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 Table of Contents  
PERSPECTIVE
Year : 2022  |  Volume : 38  |  Issue : 4  |  Page : 318-324

Schizophrenia, Recovery, and Culture: The Need for an Indian Perspective


1 Psychiatric Rehabilitation Service, Hunter New England Mental Health, Morisset; School of Medicine and Public Health, Faculty of Health, The University of Newcastle, Callaghan, NSW, Australia
2 Schizophrenia Research Foundation (India), Anna Nagar West Extension, Chennai, Tamil Nadu, India

Date of Submission16-Jun-2021
Date of Decision01-Jul-2021
Date of Acceptance06-Jul-2021
Date of Web Publication11-Jun-2022

Correspondence Address:
Dr. Srinivasan Tirupati
Hunter New England Mental Health, Morisset Hospital, Morisset, NSW 2264
Australia
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_178_21

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  Abstract 


Recovery is a concept that defined a positive and empowering experience for people with Schizophrenia. Recovery is an innately personal phenomenon, but the cultural environment can influence the recovery process. The concept of recovery originated in the West. The Eastern cultures differ in various aspects from the Western cultures. Application of the Western model of recovery in an Eastern culture like India without considering the cultural differences would be misplaced. This paper discusses two cultural factors in Indian life, namely, the family and the doctrines of Karma and Fate, that can impact recovery from Schizophrenia. Understanding the impact of culture on schizophrenia recovery should also consider cultural variations between individuals and over time. Principles and practice of Recovery-oriented mental health care in India should consider the unique local cultural environment.

Keywords: Culture, India, mental health recovery, mental health services, schizophrenia


How to cite this article:
Tirupati S, Padmavati R. Schizophrenia, Recovery, and Culture: The Need for an Indian Perspective. Indian J Soc Psychiatry 2022;38:318-24

How to cite this URL:
Tirupati S, Padmavati R. Schizophrenia, Recovery, and Culture: The Need for an Indian Perspective. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Dec 9];38:318-24. Available from: https://www.indjsp.org/text.asp?2022/38/4/318/347279




  Introduction Top


The diagnosis of Schizophrenia is often negatively value-laden with implicit life-long impairment and unrelenting deterioration in all aspects of life. The pessimistic outlook persisted despite evidence from several outcome studies showing positive global outcomes for many people with Schizophrenia (PwS). It weighed against the hope and optimism of PwS, who believed in the possibility of significant and enduring improvement in their lives.[1] A mental health consumer movement took roots in the United States of America during the late last century that fostered the prospect of recovery as an achievable goal for PwS. This grass-roots effort gained momentum and credibility with Harding's landmark study,[2] followed by the work of Anthony.[3] Several longitudinal outcome studies supported this notion of recovery from Schizophrenia. The observations from these studies brought increasing pressure to mental health to abandon the pessimism and foster the hope of achieving healthy, fulfilling lives.[4] The view that recovery was not limited to the traditional medical paradigm of symptoms resolution but described a personally meaningful experience lead to a major shift in the traditional philosophical views of many mental health systems globally.[5]


  The Cultural Context of Recovery Top


Culture comprises overt beliefs and practices and the subtle and taken-for-granted conventions that frame our sense of reality. Culture defines what is normal and abnormal and gives our lives a sense of direction and purpose.[6] It sets the diverse and shifting parameters for decision-making and action in the context of families, communities, workplaces, peer groups, and environments.[7] Cultural dynamics significantly affect many aspects of health, ranging from how health and illness are perceived, health-seeking behaviors, and attitudes of the health consumers, health care providers, and mental health systems. [8],[9],[10],[11],[12],[13] Therefore, it is crucial to understand the relationship between culture and health, especially the cultural factors that affected health-improving behaviors in all cultural settings.[14] Mental health care systems are increasingly acknowledging the intersection of cultural diversity with illness and well-being. The cultural formulation interview in the DSM-5 recognizes the importance of culture in understanding illness and recovery. The formulation provided a positive step to explore cultural identity, the conceptualization of illness, psychosocial stressors, vulnerability, resilience, and the cultural features of the relationship between the clinician and the patient.[15]

