Indian society has been undergoing tumultuous socio-political and cultural transformation over the past few decades (Bhargava, Kumar and 2017; Sethi, Thacore and Gupta 1968; Shah 2004). The influence of western cultures which encourage individualism, independence and self-expression, has touched all spheres of Indian life, igniting intrinsic yearnings for autonomy. In their striving for individuation, some individuals decide to break away from the confines of their families and choose to move interstate or overseas to forge their own identities.
Australia, viewed as one of the countries offering such opportunities, has witnessed an influx of young immigrants from India in recent years (Australian Bureau of Statistics, 2017). For those individuals who adopt multiculturalism in their way of thinking, conflicts often arise with traditional and family values that require some to seek psychological help.
Hence, it is envisaged that mental health clinicians will increasingly be called upon to treat patients from the subcontinent. To provide culturally informed therapeutic services, clinicians not familiar with Indian culture will need to acquire an understanding of the family dynamics and emotional environment in which their patients were raised, the influence of deeply-rooted traditions and religious beliefs on their personality development, and the impact of changing cultural dynamics on their current predicaments. Clinicians can acquire such knowledge from their patients by establishing an empathic relationship (Patterson, 2004) during the course of therapy and by self-directed learning.
Existing research has established that following migration, identity issues, cultural shock, bereavement, failure to realise expectations and lack of cultural assimilation can cause deleterious effects on the mental health of migrants (Akhtar, 1999; Bhugra et al, 2011; Roland, 1991). The psychosocial issues that impact on their mental health post-migration and their implications for psychotherapy merit consideration.
This qualitative article, based on personal experience, relates to Indian immigrants in Australia and presents clinical case vignettes of two patients to illustrate these issues and could be relevant to clinicians working with Indian immigrants in other Western countries. Details of clinical examples have been changed to ensure anonymity. India is a mosaic of cultural, social class and religious diversity and each patient requires an individualized therapeutic approach to avoid stereotyping.
This article aims to:
- provide an insight into aspects of Indian culture and family traditions which influence personality development and psychopathology of mental illness;
- highlight the influence of modernization in ways of thinking and lifestyle causing conflicts with traditional values in young Indians; and
- emphasise the need to adopt a contemporary therapeutic approach to help resolve their predicaments.
Clinical Example 1
A young, single male came to Australia for further studies and stayed on. He presented with long-standing lower abdominal pain, attributed to psychological factors. He kept returning to India, as he remained in conflict between fulfilling his dharma and obligation to his family and a strong urge for self-actualisation. He expressed his ambivalence about returning to live in India permanently, being influenced by the lifestyle and opportunities in Australia. He came to seek advice and directives from the therapist, as he would from a guru orteacher in India, to resolve his unforeseen predicament.
Encouraged to explore his feelings, he related his emotional conflicts to expectations of his family to return to India and join the family business. He acknowledged that he was always looking to please his family and to prove himself, but received no encouragement, which further undermined his self-confidence and self-worth. He expressed feelings of anger and resentment and remained confused regarding his priorities.
His yearning to achieve his own identity was validated as understandable by the therapist. He perceived himself as an anxious, introverted person, lacking in self-confidence and uncomfortable in large social groups. With his determination to stay on in Australia, he attended classes to become fluent in English and obtained a job, which helped him develop self-confidence.
He gradually established his own business and network of friends and married an Indian woman of his choice, having achieved a degree of self-actualisation. He has continued in therapy with increasing intervals between sessions to work through decisions he takes to negotiate his future. He had seemingly somatised his anger and resentment towards his family into abdominal pain which is no longer an issue.
Clinical Example 2
A young married male domiciled in Australia for several years, presented with complaints of marked anxiety over several weeks which he related to family issues.
He said he felt settled in Australia but that his parents were expecting him to return to India to live with them, not an uncommon parental expectation. Recent ill-health of his parents required him to visit them more frequently. This unforeseen situation led to feelings of guilt for not fulfilling his dharma of caring for his parents in their old age. He started to feel tense and irritable, and his temper outbursts were causing stress at home. His performance at work suffered.
He described himself as a nervous person, anxious in social situations but a high achiever academically. However, at school he would often be ill prior to exams for fear of failure, even though he always did well.
