Monday, February 22, 2016

Cultural pathology in India-1-LAZINESS ..CHARACTER TRAIT OR SYMPTOM?


Mental illnesses are universal i.e. found in all societies and cultures.

Mental illnesses existed in the past, exist now and will continue to exist later too.

The causes of mental illnesses such as environmental stresses and biological, psychological , genetic vulnerabilities are present everywhere.

However, the environmental stresses are unique to each culture and so the person’s manifestations of symptoms too will vary. A schizophrenic from Russia may suspect the KGB of following him, an Indian schizophrenic may believe his neighbour has put black magic on him….and so on. Though the underlying illness, e.g. Schizophrenia is the same in all countries, the manifestation of symptoms of schizophrenia varies as it is influenced by culture.

There is a fascinating chapter in the CTP (Comprehensive Textbook of Psychiatry by Kaplan & Sadock) about mental illnesses unique to different cultures. There are also new diagnosis of new mental illnesses being published in medical literature . Some of the new disorders which did not exist a few years ago include internet addiction, video game addictions, Hoarding,etc. This indicates that  new changes in lifestyles, for example the invention and wide-spread use of computers brought about these new disorders.

Here, I am writing about my observations of the oddities unique to Indian culture  I came across in the patients of a department of psychiatry  I worked in India in late 90s till 2003.

These patients of the outpatient department  of psychiatry had odd behaviours, personality traits, style of thinking, unique to Indian culture which

(a)are definitely MALADAPTIVE.

(b)Do not add up to a full diagnosis of a mental illness or a personality disorder or a neurosis

(c) have not been recognized as a mental disorder by the medical field as yet

(d) but are sufficient to warrant attention, sufficient to prevent the person from spending life as a happy, well adjusted, productive person.

Let me add here that I observed  these behaviours  not only in clients who came into the psychiatry dept seeking help but also  in Indian society.

These are not full blown mental illnesses but behaviours which I came across in my practice…these behaviours cannot be given any existing diagnostic label either from the ICD-10 or the DSM-IV R as they don’t fit the criteria. I strongly believe that most of these behaviours also exist as the Indian culture encourage or at least do not actively discourage these behaviours. Also the extremely schizophrenic nature of Indian society itself may be contributing for the development of unhealthy behaviours to cope with this society.

The “odd but not odd enough for a clinical diagnosis” behaviours and personality traits intrigue me and as I neither have the interest or energy to do more research, I have  blogged my thoughts below.

I do realize that these behaviours may not be unique to India,; they may be present in other societies too....but my experience is restricted to India. I also think that any culture with similar patterns in the  roles of parents, similar interaction patterns in the society, similar power structure, similar hierrarchy, similar role of religion, etc may produce the similar patterns of behaviour.

CULTURAL PATHOLOGY ONE: 
The lazy person: These are young men of say 20-30 years of age brought to the psychiatrist by their parents, who are usually village or small town folks, usually from farming families. They are of middle class or lower middle class. These young men are not working, they are either married or single, with at least  grade 10  level of education or a bit higher. The parents main concern when they land in the outpatients department of psychiatry is that their son work on the family owned agricultural land or get a job.

Interviews, mental status examinations, psychological testing yield no answers to the person’s lack of interest in finding work or working. They do not seem to have depression, anxiety or schizophrenia and there is no disturbance of biological functions. The biggest issue/?symptom is the lack of motivation and lack of interest to work. These youth do not mind idling away the days, either visiting the town, gambling with friends, going to movies, etc. If they happen to be married, they do not have a sense of responsibility about their wife or kids .
To some extent, the Indian society contributes to this behaviour. The youth are brought up dependent on their parents. When these youth enter their teens and refuse to participate in the house or field work, their parents are easy-going and dont push them to work; marriages are arranged for them when they are in their twenties…(there is no courtship as these marriages are arranted by parents) . The  girl  chosen to marry one of these youth, usually has little or no choice about marrying the youth.

Once married, the girl lives with her husband and parents-in-law in a joint family. She does the housework while her parents in law and brothers-in-law continue to work in the fields. The lazy person’s wife continues to look after him such as cooking for him, doing his laundry, etc. As it is a joint family, there is no danger of economic problems and this lazy person continues his idle lifestyle. The lazy person is supported by the joint family system adequately and he even has children who are looked after by his wife, brothers, his parents while he takes little or no responsibility. When brought to the psychiatry department, some report a few somatic symptoms for their ‘inability’ to work. However most of these people, lead lives in the villages and rarely are considered as needing psychological or psychiatric help.

A few of them get some sense of satisfaction or the feeling of achievement by doing very light chores and also doing chores of their choice. If a chore involves visits to the city or another village or meeting someone interesting, they offer to do it, but decline to do any task which is hard or mundane !