East and West division of the world is often used in describing differences between cultures. The East comprises Asian, African, and Latin American countries. The United States of America, Canada, Australia, New Zealand, and some parts of Europe predominantly make up the West.[16] The East-West dichotomy is disputed and considered inaccurate as it falsely suggests the two cultures are homogenous and mutually exclusive cultural identities.[17],[18] We referred to the Eastern and the Western cultures in this paper to facilitate references to literature that used the dichotomy.

The concept of mental health recovery emerged from Western cultural traditions and understandings of the human condition.[13] There was a concern over the moncultural approach to applying the Western model of recovery at a global level without considering the differences between societies.[13],[19],[20],[21],[22],[23],[24] Attempts to export the Western model mental health care practices into the rest of the world must acknowledge the sociocultural conditions affecting schizophrenia outcomes. Studies have highlighted the differences in the experience and definition of recovery in Eastern cultures such as India, Japan, and China compared to Western cultures.[20],[25],[26],[27],[28] Several cultural factors differentiate India, a prototype of the Eastern culture, from the West. The factors that can impact the mental health recovery experience include, but are not limited to, the definition of individuality and independence, the family structure and dynamics, religion and spirituality, the scope and reach of mental health care and welfare services, poverty, and stigma.[29],[30],[31] This paper discusses the influence of the family structure and dynamics and religion and spirituality on schizophrenia recovery in the Indian cultural environment.

We present two case vignettes to provide the background to the discussion on Schizophrenia recovery in the Indian cultural context compared to Western culture. One example is from India and the other from Australia.


  Case Vignettes Top


India

P is a 38-year-old single male diagnosed with Schizophrenia at the age of 24. After the initial hospitalization, he continued treatment in the community. He is in remission with prominent negative symptoms. He is an engineering graduate, currently unemployed, and lives in his parental home with his parents and brother's family. All the adults provide him all necessary care and support, including financial needs. They attend regular psychiatric consultations along with P, fill the prescriptions and supervise his medication intake. P helps the family with grocery shopping and some household chores. He does not have any friends. He relates freely with the neighbors of the multi-storeyed apartment where he lives but not with unfamiliar people. Participation in social and community-based activity always occurs with the family. His parents reported that they continue to engage in prayers at home and the temples and have gone on several pilgrimages in the country. P also attends these religious activities with the parents. The mother hopes that P will get well, get back to work, get married and have a family. P and his father do not share that hope. The family has made arrangements that his brother and sister-in-law will continue to care for him in the future if the parents die. P's father has bequeathed the family house to P to provide future financial support to him.

Australia

D is a 46-year-old single male who has had Schizophrenia since the age of 22 years. He had multiple psychiatric hospitalizations. He is in remission from the psychosis with some negative symptoms with no hospitalization in the past 8 years. He lives independently in a house provided by the Government's Department of Housing in the same suburb as his parents. When required, D seeks regular support from the Community Managed Organisation (CMO) support workers regarding housekeeping, shopping, visits to the health services, and some community activities. The National Disability Insurance Scheme funds the CMOs. The Community mental health team supervises his medical treatment. The mother keeps in contact with him at regular intervals with brief visits. D spends time with his mother at her house on occasions such as Easter and Christmas. He has no other family members or friends for any social activity. The mother engages with the coordinators of the mental health services and the CMO when required. D receives the Disability Support Pension that meets his financial needs. A government-appointed Guardian manages his finances. He has not been employed for more than 20 years and does not seek employment. He does not engage in any religious activity.


