Explanatory models and psychiatric pluralism among family members of mentally Ill persons: a narrative inquiry

ABSTRACT

Active involvement of families in mental health care in India is well documented. This study aimed to understand the explanatory models of the family members of persons suffering from common as well as severe mental illness. Narratives were collected through interviews from family members accompanying the patients at a psychiatric clinic. Data were also obtained from professionals at the clinic as well as folk healers. The Constant Comparative Method was used for analysis. The notable findings were: healthcare pluralism at institutional, cognitive and structural levels; conflicting explanatory models about mental illness; and stigma regarding mental illness. The findings suggest that in addition to explanatory models, the accessibility and availability of healers also plays a major role in treatment choices by the families.

KEYWORDS:

• explanatory models
• psychiatric pluralism mental illness
• constant comparative method
• narrative inquiry

Notes on contributors

Bidisha Banerjee is an independent researcher who lives in India. She received a PhD in Psychology from the Department of Humanities and Social Sciences, Indian Institute of Technology Kanpur, India. She completed an MPhil in Social Sciences at the Tata Institute of Social Sciences, Mumbai, and an MSc in Medical Psychology at the University of Calcutta, India. Her interest area includes qualitative research methods, cultural psychology, mental health and positive psychology. Post-PHD, she worked as Assistant Professor at Christ University, Bangalore, India.

Dr Shikha Dixit is a Professor of Psychology in the Department of Humanities and Social Sciences at the Indian Institute of Technology Kanpur, India. Her teaching and research interests include health psychology, cognitive psychology, social cognition, social representations of mental health and illness, and the application of psychology to armed forces. She has published research articles and presented papers at national and international conferences in these areas and has also supervised several PhD theses. She has used both quantitative and qualitative methods in her research.

ORCID

Bidisha Banerjee http://orcid.org/0000-0002-5551-192X

Notes

1

… laymen … utilize whatever forms of medical knowledge and practice are available to them. They are less concerned with whether the therapy is indigenous or foreign, traditional or modern, than with how much it will cost, whether or not it will work, how long it will take, and whether the physician will treat them in a sympathetic manner. (Quack, 2013, p. 408)

2 The larger study was conducted in five interconnected phases. Understanding gathered in one phase contributed to the planning of the following phase. The first phase was the pilot study. The second phase comprised of semi-structured and in-depth interviews with family members on explanatory models and experiences of caregiving. During the third phase, biomedical professionals and other staff at the clinic were interviewed. Follow-up interviews with the family members were also conducted in this phase to understand changes in narratives and caring experience. The fourth phase comprised of second follow-up with families and member checking process. After analysing the narratives, theoretical sampling was conducted. It was observed that most families consulted folk healers in the course of treatment. This emerged as one of the major categories. Therefore, the final phase was conducted to interview folk healers.

3 During the pilot study it was observed that during the course of treatment family members interact with medical professionals, administrative staff members, neighbours, friends and extended family members other than patients. They developed a network of interaction that may contribute to the meaning construction of their caring experiences. Based on this observation, we decided to conduct additional interviews with the professionals, other staff members and other accompanying persons to get multiple perspectives on caring. This decision was on par with the objectives of the larger study. At the later stage of the study it was observed that many families consulted folk or indigenous healers in the course of the treatment. Based on this observation we also decided to interview folk healers to enrich our understanding.

4 Most families who came from far places had little time for interview. Therefore, we decided to collect semi-structured interviews with them for their convenience and to prevent data loss. These interviews lasted from 20 to 30 minutes. During the initial stage of the study it was observed that most participants shared stories of their experiences. Thus narratives were collected through in-depth interviews with those participants who could spare the time. The average time for in-depth interviews was 45–90 minutes.

5 The thematic divisions highlighted in EMIC developed by Weiss et al. (1992) was used as guideline for developing an interview guide related to explanatory models. The five divisions are: pattern of distress, perceived causes, help seeking and treatment, general illness beliefs and disease-specific questions.

6 One interview was conducted with six participants who came to the clinic to admit the patient. The interview was chaotic as everyone wanted to express their opinion about the illness and the current situation at the same time. In dyadic interviews, it was observed that participants who were older in age were dominating the younger ones. In one such case, a mother of a patient and her elder sister were interviewed and it was observed that the mother often contradicted the daughter’s statements.