I have seen a similar pattern of behaviour in the cities too in the  males of joint families who run family-owned businesses such as retail shops. While one 'responsible' son or two sons are  hardworking and slog away at the family business , one or more sons may work in a very cursory manner and get away by whiling their time indulging themselves. The eldest or the most assertive brother may control the money. Here  again there is a lot of unfairness regarding how much money each son or his family can  access. The assertive ones get more from the pot while the less assertive ones get little and this leads to a lot of frustration for  wife and kids of the unassertive son(the guy who works and takes little from the pot does not feel disturbed but his wife and kids surely do!)

 Several women from such joint families(usually of the Marwadi families from north or Shetty families from south) have approached the psychiatry department for counselling and expressed their bitterness and frustration. But the problems of the joint family system in India is another huge can of worms altogether.

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Another similar set of  people are  the unemployed youth in India... at least the few I have seen in my village and taluk: They are either college or school drop outs, unemployed and  who tend to hang about ‘important’ people such as politicians or people in the political field and 'obey' these big shots.. Most of these youth are not really employed by these politicians but they seem to enjoy hanging around these men and whiling away their years. They seem to derive a sense of satisfaction and importance by being associated to these politicians who are mostly thugs. The politicians too make use of them and also manage to attract them by providing them, not consistently  but on & off, things like alcohol, food & money  and also  (as I recently discovered) sex trade workers/prostitutes especially at election time. Though there is no consistent salary or work,  these youth tend to hang around these people.
I bet there are a few people out there who may find me judgemental....that "to spend life, in a way one likes is okay and who am I to judge?" But I find this way of life parasitic, where the lazy person, seems to live off others, without guilt or any qualms. They are young, able-bodied and idle. There are millions of youth in India who are struggling to find a job and earn a living but unable to do so. However these youth are those who smply do not want to work. Not wanting to work, (a)when one is able,(b) when work is available, (c)when one is dependent on others (for food, etc) is a kind of pathological behaviour according to me.
The consistent failure of the monsoons in Tumkur has now increased the number of such youth...i.e. those who while away their time. But is this a  mental illness or a disease of society and circumstances...circumstances such as poor rains, failed crops, poor skills dervided from a lacklustrre education system, poor opportunities for jobs?
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I am not sure whether I would call the young, able-bodied people begging on the roads or the saffron-clad people, who lead their life praying and wandering as having pathological behaviours. Many beggers identify begging as a profession and so I do not find begging pathological. Being Indian and a Hindu, I have empathy for monks, mendicants, sanyasis, sadhus, etc and I don't find the behaviour of those who have given up family and work to search God,  pathological.
I must relate an interesting  case here. I had attended the case conference of a young man, who belonged to a rich business family in India. He had left his home and wanted to become a Monk. He was an only son, heir to heaps of property and businesses and his father was growing crazy trying to get his son to come back home! He had dragged his son to this psychiatric hospital and wanted the psychiatrists to cure him. Lots of mental status examinations, psychological testing, physical examinations later, the shrinks could not find anything wrong with him! Other than wanting to become a Sanyasi, this guy was perfectly normal! However, to his family's thinking, giving up home and property and wanting to become a monk was 'crazy'.

Swami Vivekananda is another example of a person who gave up home life to become a monk.

 I have heard of a few men who gave up family and  jobs and everything in their life and went in search of God or Nirvana or whatever at different points in their life. These men usually went to temples or Ashrams in the Himalayas and did not return. Let me explain here that none of these men were running away from difficulties in life, none were mentally ill, none were doing it on the sly. They had this inner urge to find God (or whatever) and left their safe, comfortable homes. They spent the reminder of their lives in these ashrams till they died.
Many of these men were deeply knowledgable about philosophy and were good debaters and teachers about their school of philosophy , their religion and rituals. Today, one finds such people in smaller numbers than in the past, but they do exist. These people  renounce the usual way of living....the usual way of living is  going through the life cycle of studies, marriage & children, work, retirement...or the 4 Ashramas i.e. Brahmacharya, Gruhasta, Vanaprastha and Sanyasa;
 These people jump into the Sanyasa ashram very early in their life, maybe without ever entering either the Gruhasta or Vanaprastha Ashramas. Having met a few of these men, I am full of admiration for their knowledge, calmness and their wisdom and though they have sought this life style, one can never accuse them of any sort of pathology. They derive meaning in life through their search for God, serving people by teaching philosophy, working in the Ashrams, doing social service. Many have left grieving wives and parents behind but this does not seem to affect them. (Hindu philosophy says that "you come into this world  alone  and you leave this world alone". These monks seem to follow this and experience no sadness when they leave  their family members). This life style is seen all over the world...the Catholic  priests who dedicate their lives to God, the nuns, The Buddhist monks in different parts of the world and so on.
But in today's very materialistic world, these people stick out like sore thumbs at times. It would be wonderful if these people were looked after by the governments of their countries so that they could dedicate their lives to Philosophy, which would benefit all mankind. In India, these monks can survive due to the alms given by people, as people have faith in the monks. But I think it would be very difficult for these men to survive in countries where  everyone is expected to earn and not beg for a living. A begging monk would look definitly odd/pathological in some places.

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