Hindu beliefs about mental health

Hinduism And Mental Health

A QUALITATIVE STUDY OF RELIGIOUS PRACTICES BY

CHRONIC MENTALLY ILL AND THEIR CAREGIVERS IN

SOUTH INDIA

R. PADMAVATI , R. THARA & ELLEN CORIN

ABSTRACT

Background: Socio-cultural explanatory factors for mental health problems determine help seeking behaviors. The study aimed to understand the reasons mentally ill patients and their families in India choose to seek help from a religious site. Materials and methods: Persons with mental illness and their families were interviewed at religious sites using a guideline questionnaire. Issues such as significant life events, explanations for perceived abnormal behavior and reasons for choosing a specific religious site for ‘treatment’ were explored. Discussion: Seeking religious help for mental disorders is often a first step in the management of mental disorders as a result of cultural explanations for the ill- ness. This behavior also has social sanctions.

Key words: chronic mental illness, religious sites, qualitative study, ritualistic practices

INTRODUCTION

Religion and religious practices are significant in every aspect of life in India as in several communities all over the world. Seeking help in a religious setting or from faith healers is a common behavior pattern among those suffering from any kind of illness, including chronic mental illnesses (Sethi & Trivedi, 1979; Sathija &Nathawat, 1984; Campion & Bhugra, 1997). The variety and diversity of traditional health care practices is an indication of healing as a cultural preoccupation. There are several resources for seeking traditional and or religious help to alleviate mental problems. These include places of worship like temples, durghas and churches in the country as well as the indigenous faith healer.

Construction of explanatory systems for changes in behavior is a norm in most cultures. Social, cultural and religious beliefs of the patients, their families and the community contri- bute significantly to the understanding of mental illnesses, assessment and diagnosis, help seeking and management (Sheehan et al., 1990; Suryani et al., 1995; Razali et al., 1996; Weiss, 1997). In a study of perceptions of and attitudes towards mental illness, Al Adawi et al. (2002) found that majority of students and the public felt that mental illness was

International Journal of Social Psychiatry. Copyright & 2005 Sage Publications (London, Thousand Oaks and

New Delhi) www.sagepublications.com Vol 51(2): 139–149. DOI: 10.1177/0020764005056761

caused by spirits. Investigating the cause of changes in behavior from the patient’s point of view, Jiloha et al. (1997) reported that over 56% of the subjects attributed their illness to supernatural agents like ghosts, evil spirits and witchcraft. A methodologically rigorous study conducted in a rural community in South India, demonstrated the ability of the impoverished illiterate rural population to recognise behavioral concomitants of mental ill- nesses (Thara et al., 1998). Epilepsy and mental retardation were seen as physical illnesses, nervous problems or due to heredity. The explanations offered for psychoses, depression or hysteria were possessions by evil spirits, devils or curse of gods. The main sources of infor- mation about the causes of mental illnesses have been the traditional healer, friends or rela- tives, astrologers, other significant persons in the community or the patients own personal knowledge (Kua et al., 1993; Razali et al., 1996; Jiloha et al., 1997).

Help seeking patterns are determined in part by the explanatory models that prevail in the community. Factors vital to resorting to religious treatment include the type of afflictions, the local interpretation of illness, the socio-economic status of the patient and the availability of healers. Kapur (1979) documented the co-existence of several kinds of healers treating mental illnesses in an Indian village. Healing methods included astrology, penance, a visit to a shrine, use of a holy object, or spirit possession to negotiate with the possessing spirit. He opined that most people chose a particular healer because the healer was known to be able to cure illnesses effectively. Jiloha et al. (1997) reported that consultation with faith healers was irrespective of level of education or the patient’s belief in the cause of illness. Investigating psychiatric status of those who were attending a temple in North India, Sathija and Nathawat (1984) identified a wide variety of psychiatric problems including anxiety neuroses, depression, dissociative states and chronic psychoses. In the rural community in South India, religious and traditional modes of treatment were opted for psychoses, depres- sion or hysteria (Thara et al. 1998). Parallel access to various forms of mental health care systems is a notable feature of help seeking practices. Medical treatment offered by medical systems such as allopathy, ayurveda, siddha, unani and homeopathy are widely accessed, as is religious help. Madan (1969) reported that nearly 66% used multiple forms of therapy. Thara et al. (1998) also reported this practice. Some studies report that religious resources are often accessed earlier as compared to seeking help from the official health care system (Campion & Bhugra, 1997). In their study, over half the number of patients seeking help at a psychiatric facility had consulted a religious healer prior to seeking medical help. The findings in these studies would be a reflection of the site where the studies were conducted.

