INDIAN CULTURE AND AGE IMPACTS ON MENTAL HEALTH TREATMENT

INTRODUCTION
Indian Culture is known to be remarkably diverse, but at the same time, it has a lot of restrictions. Culture influences symptoms of illness, diagnosis, coping strategies and attitudes towards the patient. Indians believe that those who commit sins such as loss of semen, going against religious practices, etc. get diagnosed with mental disorders and hence, such individuals are looked down at. This belief is mostly common in rural areas. Indians do not support mentally ill people and judge them negatively. The mentally ill are called “crazy” and abused physically, psychologically, and sexually.
 Since people belonging to a culture have the same belief, principles and behaviors, their understanding about mental health will also be the same. Due, to these judgmental views, mentally ill individuals do not get treatment which leads to terrible deeds such as suicide and murder. Mentally ill individuals feel even more distressed about shaming their families due to their mental illness, about being rejected and sometimes even feel responsible for the illness. Treatment choices are often influenced by the individual's beliefs, for instance, some people may choose religious or folk healing methods of treatment due to their misconceptions concerning mental illness disorders. 
 Due to cultural stigmas, students are not allowed to study mental health issues or become psychologists and psychiatrists, which hence reduces the availability of proper treatment. Studies show that 150 million people in India are affected by mental illness and only 0.3 psychiatrists per 100,000 inhabitants are available for treatment. (“Perceived stigmatization and discrimination of people with mental illness: A survey-based study of the general population in five metropolitan cities in India Boge K, Zieger A, Mungee A, Tandon A, Fuchs LM, Schomerus G, Tam Ta TM, Dettling M, Bajbouj M, Angermeyer M, Hahn E - Indian J Psychiatry,” n.d.) 
According to the Indian culture, individuals have to listen to their parents, and have to reach out to them if in need of help. Individuals who do not feel comfortable talking about their mental health problems to their family might be under considerable stress for not following the cultural practices. Also, due to fear of shaming their parents, individuals would not talk about their disorders or stress to friends, hence increasing severity of the disorder which might even lead to suicide or other terrible consequences. Hence, students might feel like being stuck in a loop where they can’t tell their parents or peers their problems and at the same time are not following their cultural practices which may increase their guilt and other distressing emotions.
LITERATURE REVIEW
I am comparing my paper with Ganesh’s paper on Knowledge and attitude of mental illness among general public of southern India. His paper states that most Indians don’t have knowledge on the cause of mental disorders and believe that sins lead to mental disorders. He states that Indians believe marriage or religious healing is a cure to mental disorders. In addition he states that Indians have negative attitudes toward mental counseling and mentally ill patients.
  Both of our results match such that Indian people who stick to Indian culture seem to have negative attitudes on mental health treatment and mental health disorders, but I find a lot of limitations in his paper. Loopholes in the study are the confounding variables such as age, gender, and interviewer effects. Also, while his study states that people seem to have wrong knowledge on mental health disorders, my study shows that people are having knowledge on causes of mental health disorders as well as treatment. 
Both our studies conclude that people do not go to psychiatrists or keep that as last option as they fear being looked down by people due to social stigma. But my results clearly show that people are aware of the treatment to seek and are slowly getting aware of mental disorders such as mood and eating disorders while his does not. Also, since the method used to collect data was quantitative, i.e. collected only yes/no responses, it is not possible to know if the participants do not have adequate knowledge on mental health treatments. For example, the question “do you visit a psychiatrist if you had emotional problem” can lead to wrong or biased results because some participants might think of mere everyday problems that cause distress as “emotional problems” and not actually the problems faced by a depressed person or someone diagnosed with anxiety. (Article et al., 2002). Hence, they might say no for the question instead of giving answers for the researcher’s intended question. 
People from rural areas were not considered and hence his research cannot be generalized. The researcher used a convenience sample and hence the sample members could have answered to support the hypothesis. Also, since all the members of the sample were chosen using convenience sampling technique, most of them would have been from the authors community. So, it could have been that only the members of that community might not be as aware compared to other communities in South India, or the culture might have been very strict in his community and hence members might have answered fearing social desirability. Hence, the results might only apply to his community rather than the entire south India or the whole of India causing bias in results.

HYPOTHESIS AND VARIABLES
My hypothesis states that “Indians who stick to the Indian culture have negative views on mental health treatment due to their cultural beliefs”. I define culture as the beliefs, practices and behaviors followed by a group of people. Attitudes on mental health treatment can be defined as views on psychiatric treatment, choice of treatments among religious or proper mental health counseling, views on person receiving treatment, etc. 
This research addresses the question, how does Indian culture affect views on mental health treatment and does this view vary by age. Age has been considered since older people tend to stick more to cultural practices and beliefs while the younger, modern generation individuals do not do so as they tend to take in new behaviors or practices from peers of other cultures that might not be or even be prohibited in their culture. To address this question, variables were identified such that culture is the independent variable and views on mental health treatment is the dependent variable. These variables were addressed by conducting semi-structured interviews with sample members and analyzing their responses.
