Preserve and strengthen family to promote mental health

INTRODUCTION Unlike the West, in India, family is the key resource in the care of patients with mental illness. Families assume the role of primary caregivers for two reasons. First, it is because of the Indian tradition of interdependence and concern for near and dear ones in adversities. Due to this most Indian families prefer to be meaningfully involved in all aspects of care of their relatives despite it being time-consuming. Second, there is a paucity of trained mental health professionals required to cater to the vast majority of the population; hence, the clinicians depend on the family. Thus, having an adequate family support is the need of the patient, clinician and the healthcare administrators. The term family has its root in the Latin word ‘familia’ that denotes a household establishment, akin to ‘famulus’, which denoted a servant who came from that household establishment. In the ancient Roman law, the word denoted the group of producers, slaves and other servants as well as members connected by common descent or marriage. Family as we understand today has been defined in the Oxford dictionary as (i) The body of persons who live in one house or under one head, including parents, children, servants, (ii) The group consisting of parents and their children, whether living together or not; in wider sense, all those who are nearly connected by blood or affinity. (iii) A person’s children reared collectively. (iv) Those descended, or claiming descent from a common ancestor. From the point of view of psychiatry, family denotes a group of individuals who live together during important phases of their life time and are bound to each other by biological and /or social and psychological relationship. It is a group defined by a sexual relationship sufficiently precise and enduring to provide for the procreation and upbringing of children.1 When we look at the family as a unit, the following features are common across the globe: it is universal, permanent, nucleus of all social relationships, has an emotional basis, has a formative influence over its members, teaches its members as to what is their social responsibility and the necessity for co-operation and follows a social regulation.2 FEATURES OF TRADITIONAL INDIAN FAMILIES India is a secular and pluralistic society characterized by tremendous cultural and ethnic diversity. In India the family is the most important institution that has survived through the ages. India, like most other less industrialized, traditional, eastern societies is a collectivist (a sense of harmony, interdependence and concern for others) society that emphasizes family integrity, family loyalty, and family unity. More specifically, collectivism is reflected in greater readiness to cooperate with family members and extended kin on decisions affecting most aspects of life, including career choice, mate selection, and marriage.3 Since ages, the Indian family has been a dominant institution in the life of individuals. It is considered strong, stable, close, resilient and enduring. In India, overwhelmingly, families adhere to a patriarchal ideology, follow the patrilineal rule of descent, are patrilocal, have familialistic value orientations, and endorse traditional gender role preferences. Historically, the traditional, ideal and desired family in India is the joint family. A joint family includes kinsmen, and generally includes three to four living generations, including uncles, aunts, nieces, nephews, and grandparents living together in the same household. Frequently, a large joint family divides after the demise of elderly parents, when there is no longer a single authority figure to hold the family together. After division, each new residential unit, in its turn, usually becomes a joint family when sons of the family marry and bring their wives to live in the family home. The lines of hierarchy and authority are clearly drawn, shaping structurally and psychologically complex family relationships. Ideals of conduct are aimed at creating and maintaining family harmony. Women are especially strongly socialized to accept a position subservient to males, to control their sexual impulses, and to subordinate their personal preferences to the needs of the family and kin group. Reciprocally, those in authority accept responsibility for meeting the needs of others in the family group. Psychologically, family members feel an intense emotional interdependence with each other and there is strong interpersonal empathy, closeness, loyalty, and interdependency.3 INTEGRATION OF FAMILY IN MENTAL HEALTH DELIVERY :INDIAN SCENARIO Until the arrival of the Britishers, there were no organized modern mental healthcare services in India and the mentally ill were looked after by their families or in religious institutions or simply roamed free. The Britishers established ‘mental asylums’ – institutions which were popular in the European countries, where the community felt safe to keep the unwanted, dangerous mentally ill in closed institutions away from family and society. This was initially for their soldiers but the benefits were gradually extended to the Indian population as well. The first mental asylum was established in Bombay in 1745, the second in Calcutta (1781), the third in Madras (1794) and the fourth in Monghyr, Bihar (1795). Around the same time, Philippe Pinel (1745-1826) in France, William Tuke (1732-1822) in England and Benjamin Rush (1745-1813) in United States ushered in the era of ‘moral treatment’ in psychiatry, which included humane care, avoiding physical restraints, better staff patient interaction and an open door system. Adolf Meyer, in 1909, advocated management of mentally ill patients outside the institutions and proposed a comprehensive ‘community mental health approach’ in which psychiatrists, family physicians, police, teachers and social workers would work together to organize primary, secondary, and