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International Review of Psychiatry (2001), 13, 125–130
ISSN 0954–0261 print/ISSN 1369–1627 online/01/0200125–06 © Institute of PsychiatryDOI: 10.1080/09540260120037362
Introduction
Hinduism is the name given in the nineteenthcentury to describe a broad range of religions inIndia. It comes from the Persian word bindu andSanskrit word sindhu which means ‘river’ and refersto the people of the Indus Valley Civilization of India.About 80% of India’s one billion people considerthemselves Hindus and there are about 30 millionmore Hindus dispersed throughout the world(Bowker, 1997). In understanding the psychiatrictreatment of Hindus, one must have basicunderstanding of Hinduism.
Hinduism is one of the oldest religions of theworld. It has no known beginning, has no humanfounder and predates recorded history. Its rootsspring from the traditions of the people of IndusValley, 2500 BC–1500 BC, the Dravidian Culture,which persists even today among the Tamils insouthern India, and from the Vedic religion of theAryans who invaded India from about 1500 BC. Thisinvasion and the original home of Aryans is stillbeing debated. Therefore Hinduism is an integralpart of many human lives and is well integrated withthe cultural practices of its followers.
The major scriptures of Hinduism are the Vedas, theUpanishad, and the Bhagwad Gita. These Hinduscriptures are written in Sanskrit. The Vedas areconsidered the oldest and the name means ‘eternaltruth’. There are two texts; one is the Shruti text,which was passed on orally from one person to theother. The second one is the Smriti text, which means‘that which is remembered’. Hinduism is recorded in
the four Vedas. They are: Rigveda, Yajurveda,Samaveda and Atharvaveda. TheVedas describe theworship of God as nature such as fire, water, wind, etc.This worship was to express gratitude for survival ofcreatures, however, with time this worship took manydifferent forms. They consisted of elaborate systems ofrituals and sacrifices to please the Gods. In time Godswere retained only in name and the ritual itself cameto occupy the place of the Gods (Majumdar, 1988).Many originally sensible hygienic practices were givenreligious status in order to enhance their observance.This religious status became fossilized intomeaningless rituals. Atharva-Veda mentions mentalillness largely as a result of divine curses. The spiritualand possession concepts of mental illness in theAtharvaveda was retained and not displaced by thesubsequent development of the medical humeralsystem. Upanishad reformed some of the Vedic rituals,and the Ramayana and the Mahabharata playedimportant roles in understanding of theVedic systemof thought. The Bhagwad Gita that was recited byLord Krishna in the epic Mahabharata plays a veryimportant role in the lives of many Hindus today. Itfocuses on the philosophy of joyous living—a life ofutmost happiness and least suffering. It is based on afundamental understanding of human personality, itsstrengths and its weaknesses. Therefore, inunderstanding Hinduism one identifies auniversalizing core. This concept of universalityimplies plurality rather than uniformity or isomorphicequality (Sharma, 1993). Hinduism, therefore, is asystem of philosophy rooted in the experience of manyRrisis, or Saints.
Correspondence to: Nalini V. Juthani, MD, Director, Psychiatric Education, Bronx-Lebanon Medical Center, 1276 FultonAvenue, Bronx, New York 10456, USA.
Psychiatric treatment of Hindus
NALINI V. JUTHANI
Bronx-Lebanon Medical Center, New York, USA
SummaryHinduism is one of the oldest religions of the world with no known beginning, no human founder. It predates recorded history. Hindusbelieve that there is one creator, all life is sacred, and therefore non-violence or Ahimsa is the highest Dharma of a Hindu. Belief inreincarnation gives continuity of life from one birth to the other until the soul is realized and reaches Nirvana. Ayurveda, an ancientIndian medical practice, is commonly used to treat patients. Other alternative medicines such as homeopathic treatments, messagetherapy are also commonly used for preventive as well as curative practices. Hindus in India tend to be more ritualistic than in theWestern world. Treatment of Hindus has to be culturally sensitive and include Hindu beliefs and practices. Clinicians have to be awarethat patients are rarely self-referred and the role of the family is crucial. Clinicians should distinguish between healthy and unhealthyreligiosity based on how it interferes with adaptation to life situations.