Dimensions for the independent variable, culture, are the cultural beliefs and practices, whether sample members stick to their cultural practices, respondents’ views on their cultural beliefs, cultural restrictions, etc. Dimensions for the dependent variable, views on mental health treatment, are what type of treatment Indians prefer, willingness of Indian patients to receive treatment and views on psychiatric treatment.
METHOD:
To operationalize culture and attitudes on mental health treatment, I asked respondents questions regarding the Indian cultural practices, preference of treatment, their knowledge on mental health counseling and what the Indian culture states about mental health disorder through telephone interviews. To assess the hypothesis, I took a sample consisting of 8 Indian individuals of various ages ranging between “20-54” years. The sample members were chosen using purposive sampling and convenience sampling methods. The sample was divided into 2 groups- one consisting of older members between the ages of “50-54” years and another of younger members between the ages of “20-25” years. 
The data from all sample members helped me understand the cultural impacts on mental health treatment. Sample members of different ages were chosen so as to compare the views of mental health treatment between the older and younger members and hence to understand the effect of age on views on mental health treatment. Since older members tend to stick more to cultural practices compared to younger members, I can understand the cultural views on mental health treatment. Also, older members have different stressors compared to the younger members and hence there is a probability of older members requiring different treatment compared to younger members. Older members get stressed due to financial, physical health and family problems while younger members get stressed due to social expectations, relationship and family problems, and career issues. Hence, purposive sampling was used since older members had distinguishing features compared to younger members. Since the research had to be completed in 3 weeks a small sample was used and sample members consisted only of friends and family, i.e. convenience sampling technique was used to choose the sample.
 	Also, I have chosen participants from various parts of India, since different parts of India have slightly different cultures and since various cultures define major mental disorders differently. The target population consists of all Indians. 
Both positivist and interpretivist approaches were used in the research. Positivist approach was used such that I have stated my hypothesis as something that is true, and I was trying to prove it true. Interpretivist approach was used since I had used respondents’ interpretations or experiences with mental health disorders as my data.
Open ended questions were asked during the interview so as to collect detailed information on attitudes towards mental health treatment and cultural beliefs. Open ended questions about preferences and views on mental health treatment, views on cultural practices were also asked. In addition, there were open-ended questions about what participants think about psychiatric mental health treatment and why they think so, participants experience with mental health problems and their cultural beliefs on mental health treatment. 
Hence, semi-structure interviews, were used to ask such questions since they do not limit number of questions or probes to be asked as well as don’t have a certain order of questions to be followed, hence not breaking flow of the conversation. Also, answers to open ended questions will be easier to record through an interview rather than doing both surveys and interviews or only surveys, since they will only increase time and effort spent on research. Semi-structured interviews provide an environment of “natural conversations” and hence provide “true beliefs or views” from the respondent providing unbiased answers. Other types of interviews would provide a research or lab setting and hence the respondents might answer to favor the hypothesis. 
Interview questions on the interview schedule were face valid since they asked regarding mental health treatment as well as culture, which were the 2 main variables I was assessing. Also, they were predictively valid since, if a person answers that there is nothing like mental health, they would also answer that they won’t go for mental health counseling for such problems, and also predicts that the person has never experienced any mental health problems. My questions are also internally reliable since they all talk or ask about mental health treatment and culture. 
10–15 min interviews were conducted through telephone since the participants were in different parts of the world compared to me. The interview initially started with demographic questions asking about age, gender, and marital status. These were the attribute codes of my study and the index codes were culture, type of mental health treatment preferred and views on mental health treatment. Analytic code was the question- “how would you define mental health disorders or what disorders would you categorize as mental health disorders?”.
To understand culture, I asked questions such as “what are your cultural practices such as morning rituals, what are your cultural restrictions, etc.” which helped me understand the Indian cultural practices and beliefs as wells as causes of mental health disorders that people believe. 
To understand the attitudes on mental health treatment questions were asked regarding preference of treatment, knowledge on mental health counseling, experience with mental health disorder if individual or family member was diagnosed with one and feelings if individual or family member was diagnosed with a mental health disorder. 
ANALYSIS ON METHOD:
Questions on views on mental health treatment will help me understand the type of treatment people prefer and their knowledge on the treatment provided in mental health hospitals. Also, they help me understand the feelings of family members of the individual diagnosed with a mental health disorder as well as the individual, which hence will help me understand the cause for unwillingness for receiving treatment. Asking about who they would prefer talking to when distressed provides information on comfort level and whether individuals prefer following or not following cultural practices. Indian culture does not consider mental health very important and does not give it equal importance as a physical problem. Hence, parents do not teach their children anything about such disorders and if the child is diagnosed with a disorder, they try to hide it from their community and feel shameful. 
Questions on culture, will bring out the type of treatment people receive due to their cultural knowledge on mental health. Also, understanding if individuals actually feel comfortable to talk to their family and understanding if family members will support the child for mental health problems is a great indicator of cultural impact of mental health treatment as well as, a great indicator of mental distress. Belief about causes of mental health disorders was asked because only if people understand the cause of the disorder, can they seek the right treatment for it. 