This present study aimed at understanding the reasons why religious sites were chosen by the patients and their families for managing abnormal behaviours. The main objectives of the study were to:

1. To elicit the explanations offered for psychiatric symptoms by patients and their families at various religious sites in South India.

2. To understand why people resort to religious places for help to manage abnormal behaviours.

3. To study the ‘religious’ behaviors adopted by families and patients.

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MATERIALS AND METHODS

Participants: Twenty six participants who were interviewed were persons who appeared to have a chronic psychotic illness and their family members present at the site. A diagnosis of a psychotic illness, especially schizophrenia, was made on the basis of information obtained from the family member and where possible, an examination of the patient.

Locations: Interviews were carried out at three Muslim darghas at Kovalam, Yerwadi and Nagoor and two Hindu temples at Sholingur and Hanumanthapuram, in the state of Tamil Nadu, South India. These places of worship were popular for the ‘curing’ of abnormal behaviors. Each site had specific rituals and practices, largely in accordance with the religion.

Interview technique In-depth interviews using an interview guide were undertaken. The interviews focused on onset of illness, course, significant events in the lives of the patients, explanations for per- ceived abnormal behavior, experiences with treatment, and reasons for choosing a specific religious site for ‘treatment’.

The interviews were carried out at the religious site in Tamil, the local language, by psychiatrists or psychiatric social workers trained to undertake qualitative interviews. The caregiver and/or patients were interviewed after having obtained informed consent. The interviews were tape recorded, translated and transcribed. Thematic analysis was done by systematically coding segments of the interviews.

RESULTS

The participants consisted of caregivers and/or patients at the various sites. A total number of 26 exhaustive interviews were carried out at the various sites, after obtaining consent. The number of patients included 12 men and 14 women. The average age of the patients was 42� 18 years (range 22–71 years). The average duration of illness of the persons recruited for the study was over ten years (SD 4.5 years). Most patients at the religious sites had not received medical treatment for several years. They had either not sought medical treatment at all or had given up medical treatment.

Of the 26 interviews, interviews were carried out with eight patients alone as there were no family members. These interviews were sufficiently informative for analysis. Of the 18 patients whose caregivers were interviewed, 11 interviews were comprised of a caregiver– patient pair. The majority of caregivers were mothers or wives. In two cases, male spouses, less than 25 years of age, were staying with their sick wives at the temples. In seven cases, the respondents were only caregivers, as the patients were too sick to be interviewed or had refused to be interviewed.

Duration of stay of the respondents at the sites varied. People who were interviewed were seen to stay in the place for a minimum period of one month to as long as five years. Difficult living conditions, often inhumane, poverty and physical illnesses, did not deter people from staying there. We did not include patients who just visited the place, but did not stay there.

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Persons in charge of the sites willingly gave permission for conducting the interviews. Five caregivers refused to be interviewed, stating that they were not willing to discuss a divine matter with anyone.

The main findings of the interviews were:

Explanations Explanations for the illness were largely based on culturally accepted reasons such as evil spirits, planetary positions or sins of the past birth. The explanations were ones that were commonly available in the community and were often suggestions by various persons like close family, faith healers, priests, astrologers or significant others.

The belief that the cause of the change in behavior was due to the effect of evil spirits was an oft-repeated theme in most narratives. In most cases, the evil spirit was reported to be as directed by other relatives or neighbors. The following narrative of an interview with a woman patient at a Hindu temple is an example:

Q. What do you think is the cause of this illness? A. This is not an illness. If it was, then I should have become better by going to the doctor.

This has been done by men who make evil spirits to trouble us. They will trouble us very badly and make us lose consciousness, make us unaware of what we are doing or saying. When I was pregnant, they took me to a hospital where they gave me glucose water. The water would enter me for some time and then stop by itself. It is all the effect of evil spirits.

Q. Who do you think was responsible for this? A. I know that it was my uncle who did this black magic on me.

Confirmation of the correctness of the religious explanation was evident especially in those cases where the problem seemed to improve. A respondent at a dargha, stated:

If he did not become alright after coming here, then we should think of other reasons (for his change in behavior). But he is now alright. People who come here leave only after they become alright. Nobody goes away without a cure.

