Preserve and strengthen family to promote mental health

Abstract

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 individuals.[4] The community mental health movement in USA had 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 had 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 had 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 had 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 had 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 had 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. FAMILY It is important to that the members a to care for their ill The impact of mental on the caregivers has been in the of psychological of is defined as of or which the life of the others members of the household the The of of has two the and the as proposed by and in household of and and time the mental social and In is the of the impact of It of the psychological impact on the and includes of or all of which in and of across a of that of patients with have the where a majority of caregivers have the of on the household including care of children, of and outside the of time of the on their and the in with and by and the impact on the mental and physical of the The of psychological has been to be with to of the caregivers to be from across which have the or are with of social and a social in and with as or not has a has been less on In have been with patients social is patients with of and caregivers who are and have to of social It has been that of the caregivers feel a sense of or from India have that the of care of is to or physical The of in has on family the that family in other is to have caregivers of patients with where majority of the caregivers in their mental Indian have with to impact of the care role on the emotional and physical have of family others have despite of caregivers in the It has been that over the and other family members, especially children, over the are which have the of mental in have that of the of of is by the which of its in the have that of of is to the of of but less the of of of caregivers have been two and to to and measures as or of In the less are at the emotional by measures as avoiding or to the The most of across a have been social of caregivers and social support for of and together with of support have been with a of as Indian have that of social support as a have been to be to that the of caregivers of and are caregivers of patients with of the the caregivers of It is that the of and have a influence on the in the is from there have the needs of patients with and the of needs by patients has from to the of most of needs by the patients in need for house after psychological and have that mental health services in the are to of these needs of This is to and and of the In a from India, the needs of the patients of as by the patients and their family members, and that the of needs of patients as by the caregivers was to that by and in to the West, where most of the needs of the patients are needs of patients in Indian were The most needs by patients and their caregivers were need for other have that the with mental have and need for or the need for and emotional the need for The to and are not in a with and social for a to the of A that in the Indian most of the needs in and patients are by their family members with from In with in the family from India have the of their patient after their and these to be by relatives have been less the in with patient It is well that life of a with mental It their family members and In to the of on of there has been of family are from caregivers of patients with mental Family the of and is to which to mental illness. 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. FAMILY A by caregivers of elderly or mentally ill relatives and which these to assume the care The first and most important group of was with the and psychological included of and with and life were as of family of and a need to in the religious or personal and family which families of patients with with and social that of these families an in the patients and their to to the the was and families were and in with have of in caregivers of In a of the caregivers that had to persons with More that for their to their in life and a greater sense of OF FAMILY IN MENTAL Family has the of in the of to the of The of the of emotional health of family members, and of families have been to be to In this have to A family is a in which and on the of members of the family and other members to families are most a of the or other of parents, mental or or the parents their parents and family and of family and role family (a family that with or and parents who control by or their needs or not to or of that is to of for to the the family which is as a was to be to living in families in which there is emotional and or by in family A of that and patients are in the and is in from joint The being that in a family there is and for of in of which to of in to of a for in the of the other in the of the joint are to all be to of the which to interpersonal or because of of a The of in has been reflected in of and is with an for the of the of parents with and in as the of was with a of in was is with an in for and during and It has been that a influence on the of the it is the of the by the that of the and of of and a of and to In as by to better social and to is by with to large on measures of and This the that to be a that the of in in to in a for interpersonal which is as a in of have been to be at for as or with other of household It has been that of involved parents, and of have when the was under the influence of Family is with and as well as of in important defined in to family is which the of and emotional over in a family. initially for patients with and their is across the health care and in is a and of in as and is one of the of and is with the patient In a in of social support and of with extended family the of a OF FAMILY IN OF of family in The was as a that for interaction the biological and the aspects of a person’s biological has influence and More the of social has been as a for the In these the family is the most family an role in the management of of family which be in the of mentally the the and emotional needs of its be to needs of the family provide and and and and the and and with and through accept when and be of family have for the of family a or as a of have concern for family and is the most of family to The of family to has been to a relationship with caregivers on and empathy, on the of caregivers and in community to to of and of the families to social and personal families to and the in the families to of the patient, emotional support to caregivers and of for support and family of and of life for patients with and of family for management and the of there is a of on of with of over the for control In of the most and with an of the of for the family was to the for control of a of three of family and a new of the most over that to which included family and to and and to two after the across these four for and were and The for was This that the with family better of those who did not family In the of family are from that family or in with interpersonal social was in and in in patients with on In these family was over and included and the other of other less have not these In the of a family to greater in patients with and family family had greater of patients who and in and patients who were family are for two of the most with and In a of of for and for that on and or group to in and for to of This of was as as considered to be the of have to be or in for with has the of family and includes family in its most the for This that persons with and their families who have with each other be a family the key of which emotional support and in to with and The for and the for family and the the of have been in the Indian to the role of family in the management of of the Indian of family and in have been in Family in the the common of all these is that family to better of family in a in the of of with have been to approach during the first after and that one in three persons with to at of their in from to as in from a role in the families a role in in patients with mental illness. This is by to the patient, and the taking the patient to at of the on and to persons with have that be when family members or others are on or others to and in their of caregivers of patients in that in the was for management in each the responsibility was by and other has that to in has a strong with family of and percentage with of family in The role that families in the support and care of a with a mental has over the The of is to an who from mental to or to the In with the of in the care of with mental Family being the most has a role in of In has been that in countries, caregivers have a role to in the and social of the patient, not because of family that in these traditional but because professionals to these is a of and support for mental care in are and for a majority of patients who in In a families have caregivers of the first and A the role of family support group in of mentally ill patients that family members with a of are to support of this of group were of in with the patient at emotional support in relationship with the patient the in and In a by community was to be better in and to in traditional Indian family the there have been from the traditional ideal Indian family and the living on social and live in joint which of in from the ideal joint others live in family and in other a with their children, as is the most common in the in family are reflected by the to the the population was the of a which a in which that the of at a the population and this in This that of families is in the society which is in in the in the of household and by that the ideal joint family is there are strong of of relatives live near each and are to each other to and when relatives live in strong of and to provide each other with emotional and other It has been that and taking place in Indian society have a on the needs of families and changes, which from to in of the traditional caregivers the and the have caregivers a second of It that the joint family not have families to be in a where are structurally but to as joint families of families not live under the same but to there has been of traditional support and and on to an to emotional and social and are bound to have an on the of families to provide care for the mentally It is reflected in the the of the Indian families of with mental illness. changes, of community care and support for patients families are to It is that in a like with and in family make the there is no with the in with to family to to it would be to all these have the is the of in family for mental health It is to assume that the of and is at a a of persons would be a to or joint to in their life time and being to the in of and the of It is that is affecting the of population especially the of society children and and The of and with are and includes family and and is on the mentally ill in the community for better and of mentally ill the society. there is on the and the mental In a like India, where the mental healthcare needs have but an important resource in the of in the care of the mentally ill is the mental health professionals in India have an important role in the of the needs of mentally ill are to be for in a better needs to be In a with and severely mentally but one for community mental healthcare is the need of the mental health which is not to in the required during the is an to and in the care of mentally ill and Unlike in the West, all the patients and handicapped persons are in the community. community mental health and adequate to the family members and care of the ill individuals.[4] this it would be to the and of the Indian family would impact for with mental illness. 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