RESULTS:
Most younger members said that they feel the Indian culture helps one grow mentally but at the same time is stressful, while older members stated that their culture is enriching and helped them grow mentally. Also, some of the sample members stated that they would prefer exercise and counseling as treatment, which was shocking and contradictory to my hypothesis. They felt that exercise would help refresh their mind and hence be helpful; and talking to psychologists would be helpful since they can let out their stress and at the same time not be judged. While all the respondents said they would prefer talking to family, friends and psychologists when distressed, they said that medications would be their last option and would be chosen only if their disorder becomes too severe. 
Only 2 respondents indicated experience with mental health disorders. One of the respondents belonged to the younger member sample and indicated being diagnosed with depression and the other one was an older member who indicated that his child was diagnosed with autism spectrum disorder. The younger member indicated that he was lucky enough to be around people who were aware of depression and hence asked him to consult a psychologist. He also stated that while his parents were supportive, they did tell him to not tell anyone about his depression as they feared he would be called “crazy” due to the stigma in India. The older member said that the child was taken to a psychiatrist for treatment. He stated that he felt worried and concerned for his child but at the same time felt a bit shameful and terribly sad in front of his relatives. 
Attitudes on family members receiving treatment ranged from happy that they are receiving proper treatment and hence going to get cured, to high anxiety due to social stigma. While the younger members seem to state positive views on receiving treatment such as happy or concerned about individual receiving treatment but will not judge them for receiving treatment, older members seem to be worried and anxious due to social stigma. 
Another difference was observed between the older and younger on cultural restrictions. The younger members who mostly were female stated many restrictions such as not being allowed to or being judged for talking to opposite sex class or office mates, while the older members stated that the culture offers no restrictions. This shows that older members like their culture a lot and do not feel any restrictions as “restrictions” since they had been following it since years.
DISCUSSION:
It is observed that older members seem to prefer and like their culture, while younger members who though like their culture still feel there are some restrictions that can cause mental stress. The younger members of the modern world who meet people from different cultures, try to incorporate some of their own culture as well as that of the people they meet, hence causing them to feel restrictions in their culture. 
Results do slightly support my hypothesis even though there are a lot of contradictions. These contradictions are mainly from responses of the older members. Even though the older members feared social stigma about receiving treatment, they did state that they would receive treatment from psychologists if needed and were aware of mental disorders such as mood disorders and personality disorders in addition to psychotic and developmental disorders. Also, though they feared stigma, they mostly seem to fear their child being bullied rather than fearing shame for family (which they stated in some cases). In addition, due to their awareness of the disorders they seem to understand if a family member is at risk or is going through a disorder. 
The results still support my hypothesis since the older family members feared stigma and kept reaching out to psychologists and psychiatrists as last option showing negative attitudes toward treatment. Hence, even though the older members who stick to their cultural practices were aware of mental health disorders and treatment, they seem to fear social stigma and were less willing to receive mental health treatment unless desperately required. The younger members on the other side seemed to have positive attitudes showing that, those who don’t stick to the Indian culture seem to have positive attitudes towards treatment which therefore proves my hypothesis. 
Also, views on mental health treatment are affected by the age differences such that younger members seem to be more aware on mental health treatment and disorders compared to older members. Also, younger members preferred going to mental health counselors and dint keep them as a last option like the older members. While older members said that they feared the child being bullied if people become aware of her disorder, the younger members feared that they might bring shame to their family due to the stigma on mental health in India.
Hence, since most of the younger members who don’t stick to their had positive attitudes on mental health treatment and some of the older members who stuck to their culture had negative attitudes, it is proved that Indians who stick to their culture or follow cultural practices strictly have negative attitudes on mental health treatment.
LIMITATIONS: 
I was not able to conduct a semi-structured interview properly. This was because the respondents were in different time zones compared to me and hence, I was not able to conduct a semi-structured interview by telephone. So, I sent the interview schedule (i.e. the questions to be asked) to the respondents as a text message and asked them to send their responses as a voice message.
 Also, I was not able to include key informants, who were psychiatrists, in my sample as they had immense workload. Hence, I was not able to get views from those who were much more educated in the topic which is a huge loss to my data .Most older family members also did not want to answer my interview due to work restrictions but I had to convince them to do so. Due to this work restrictions older family members might have answered in an undetailed manner which might have caused bias in my results
Also, all of the participants though Indians, resided in a different country which might have affected my results. This is because residing in a foreign country might have made participants more aware and more open to mental health treatment. Having a small sample does not make it representative of the entire target population hence making my results not generalizable. Also, all the participants were rich or middle class hence not including individuals from rural areas which again makes the sample unrepresentative of the population.
Since the respondents were my friends and family their answers might have social desirability bis and interviewer effects which might have caused error in my results. They might have also answered to favor my hypothesis causing bias in my results again
CONCLUSION:
I conclude the paper by stating that Indian culture has a huge role in negative attitudes of people toward mental health treatment and hence affects their willingness to receive proper treatment as well as preference of treatment. Age also has an impact on choice of treatment as older people seem to stick more to the Indian culture compared to younger members and hence have less awareness on treatment and have negative attitudes towards it. Even though this is happening, people seem to start getting more aware on mental health disorders and treatment hence reducing stigma and terrible consequences such as suicide.

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