  Recovery in the Indian Context Top


The Family

The various definitions of recovery referred not only to the content and process of recovery but identified the PwS as central to the process. For example, the frequently cited definition by Anthony[3] described recovery as “…a deeply personal, unique process of changing one's attitudes, values, feelings, goals, skills and/or roles.” Although the person is central to recovery, the process occurs in the social milieu.[32] The cultural dynamics relating to individualism can modulate a person's perception and expression of individuality.[18] Hofstede[16] drew the contrast between Western societies as “Individualistic” and Eastern societies like India as “Collectivist.” In individualistic cultures, everyone was expected to look after themselves and their immediate family. In a collectivist society, “people from birth onwards are integrated into strong, cohesive in-groups, often extended families... which continue protecting them in exchange for unquestioning loyalty.”[16] The independent-interdependent dimension is another way to describe individualistic and collectivist societies.[33] Individualistic society values the goals of autonomy, independence, and distinction of self from the group. In contrast, a collectivist society emphasizes on conformity to the group and interdependence.[29]

The notion of “family” replaces 'individual' in the collectivist Indian society. The family plays a central and lifetime role in caring for its members and works collectively to care and provide for its members.[18] The family fulfills the physical, spiritual, and emotional needs of its members in a supportive manner. It provides security and encouragement, makes decisions, and acts in consideration of the family's welfare.[18],[29] Despite the ongoing changes in the social network and family organization systems, the family is still a focal point and forms an indispensable resource for mental health in India.[29] Life in a family is about the whole unit as an in-group and less about the personal autonomy and priorities of the PwS.[18],[33] For example, independent living, a hallmark of recovery in Western societies, was said not to apply to Eastern cultures like India and China.[25],[26] Gopal and Henderson[20] noted that a group of PwS in India sought to live with the family in harmony as a part of their recovery. An Indian study showed that PwS referred to independence in terms of their roles and responsibilities as part of the family environment.[23] The “independence” in the Indian society was related less to the individual's self-determined needs and goals, rights and responsibilities, and self-direction.

Women in India experience a greater degree of the family's collectivist influence. In India and similar cultures, there tends to be a power imbalance between men and women, resulting in women having far less independence.[34],[35],[36] Sharma and Pathak[36] described the woman's life in India in the following lines.

”The Indian culture is unique. Joint family system, patriarchy, marriage a must, especially women; marriage is a sacrosanct union, permanent union; subservient status of daughter-in-laws at home, preference for the male child, practice of dowry, lower educational status of women, strict code of conduct for females, and primary roles of women being childbearing and child rearing.”

Women in India occupy a secondary status to men in the family hierarchy and face significant limitations in decision-making about their own lives. The women face other forms of woman-specific disempowerment and discrimination, including constraints in healthcare access, socio-economic disadvantage, access to education and economic independence, and restrictive role delineation as carers of others in the family.[36],[37],[38],[39] Such a situation significantly limits an Indian woman's ability to express and practice individuality. Therefore, her experience of personal recovery could be quite different from a woman in an individualistic society.[18],[36],[40] The Western model of individuality to define recovery would be far more out of place for a woman in India. Some studies from India that showed better outcomes for women with schizophrenia[41] did not address their personal recovery experience as individuals.


  Religion and Spirituality Top


Religion refers to socially based beliefs and traditions, often associated with ritual and ceremony. Spirituality involves a deep-seated individual sense of connection through which each person's life contributes to a valued and greater “whole.”[42] Religion and spirituality have overlapping boundaries. Spirituality is a common factor in all the religion. Religion is institutionalized spirituality.[43] The proposed definitions and functions of religion overlap with definitions of culture. The relationship between an individual's religion and culture is inseparable.[44] In mental health, religion and spirituality play a vital role in an individual's personal and social life. They work as a powerful medium to help in the healing process.[45] Religion and spirituality were effective ways of coping with Schizophrenia that fostered recovery.[46] These two factors could enhance mental and social health through doctrines on the ways of life and promotion of resilience.[47],[48]