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Overview of Hindu beliefs
One creator
The Hindu ‘believes in one creator and a supremereality which is the ground for one’s divinity’. TheUpanishad calls this divine reality simply Atman,Brahma or Self. This self is seen to be one, the samein everyone. The self is in all creatures and is notdifferent from the ultimate reality called God(Easwaran, 1987a). This reality is said to be beyonddescription but it is a ‘pure consciousness’ whichmakes the eye see and the mind think. This divinepower is changeless, holds everything together,creates, destroys and recreates. This informing poweror spirit is God who is recognized by many names.These names are both male and female. In theBhagwad Gita there is a great verse which states inSanskrit, Yada Yade hi Dharmasya, Glanir BhavatiBharate, Abhuthanam Dharmasya TadatmanamSrujamyaham. ‘Whenever righteousness declines andthe purpose of life is lost, I manifest myself on earth.I am born in every age to protect the good, destroythe evil, and re-establish the truth.’ This is howHindus look upon Krishna, Buddha, Rama, Vishnuand others, as divine reincarnations of God(Easwaran, 1987b). Several sects of Hinduism havedeveloped based on individual’s faith in thesereincarnated beings.
All life is sacred
Although Hinduism considers the concept of God asever loving and purely benevolent, people who feelguilty about their wrong doings may perceive God aspunitive or punishing. They may feel fearful and mayworship images of God that look angry andfrightening. Hindus believe that God-Spirit is in alllives and manifests as love, truth and light. All life istherefore, sacred, to be loved and respected. Thebelief of non-violence, Ahimsa, is based on thisconcept. The religion Jainism and Buddhism hasinvolved themselves in a continuous exchange ofthoughts and beliefs with Hinduism especially in thebelief of ‘Ahimsa’ or non-violence.
Karma
Hindus believe in the Law of Karma. All deeds of ahuman being are called Karma. The Law of Karmastates that every event is both a cause and an effect.‘As you sow so shall you reap.’ Every action will haveits reaction and every cause will have its destinydetermined in due course of time (Thakkar, 1988).Hindus believe that their suffering from mentalillness is also due to Karma of the past. This Law ofKarma also states that we can change what happensto us by our awareness and efforts to changeourselves. This is called Purusharth.
Reincarnation
Hindus believe that the soul is immortal and takesmany different births until it is completely self-realized.Hindu spirituality therefore can be understood as ajourney of a soul toward union with the Creator.
This is called Nirvana, meaning the stage whenthe soul ultimately finds spiritual knowledge andbecomes realized and is liberated from the cycles ofbirth and death. Therefore a Hindu’s ultimate goal isto live a life by ways of conduct as described byDharma. Such a life progresses in self-realization.
Dharma
Dharma is the essential order of things that bringsintegrity and harmony to the universe. It also meansgoodness of purpose, rightness and selflessness. It ispossible to live by Dharma when oneness of all lifeis understood. The Upanishad describes that all livesare interconnected because at its deepest levelcreation is indivisible. Therefore a disturbance in oneplace sends ripples everywhere until balance isrestored. The highest Dharma of a Hindu is topractice ‘Ahimsa’ or non-violence.
Ancestor worship
Hindus revere and worship their ancestors who oftenwatch over them and serve as a source of inspiration.Some Hindus feel that their ancestors give themguidance and positive thoughts while some feel thattheir ancestors are angry with them for failing tocarry out their desired rituals after death. Culturallyaccepted thoughts have to be differentiated frompsychotic thoughts in such people.
Astrology
Hindus believe in working with the cosmos. Manybelieve in astrology and especially in India, name theirchildren based on the stars’ position at the time of birth.Every person’s horoscope is prepared after birth and allmajor life events are planned according to astrologicalpredictions. Horoscope matching of the man andwoman is a common practice in arranged marriages. Ifthe horoscopes do not match, it is believed that thecouples will not be compatible. Marital discord isblamed on non-matched horoscopes.
