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 Table of Contents  
Year : 2016  |  Volume : 32  |  Issue : 1  |  Page : 25-27

Cross-cultural differences in caregiving: The relevance to community care in India

School of Psychiatry and Clinical Neurosciences, Community, Culture and Mental Health Unit, Fremantle Hospital, The University of Western Australia, Crawley WA, Australia

Date of Web Publication17-Feb-2016

Correspondence Address:
Prof. Mohan Isaac
School of Psychiatry and Clinical Neurosciences, Community, Culture and Mental Health Unit, Fremantle Hospital, The University of Western Australia (M704), 35, Stirling Highway, CRAWLEY WA 6009
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9962.176763

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Deinstitutionalization movement in the West brought about community care movement of mentally ill. Because of this, caring for the mentally ill became an important aspect. In resource-rich countries, caregiving is done by trained persons and in resource-poor country (like India), caregiving was done by untrained family members. Cross-cultural factors such as interdependence and greater family involvement in care have contributed for family members' decision-making in caregiving in India. Nevertheless, cross-cultural similarities in caregiving are more striking than differences. Genuine caregiving of mentally ill will make significant difference to the recipient. In India, majority of the persons with mental illness are cared by family members. Family members lack knowledge about the nature of the illness, have little support and advice by the medical professional, and have difficulties in understanding illness-related behavior. Hence, in India, there is need to develop effective, user-friendly, educational modules in all languages; to increase the knowledge of the carers about the mental illness, and help in decreasing their distress.

Keywords: Caregiving, culture, mental illness

How to cite this article:
Isaac M. Cross-cultural differences in caregiving: The relevance to community care in India. Indian J Soc Psychiatry 2016;32:25-7

How to cite this URL:
Isaac M. Cross-cultural differences in caregiving: The relevance to community care in India. Indian J Soc Psychiatry [serial online] 2016 [cited 2022 Oct 5];32:25-7. Available from: https://www.indjsp.org/text.asp?2016/32/1/25/176763

  Introduction Top

"What credibility and what societal relevance do we have as a profession, if we disseminate the evidence in scientific journals but do not care about the political action required to implement it?"
"The political mission of psychiatry" - Priebe. [1]

Comprehensive management of persons with severe mentally ill disorders not only involves treatment of patients but also requires addressing the issues related to caregiving. In resource-poor countries such as India, families of patients with severe mental illness have been carers (informal) for their family members. In Western countries, trained caregivers (formal) provide care for the mentally ill.

In India, majority of the persons with severe mental disorders stay with family and family members are the carers. Studies conducted on schizophrenia in India have showed that around 90% of them stay with their family members compared to one-third or two-third in Western countries. [2],[3],[4],[5]

This article will cover briefly on (1) caregiving for persons with severe mental disorders, in the West; (2) role of family in mental illness; (3) certain universal aspects of caregiving for persons with severe mental disorders; (4) Cross-cultural norms regarding caregiving; (5) impact of caregiving on caregivers; (6) family interventions; and (7) caregiving: Relevance to delivery of community care in India.

  Caregiving for Persons with Severe Mental Disorders in the West Top

Community care movement of mentally ill in the West was brought about due to deinstitutionalization movement. This movement started in the mid-part of the last century moved many patients with severe mental illness or developmental disorder from mental asylum to community. The deinstitutionalization movement as per Eisenberg and Guttmacher was initiated by three factors: (1) A sociopolitical movement for community mental health services and open hospitals; (2) the advent of psychotropic drugs able to manage psychotic episodes; and (3) financial imperatives (in the USA specifically, to shift costs from state to federal budgets). [6] This shift into community care had overall benefits but had its share of problems. Community care movement had its share of problems due to political will, funding, manpower, and stigma attached to patients and carers with mental illness. Because of this movement, caring for the mentally ill persons had become an important issue. In resource-rich countries, the caregiving was taken by trained paid manpower (formal) and in resource-poor countries, the caregiving was taken by the informal caregiving (family members, relatives, friends, etc.).

  Role of Family in Mental Illness Top

Initial ideas about role of family in mental illness were heavily influenced by the psychoanalytical theories. Family member's influences were thought to be etiological in serious mental illness. The classic example was concept of "schizophrenogenic mother" (dominant and overprotective but basically rejecting mother) in causing schizophrenia. [7] Family members were blamed for faulty, subtle communication styles (e.g., double-blind communication, marital schism, and marital skew) and accused of inadvertently abusing their offspring. [8],[9] These theories lead to family therapy which tried to help families correct faulty communication styles which were not successful. In around 1970s, psychodynamic theories about causation of schizophrenia were in decline and biological explanatory theories of schizophrenia were giving results. Family members/relatives rejected their role in causation of illness. Around the same time, relatives of families with schizophrenia formed National Advocacy Organizations (National Alliance on Mental Illness) which also rejected role of family in etiology of schizophrenia. As per Leff, "despite lack of confirmatory evidence, there was a pervasive climate among psychiatric professionals of blaming relatives, and consequently ostracizing them. Relatives were naturally deeply hurt, baffled, and resentful of this exclusion by their loved one's professional carers." [10]