Attribution of the illness to the doctrine of ‘Karma’, an important theme in Hindu Philoso- phy, is seen in the following narrative:

Q. What do you think is the cause for your son’s problems? A. I think it is his Karma that he has got schizophrenia. The actions of your previous

birth make you suffer in the present birth. That is what we Hindus believe.

Help seeking While the choice of source of help was largely based on the explanations for the illness, there were other factors which influenced the choice. In a majority, seeking religious treatment was advised by significant others. The significant others included people who had experienced a ‘cure’ at these centers, priests, astrologers, faith healers or elders in the family. As most

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psychotic persons do not seek help for themselves, the initiative to seek religious treatment was usually by the family. Various significant persons often negotiated this decision through time, each of whom would have their own impression of what to do.

The choice of the place of worship often went beyond the boundaries of religious faith. Irrespective of their religion by birth, patients and families went to temples or dargha or a church for a ‘cure’. Very occasionally, conversions to other religions were seen. Hindus were seen to visit a Muslim dargha for treatment. A Christian or a Muslim would visit a temple in the hope of a ‘cure’.

This is a narrative of a Hindu informant interviewed at a Dargha:

Q. You are Hindu. How did you decide to come to this dargha? A. This place is known for healing persons with such problems. Also, a boy in my village

became better after coming here. So, we came here.

Another respondent at a temple stated:

A. Many people come here for getting cured. Muslims and Christians also come and worship here. They also perform the rituals that are to be done here.

In many instances, medical treatment was sought some time during the course of illness, irrespective of the perception of causation of illness. The general awareness of medical treat- ment facilities was evident during the interviews. In a few cases, healers at the religious sites have referred patients to the medical facilities. There has been a vacillation between religious treatments and medical treatments:

A. We went to several places for treatment. We saw doctors and even went to the mental hospital. They gave me electric shocks. But I did not become better. So, I went to a faith healer in the next village. He told that an evil spirit was giving trouble. So I went to a Dargha in Ajmer, in North India. But I did not become better. Instead I got worse. So I came to Nagore. I have been staying here for 3 years now. I am actually a Christian. But I have converted to the Muslim Faith.

One important observation was that in a number of cases it was evident that family members were staying with the patient for indefinite periods of time. Often, this was at the cost of a job and an income. Support was usually forthcoming from other family members for the stay of the patient and the caregiver. In cases where there was no one to provide support, the patient and the relative lived on the generosity of the people who visited the place of worship. They received support from people who gave alms, which was a prescribed ritualistic behavior, necessary for a ‘cure’.

Q. Have you been staying with your son here, since the beginning? A. Yes, only I am there to look after him. Q. What do you do for food? A. They give us food tokens for our meals.

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Q. Who does that? A. The authorities. People donate money to the dargha to supply food. This is done for

penance.

Rituals In almost all the centers, ritualistic behavior patterns were observed. In temples, usually a set pattern of offering prayers, specific to the site was noted. The rituals that were practiced, included making offerings (money, kind), engaging in physical acts like going around the place of worship several times, fasting, eating raw fruit like lime, letting oneself be chained/whipped. The patient or the relative could undertake the ritual for the desired effect. All these processes were viewed as necessary for recovery.

To cite an example of the rituals in the Hindu temple at Sholingur:

Q. How long do you have to stay at this temple? A. For 48 days. Q. What do you do here? A. Every morning we should take a bath and go to the temple on the hill. We should go

around 108 times. All this should be done without eating or drinking anything. After completing the rounds, we take a sip of the holy water at the temple spring. We should go back down the hill and prepare a meal. Only one meal is eaten during the day.

The rituals performed at most darghas were in the form of prayers and penances:

Q. What do you do here? A. We pray to the Baba of this place. We go round the tomb several times during the day.

People who can afford it give offerings at the tomb, like flowers, camphor, money. Some give the alms to poor people. Sometimes, the priest here will tie a talisman around the arm of the patient.

Q. How effective do you think is all this? A. Many people become better and go away. We have to wait patiently till the evil spirits

leave the body.

Several reasons were stated for practicing such rituals. Most common was that the ritual was prescribed by the key persons in charge of the place of worship. Also ‘faith’ was an attribute to such behaviors. People reported having a deep faith in the place of worship and the ritual that was practiced. This faith created a sense of hope in a ‘cure’:

Q. Have you seen many persons who have benefited by coming to this temple and becom- ing better?

A. Yes. People of all faiths come here for a ‘cure’. They go away only after becoming better. This God is powerful. Everyone who comes here and does penance will com- pletely recover. It is a strong faith that we have.