Ayurveda
Ayurveda consists of traditional texts derived from theVedas and deals with the Indian method of medicine.Of the original eight texts, the Caraka Samhita textdeals with medical diagnoses and treatment. Bhugra(1996) states that Caraka described the function of themind as direction of the senses, control of the self,
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Psychiatric treatment of Hindus 127
reasoning and deliberation. Caraka advanced a holisticview of life that included physical, social, ethical andspiritual aspects of health and disease. Caraka describedthe human body as being an aggregate volume of cellswhere growth depends on Karma, Vayu (air or bio-energy) and Svabhava (personal nature). Life or Ayu isdescribed as a combination of Shareera (body), Indriya(senses), Satva (psyche) and Atma (soul). Manas(mind) has three operational qualities: Satva, Rajas andTamas. These concepts are to this day used byAyurvedic practitioners. Satva includes self-control, self-knowledge and an ability to discriminate or makethought out choices. Rajas is indicated by violence, envyand authoritarianism. Tamas reflects dullness andinactivity. The classification of mental illness conformsto Ayurvedic categories of nija (endogenous, arising outof imbalance of doshas) and agantu (exogenous,mostly possession states) (Desai, 1989).
Alternative medicine
Hindus believe that physical and mental illnessdevelop due to imbalance between natural forces andinternal human forces. They can be balanced byingesting natural products such as medicinesprepared from roots of vegetation and minerals.Alternative medicines such as Ayurvedic andhomeopathic treatments, massage therapy, etc. arecommonly used for preventive as well as curativepurposes. According to Ayurvedic understanding,every human has a body type which is like a blueprint outlining the innate tendencies of an individual.By knowing one’s body type an Ayurvedicpractitioner can tell which diet, physical activities andtherapies can help treat a person (Chopra, 1991).
Possession states
Hindu patients in India may present with possessionstates. As described earlier, many Hindu patientsconsider that mental illness has supernatural causes.These causes include possession by supernaturalpowers, sorcery and the evil eye. The management ofthis state has covered a wide range of treatmentsincluding prayers, sacrifices, worship of spirits andgods, charms and herbal medicines. Patients respondto performance of rituals, worship of a particulardeity, offerings to deities, recitation of mantras andchanting. Underneath such possession states somepatients may have unconscious desires to bring thebehavior of family members into compliance withtheir own wishes
Caste
The caste system is based on the principles of dharma,Karma and distribution of labor. Helweg (1997)believes that inequality, purity and reincarnation are
to be considered as well: the framework of the castesystem sets positions the most pure close to God andthe less pure farther off. One’s position in a currentbirth is determined by how well one led one’s past life.A person who was pious and lived dutifully (dharma)was rewarded (Karma) with a better position in thenext life. This concept gives incentive to live a piouslife in order to reap the fruits in future, and toleratewhat one has in the current life.
Most people in rural areas follow their family’svocation. Bhahmins preached, Kshatr iya wereprotectors and fought wars, Vaishya were professionalsand businessmen and Shudra or untouchables carriedout the cleaning jobs. This is how Shudra wereconsidered less pure and Brahmins were consideredpure. Although the caste system still prevails in ruralIndia, the efforts of Mahatma Gandhi and othershave reduced its intense effects on the society. Todaythe caste system may come in play when marriagesare arranged. In Hindu society social status is basedon a family or group evaluation rather than anindividual’s endeavor. This collective identitydetermines an individual’s ranking.
Hindu families
Traditionally a Hindu family comprises threegenerations living under the same roof. The head ofthe family is the grandfather who makes finaldecisions for everyone in the family. There is ahierarchy among family members. Males are valuedbecause they continue the family name. Women gainpower after becoming mother-in-law of her son’swife. Although in reality men control decisions inbusiness settings and women control decisionsrelated to personal life, outwardly men areconsidered the ultimate decision-makers. The head ofthe family arranges marriages. Ideally marriages arearranged within the same caste and class system.Family reputation plays a very important role inselection of the bride and groom. Love between thecouple develops after marriage and they are expectedto make compromises until a harmonious family lifeis established. The mother and extended femalefamily members raise the children. When childrengrow up to be adults, they are responsible for the careof their elderly parents. To place elderly parents in ahome is looked down upon.
It is important to keep in mind that such tightlyknit family systems are disintegrating withurbanization and industrialization. When a familymigrates to the Western world, their patriarchal andhierarchical values meet challenges. Hindu women,under the influence of Western society, becomerapidly independent. Children raised in the Westernsociety present many conflicts for Hindu parents.Mental illness is perceived as a weakness of characterand inability to cope with stressors of life.