tertiary preventive measures in the community. All these changes, taking place in Europe and America did not make any impact on the Indian scene. Till 1946, the approach of the Government was to establish custodial and no therapeutic centers, for a small percentage of severely mentally ill and handicapped The community mental health in its and and a in to establish community mental health and care for mentally who would from mental A large of community mental health were over a of time, the community approach because severely ill patients who were did not to the community mental health were not by their which in were in and In India there has been a tradition of families in the of mentally ill In the of involved the family members of the mentally ill in the by to with their patients in open in the that the patients and were home. on this family were established in The benefits were and family members as in their community as other patients and their family members to approach for This of the family in the care of the patient the of the trained and from the and of that were not the most to It was that be included in the to make in the Indian on families of and their four that of the patients living in mental no with any family that the of care for a the work of the patient and the to mental were the for the that of the patients in the one or family members, of did not have a single from a in the two of the mental have that large of patients have no with the the were at Bombay and Calcutta in and and in and The a of over the mental – were patients with mental health and in the of the health system. from family point of the patient with the family and the family was involved in the care of mentally ill It is important to that over the with the in and and in of better and are in their family on and This is by of on the aspects of care in when one to these it becomes that the family the patient to a mental as a of The of the primary care approach in the of mental The a in and the for health The were in and near and of from the of mental health and health the first of and it was in the in with the of community in the of the MENTAL HEALTH The traditional joint family that in India is as a of social and support and is for its of and to in of have that traditional joint families for of in families for the mentally ill and be for the and of mental of the role of the family in to mental health have that the family is to be with the joint that patients from families when to families because of the joint family that patients who from families and a better to a three have that the the in of it being an extended or joint the it was to for a in of having A by patients living in and India and that patients were who by the on the of of and the of – that persons with did better in India and other countries, when to their and of this has been to family support these patients in and on a of Indian have the of therapeutic including family by that the of and in in the first two of the illness. In India, traditional joint family where family members together with their and children, have been in by More the family has a and social in of role relationships, and In the of the in the and that with and in family make the care OF FAMILY IN MENTAL HEALTH SCENARIO IN The to services has the role of the The family and role has been in the and in The role of family becomes greater in a like with one where there is a paucity of trained with the of mental health professionals not a and are It is to that a large of the mental health care place in the community the family as the primary care This is from what in the West, where the of care to the community as a of the with to patients with with their families in India like the United and United States of America of families in the care of that less of patients in the with their the figure in India was In view of the of mental health in India, community care by a as in the countries, including an of trained social and would be in a like India, the term patients outside but with their it that the of care to be with the family. 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In turn, family members for being for the mental illness. This to family members avoiding with and with the to and of as to all of including healthcare services and are by patients and have been affecting the of of the patient, or of the family. 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The that in with including India, the of health was and were being by individuals and have to the the has to the of family members who have an all important role in the and of to better for including and services is to be measures as of of community to and well and are mental health to have the being caregivers need to be through of support and being in the Family of mentally ill be a in that In a of European countries, there to provide for families to care of their patients with The mental health professionals this with the Family on to patients and key relatives and of household and in these is to the of life of with mental and their the of impact of family in is well are in care and are that in to on the of needs to be to the mental health and of family and support have to be extended to the family and the India and the West, in the West, be to the there is need to a of and of on this has been a of or support for family members of persons with in the and to in The families need and for with mentally ill be to that from of their the institution of family because of and the society in and be to the of the institution of family for the of those ill mentally ill who be the because of of mental health in has to a of family in the care of the mentally ill to the ill of this and make this a place to live to this to which has and to and who and to patients and their families who have to the of this and the of of and of who came with their and support to this by and for a would like to to and for their with this