Early studies of outcome of relocating long-term mental hospital residents into community settings were conducted by Brown and Brown et al. in the UK. [11],[12],[13] Studies done in different cultures and countries have consistently reported that high warmth in interpersonal environment of the households where patients resided was an important predictor of good outcome. Worst outcomes were in environments where there was critical comments, little or no warmth, and support. [3],[10]

  Universal Aspects of Caregiving Top

Literature has consistently shown that genuine caregiving makes significant difference for the recipient. [3],[14] Studies in all societies worldwide have showed that more often women than men care for patients with mentally ill. [2],[15] Caring for patients with severe mental illness for prolonged duration has physical, social, emotional, and financial impacts of caregivers. [15],[16],[17] The contribution of the carers for management of patients with severe mental illness is often not adequately recognized. The carers more often crave for more information about illness, skills, respite, and recognition for their care.

  Cross-cultural Norms Regarding Caregiving Top

Centre for Advanced Research on Language Acquisition defined culture as "shared patterns of behaviors and interactions, cognitive constructs, and affective understanding that are learned through a process of socialization. These shared patterns identify the members of a culture group while also distinguishing those of another group." [18] Western Anglo-Saxon culture emphasizes on independence and individual productivity whereas Asian (Indian) emphasizes on interdependence, greater family involvement in care, and decision-making. [19]

Family members being caregivers in India are mainly due to cultural beliefs (such as kinship obligation, family taking preeminent role in decision taking) and/or lack of mental health infrastructure. Although rapid societal changes (urbanization, nuclear families, etc.) have made caregiving burdensome to family members, still family involvement in care was preference of the family members. [20]

  Impact of Caregiving in Caregivers Top

Caring for a patient at home involves considerable "burden." Burden is one of the most commonly studied impacts on the caregivers worldwide. It is divided into objective burden (physical problems, financial problems, and restriction on social life due to caregiving experienced by family members) and subjective burden (caregiver's emotional reaction such as distress, perceived loss, and worry). [21] Studies have showed that chronic severe mental illness causes significant extent of caregiver burden. [2],[3],[17]

  Family-based Interventions Top

While optimal drug therapy is the cornerstone of the clinical management of persons with severe mental illness, substantial benefits have been reported with addition of family interventions. Family interventions are called by various titles, such as family work, behavioral family therapy, and family psychoeducation. The common elements of family intervention are education about the illness, assessment of family's strengths, and weaknesses; training in problem-solving skills; and improving communication skills. [10] Family intervention studies have showed to reduce of residual symptoms, improve social functioning; enhance family function; reduce stress, greater drug compliance, dose reduction, carer morbidity, and cost of care in schizophrenia and other mental disorders. [22] The improvement in these factors leads to clinically significant impact on the course of major mental disorders. There are very few studies in India on family interventions in mental illness (on schizophrenia) which showed impact on caregivers. [23],[24],[25]

  Caregiving: Relevance to Delivery of Community Care in India Top

In India, large proportion of patients is cared for by families, extended families, and other care providers. Relatives have difficulties in understanding illness-related behavior. They often lack knowledge about the nature of the illness. Families often tolerate a great deal and do not complain much. Relatives often receive very little support, advice, or information from the professionals engaged in treating the patient. [3],[26] Families want better communication with care providers and more information about illness.

In India, there is lack of manpower and resource for caregivers of patients with mental illness. There is a need to provide pragmatic family educational interventions at all mental health care settings. Develop effective, user friendly, educational modules, in all languages in the country. Develop and widely disseminate manuals for families about mental illness (in vernacular), all over the country. This will increase the knowledge of the carers about the mental illness and help in decreasing their distress.

There is a need to support the development of "Associations of families of the mentally ill" in every state and empower and involve them in care. Generate governmental support as well as support from philanthropic organizations / foundations for formation and sustenance of family groups / associations.

