By Vanessa Mendis
Bali, thovil, shanthikarma, exorcisms, and other religious and culture-bound rituals have always been used in conjunction with helping individuals out when medical science seems to fail to find an answer. However, also dangerously ubiquitous is stigmatising the practice of seeking for mental health assistance, with phrases being thrown around such as, “eyata pissudda koheda” and the like, which push people towards rejecting psychological help. What does this mean for us as a nation? Can we strike a balance; is there even a balance?
We sat down with Child Protection Force Clinical Psychologist Uttara Ilangakoon, who specialises in trauma, and Counselling Psychologist Nivendra Uduman, whose practice focuses on capacity building, suicide prevention, and LGBTQIA issues, to discuss a widely spoken about but very much obscure topic.
In your opinion, do the cultural and religious components embedded in our lives have an impact on how people reach out for mental health assistance?
Nivendra: That’s a resounding yes. Culture, religion and society have an impact on how people understand mental health, how they cope with mental health and daily life issues, and whether they decide to seek help. We are very rooted in our cultural and religious beliefs, and these also change geographically from one area to another. In fact even the terminology used to describe certain mental health issues can change based on the area.
Uttara: Yes, people have shown reluctance to approach mental health professionals based on cultural stigmas, such as people in a community being ashamed, or feeling that reaching out for help is a weakness. The lack of understanding and awareness of what one is experiencing as symptoms can also stop them from reaching out, along with the inadequacy of a cultural support system.
[caption id="attachment_129566" align="alignright" width="389"]
"If people feel that there is a lack of cultural support within their society, they tend to look for methods that are more accepted by the community. Or, they could become so ashamed and afraid, that they would try to look for help in secrecy" Child Protection Force Clinical Psychologist Uttara Ilangakoon [/caption]
Have you experienced these impacts in your profession with your clients?
Nivendra: In our culture, we’re more acclimated to expressing physical symptoms, instead of mental health or emotional symptoms. People express physical ailments better, medically there is assistance offered sooner, and there is better family support, unlike in the case of non-physical conditions. This also leads to professionals misdiagnosing. Another key problem is the local languages. Sinhalese and Tamil don’t really support people to express emotional experiences. They can be either technical or “too much”. There are very few words to express emotional ailments, and they can be complicated.
An aspect we overlook a lot is whether the culture of the mental health professional facilitates for the client to seek help. If the two parties come from cultures that clash, there will be a disconnect. This is why it is compulsory that a mental health professional is culturally competent. Our cultural and religious belief systems are generational, and not something we just wake up one day and find. If not handled with respect and sensitivity, and if it is addressed just clinically, this can act as a barrier to people seeking mental health assistance. We see this a lot, where people become hesitant to reach out if the professional is not from the same culture as them.
What social factors can be attributed to mental health and the stigma that surrounds it?
Nivendra: Firstly, we need to understand that social issues such as poverty and war, which Sri Lanka has seen, are contributing factors in the occurrence of mental health issues. On the other hand, our social, cultural, and religious norms also add to the stigma on the level of how people give meaning to their illness or symptoms. “Is it real or imagined?” is the common question they ask themselves.
Another common phrase often heard is that “it’s all in your head”. As a society, we are very aware of our body, but there is a big disconnect about our brain and mind. Many family members and people around the person ailing could wonder if this is a real condition, whether they are just looking for sympathy, and if sympathy should be shown. We’d readily ask somebody with a broken leg to take it easy, but something we cannot see like depression can be dismissed, because our culture does alienate mental health.
Uttara: Cultural support and stigma is a big component here. If people feel that there is a lack of cultural support within their society, they tend to look for methods that are more accepted by the community. Or, they could become so ashamed and afraid, that they would try to look for help in secrecy.
[caption id="attachment_129568" align="alignleft" width="391"]
"There cannot be a power imbalance. While religious/cultural practices can be distressing to the person undergoing them, sometimes people also find comfort in them too. But creating this balance through education and empowerment is crucial" Counselling Psychologist Nivendra Uduman[/caption]
Especially in rural areas, can conditions like paranoid delusions or schizophrenia be attributed to needing an exorcism, thovil, or shanthikarma as a remedy? Have you experienced this in your practice?
Nivendra: I have and not just in my practice. In many of my travels in the country, I have come across such instances and sometimes, like in the recent past, these can become abusive and aggressive towards the person who is at the receiving end. However, there is another side to this, where it can help people because of the belief systems involved, and therefore, we shouldn’t completely negate them. Instead, we can strike a balance where we can use traditional religious healing methods in combination with medical and psychological help to give the individual the best chance possible, especially for conditions such as schizophrenia.
Uttara: Even in therapy, there are individuals who openly state that religious practices, such as prayer, and going to a church or temple, can help them alleviate their discomfort. When somebody comes in with that approach, we need to acknowledge and respect it. However, some individuals can go to an extreme with such practices.
In our culture, people feel more comfortable approaching a community or religious leader for support than a mental health professional, and therefore, they have more insight about what a person could be going through. So if these leaders can work in tandem with mental health professionals, we can create a balanced system that will allow for better and all-round assistance for individuals.
A recent well-known incident was the case of the girl who underwent an exorcism. How do you create a balance that is safe?
Nivendra: We need to empower people to use their voice. People need to question when they feel the need to do so. If people are educated and empowered, we can stop such abuse from happening. There cannot be a power imbalance. While religious/cultural practices can be distressing to the person undergoing them, sometimes people also find comfort in them too. But creating this balance through education and empowerment is crucial.
