countries in the world, there’s only one psychiatrist per 100,000 people. In India, where I spent the last three months, the country spends 1% of its GDP on health (the OECD average is 9%), and 0.1% of that on mental health services – one of the lowest figures in the world. There’s one psychiatrist for every 300,000 Indians, though in fact most psychiatrists are based in the big cities. In poorer rural regions, there might be one psychiatrist for every million people.

There’s a lot of stigma around mental illness around the world, and little awareness of psychotherapy. And there’s a cultural and language problem for both psychiatry and psychotherapy. Sadia Saeed Raval, who runs the Inner Space therapy centre in Mumbai, says: ‘Therapy in India is mainly Anglophone. The training is in English, the terminology is English, and the therapy techniques tend to be developed in the West.’ 

At a recent event I attended on mental health in India, the discussions were almost all in English, and even when a psychiatrist spoke in Hindi, he still used English words like ‘stigma’ and ‘depression’. The WHO’s own campaign posters, ‘Let’s Talk’, are also all in English. Imagine if we in the UK only had Indian words for depression, anxiety or other internal states.

This Anglicisation of therapy has limited its cultural dispersal in low and middle income countries to affluent, westernized elites. So how does everyone else cope with mental illness? In large part, by turning to religious or spiritual healing. This might sometimes work – it can help provide meaning, community support, meditation, and the powerful placebo of hope. But it doesn’t always work, and in some cases can be harmful.

What to do? Obviously, the best thing would be for countries to increase their spending on mental health services. I imagine the WHO is trying to get its member states to do that. But we shouldn’t assume that western psychiatry has all the answers to the meaning of life (look at suicide rates, where some Western countries do worse than many non-Western countries).

We can also try to help bridge the cultural gap between western psychiatry and psychotherapy, and non-western cultures. And here the medical humanities can help.

In the UK, the most popular and evidence-based therapy for depression and anxiety is Cognitive Behavioural Therapy (CBT). As I and others have researched, CBT has its roots in the ‘healing wisdom’ of Stoicism and, to a lesser extent, Buddhism.

That means that it is easily translatable into other cultural contexts, because the idea of ‘healing wisdom’ appears not just in Greek philosophy but also in Christianity, Islam, Judaism, Hinduism, Jainism and many other religious and spiritual traditions. Indeed, Stoicism was a big influence on therapeutic wisdom books in Christianity (Boethius’ Consolations of Philosophy, for example) and Islam (eg Al-Kindi’s On Dispelling Sadness).

There is also a great deal of similarity between Stoic-CBT therapeutic ideas and those found in the wisdom texts of Hinduism and Buddhism. For instance, Stoicism / CBT is based on Epictetus’ idea that ‘it’s not events, but our opinion about events, that cause us suffering’. Likewise, the Buddha taught: ‘We are what we think. All that we are arises with our thoughts. With our thoughts we make the world’.

Many different wisdom traditions recommend learning detachment, both from one’s own thoughts and desires, and from the ups and downs of fortune, and learning to accept the limit of one’s control over the world – both of which are central concepts in CBT and Positive Psychology. Many also recommend some form of mindfulness and techniques for improving it – Stoicism-CBT recommends keeping track of your thoughts and behaviour in a journal, Jesuits practice ‘recollection’ at the end of the day, Orthodox Christians practice ‘nepsis‘ or watchfulness, and so on. 

Many wisdom traditions also emphasize that changing the self takes repetition and practice (askesis in ancient Greek), as CBT does. Proverbs, in the Bible, talks about seeking wisdom, and inscribing wisdom on the ‘tablet of your heart’ through memory and practice. The Bhagavad Gita says: ‘It is difficult to curb the restless mind, but it is possible by constant practice and by detachment’.

There is some evidence that CBT works better when its basic ideas and techniques are connected and translated into local language and local culture. Here, for example, is a paper on Islamically modified CBT. Others have developed Christian CBT, and of course mindfulness-CBT now has a strong evidence base, although ironically it is barely known or practiced in India, the home of Buddhism.

Medical humanities scholars can help explore the cultural connections between western psychotherapy and various wisdom traditions around the world, and help to discover the local vernacular for local emotional states.This will help people overcome their suspicion of therapy. Speaking personally, for example, I’ve done workshops on healing wisdom for evangelical Christians, where you can describe the basic ideas of CBT purely using quotes from the Bible and Christian wisdom literature. That is helpful for an audience which has traditionally been wary of psychiatry and psychology, partly because of psychiatry’s long history of hostility towards religion.