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The practice of restraining Contrary to ritualistic practices, the use of chains to restrain the patient is seen to be resorted to only in the event of a violent behavior. The process of containing the patient in this manner is not viewed as a therapeutic process:

A. We have to tie him to the tree with chains. Otherwise he goes round everywhere and starts to beat people. I tried to remove the chain several times. But each time he would run away. The watchmen here would catch him and bring him back. I am not going to remove the chain till he becomes alright.

Q. Are all persons who come here chained? A. No. If they are very violent, then they are chained. Q. Do you think that chaining is necessary for the patient to improve? A. No, this is done only to control the patient and prevent him from running away.

Culmination process Culmination of the ‘ritualistic process’ was dependant on certain symbolic expressions. Dreams commonly confirmed recovery and gave patients permission to go. Indications given in a dream in a symbolic way were particularly significant and expected by the patients and their families sometimes for months. For example, a dream of being given a bus ticket or the Baba of the dargha appearing in the dream indicated ‘permission’ to leave the place. The Baba is one who is revered as a saint of the particular Dargha:

Q. When will you return home? A. Not yet. I will leave only after I am alright. Q. How will you know that you are alright? A. I will get a dream which will tell me that I can leave this place. Q. What will the dream be? A. Baba will come in my dream and tell me that I can leave. Or, the dream will be as if I

am traveling in a bus.

Other indicators for ending a ritual were also noted in the narratives. For example, if chains around the feet or hands opened by themselves, the patient could leave. In Hanumantha- puram temple, flowers were placed at the hands of the idol of Lord of the Temple. If a flower remained where it was placed, it was interpreted as permission to leave. If the flower fell off, it meant that the permission was not granted. More significantly, it was a popu- lar opinion that if a patient left without permission, he/she would not be cured and would have to come back. Impatience observed with medical treatment was not seen with religious treatment.

DISCUSSION

This study has demonstrated the influence of the socio-cultural milieu on various facets of the lives of the mentally ill, particularly the help seeking behavior pattern. This has been reported in studies published over several decades, (Madan, 1969; Kapur, 1979; Mohan, 1982; Sathija

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et al., 1984; Thara et al., 1998) indicating that the socio-cultural explanations for abnormal behaviors have been stable over time as well as over social change (Jiloha et al. 1997).

Possession by evil spirits has been a repeated theme of causation of abnormal behavior across all interviews in this study and is noted to be a shared phenomenon. This is in contrast to the findings of another study where Srinivasan and Thara (2001) reported that the attribu- tion of supernatural causes to schizophrenia was not widespread, at least in urban areas in India. With the present study being undertaken at religious sites, the main attribution has been to the supernatural. The shared belief system allows for a common understanding of the illness and facilitates communication between the patient, his or her family, the larger community and the healer, thus enhancing the cooperation required for efficacy of therapy (Kakar, 1982).

Help seeking is usually undertaken by the family and a collective decision is always taken. Suggestions from significant others in the community appear to be more easily accepted than a scientifically detailed explanation by medical personnel. Families play a vital role in the process of decision making in the kind of treatment that needed to be accessed. Banerjee (1997) opined that at least four motivational factors appear to determine the decision making: (1) strong belief of the decision maker in faith healing; (2) easy approachability; (3) social stigma associated with psychiatric consultation; and (4) the belief system about the causation of mental disorder. In this study the two factors that influenced help-seeking decisions were the culturally accepted reasons for abnormal behaviors and the strong faith of the decision maker on faith healing. A cause outside the individual and locus of control in the external environment is much more easily acceptable than an explanation, which seeks to identify a ‘problem’ within the individual.

Help-seeking behaviors are also seen to traverse the boundaries of religious faith in a number of narratives in this study. According to Campion and Bhugra (1997), this behavior indicates that in times of distress the religion of the healer or the place of worship is of less significance than the relief from the distressing symptom. India being a land of several reli- gions, it is seen that people will often attend various places of worship irrespective of their own religion. This confirms the pluralism of help-seeking behavior. The faith in a particular healer or place of worship is more indicative of a belief and hope for cure rather than a faith in a particular religion.