Religion and spirituality profoundly shape the interpersonal relationships of people in India.[49] Hinduism is the most influential religion in India. It exerts considerable influence on the societal structure and culture of India today.[50] The Hindu doctrines of Karma and Fate impact the experience of suffering and acceptance of it. The principle of Karma is the law of cause and effect, central to Hindu religious consciousness. The doctrine denotes that every thought, word, and action accumulates Karma that affects current and future life.[51],[52] The philosophy of Fate is the belief that all life events are predetermined and therefore inevitable. Fate is ascribed to God's actions and cannot be modified.[53] Karma is a natural law and can be modified.[54] The acceptance driven by the two doctrines is seen as means to a greater end since one becomes less attached to changing it.[55] Suffering is a way to progress on the spiritual path, be tested, and learn from a challenging experience.[55]

Some view the Karma and Fate philosophies as unfavorable coping mechanisms since they evoke guilt and resignation. The attribution of events and outcomes to an external locus of control,[56] inherent in these doctrines, could reduce the extent of personal efforts towards recovery and reduce the chances of rehabilitation and recovery.[57],[58],[59] However, the sense of control of one's life by forces beyond control is said to enable acceptance of suffering from mental illness and its consequences. The equipoise and surrender to the will of God help in coping with disability.[54],[60] The attitude of satisfaction with what one has serves to protect the mental health of Indian society in the face of large-scale poverty and deprivation.[60] The doctrine of Karma can promote internal control by allowing acting to modify the cumulative effect of a negative or “bad” Karma towards a “good” Karma and thereby influence outcomes.[61]

The everyday life in India influenced by the Karma and Fate doctrines is not Hindu-specific.[54] The Hindu element is so much a part of Indian culture that some of it has influenced non-Hindu aspects of Indian life, manners, and customs. There is a significant number of people of other faiths other than Hinduism in India. Its doctrines and practices have rubbed off on many non-Hindu communities in Indian society.[62] There is considerable overlap between Hindu and other theologies in India, including Christian. Islamic, Jain, and Buddhist. A study in India on people from Hinduism, Islam, Sikhism, and Christianity faiths showed that all the four groups shared the doctrines of Karma and Fate.[63] Therefore, the attitudes and behaviors influenced by the Karma and Fate doctrines can be an Indian cultural phenomenon not limited to people of the Hindu faith.


  Cultural Heterogeneity, Change, and Comparability Top


Studies describing the collectivism and religious orientation of the Indian society do not take into consideration cultural heterogeneity and changes occurring over time and within the population. Comparisons of the Eastern and Western cultures need to recognize the changing nature of cultures.[17] In addition, there are similar equivalent cultural elements in both the Eastern and the Western societies. The role of the family and religion in health and wellness is relevant to Western cultures as well.[64],[65]


  Cultural Heterogeneity Top


Comparing cultural factors and dynamics in an Eastern culture like India as an exact opposite of the Western culture can be fallacious. The cultural milieu can vary in structure and dynamics over time and place.[17] Worldwide migration, acculturation, and enculturation processes created communities with complex cultural identities and practices.[17] Globalization of cultures, often influenced by mass communication systems like social media, has a significant impact creating an amalgam of cultural attitudes and practices within a community.[66] These changes have impacted Indian society as well. Individuals within a cultural system can also vary in how they endorse or reject their culture's ideals.[67] The assumption that people will fully adopt the characteristics of the culture could be misplaced as it does not reflect a cognizance that the enculturation process does not occur on an all-or-none basis.[68] The enculturation process could also be different across generations.[69] The intricacies and heterogeneity within and across people and cultures need consideration.[11] Because there could be between-individual variations within a culture, there is a necessity to be mindful of the individual's unique lived cultural environment when studying the impact of culture on Schizophrenia recovery.[18]


