Seat 31E, an aisle seat. Aditi sat down as the line of passengers continued past her. Immediately, she whipped out her new brown notebook, opened the first page, and wrote, “To-Do List: Week 1.”
She was finally on the plane, leaving India to go to the US for graduate school. She knew exactly what she needed to do first: “Find a good mental health therapist.”
When I talked to her about it, Aditi (name changed) described how she had felt trapped for years in India, suffering with depression in silence and humiliation. She was long overdue to schedule an appointment with a psychologist, but she hadn’t dared to do so on her own before. In her home in India, her parents did not help her, and her friends could only do so much to emotionally support her. She finally resigned herself to the fact that it just wouldn’t happen in India – Log kya kahenge? What will people say?
As the plane taxied, Aditi considered the freedom that lay ahead of her: freedom from the traumas of a sexually abusive marriage, freedom from living with her parents, freedom from the constant questions and haranguing. She could experience the freedom to create a new life for herself.
After she escaped the husband who beat and raped her, Aditi had suffered all over again. She recalls feeling worse once she went back home to her parents: “The trauma levels at home with my parents were equal to the levels there [with my husband and his family].” She was besieged by the intrusive curiosity of her relatives, who all demanded to know why she was back there. Her parents forbade her from speaking the truth, instead making up excuses to tell other people, and blaming her for abandoning her husband. They insisted she continue wearing her mangal sutra, to denote her marriage. They urged her to return and fix her marriage, and she had to fend them off daily. She told them she had nightmares and was traumatised, but they didn’t listen to her distress.
She wanted to find a psychologist, but didn’t know where to start searching, or how to trust that she might find a decent one; especially since she was forced into meeting counsellors by her parents and husband’s family. Each of these therapists was instructed to make Aditi feel guilty for leaving her marriage and ‘tarnishing’ her image in society.
One said to her, “Your life will be spoiled forever if you continue with this drama. Men will be men, you need to deal with it.” This psychologist was a court-appointed counsellor, and Aditi later found that the person was paid off by Aditi’s husband’s family. Everyone’s chief concern seemed to be what society would think of Aditi, and how best to maintain her social reputation. Log kya kahenge?
What will people say?
In India, this singular age-old social precept is relevant for everyone. It cuts across the lines of gender, caste, religion, socio-economic class, and region. It reigns supreme in regulating people’s decisions, because should people’s vulnerabilities become public knowledge, they will invite judgement, gossip and drama. It also suppresses much-needed psychological care.
A 2011 World Health Organisation-sponsored study found that 36% of Indians suffered from a Major Depressive Episode (MDE) within their lifetime. That means India has the most number of people in the world who suffer from some form of depression at some point in their lives. The social pressure to be “normal” manifests in unhealthy stigma and pressure against getting help.
Stigma to appear normal. Stigma to keep the family drama invisible. Stigma to protect the family honor. Stigma to force yourself out of the need for help.
The long-held taboo has prevented millions in India from accessing mental health care. During a televised expert panel discussion on NDTV in 2017, Chaitali Sinha, a psychologist at HAQ: Center for Child Rights in India and a practitioner-researcher with the global Mental Health Innovation Network, deplored the “cocktail of stigma and ignorance” that prevents people from seeking help. A fellow panelist on the same show, Dr Shyam Bhat, one of India’s leading psychiatrists, bemoaned the current state. “We’re still talking about shame, about stigma,” he said. “We have a long way to go…to successfully address the challenges to getting quality mental health care in India.”
Aditi in the US
But at least in the US, and for Aditi, things were changing.
Aditi arrived in the US, and promptly began her extensive search for a psychologist. She completed questionnaires about herself, combed through forums online, cold-called clinics around the city, and met with different practitioners to find the one she clicked with best. With the anchor of anonymity here, and without whispers warning of log kya kahenge, she grew stronger.
But, she wondered, would things ever change back home?
A few months later, she decided to share her story with her entire class. She wasn’t sure what they would think, because everyone seemed to have an undisturbed and normal life, what if they didn’t understand or couldn’t relate to her? Log kya kahenge?
She began nervously, but soon gained confidence from the unwavering attention of her audience. As soon as she finished, her classmates crowded around to thank her for her courage. Many of them reached out about the struggles they were going through as well. Some shared their own journeys of healing.
One classmate, also from India, recalls her presentation as the revelation he needed. He had been feeling depressed for years, and it was affecting his day-to-day life. Aditi’s story inspired him to search for a therapist here. “I hadn’t even considered it to be an option back in India,” he told me later. “I could never tell anyone, so I just tried to deal with it and get over myself; it was easier to blame myself and try to ignore my feelings.”
Why is the issue of mental health care so complex? The term encompasses a lot: from more common temporary and acute moments of anxiety and depression, to severe chronic disorders such as schizophrenia or bipolar disease. It is inaccurate and unfair to put everything or everyone into one box.
Risk factors are wide-ranging: biological preconditions can influence the likelihood of being diagnosed with a severe mental illness; psychological factors and stressors can trigger episodes of anxiety and depression; the social environment can exacerbate or lessen the extent to which someone experiences poor mental health.
Mental healthcare in India
Regardless of disorder, however, data compiled by IndiaSpend and WHO reveal a staggering treatment gap for all mental health disorders in India: only 10% of patients in the country get treated. In comparison, in the US, that figure is 44%. In South Korea, 82% gets access to treatment.