At the same time, we should remind ourselves that cultures aren’t static and monolithic. There is no such thing as ‘Indian culture’, for example, there are many Indian cultures, all in flux. A 2013 article in the Indian Journal of Psychiatry calls for the ‘Indianization of psychiatry’ to take account of cultural differences such as the greater emphasis on traditional family structures. Fine – but Indian therapists also tell me of the stress and suffering caused to some Indian women by the traditional understanding that their role is entirely to support their husband and his family. Therapy can help people not just adjust to traditional roles, but also help them evolve into new roles, new identities, a new place in society.

Working with local spiritual healers

A second way that medical humanities researchers can help to bridge the cultural gap between non-western cultures and western psychiatry / psychotherapy is by working with local religious and spiritual leaders, facilitating dialogues of mutual respect to work together.

Aaron Beck, one of the inventors of CBT, with the Dalai Lama, who has spoken about the close similarity between CBT and Buddhism’s theories of the emotions

At my university, Queen Mary University of London, a team of psychiatrists are working with local Muslim spiritual healers, to try and improve relationships with a community that has traditionally been very wary of psychiatry. The latest issue of the WHO’s Panorama magazine has an article on psychiatrists working with Kyrgyz spiritual healers. In India, I think it would help to work with local spiritual leaders like Sadhguru, the best-selling yogi who regularly speaks on yoga as a means to mental health. We already know how fruitful the dialogue has been between western psychiatrists and psychologists and the Dalai Lama – it has helped western psychotherapy advance. 

Finally, I think technology has a role to play in improving global mental health. Governments are spending far too little on mental health services, and should be encouraged to spend more. But could the WHO or other organizations like the Wellcome Trust help to develop apps, websites and online courses, in local languages and local cultural terms, to disseminate basic therapeutic ideas and techniques? It would not be enough, but it would be something. And it would be cheap. 

I’m working with the WHO on a project called the Cultural Contexts of Health. Find out more about it here. 

How to keep calm in Kolkata

Life can be stressful in Kolkata – the crowds, the poverty, the heat, the constant cacophony of car-horns. And that’s just for me, a pampered western tourist. So how do the locals cope? More to the point, to what extent do locals seek therapy for mental health problems like depression, or for general life advice? To find out, I interviewed two Kolkata therapists, Mansi Poddar (left) and Charvi Jain (right), both of whom have successful local practices. 

Why did you become a therapist?

Mansi Poddar: Since I was a kid, people have come to me to tell me their stories. When I was studying in Boston, I had a brilliant therapist, and she encouraged me to become one too. I did a masters at NYU, then came and started practicing here.

Charvi Jain: I come from a business family and was expected to go into business too. But I worked with an organization called Make a Difference, which works with underprivileged children, and that showed me I wanted to work around people, helping them. I did a masters at the Tata Institute of Social Sciences in Bombay. It was 95% women on the course, five men, and only one of them Indian! It’s still a woman’s job, because men feel more pressure to make money. After the masters I specialized in Cognitive Behavioural Therapy (CBT). It’s not a very well-known profession – I often have to explain what I do. It’s a bit easier after Dear Zindagi [a Bollywood film last year about a young woman who gets therapy]. But some of my relatives still don’t approve, they say it’s a waste of time. But I’m doing well – my appointments are fully booked for the next two weeks and I’m thinking of expanding.

How normal is it for people in Kolkata to go to a therapist? 

Mansi: It’s not very normal. There’s a lot of stigma. People who do come feel a lot of shame about it, like it means they’re weak, so I have to work to remove that stigma for them.If you want to insult someone, you call them crazy or a psycho. Parents would say ‘if you don’t behave, we’ll send you to Ranchi [a famous psychiatric asylum]. People see beggars in the street with psychiatric problems and worry they’ll end up like that. There’s a fear of poverty, of family not accepting their problem. Families contribute a lot to the stigma by denying the reality of mental illness.

Charvi: People in their 20s or early 30s are more open to therapy, partly through exposure to American TV shows like Suits or Two and a Half Men, which mention therapy. But people in their 30s or older tend not to come unless there’s a serious crisis. Often, people won’t tell their family or close friends they are getting therapy. Students may not tell their parents, and can’t pay for the sessions. Families can strengthen the stigma – you often hear ‘it’s all in your head’. I’m seeing a teenage girl with depression, and initially the family were supportive, but then when she didn’t get better they labelled her as lazy. People think they’re weak for not being able to cope without help. I tell them it’s the opposite – they’re strong for seeking help. Or they trivialize their problems – they say ‘do I really need therapy?’