  Cultural Change in Indian Society Top


The other fallacy is presuming the Indian cultural scene as static. Cross-cultural comparative methods tend to overlook the transformation of cultures over time.[70] Although the traditional joint household, both in ideal and in practice, remains the primary social force in India, it is changing since the late twentieth century. The increasing commercialization of the economy, development of the modern state, and urbanization have contributed to the nuclearization of Indian family units and the disintegration of family-based support systems.[29] Singh[71] noted changing values and culture of Indian youth. The move towards individualism, identified as a Western cultural ideal, significantly impacted Indian youth.[71] The change moves the new generation away from their roles and responsibilities as members of an extended family.[72] Globalization has also brought changes in Indian women, promoting their education, employment, and empowerment and moving them towards individualism and independence.[73] As a result of these changes, Indian society may have a complex mixture of independent and interdependent characteristics or constraints. Therefore, there is a need for exercising caution when polarizing cultures like India as purely collectivist.


  Cultural Comparability Top


The significant role of the family and religion in the care of PwS is not unique to India. Here are some quotations from Australians participating in the cross-cultural study comparing schizophrenia recovery in India and Australia.[74] They highlight the comparability of some cultural features in Australia and India. The following responses from Australian participants highlighted the family's role in a society considered prototypically Western and individualistic.

” I think they [families] play a very important part… Australian society wants everybody to be independent but we are still part of a family regardless if we are living 200 miles away. So I think that carers and family… regardless of whether or not you have a mental illness you are still part of that family and so they play a very important part…”

–(Mental Health Professional[MHP])

I had family support, yeah, my family has always supported me all the way… they would visit me in hospital. My mum would come around and help me clean my house. Mum and dad would look after me financially…”

–(PwS)

The following quotes indicate that religion and spirituality in recovery are not specific to life in India.

“… for a lot of our clients…their religion is very important to them, so for them, that's where they get a sense of strength from, and a source of strength.”

–(MHP)

“Everyone else has given up on him. The church hasn't given up on him. That's one thing that works for him. And that is a part of his recovery.”

–(Mother of a PwS)

“My religious side has helped me. I am getting help, you know. I'm praying to God, I am saying, “You know, God, I am powerless over this... Can you help me? I can't do it myself.”

–(PwS)


  Recovery-Oriented Mental Health Care in India Top


Recovery-Oriented Mental Health Care (ROMHC) model focuses on the ability of PwS to redefine themselves and “live well” beyond being less symptomatic.[75] The model recognizes the person's choice and self-determination as vital to successful treatment and recovery. It places the people with mental health issues central to mental health care and service delivery.[76],[77],[78] Transplanting the Western RoMHC model into the Indian cultural milieu needs care and discretion. A Western cultural point of view could see the effect of the collectivist orientation of the family and the religious and spiritual practices on an individual as disempowering and working against the goal of personal recovery. The impact of these cultural factors need not be negative. The family dynamic of interdependence could be a supportive factor to resilience and coping with disease.[48] Religion and spirituality can be the support mechanisms to deal with adversity due to Schizophrenia by instilling hope, purpose, and meaning in the lives of PwS and their families.[46] Although we noted that the family and religion have relevance to schizophrenia recovery across cultures, their impact on PwS in an Eastern culture like India may be more pervasive. Linking the existing natural helping systems with individual strengths and competencies promotes personal empowerment.[79] ROMHC in India should take advantage of the supporting and protective role of the cultural factors and incorporate them into the care process.


  Conclusion Top


The recovery journey experience of persons with Schizophrenia in India may be different from their counterparts in Western culture. Their journey is grounded in the prevailing cultural environment, which can vary across individuals and over time. The family dynamics and the religious and spiritual orientations can significantly modulate recovery in the Indian cultural context. Therefore, a culturally naïve application of the Western recovery model to mental health care in India will not be relevant or practical. Any recovery-oriented mental health care in India for PwS can be effective and acceptable if it utilizes the unique local cultural processes to promote and sustain recovery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his/her consent for images and other clinical information to be reported in the journal. The patient understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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