7 The semi-structured interviews with mental health professionals and staff lasted for 30-45 minutes.

8 The first author could understand and speak Bengali, Hindi and English.

9 Patton (2002) has recommended three reflexive sets of questions. The first sets of reflexive questions are for the self or the researcher (e.g. ‘What do I know? How do I know what I know?’). The second sets of reflexive questions are for the participants of the research (e.g. ‘How do they know what they know? What shapes and has shaped their worldview?’). The third sets of reflexive questions are for the audience (e.g. ‘How do they make sense of what I give them? What perspective do they bring to the findings I offer?’) (Patton, 2002, p. 66).

10 During the pilot study it was observed that families were not comfortable giving written consent. Most families, whether they were from the city or a semi-urban area, refused to be interviewed when asked for written consent. There were also some family members from rural areas who could not read or write. The secretary of the NGO had suggested that only verbal consent could be taken from participants to avoid data loss. Based on these observations and suggestions we decided to record verbal consent. During the research process it was observed that many families provided false names and contact information to the registration desk to conceal their identity. The interviews with the administrative staff at the clinic and psychiatrists also revealed the same concern.

11 Paglami is a Bengali word for ‘madness’, ‘insanity’ or ‘mental illness’. In Bengali, matha denotes ‘head’ and matha-r gondogol, matha kharap, matha-r problem denote ‘problems in the head’ that indicates mental illness. Mon-errog also denotes ‘mental illness’. Mon, which is derived from Sanskrit Mana/Manasa, means ‘mind’ and Rog means ‘illness’.

12 Unmad and pagol denote ‘person with mental illness’, ‘mad’ or ‘crazy’. Unmad, pagol, ‘abnormal’ and ‘mental’ are used in the context of severe mental illness. However, pagol and ‘mental’ are also used casually (not always for denoting severe mental illness) in general.

13 Nerve-er dosh means ‘nerve related problem’. The term dosh is derived from Sanskrit word dosha, which means ‘problem’.

14 Rice is the staple food of West Bengal and avoiding rice is not considered to be good for the health.

15 Commonly known as guruji, mataji or peer baba.

16 The Oxford dictionary defines ‘quack’ as ‘an unqualified person who dishonestly claims to have medical knowledge’. However, in rural parts of India, ‘quacks’ or ‘the rural medical practitioners who practice modern medicine without any formal training or legal sanction represent the dominant group. The market is underground in the technical sense (since there is no legal sanction) but open in all practical grounds’ (Kanjilal, 2013; cited in Dutta, 2013, p. 44). The popularity of these practitioners is the product of thw lack of healthcare facilities in rural parts of India (Dutta, 2013). In the present study families who came from rural places expressed that they frequently visit the quacks because they are available, affordable and popular. When required they make home visits and sometimes they accompany the family to the hospital or health centre, which are far away, as they know about illness and treatments.

17 In many cases the family jointly decided whether the illness symptoms are the influence of evil spirits or are medical problems. It was observed that very few participants who had prior knowledge regarding mental illness (through reading magazines or watching television programmes) made the decision themselves and visited a psychiatrist. Most families who had the biomedical understanding of illness visited a general practitioner first and then the psychiatrist. In most cases, families took advice and suggestions from close friends and neighbours or those who they could trust about confidentiality.

18 The patient was diagnosed with the bipolar disorder.

19 The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization.

20 During analysis of family members’ narratives, marriage appeared as a subcategory under ‘biological paradigm’, ‘psychosocial paradigm’ and also in ‘the role of significant others’. Marriage appeared as a major category in professional and administrative staff’s accounts. Therefore, the researchers decided to treat it as a separate category under professionals’ accounts.

21 Amulets.

22 Healing rituals commonly used by the folk healers.

23 According to Halliburton (2004), effectiveness in the context of healing refers not just to ‘the ability and quality of a healing system, but to refer also to a situation in which patients respond positively to a therapy due to their particular preferences or desires’ (p. 89). In this study he also discussed the relative ‘pleasantness’ (Halliburton, 2003, p. 180) of a treatment.