Encouraged to explore and reflect on his feelings, he gained insight into his childhood symptoms of anxiety and lifelong need to identify with his successful father and earn his approval. His feelings were validated as understandable and he accepted the cultural norm that being aloof and conservative did not imply that his father did not love and appreciate him, but that in Indian culture it has been the mother’s role to take care of children, and fathers tended not to express their affection openly. He acknowledged that, being a high achiever and brilliant academically in his own right, he no longer needed his father’s approval in this respect.
During therapy, he informed his parents of his decision to stay in Australia. He felt a sense of relief when they accepted his decision, resulting in an amicable resolution of his conflict. His guilt from obligations placed on sons to take care of elderly parents was further resolved when he was able to make satisfactory arrangements for their care in India. He felt settled enough to terminate therapy.
The clinical examples illustrate the unforeseen family and cultural issues which surface for some Indian immigrants and impact on their emotional wellbeing post-migration. A grasp of traditions and family dynamics is vital to understand the conflicts some Indian immigrants can be faced with and merits elaboration.
Traditionally, mainly for socio-economic reasons, most Indians are raised in a hierarchical extended family system. They live with their parents and several other relatives in one household and support one another in times of emotional and economic need. The family elders make important life decisions for younger members of the family, such as their education, careers and marriage. Thus, during their early development, individuals are deprived of the opportunity to learn how to take decisions or responsibility for themselves and imbibing an obligation or dharma to support the family, maintain its cohesion and to look after elderly family members (Bhargava et al, 2017; Bhatt, 2015; Juthani, 2001; Kakar and Kakar, 2007).
Since the integrity and unity of the family is paramount and intricately woven into the fabric of Indian life and psyche, an individual’s identity is enmeshed within family relationships (Roland, 1991). Open expression and discussion of disagreeable feelings, such as anger, anxiety, depression and resentment, is discouraged for fear of alienation within the family. These feelings are thus suppressed or repressed, finding expression in somatic symptoms or dissociative states. It is argued that the psychodynamics of living within an extended hierarchical family fosters dependency and consequently leads to a “lack of firm sense of self” (Kakar and Kakar 2007, p.14), a lack of assertiveness and poor development of self-worth and self-esteem. Women in particular have borne the brunt of culturally imposed discrimination and devaluation over the centuries in a culture of female submissiveness, reflected in their psychological development (Avasthi, Kate and Grover 2013; Kakar and Kakar 2007).
While such a family environment has benefits in offering a sense of emotional security, individuation and the “fullest possible expression in life of the innate potentialities of an individual, the realization of his own uniqueness as a personality” (Storr, 1963, p.27) and Maslow’s self-actualization (Patterson, 1978) remains virtually unachievable.
Modern technology, social media, the internet and international travel have exposed the Indian population to world cultures and societies and served to stimulate new ways of thinking, bringing about changes in people’s perceptions of themselves and their identities.
This has brought about a noticeable transformation in some of India’s deeply entrenched psycho-philosophical structures, as many new-generation Indians incorporate Western ideals of independence and self-expression into their lives (Bhargava et al, 2017; Shah, 2004). With increases in levels of education, job opportunities and earning capacity, new options have become possible, affording them opportunities to seek jobs away from their families, to meet diverse groups of people at work and socially, and for greater interaction between genders. They are eager to take on responsibilities in the workplace and other spheres of life, and end their dependency on their families, leading to the breakup of extended families (Bhatt, 2015).
While most individuals make a satisfactory transition, some, as they venture out into the new and unknown psychosocial territories, find the move triggers anxiety and depression (Trivedi, Sareen and Dhyani, 2008) as they are now confronted with the reality of separation from the support and safety of their families and are required to be self-reliant, take decisions and assume responsibility for their lives (Kakar and Kakar, 2007). They may experience a sense of loss, insecurity and vulnerability, with subsequent feelings of isolation, loneliness and helplessness when faced with difficult situations (Akhtar, 1999; Bhugra et al, 2011; Roland, 1991) which would have previously been the responsibility of their elders to resolve.
Unable to resolve their unsettling conflicts, some immigrants decide to return home. Others who opt to remain in Australia, while adapting to some values of the host culture, settle within a similarly minded Indian community. In the event of their needing psychological help, going by their individual beliefs of attributing emotional problems to an “external locus of control” (Avasthi, Kate and Grover, 2013) such as karma (past actions influencing the future), supernatural influences, divine intervention or evil forces, they are likely to resort to the ancient Indian system of Ayurveda, consult “holy men” or “god-men” (Kakar and Kakar, 2007; Juthani, 2001), perform religious rituals, obtain amulets, seek advice from astrologers or palmists, or resolve their emotional issues within the conceptual causal frameworks of karma and dharma (Surya and Jayaram, 1964). As a last resort they may decide to consult professional therapists or pursue traditional and modern treatments concurrently (Bhargava et al, 2017; Bhatt, 2015).
