BY NADIA MICALI - Dept. of Psychological Medicine, Institute of Psychiatry - De Crespigny Park - London
A Passage to India
It feels quite odd to start this correspondence from the UK moving across the globe and writing about India.
The main reason for this choice is the opportunity I had to attend a conference- The International Congress of Child and Adolescent Psychiatry and Allied Professions (ICCAPAP)- in New Delhi a few weeks ago. The second reason is the strong link that still persists between India and the UK, and the implications this has on our clinical practice.
The aim of the conference was to integrate different aspects of child psychiatry, including social and cultural issues relating to the host country, service development in developing countries and India itself, but also etiology and treatment of child psychiatric disorders, seen from a "western" point of view.
Child Psychiatry as a specialty, has developed mainly during the last century in Europe and in the United States, from there its developments were exported to the rest of the world.
The state of the Indian economy, very similar to that of other developing countries, has an important influence on the way children are looked after in this country. An Indian Economics student told me on the train: " we have primary needs, such as malnutrition, perinatal mortality and illiteracy, our childrens mental health obviously becomes secondary".
Nevertheless, Prof. S. Malhotra quoted that the number of children in India is about 350 millions, there are 20 child psychiatrists in the whole country and about 50 general psychiatrists who practice child psychiatry.
Moreover most of the clinics are in big cities and 80% of the population, which lives in rural and semi-rural areas, has no access to them. There is a lack of human resources, in terms of adequately trained psychiatrists, and also an unbalance in services in different areas of the country.
Albeit, it was reported at the conference that the prevalence of child psychiatric disorders in India was shown to be, in a study carried out in three different sites across the country, similar to the Isle of Wight studies. Clearly, the prevalence of some disorders is higher in countries like India compared to Western countries, for example neuropsychiatric disorders, such as epilepsy or learning disabilities, somatization and conversion disorders, and non-specific somatic symptoms. In contrast, disorders, such as ADHD or eating disorders are much less common.
Cultural influences on models of child psychological development play an important role in our understanding of child psychiatric symptoms.
Regarding child development, I learned on this occasion that according to Ayurveda, one of the oldest philosophical and medical systems, the psychological development of children starts at the moment of conception. Birth is in fact the end of the first stage of development, it follows that a childs personality develops during gestation, rather than during childhood. Moreover, in keeping with the doctrine of the transmigration of souls, it is thought that children are born with innate dispositions from previous lives and there is less pressure from parents to mould the character of the child. Care taking is therefore more flexible and indulgent.
Moving onto treatment, several therapeutic approaches were discussed, including pharmacological ones, quite common in India as well.
A psychologist practising in Varanasi told me that a fundamental aspect of treatment is involving families. In Indian families a childs upbringing is child centred and favours dependence, rather than independence like western societies. It emphasises group conformity and group approval more than the fulfilment of personal desires. There appears to be a strong consideration of everyones feelings in the family set-up, with a sense of security and sacrifice.
Involving the family in the therapeutic process is very relevant, together with the need to integrate more traditional care approaches with western ones. The therapeutic target, according to a social worker from Chennai, is often building on "simple" ties between parents and children, and encouraging love and bonding.
The socio-cultural influences on Indian child psychiatry practice gave me a different perspective on the western models of pathogenesis and treatment of mental illness that we often "impose" on our patients and their families. This rings true mainly here in the UK, where several individuals from different ethnic groups come to us for help. South Asians and Afro-Caribbean communities are numerous in London and we are often faced with the dilemma of trying to evaluate their experiences with a " western" approach.
This applies most probably to any of us who works clinically and therapeutically with ethnic minorities. Being able to incorporate in one own everyday clinical practice a non-ethnocentric stance, opposite to the western one, is a necessary tool in our society.
Although cross-cultural psychiatry is widely written about, we often find ourselves forgetting, in our daily practice, the influences of culture on our patients.
To conclude, I believe that being able to confront ourselves with social and cultural models other than ours could be a very useful means in the understanding of the influences culture has on us, and in being able to apply this understanding to specific clinical problems.