The decision to resort to a particular type of facility does not require adhesion to a specific explanation but would also be contingent on other factors, such as the type of afflictions, the local interpretation of illness, the socio-economic status of the patient and the availability of healers. At a more practical level, it can be seen that many families have found it convenient to leave their sick, often-unmanageable relative in a religious site, with the practice having a social sanction. The cost of care at a religious site is less when compared to the cost of seeking medical help. Sometimes patients themselves also find it easier to stay on at the facilities. The outside world would mean having to fend for themselves, hold a job, or look after a family.

It has been noted through the narratives that in general, people were aware of and have accessed medical treatment offered at the government health facilities or at private psychiatric care settings. The vacillation between different modalities of help resources indicates the plur- alism of help-seeking behavior. The persons using the various systems do not appear to be destabilized by the different epistemologies and their components.

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Ritualistic practices at religious sites have a wide framework, incorporating social, religious and mythical domains. For example, the healing that takes place in a Hindu shrine allows patients to express and resolve social and psychic suffering (Pfleiderer, 1988). The collective therapeutic rituals involve use of holy substances, rites designed to drive away spirits, prayers and trances. The significance of the symbols used in these rituals lies in the belief that these symbols have a divine power (Kakar, 1982). The sense of interaction and co- existence of multiple traditions and local culture (Csordas & Lewton, 1998) is evident across all interviews.

The process of culmination of the help-seeking behavior is also determined by norms estab- lished in the place of worship. Interpretation of symbolic events or dreams provides explana- tions in terms of divine power. The symbolic framing of the end phase of treatment shifts the onus of the decision from the patients and the families. There is a sanction to the idea that a cure was taking place, has been completed and the patient is now cured.

The emphasis on Dream and its interpretation is very often satisfying to the listener. Communication of psychic events, including mental distress through narration of dreams is a well known device in the Indian subcontinent (Kakar, 1982). In the context of this study, dreams are often an essential sign of achieving recovery. In both Hinduism and Islam, it is strongly believed that dreams convey important messages. Interpretation of dreams instill a great deal of confidence in the patient and his/her family and thereby reinforces the faith in a specific resource.

CONCLUSIONS

This study confirms the importance of religious sites in the help-seeking trajectory for psy- chotic patients as well as the general pluralistic character for help seeking in India, at least in the case of psychotic patients. It indicates the role played by the explanatory models in the choice of treatment. However, there are several other issues pertaining to explanations that influence the choice of treatment including the common co-existence of several explana- tions for a particular case, or the development of explanations through time.

Explanations for causes of changes in behavior are commonly perceived from a socio- cultural belief system. The emphasis on causations outside the individual appear to be easily accepted. Help-seeking behaviors are based on a perceived cause for the change in behavior, the local interpretation of the behavior, the type of affliction, the socio-economic condition of the person and the availability of the healer. The choice of a religious site goes beyond the boundaries of religious faith. The pluralistic nature of help-seeking behaviors indicates an emphasis on the need for cure as a priority. Ritualistic behaviors and their symbolic mean- ings are readily accepted and followed with full faith. The ritualistic paradigm has a social sanction.

The interlink between various resources accessed for help seeking is informal with no specific pattern or system for the vacillation between the resources. The persons using various systems do not appear to be destabilized by the different epistemologies and their com- ponents. This would open doors for more formal collaborations between the systems

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particularly between the religious systems and the formal psychiatric medical care system. Future research needs to address the issues related to the perceived success of the religious healing methods. The role of the religious healers and places of worship in the care and man- agement of mental health issues needs to be clarified, understood and perhaps made a resource for provision of mental health care.

ACKNOWLEDGEMENTS

We wish to express our sincere thanks to Mr J.R. Aynkaran and Mr Babu Charles, who helped to undertake the interviews.

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Dr R. Padmavati MD, DPM, Deputy Director, Schizophrenia Research Foundation, Chennai, India.

Dr R. Thara, PhD, Director, Schizophrenia Research Foundation, Chennai, India.

Prof. Ellen Corin, PhD, Departments of Psychiatry and Anthropology, McGill University and Douglas Hospital Research Centre, 6875 Boul Lasalle Pavillon Dobel, Montreal, Quebec, H4H IR3, Canada. Email: corell@douglas.mcgill.ca

Correspondence toDrR. Padmavati, MD,DPM,DeputyDirector, Schizophrenia Research Foundation, R/7ANorth Main Road, Anna Nagar West Extension, Chennai 600 017, INDIA. Email: scarf@vsnl.com

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