Some recently arrived young professionals and students with a modern outlook who are determined to establish themselves in their new cultural milieu find themselves in lingering conflicts with traditional and social mores impacting on their emotional well-being. From their viewpoint, acculturation is not an issue. They seek help in therapies which resonate with their new ways of thinking to free themselves from the “cultural noose” (Ilaiah, 2009) of traditions, which they have come to consider as archaic and do not hold sway over them.
As such, they do not relate to therapies which direct them into relationships based on dependency, considered as the “ideal of maturity” in the Indian cultural context (Avasthi, Kate and Grover, 2013; Surya, 1966, cited in Neki, 1973) but rather work towards interdependence (Ananth, 1984), a compromise, so as to avoid a total split from their families. They avail themselves of the contextual view of Indian ethical concepts of right and wrong (Kakar and Kakar, 2007), which allows them scope to modify some aspects of their traditions to suit their modern lifestyle. The often-suggested revival of ancient Indian guru-chela (teacher-pupil) system of teaching (Neki, 1973), still current in Indian schools (Bhagat, 2010), will be untenable with them as a therapeutic paradigm. Being didactic and directive, the effectiveness of such therapeutic procedures is questionable with young Indians of modern outlook (Manickam, 2010), and the draw of these types of therapeutic approaches “seem to be waning” (Bhargava et al, 2017).
In order to remain relevant and effective, psychotherapeutic paradigms must have a considerable amount of contemporariness about them. Thus, to cater for the therapeutic needs of modern-thinking Indians, a shift from totally traditional Indian therapies to a more contemporary therapeutic approach (Gawler–Wright 2004, p.13), is called for.
Establishing a collaborative, empathic relationship with unconditional positive regard for patients’ viewpoints (Patterson, 2004; Jacob, 2013) concerning their difficulties is crucial in the healing process (Carstairs, 1965; Storr, 1963). Employing such an approach, the patients are guided to engage in self-exploration; to think and express their feelings which are validated without them feeling judged. The aim is to encourage patients to explore solutions to their problems that work for them in their cultural context (Manickam, 2013). As is evident in the clinical examples described, patients are aware of the source of their problems, albeit at different levels of consciousness. They are encouraged to engage in exploring intrapsychic conflicts and feelings through self-examination which, from a contemporary therapeutic viewpoint, “is simply not a feature of Indian culture and its literary traditions” and is not encouraged (Kakar, 1982, p.7). Since such modes of thinking may be alien to their upbringing and personality development, patients gain a sense of confidence and empowerment in resolving their problems in a manner that is ego-syntonic and less influenced by the beliefs and values of their therapist or their guru or necessarily their elders.
In the cases presented, through employing an empathic and non-judgmental approach, and acknowledging and validating the patients’ need to establish their own identities within a culturally sensitive environment, the patients were encouraged to introspect and arrive at solutions to their problems that they felt compatible with.
Eclectic psychotherapy is effective with Indian patients (Avasthi, Kate and Grover, 2013) and has a place in therapy with Indian migrants with Western modes of thinking (Bhargava et al, 2017; Hoch 1990; Manickam, 2013; Sethi, 1977).
Thus, a collaborative, flexible and integrative psychotherapeutic approach drawing on clinically useful elements from different therapeutic modalities – cognitive, psychodynamic, humanistic, behavioural and socio-cultural orientated models – addressing their current needs merits consideration, and could be of relevance to therapists working with immigrants in different cultures.
Having undergone a new and different learning experience through therapy, patients develop skills to negotiate between cultures and live in harmony within syncretic Indian and Western value systems which they themselves establish, as they strive towards their goals of achieving self-actualization and face future challenges.
Vinod Thacore is a Consultant Psychiatrist with Monash Health, Melbourne, Australia. He works with a team of case managers, occupational therapists and nurses in a 22-bed community rehabilitation facility for psychiatric patients. He also consults in a ‘complex care’ programme with a team of case managers and clinical psychologists in managing patients in the community with psychosocial and physical problems to prevent relapses and frequent hospital admissions. He has a special interest in cultural issues in psychiatry. Contact: Doveton Community Care Unit, 20 Matipo Street, Doveton, 3177, Vic., Australia. Phone: +61 3 8572 4888 Fax: +61 3 8572 4860 Email: firstname.lastname@example.org and email@example.com
Akhtar, S. 1999. Immigration and Identity: Turmoil, Treatment and Transformation. Lanham, New Jersey: Jason Aronson Inc.