  Conclusion Top

This brief article would like to highlight that caregiving has an impact on the course of mental illness. Cross-cultural similarities in caregiving (such as genuine caring impacts illness and carers need for appreciation) are more striking than differences.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Priebe S. The political mission of psychiatry. World Psychiatry 2015;14:1-2.  Back to cited text no. 1
Chakrabarti S. Impact of schizophrenia on caregivers: The Indian perspective. In: Kulhara P, Avasthi A, Grover S, editors. Schizophrenia: The Indian Scene. Chandigarh, India: Dept. of Psychiatry, PGIMER (Psyrom); 2010. p. 215-62.  Back to cited text no. 2
Isaac M, Chand P, Murthy P. Schizophrenia outcome measures in the wider international community. Br J Psychiatry Suppl 2007;50:s71-7.  Back to cited text no. 3
Barrowclogh C. Families of people with schizophrenia. In: Sartorius N, Leff J, Lopez-Ibor JJ, Okasha A, editors. Families and Mental Disorders: From Burden to Empowerment. Chichester, England: John Wiley and Sons, Ltd.; 2005. p. 1-24.  Back to cited text no. 4
Shankar R, Rao K. From burden to empowerment: The journey of family caregivers in India. In: Sartorius N, Leff J, Lopez-Ibor JJ, Okasha A, editors. Families and Mental Disorders: From Burden to Empowerment. Chichester, England: John Wiley & Sons, Ltd.; 2005. p. 259-90.  Back to cited text no. 5
Eisenberg L, Guttmacher LB. Were we all asleep at the switch? A personal reminiscence of psychiatry from 1940 to 2010. Acta Psychiatr Scand 2010;122:89-102.  Back to cited text no. 6
Fromm-Reichmann F. Notes on the development of treatment of schizophrenics by psychoanalytic psychotherapy. Psychiatry 1948;11:263-73.  Back to cited text no. 7
Lidz T, Cornelison AR, Fleck S, Terry D. The intrafamilial environment of schizophrenic patients. II. Marital schism and marital skew. Am J Psychiatry 1957;114:241-8.  Back to cited text no. 8
Bateson G, Jackson DD, Haley J, Weakland J. Toward a theory of schizophrenia. Behav Sci 1956;1:251-64.  Back to cited text no. 9
Leff J. Needs of the families of people with schizophrenia. Adv Psychiatr Treat 1998;4:277-84.  Back to cited text no. 10
Brown GW. Experiences of discharged chronic schizophrenic patients in various types of living group. Milbank Mem Fund Q 1959;37:105-31.  Back to cited text no. 11
Brown GW, Carstairs GM, Topping G. Post-hospital adjustment of chronic mental patients. Lancet 1958;2:685-8.  Back to cited text no. 12
Brown GW, Birley JL, Wing JK. Influence of family life on the course of schizophrenic disorders: A replication. Br J Psychiatry 1972;121:241-58.  Back to cited text no. 13
Andreasen NC. John and Alicia Nash: A beautiful love story. Am J Psychiatry 2015;172:710-3.  Back to cited text no. 14
Awad AG, Voruganti LN. The burden of schizophrenia on caregivers: A review. Pharmacoeconomics 2008;26:149-62.  Back to cited text no. 15
Chakrabarti S, Kulhara P. Family burden of caring for people with mental illness. Br J Psychiatry 1999;174:463.  Back to cited text no. 16
Janardhana N, Raghunandan S, Naidu DM, Saraswathi L, Seshan V. Care giving of people with severe mental illness: An Indian experience. Indian J Psychol Med 2015;37:184-94.  Back to cited text no. 17
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CARLA Centre for Advanced Research on Language Acquisition. Minneapolis: Regents of the University of Minnesota; ©2016. Available from: http://www.carla.umn.edu/culture/definitions.html. [Last updated on 2014 May 27].  Back to cited text no. 18
Segall MH, Lonner WJ, Berry JW. Cross cultural psychology as a scholarly discipline: On the flowering of culture in behavior research. Am Psychol 1998;53:1101-10.  Back to cited text no. 19
Kulhara P, Wig NN. The chronicity of schizophrenia in North West India. Results of a follow-up study. Br J Psychiatry 1978;132:186-90.  Back to cited text no. 20
Hoenig J, Hamilton MW. The schizophrenic patient in the community and his effect on the household. Int J Soc Psychiatry 1966;12:165-76.  Back to cited text no. 21
Falloon IR. Family interventions for mental disorders: Efficacy and effectiveness. World Psychiatry 2003;2:20-8.  Back to cited text no. 22
Pai S, Channabasavanna SM, Nagarajaiah M, Raghuram R. Home care for chronic mental illness in Bangalore: An experiment in the prevention of repeated hospitalization. Br J Psychiatry 1985;147:175-9.  Back to cited text no. 23
Das S, Saravanan B, Karunakaran KP, Manoranjitham S, Ezhilarasu P, Jacob KS. Effect of a structured educational intervention on explanatory models of relatives of patients with schizophrenia: Randomised controlled trial. Br J Psychiatry 2006;188:286-7.  Back to cited text no. 24
Kulhara P, Chakrabarti S, Avasthi A, Sharma A, Sharma S. Psychoeducational intervention for caregivers of Indian patients with schizophrenia: A randomised-controlled trial. Acta Psychiatr Scand 2009;119:472-83.  Back to cited text no. 25
Thara R, Kamath S, Kumar S. Women with schizophrenia and broken marriages - Doubly disadvantaged? Part II: Family perspective. Int J Soc Psychiatry 2003;49:233-40.  Back to cited text no. 26

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