The sheer dearth of experts is astounding. In India, there are three psychiatrists for every one million people. In the UK, there are over 14,000 psychiatrists for every one million.
In India’s health budget, mental healthcare costs account for a miniscule 0.06%. In Bangladesh, it is is 0.44%. Not much higher, but it’s still higher. The barriers to receiving adequate care are numerous and enormous.
Access to mental healthcare in India is poor in both urban and rural areas. Nuanced professional training is not the norm. Insurance does not make mental healthcare affordable. There is an overemphasis on medication. Few even understand the difference between psychological attention and psychiatric care. The list goes on.
Often, blame has been cast upon the institutional barriers to mental health services. The Mental Health Care Bill of 2016 for India provides much-needed and long overdue comprehensive legislation to target these systemic obstacles.
It grants every individual the right to access mental health treatment funded by the government, the right to information and decision-making power by patients themselves, the right for the mentally ill to remain in a community and not be segregated from society, the right to confidentiality, prohibitions on electroconvulsive therapy, the decriminalisation of suicide, and more. The bill has changed the focus, from a purely physical-health-based to a care-based system.
Despite such progress on paper, however, there remains a pathetic lack of social infrastructure in dealing with this issue, and this suppresses demand for care. Social stigma and discrimination haven’t gone anywhere. They are still the largest barriers to mental health service utilisation, confirms a report published in the International Health journal.
A lucky break
Aditi thought herself among the lucky ones who had left India and escaped the entrapment of the prevalent social stigma. In the US, her opportunities to find help were plenty.
After months of trial and error, she found a psychologist who was perfect. Each week’s appointment brings with it new revelations and a liberating space to talk about the trauma and distress she is experiencing.
During one of her sessions, she described to her therapist how much of her unease relates to her troubled relationship with her parents. When she was at home with them, she knew her parents would be angry that she left her in-laws’ house; they explicitly expressed disappointment over her inability to sustain the marriage.
They had to face society with a daughter whose marriage didn’t work, and who returned home. In their minds, they were trying to protect their daughter by keeping up appearances and presenting a united and stable front. This would come at the cost of Aditi’s mental health.
Her therapist at this point suggested that Aditi write a letter to her parents to express her feelings and depression. She hesitated initially, because she suspects her mother blames her for what happened. She is too scared to ask her mother about this, because she doesn’t want her fears to be validated.
Her parents had often said to her, “You’re mental, you’re mad, you’re just not thinking the right thoughts. You’re not okay because of your own doing. Stop saying you have a mental problem, it’s not true.”
Impulsively, she finally acquiesced to the therapist’s suggestion, and drafted an email. A few thousand words later, she sent the letter to both of them.
Then, she waited.
Parents go cold
Aditi’s parents had for years called her daily. After she emailed the letter, the calls stopped.
A few days later, she received a call from her mother. She asked her when Aditi would get married again so that she could go back to a “normal life. Aditi didn’t respond. She found their ignorance and denial about their own daughter’s well-being too emotionally draining. She had left India 8,000 miles behind, and had thought that she left the social stigma behind as well. She thought she was lucky to be here; lucky to not face social pressure; lucky to regain her confidence and overcome her mental health concerns. This wasn’t India. Now she knew she was not entirely free. Log kya kahenge? This still followed her around.
For her parents at home, and her friends and extended relatives unaware of her situation, nothing had changed. She wasn’t yet free of what people would think. If she discussed her need for professional help, she would be labelled “mental.” “If you have any kind of ‘mental issues,’ then people think you’re mad and that you should be locked up and isolated,” Aditi said to me angrily. “There is no range.”
She feared she would be locked away and taken away from her life against her will. This was not “care.”
Social stigma in India
It is hard to expect a society to “care” about mental health issues if they don’t understand them. Psychologists and mental health experts are trying to change that.
“There is no clear understanding of what mental health care is in India,” said Jyothi Ravichandran, founder of Thrive Foundation in India, which works on mental health in low-income schools. “The biggest challenge is understanding that mental health is a priority; should be a priority.”
“Everyone wants to deny that there is a problem, because acknowledging that there is one means you will have to change,” she said. “Change is difficult, and requires entirely different ways of interacting with other people in society.”
Social stigma in India is hiding in plain sight, because people do not acknowledge it. “It’s not about just preparing the patients, it is about preparing society,” Jyothi concluded. Everyone needs to buy in to the urgency of shifting societal norms around mental health care in India.
An uncertain path ahead
Aditi’s progress, meanwhile, remains slow. For every few steps forward which she takes on her mental health, Indian society – even from oceans away – manages to bring her back.
Though she is getting the care she needs here, her family’s and friend’s attitudes could impact her long-term healing.
Aditi has no plans of ever living with or near her parents again.
Repairing her relationship with them seems impossible. “I won’t even tell them I’m going to a psychologist until I am stronger. Otherwise, their blame will continue to hurt me,” she said. She knows their main concern is what society will think of them, and this is what worsened her mental health in the first place.
Aditi’s story is just one. Some would argue she is one of the lucky ones. There are millions who will never be supported by their communities in India in their search for mental health care.
The future of mental health issues in India could be decided by its patients, but instead it may be decided by society around them. But if the taboos on mental health care persist, it will reflect badly on society, not on the individual.
Nikita Taniparti is pursuing her Masters in Public Administration in International Development at Harvard University, John F. Kennedy School of Government.