From a Westerner’s perspective, in understanding
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Indian culture and families two themes come tomind, the caste system and the emphasis on familyhonor or izzat. The concept of izzat has ramificationsfor the Hindu families in the US. They are usuallyvery sensitive and observant as to how peopleevaluate their behavior. Community service isconsidered a great value. This service can be usingany asset one has, may it be money, or physicalinvolvement. In return they expect to receiverecognition. A family member identified with amental disorder can ruin the honor of the entirefamily and destroy the chances of finding a goodmatch for other members of the family.
Common practices of Hindus
To provide culturally and religiously sensitivetreatment to Hindus, clinicians must understandcommon practices of Hindu followers. A Hinduconsiders Hinduism as not only a religion but also away of life. A Hindu strives to evolve from a materialhuman to a spiritual one and considers God a silentpartner and an inspirer.
The day-to-day practice of a Hindu may be carriedout as a tradition without understanding its meaningand purpose, although it may bring peace to thatindividual.
Prayers are said in the morning, before meals andat night to express gratitude to God. Since God isnot visible Hindus offer tremendous gratitude toGuru, Parents, and Elders. One bows and touchesthe feet of one’s Guru, Parents, and Elders to receiveblessings and express gratitude. A symbolic joining oftwo hands and saying Namaskar is a traditional wayof greeting another person and paying reverence tothe God within another person.
Reading scriptures, and listening to the discoursesgiven by a Guru confer spiritual knowledge anddevelop positive thoughts directed at living arighteous life or carrying out Dharma.
By doing Karma (deeds) one evolves from a self-centered materialistic life to a more selfless life. Thisincludes charity or ‘giving’ through one’s resources,may it be physical, emotional or economical.
Worship is offered to an idol of a deity of one’schoice and faith. This idol worship teaches one toconcentrate one’s mind on the deity’s virtues andabsorb its values and quality of life. A state of idolworship leads on to a state of meditation. It is duringthis state of meditation that the conscious mind andthe unconscious mind unify in the worship of God.The unconscious instincts and libidinal desiressublimate into spiritual love and fullness (Athavale,1992). The words ‘OM’ or ‘Shanti’ (‘Peace’) are oftenrecited during meditation. Hindus, who aredistressed, anxious, and ill at ease, find great solacein idol worship and chanting. Idol worship is done inthe temple or at home. Most Hindus have a placeidentified for a home-temple in their homes.
Fasting on a regular bi-monthly or monthly basisis intended to regulate and control one’s desires.Some people will fast as a penance and to receiveforgiveness.
Visiting people selflessly to provide warmth,support, and share spiritual thoughts is consideredGod’s work.
Hindus desire to have their bodies cremated afterdeath, the ashes to be sprinkled in the Holy RiverGanges. It means an ultimate merger of the bodywith nature. Hindus believe that if such a rite afterdeath is not carried out then the soul of the deadmay not rest in peace. Some Hindus develop guilt ifthey fail to carry out this practice successfully fortheir parents or loved ones.
Treatment of Hindus
Religion, culture and health are integral part ofHindu lives. Physical and mental illnesses areconsidered interrelated, and chronic illness carry astigma in general. Therefore, it is less painful toconsider short-term view of treatment.
Referral
Hindus are rarely self-referred. A family member or afriend of the family makes the first appointment for theidentified patient. After the initial attempts to get betterusing alternative therapy, one would talk to the wiseperson in the extended family who may refer the patientto a folk healer or a priest. A few religious rituals,prayers or acts of charity may be carried out at therecommendation of the folk healer or a priest. This ismost common in treating Hindus in rural India. Ifthat fails, then the patient is referred to a medicaldoctor who may refer the patient to a psychiatrist.
Expectations
Hindu patients and families believe that a bodilyailment is a temporary condition and the body canbe brought back to a balanced state by short-termintervention. They expect that:
1. The psychiatrist will listen to every family memberpresent at the time of evaluation and involve himor her in treatment. The concerned members ofthe family do not see a confidentiality issue.
2. The psychiatrist will provide symptom reliefthrough prescribing medications.
3. The psychiatrist will be an advisor, teacher, andguidance counselor—almost like a Guru. A Hindupatient will therefore expect the psychiatrist totake a more directive role than the traditional non-directive stance of Western psychiatrists.