And they still don’t know the distinction between a therapist and a psychiatrist. Many clinical psychologists here still have a very medical approach – their room is like a doctor’s chamber, with a table in between them and the client. That’s why I called my company Over A Cup of Tea. If people have been to counsellors before, often their experience wasn’t good – they get labelled, judged, with lots of morals enforced on them.

Mansi: Psychiatrists can also enforce their moral judgments. You still get psychiatrists recommending conversion therapy for homosexuality [which is illegal in India]. Or doctors saying ‘stop thinking about stuff so much, it’s not a big deal’.

Indian culture may not be very aware about therapy, but it does have a strong spiritual and religious culture – meditation, yoga and so on. Is that helpful? Do you draw on that in therapy?

Mansi: If people have a spirituality, it can be a great support system. Those who combine Cognitive Behavioural Therapy with their spirituality or faith tend to have a better outcome. On the other hand, spirituality can be too positive, it can encourage over-detachment. It can be like a drug – you keep needing to go to another workshop or retreat, and if you stop, things start falling apart.

Charvi: People sometimes bring in their religious or spiritual beliefs. If you can connect the therapy to that, it works better. For example, if someone is a Jain, like me, you can connect the therapy to the Jain idea of the ‘power within’. But usually people have already tried to get better through yoga or meditation. So if you mention it, it’s like a cliche.

How applicable have you found Cognitive Behavioural Therapy to Indian culture and Indian minds? 

Mansi: It’s quite applicable and works quite well, partly because it fits with older Indian spiritual ideas [indeed, the inventor of CBT, Aaron Beck, was quite influenced by Buddhism and the Dalai Lama has said it’s very close to Buddhist theories of the emotions]. Mindfulness-CBT is obviously close to Indian spirituality, though it’s still very new here. I sometimes recommend clients use Headspace [a British meditation app].

Charvi: People find CBT very intriguing. Often they have Googled their problems, self-diagnosed, and found that CBT is effective for depression or anxiety.

Is therapy just for the well-off in India? 

Mansi: I’m trying to create awareness among the less well-off but awareness is greater among the better-educated.

Charvi: Therapy is quite reasonably priced here, around INR500 a session [about $7]. I see people from lots of different classes.

India scored quite low in a UN global happiness survey last year – below Somalia in fact. And it has one of the higher suicide levels in the world, particularly for young people. Is it quite a stressed, unhappy culture? If so, why? 

Mansi:  I think a huge amount of depression goes unreported in India. I see a lot of depression among women, due to gender inequality in our culture. They are encouraged not to be individuals, to live purely for the happiness of their husband and his family. If they have a good husband and in-laws, it can be fine, but if not, it’s hellish. And if they have ‘home-maker depression’, there’s not much I can do for them, it’s a systemic problem. They can’t afford to divorce and be financially independent, and their families might not have them back. There are extreme cases of abuse, but in general it can be an insidious abuse where the mother-in-law makes their life hell. It comes from the man not supporting his wife, wanting to be a good son instead. Some women are standing up and breaking out of this. Maybe they demand more autonomy within the marriage, maybe they get divorced and start an independent life. It can be a huge struggle for them, but once they get there they enjoy better mental health. As for men, they often report problems at work, where office life can be very hierarchical and they feel bullied by their boss.

Charvi: There’s a lot of discontent – Indians tend to compare their life with others’ lives, with their friends or neighbours, and feel they’re not living well in comparison. There’s always someone doing better. Status anxiety is also very prevalent – people rely on external validation to feel they’re OK and doing well. I think a big problem is that, in the context of families and relationships, boundaries are very blurred. If you want to follow your passion, that comes with a lot of guilt – people feel obliged to be with their parents. But if they obey their parents, they feel they’re missing out and their lives lack meaning.

How about student mental health? Is there a lot of pressure to do well in your exams?

Mansi: A huge amount. I worked on a campaign, Release the Pressure, about exam pressure and how harmful it can be. People think their exam results define their worth as a human being. I hear people say ‘she got 98% in her exams’ about a 36-year-old. Now there’s a slight change, parents are backing off a bit, or trying to expose their children more to things like the arts, outside of school.

What about sex therapy? 

Mansi: I used to get a lot of work for sex therapy, and still get some. But I’ve had some bad experiences around it. A woman therapist working with me – I wouldn’t be able to handle that.

So how can public awareness around mental health be improved in India?

Charvi: There’s more talk about well-being in the media, in weekend supplements and things. But it tends to be more about physical health. I use articles and videos to try and increase awareness. [Mansi also often writes articles on mental health].

Here’s the video for the Release the Pressure campaign: