The New York Review Abroad

by Robert B. Silvers

  It is at any rate safe to say that rural India does not run to the shrink with a problem as Manhattan does; nor indeed could it in view of the scarcity of psychiatric resources. When India gained independence, there were about fifty psychiatrists in the country, many of them army doctors; now the number is estimated at only about 500 for India’s 640 million people; others—perhaps too many—leave India to practice abroad. Medical and psychiatric facilities range from the basic care given free in clinics and large hospitals, through part-payment, to expensive private treatment.

  Only the severest cases from the 66 per 1,000 seek official medical help, Verghese considers, the criterion being inability to go out to work or to housekeep. Most—about 80 percent, he estimates—have been to at least one local healer before coming to the hospital. With hysterical and neurotic symptoms he believes the healers can have great success; patients, particularly those from rural areas, are likely to attribute their symptoms to witchcraft or the violation of a taboo, which provides a rationale for the healer.

  Erna Hoch, a Swiss psychiatrist who has lived in rural Kashmir, has studied the work of “pirs” and “faquirs” there. She argues that they use processes that—covertly, anyway—also have a place in Western psychotherapy. The healer may act as a catalyst to the illness; he may “transfer” some of his own health or energy to the patient; he may offer a symbolic rebirth; he may operate a kind of temporary “dialysis” whereby he absorbs the patient’s sickness (“every psychotherapist at some time or other has felt like blotting paper that has to absorb the patient’s anger and other negative emotions,” she adds). She observed frequent instant “cures,” not always lasting ones—though where illness is attributed to wrong actions there is a strong incentive to stay cured. The prescribing of rituals and penances seemed to be among the most effective therapies.2

  In their study of mental illness in a south Indian community, the British psychologists G. M. Carstairs and R. L. Kapur describe the work of a local healer, the Mantarwadi, or expert in horoscopes and mantras:

  There were about 20 clients who, it seemed, had been waiting patiently since the early hours of the morning. Without even looking at them the Mantarwadi sat down on the only chair in the room (a bench was soon brought in for us) and started drawing with a chalk the zodiac chart for the day on the desk in front of him.

  Having completed this chart he casually summoned the client sitting nearest and from the clock checked the exact time the client came face to face with him. With a wave of the hand he forbade the man from talking—as he evidently wanted to—about his present misery. The next few minutes were spent in some further calculations while the client waited patiently. Having finished the calculations the Mantarwadi spoke out with a clear commanding voice: “You are 60, you come from a place where the fish abound and you want relief from the pains and aches which have been haunting you for a long time.” “And fever,” said the client. “And fever,” agreed the Mantarwadi.… “Is it true or is it not that your father is dead?” “Yes,” agreed the client. “Then is it true or is it not that during the last three years at least once you did not complete the ritual of Shradda?” The client hung his head down and acquiesced meekly. “Well this is what comes of not attending to your dead ancestors. You will need to arrange a ritual feast to which at least five Brahmins must be invited. You will have to go to Dharmasthala and bathe in the holy water. And here is a thread which you must wear on your aching knees.” Saying this he held out a piece of string, whispered a mantra over it and gave it to the man.

  The man folded his hands, touched his forehead to the ground in front of the healer, and left after putting a rupee note on the desk.3

  In the community of 9,000 people studied by Carstairs and Kapur there were twenty-three healers, two doctors, and a government health center. It was common for patients to consult both doctor and healer. “There are many ways to truth,” says Indian tradition and philosophy.

  Conventional psychiatric techniques, however, in Vellore and elsewhere, are borrowed from the Western repertoire: electro-convulsive therapy, drugs, occupational therapy, simple psychotherapy, behavior therapy; and psychiatric training follows the Western pattern. ECT is cheaper than drugs and so is freely prescribed. Dr. Verghese’s department gives twenty-five to thirty a day—without anaesthetic because an anaesthetist would be an expensive luxury. His psychotherapeutic sessions are not, of course, modeled on psychoanalysis (though Freudian concepts are familiar here, as everywhere else); Indian patients, he says, expect support and advice from their doctors.

  One aspect of his work he is justifiably proud of: his “family participation” scheme, which is either as old as the hills, or very new, or both. The Centre has facilities for forty-two patients to be accommodated with one or two family members. (There is far less institutionalization in India than in the West; patients who are really “put away” are either from the dispossessed of the big cities, or else have no relatives.) Each family has a simple suite in the huts that surround the compound. The scheme has several advantages: cheapness is one, for relatives cook for the patient and look after him. Another is that they can be taught to understand the illness and care for the patient on discharge. And it agrees well with the Indian tradition of expecting relatives to provide much of the food and care for hospital patients; the Centre’s patients, with their strong family ties, find it comforting. “They are frightened of coming here,” says Dr. Verghese, “but when it is time to leave they don’t want to go.”

  What does Vellore’s pattern of mental health care have to say about ordinary neurotic illness in an undeveloped area? One striking difference between West and East is that most of the patients coming to the Centre complain of physical rather than mental symptoms. This might seem to be a result of CMC’s special position: because it is well known for its neurological department, many patients have been sent there for physical investigations before being referred as psychiatric cases. But the observation is supported by the very careful research done by Carstairs and Kapur. They studied psychiatric symptoms in a community rather than a hospital; and they too found pains, headaches, and hysterical symptoms to be the commonest complaints, present in about 18 percent of their population, after they had established that malnutrition and anemia were not the causes. Sleeplessness, forgetfulness, anxiety, and depression followed with diminishing frequency.

  Medard Boss, a Swiss psychiatrist who visited and lectured in India, has suggested that Indian patients may actually be more like the patients from whom Freud drew his theories than are modern Westerners.4 Greater self-consciousness, an intellectual acquaintance, however vague, with the concept of repression, has, for instance, in some mysterious way caused “conversion hysteria” almost to disappear from the sophisticated patient’s repertoire of symptoms. Patients in the West now generally present themselves plainly as sad or anxious rather than hampered by the pains, paralyses, ties, and fugues that once took their way more or less dissociated from their owners’ awareness.

  Another fact plainly different from Western expectations is that more men than women are admitted to Vellore’s Mental Health Centre. This does not necessarily mean that the women have fewer psychological problems—Dr. Verghese believes that they suffer from neurotic symptoms more than men, and this has some support from research—but that men seem more likely to become psychotic. Carstairs and Kapur found the same, and it would be interesting to know whether there is other corroboration. Verghese’s explanation is that, while Indian communities can tolerate schizophrenic members who in the West would be hospitalized, women are more easily carried by the family and community in this way than the breadwinners, for whom a cure is urgent.

  South to Pondicherry, ceded to India by the French in 1954, home of the Aurobindo ashram. It was here that the distinguished psychiatrist N.C. Surya came when he threw up his job as director of the National Institute of Mental Health at Bangalore. Trained in Europe and the US, formerly a Marxist, he was following an Indian tradition o
f abandoning the world for spiritual concerns when the moment is right; Aurobindo, founder of the ashram, did the same when he gave up his fight for Indian independence and retreated to Pondicherry. While outside Pondicherry steams in the sun, the ashram library is all greenery, coolness, and hush. Dr. Surya comes out of the library carrying the rolled umbrella (against the sun) that, like an Englishman, he seldom opens.

  “You must understand first that I am leading a perfectly selfish life. I am doing what I know is right for me; about other people I don’t know. I only know that I must get this machine”—he slaps his chest—“into better harmony, gradually and bit by bit. First I am learning to drive my own chariot; after that I can think of outside affairs. All illness is caused here, in ourselves. We treat machines well, we treat animals well, but we wreck the body. Yet people don’t want to change; man is in love with suffering, Aurobindo said. If only we don’t perceive things as harmful then they won’t make us ill. This suffering is the same anywhere: yes, the rich have the leisure to be neurotic, but the poor man out on the street has his illnesses too. There is just as much strife and anger in the villages as anywhere else.

  “The doctor, the psychiatrist, can only heal by being in alignment with himself and absorbing the patient’s illness. Yes, just like a sponge. For this he must have experience in the management of at least one total human being, and that can only be himself. And he must never start to believe he can take on the burdens of the whole world; he must limit himself and be humble.

  “I mistrust explanations. A man can come to you with one headache and you can end up sending him away with ten more. More and more people are making money by writing books, thinking up more and more psychological explanations. The simplest, quickest method is best. I don’t necessarily consider myself the agent of cure. The patient is that himself; or someone else may come along, a kind uncle.…

  “Do you know the books of Ivan Illich? I have much sympathy with him. We are teaching people to be helpless with our explanations. Everyone has a natural problem-solving ability and psychiatry is eroding it. A man came to me saying that he had suffered so much through his parents. I said, ‘How old are you?’ ‘Twenty-one.’ ‘Where are your parents?’ ‘Three hundred miles away.’ ‘Then why do you still tell me about your mother and father—are they in the next room? Are they sitting on your head?’ When a man is grown-up he must decide to liberate himself and he can do so.”

  Pondicherry, in its steamy southeastern corner, could hardly be more different from Ahmedabad in the northern state of Gujerat. This is a large and relatively prosperous industrial city which has been dominated for centuries by its textile industry. Gandhi, returning to live in India in 1915, set up his first ashram on the bank of the Sabarmati River there; and in 1918 he led a mill-workers’ strike against the powerful mill owner Ambalal Sarabhai.

  Gandhi’s helper in organizing the strike was Sarabhai’s sister Anasuya, a suffragette and trade union leader who became known as the Mother of the Labour Union. Even though Sarabhai fought the strike, he was an admirer of Gandhi and an enlightened man who was unconventional enough to keep his wife out of purdah.

  The Sarabhais clearly are an unusual family and so it is no surprise that Kamalini Sarabhai, wife of Ambalal’s son Gautam, is one of the rare Indian psychoanalysts who trained abroad but works in India. (There is an autonomous Indian Psychoanalytic Society in Calcutta, established in 1922 by Girindrasekhar Bose, a distant admirer of Freud; it has about thirty-five members of whom a number have emigrated or retired.) “My father-in-law made it quite clear to me that I had to go out and do something for myself,” Mrs. Sarabhai says; she responded by taking her two daughters with her to England—her husband joining her whenever he could—and undertaking six years of psychoanalytic training at London’s Psychoanalytical Society. Perhaps she was influenced by the fact that Ambalal Sarabhai once visited Vienna—anonymously—to consult Freud.5

  Mrs. Sarabhai is also a director of the Bakubhai Mansukhai (BM for short) Institute of Ahmedabad. Here perhaps Indian mental health care at its most Western is to be found—though there is nothing slavish about its attitudes and it is entirely staffed by Indians. The American psychologists Lois and Gardner Murphy advised on its founding in 1951, and it has strong links with English centers such as the Tavistock. The BM Institute has a school and workshop for the retarded, an infant assessment clinic, an audiology clinic, a family therapy center, and a day-care unit, as well as its psychotherapy program, school for normal children, and training and research schemes.

  At a case conference the previous day’s cases are discussed. A depressed, backward boy of twelve: he has lived in the city with his grandparents since he was four so that he could attend school, and his grandmother beats him; his aunt wants the Institute’s intervention. The baby daughter of a well-to-do family doesn’t speak or respond to speech; her hearing is to be tested. An adolescent has failed his exams, won’t read, has few employment prospects; he also has fits, and is referred by the school for neurological tests. A nine-year-old Tamil boy who had tuberculous meningitis at two years old did not walk or talk until he was six; the Institute’s help is asked in giving him special education.

  Though the Institute’s prime concern is children, it takes more adults than children for psychotherapy. The clientele for therapy is probably rather more sophisticated and well-to-do than that of the CMC Mental Health Centre. The therapy given is not only classical psychoanalysis but a mixture of counseling, family therapy, and group work. What sort of patient explicitly seeks psychotherapy, I ask. Mrs. Sarabhai gives the example of a severely depressed Muslim foreman from one of the mills who complained that the hospital’s pills had done him no good; he wanted “talking treatment” instead. Did she encounter any specially typical psychiatric problems? Two that came to mind were the young male who is anxious, afraid of a strict father, unable to make independent decisions; and the “first-generation learner” who comes from an illiterate family and breaks down under the pressure of social change.

  The surprise, at first, is that mental illness and its treatment in India are not more strikingly different from Western patterns. Even a profoundly different religious outlook, social organization, and standard of living clearly do not affect basic vulnerability to anxiety, depression, or breakdown. Freud may have been partly right, though, in assuming that neurosis is the price we pay for civilization, for even in India urbanization and increased sophistication are apparently accompanied by a higher incidence of symptoms. A recent collection of papers6 from a seminar led in India by Erik Erikson presents a picture of increasingly prevalent anomie, Eastern-style. In it the associate director of the BM Institute argues that there is an “identity vacuum” for Indians at the present time: values that are appropriate in an uncompetitive agrarian society break down under modern pressures; traditions and established roles are threatened by the mass media.

  But after similarities between East and West are noted, the dissimilarities become more evident. One of the most distinct is the greater tendency among Indian psychiatric patients to convert mental pain into physical; perhaps convert is the wrong word—the Indian patient may not feel the strict body/mind distinction that we take for granted. Erna Hoch has written that “if one tries to differentiate whether a person who says ‘my heart does not feel like it’ or ‘my liver is not doing its work’ actually means the physical organ or some emotional disturbance, one often evokes puzzlement, as a separation of the two has never been made in the patient’s way of thinking.”7

  An Indian psychoanalyst now practicing in England describes another way in which she found Indian patients different from Western ones. “They seemed to have no resistances! They accepted everything I said, just swallowed it up. This was very hard for me. I found myself making too many interpretations. And they would arrive so early and so eagerly!” Many—superficially at any rate—had an almost religious faith in the therapist’s mystique. Medard Boss, however, noted that although his Indian patients
had boundless faith in him, their dependency and immaturities close to the surface and causing them no conflict, they were relatively lacking in motivation to mature and become more independent.

  J. S. Neki of the All-India Institute of Medical Sciences in New Delhi has suggested a different model for the therapeutic relationship in India, that of guru and disciple. Though there are obvious differences between the roles of guru and therapist—the guru teaches the control of negative emotions rather than their exploration, and he does not withhold himself emotionally from the disciple—Neki sees many similarities: both are dispassionate and persevering, preferring to help the pupil formulate questions rather than give the answer themselves, and both teach him to look inward rather than outward.8

  Neki has also examined the great difference between India and the West in attitudes toward dependency. In psychotherapy it becomes a key issue: the Western patient fights against dependence, the Western therapist treats it as a problem that has to be managed and kept under control. Neki sees both partners as caught in an anxiety specific to Western culture: “both of them engage in a struggle to defend their own personal independence in a climate that inevitably becomes charged with anxiety and sometimes even with hostility.”9 In India, he argues, dependency of one person on another is taken for granted, and “where letting others take charge of you is not considered ignoble or undignified, no outrage of personal dignity occurs by depending on them.” The Western therapist’s formality is taken for unfriendliness; the Indian’s natural behavior is to