Ananth, J. 1984. Treatment of Immigrant Indian Patients. Canadian Journal of Psychiatry, 29(6): pp.490-493
Australian Bureau of Statistics. 2017. Migration, Australia 2015-2016. [online] Available at: https://www.abs.gov.au/ausstats/abs@.nsf/lookup/3412.0Media%20Release12015-16
Avasthi, A., Kate, N. and Grover, S. 2013. Indianization of psychiatry utilizing Indian mental concepts. Indian Journal Psychiatry, 55: pp.136-44
Bhagat, C. 2010. The Great Indian Psychotherapy. The Times of India. 26 September
Bhargava, R., Kumar, N. and Gupta, A. 2017. Indian Perspective on Psychotherapy: Cultural Issues. Journal of Contemporary Psychotherapy, 47(2), pp.95-103
Bhatt, G. 2015. Encountering Culture: Psychotherapy and Counselling Practice in India. International Psychology Bulletin, 19(1) pp.38-41
Bhugra, D., Gupta, S., Bhui, K., Craig, T., and Dogra, N. 2011. WPA guidance on mental health and mental health care in migrants. World Psychiatry, 10(1): pp.2-10
Carstairs, G.M. 1965. Cultural elements in the response to treatment. In De Reuck, A, Porter, R., eds. Ciba Foundation Symposium Transcultural Psychiatry. London: Churchill pp. 169-94
Gawler-Wright, P. 2004-13. Introduction to the Principles of Contemporary Psychotherapy. [online] BeeLeaf Institute of Contemporary Psychotherapy. Available at: http://www.beeleaf.com/downloads
Hoch, E. M. 1990. Experiences with psychotherapy training in India. Psychotherapy Psychosomatics, 53 pp.14-20
Ilaiah, K. 2009. Post–Hindu India. New Delhi: SAGE Publications
Jacob, K. S. 2013. Employing Psychotherapy Across Cultures and Contexts. Indian Journal of Psychology. Med. 35(4) pp.323-325
Juthani, N. V. 2001. Psychiatric Treatment of Hindus. International Review of Psychiatry, 13(2) pp.125-130
Kakar, S. 1982. Shamans, Mystics and Doctors. New Delhi: Oxford University Press
Kakar, S. and Kakar, K. 2007. The Indians. New Delhi: Penguin
Manickam, L.S.S. 2010. Psychotherapy in India. Indian Journal of Psychiatry, 52, Summer Issue, pp.366-370
Manickam, L.S.S. 2013. Integrative change model in psychotherapy: Perspectives from Indian thought. Indian Journal of Psychiatry, 55, (Suppl 2): Summer Issue, pp.322-S328
Neki, J.S. 1973. Guru-Chela relationship: The possibility of a therapeutic paradigm. American Journal of Orthopsychiatry, 43, pp.755-66
Patterson, C.H. 1978. Cross-cultural or intercultural psychotherapy. International Journal for the Advancement of Counselling, 1, pp.231-47
Patterson, C.H. 2004. Do we need multicultural counselling competencies? Journal of Mental Health Counselling, 26(1) pp.67-73
Roland, A. 1991. In search of self in India and Japan. Toward a cross cultural psychology. New Jersey: Princeton University Press
Sethi, B.B. 1977. Editorial: Need for an Indian psychotherapeutic model. Indian Journal of Psychiatry, 19:1
Sethi, B.B, Thacore, V.R, and Gupta, S.C. 1968. Changing patterns of culture and psychiatry in India. American Journal of Psychotherapy, 22: pp.46-54
Shah, G. 2004. Social movements in India. A review of literature. New Delhi: SAGE Publications
Storr, A. 1963. The integrity of the personality. London: Penguin
Surya, N.C. and Jayaram, S.S. 1964. Some basic considerations in the practice of psychotherapy in the Indian setting. Indian Journal of Psychiatry, 6, pp.153-156
Trivedi, J.K., Sareen, H., and Dhyani, M. 2008. Rapid urbanization – its impact on mental health: A South Asian perspective. Indian Journal of Psychiatry, 50(3) pp.161-165
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