4. The psychiatrist will understand their feeling thatmental illness in the family is highly stigmatized.An illness in one member brings shame to theentire family.
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Psychiatric treatment of Hindus 129
Initial evaluation
The clinician should listen to the identified familyspokesperson first to learn about the reason forconsultation. This spokesperson is usually educated,a good communicator and a liaison in establishing adoctor–family relationship. Patient compliance maydepend on this doctor–family rapport.
The clinician should maintain control, beinteractive and focus on the symptoms of the patient.A non-judgmental, passive, neutral stance on the partof a therapist produces anxiety in the patient.
After identifying the problems, the patient and thefamily can be seen together and educated about thenature of the illness and possible treatmentmodalities that can be prescribed. A hopeful positivestance on the nature of the illness helps establishconfidence in the patient. It is imperative tounderscore that illness is biologically based and notan outcome of the patient’s or family’s negligence orwrong doing in the past.
A careful history of all alternative and herbaltreatment consumed by the patient should beobtained. Any religious intervention such as idolworship, chanting, and meditation should beaccepted. However, excessive preoccupation withreligious rituals should be explored for obsessivecompulsive disorder. Hindus tend to deny the illnessand try to cope with symptoms through excessivereligious rituals, which are culturally accepted.
Subsequent sessions
Hindus tend to conceal pathology and suffer quietlyto save the family from shame. Be authoritative andexpect that the patient will be honest and carry outthe prescribed treatment plan, but do not expectcompliance automatically. Patients tend to expressagreement with what they are told as part of showingrespect toward the psychiatrist but may continue tomodify dosage of medications, mix them with herbalmedications without consulting the psychiatrist.
Aim for symptom relief through medications. Themajority of patients will need elaborate explanationregarding the need to take medications for longerperiods of time. Involve the family at every stage oftreatment and make special efforts to involve thosefamily members who do not show up for sessions.
Self-growth and character change are desired onlyby a very few highly motivated patients. Mostpatients will accept cognitive behavioralpsychotherapy and some will respond to traditionalexploratory insight oriented psychotherapy. Themajority of Hindus consider that self-developmentoccurs through religious and spiritual routes and notthrough therapy. Clinicians must respect this culturalbelief. Patients may explain their suffering as theunseen works of their Karma in past births. Do notdismiss this belief but listen empathically and providesupport. Offer advice to prevent illness and improve
health. Such an attitude of acceptance goes a longway in gaining patient’s compliance and easing cross-cultural tensions (Juthani, 1998).
Long-term treatment
Patient compliance with medications rarely lasts long.Hindu patients may not show up for treatment andmay continue to shop for second, third, and moreopinions to satisfy their wish that chronic treatment isnot necessary. Accept these patients when they returnand show empathy towards their suffering. At times aclinician may support the family’s decision to see onlya faith healer. In many instances traditional healingceremonies provide attention of the entire family onto the patient who may feel wanted, accepted, andcared for. Such healing ceremonies may work similarlyto psychotherapy for that patient. Yoga and meditationcan be prescribed for long-term management ofanxiety. Patients easily accept these modalities.
Conclusion
Clinicians may encounter Hindu patients at variousstages of cultural and religious development. Hindusin India tend to be more ritualistic than in theWestern world, however, Hindus who have lived incountries such as Guyana and Trinidad for three tofour generations may believe in rituals that weretraditionally carried out over a century ago. Havingunderstood their cultural, religious and spiritual waysof life, clinician should distinguish between healthy,and unhealthy religious ways in a patient’s adaptationto life situations. Healthy spirituality involvescourage, prudence, love for oneself and others and anopen mind for further development. True knowledgeand open mindedness lead to wisdom. Such patientsuse their spiritual development to integratepsychological growth. From a Hindu viewpoint,unhealthy religiosity involves excessive fear, lack ofprudence, self-centeredness, self-hate, hate of others,ignorance and closed mindedness. Delusions,hallucinations and psychotic levels of anxiety ofreligious nature are seen in such patients. Aconstantly angry person may perceive God aspunitive and sadistic. Such unhealthy religiosity leadsto stunted emotional and spiritual growth anddestructiveness (Xavier, 1987). Integration ofreligious and spiritually based psychotherapy withmedications may lead to better outcomes.
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