Research suggests that individuals can present clinically, where they express symptoms in a religious or cultural context due to their upbringing or embedded norms. Do you agree?
Uttara: Yes, they do, and I agree. I think it’s necessary that as mental health professionals, we have a sound understanding of our cultural, religious, and societal beliefs. If we can respect these while bringing in the mental health assistance, there will be better reciprocity and rapport. Cultural sensitivity is a must to help individuals feel comfortable to speak to us.
There is a tendency, somewhat, to treat psychological or psychosomatic conditions in a textbook context. Professionals may sometimes encourage religious practices, or even the idea of ‘marriage will sort it out’ to individuals. Does this hinder psychological help?
Uttara: I think as individuals, professionals have different approaches. How a professional guides somebody or offers support can be subjective to an extent. However, as professionals, it is good if we can be objective. As a community, some of these approaches you reach may have been normalised, and a professional may be bringing in that context, because it allows them to survive within that community and help people.
Do you feel that cultural stigmas restrict professionals from helping to the actual extent that they want to?
Uttara: Yes. That’s why the method of reaching out to somebody is important. We are a multicultural nation with different religions, beliefs, and rituals. In the moments where we cannot fully provide assistance, we need to also understand that there is a limit, and in such instances, if we can connect with others in a given community so that the individual who is in need of help, may be able to find the assistance they need in one way or the other.
Where do we stand in terms of awareness and assistance in mental health?
Uttara: There is a lot that needs to be done. There needs to be education on the kind of assistance and to what extent it can have an impact needs to be present. It’s not just in the rural areas that this is lacking; in urban areas too we come across people who may lack that awareness. With regards to support and the resources available, there seems to be an improvement as compared to before. There are psychiatric units, people can get directed to base hospitals for assistance. But the extent to which these are available is a question. For example, in a rural area, people may have to travel long distances to get help.
Nivendra: It’s easy for us to sit in Colombo and say reach for help. But in rural areas, people may not have access to psychological assistance, and maybe culture and religion is all they have. They cannot stop work for the day if they are to earn, and so instead of being condescending and labelling these practices as non-pragmatic, non-empirical, and so on, we need to think about priorities of these people – is it about feeding a family or getting help? We have come a long way in the psychological aspect, but there is a long way to go still. There are awareness programmes, some of which I have been involved in too, as well as initiatives to train people to recognise symptoms, but there is a long road ahead.
We belong to an island that boasts a proud cultural and religious heritage. Colourful, rich and diverse, these various cultural and religious components are inextricably woven into our lifestyles and bound to our thought patterns. Even unconsciously, these are a part of how we process anything, whether we like it or not. Our schemas are impacted by them. That said, we cannot negate and dismiss the cultural and religious norms from all of our society. Then the way forward is clearly developing empathy, cultural sensitivity and respect along with tolerance. Normalising asking for mental health assistance, not stigmatising those who are ailing, providing empathy and support in whatever ways that we can are all things that we can do, without having to be psychology professionals. The key understanding that our words and actions may make the difference between saving a life or endangering it, and that the psychological and cultural/religious worlds need not always collide, and rather can co-exist in harmony, is the key that will unlock the doors to a mentally sound and healthy nation. PHOTOS Pradeep Dambarage and Sudarsha Lakmal
"If people feel that there is a lack of cultural support within their society, they tend to look for methods that are more accepted by the community. Or, they could become so ashamed and afraid, that they would try to look for help in secrecy" Child Protection Force Clinical Psychologist Uttara Ilangakoon [/caption]
Have you experienced these impacts in your profession with your clients?
Nivendra: In our culture, we’re more acclimated to expressing physical symptoms, instead of mental health or emotional symptoms. People express physical ailments better, medically there is assistance offered sooner, and there is better family support, unlike in the case of non-physical conditions. This also leads to professionals misdiagnosing. Another key problem is the local languages. Sinhalese and Tamil don’t really support people to express emotional experiences. They can be either technical or “too much”. There are very few words to express emotional ailments, and they can be complicated.
An aspect we overlook a lot is whether the culture of the mental health professional facilitates for the client to seek help. If the two parties come from cultures that clash, there will be a disconnect. This is why it is compulsory that a mental health professional is culturally competent. Our cultural and religious belief systems are generational, and not something we just wake up one day and find. If not handled with respect and sensitivity, and if it is addressed just clinically, this can act as a barrier to people seeking mental health assistance. We see this a lot, where people become hesitant to reach out if the professional is not from the same culture as them.
What social factors can be attributed to mental health and the stigma that surrounds it?
Nivendra: Firstly, we need to understand that social issues such as poverty and war, which Sri Lanka has seen, are contributing factors in the occurrence of mental health issues. On the other hand, our social, cultural, and religious norms also add to the stigma on the level of how people give meaning to their illness or symptoms. “Is it real or imagined?” is the common question they ask themselves.
Another common phrase often heard is that “it’s all in your head”. As a society, we are very aware of our body, but there is a big disconnect about our brain and mind. Many family members and people around the person ailing could wonder if this is a real condition, whether they are just looking for sympathy, and if sympathy should be shown. We’d readily ask somebody with a broken leg to take it easy, but something we cannot see like depression can be dismissed, because our culture does alienate mental health.
Uttara: Cultural support and stigma is a big component here. If people feel that there is a lack of cultural support within their society, they tend to look for methods that are more accepted by the community. Or, they could become so ashamed and afraid, that they would try to look for help in secrecy.
[caption id="attachment_129568" align="alignleft" width="391"] "There cannot be a power imbalance. While religious/cultural practices can be distressing to the person undergoing them, sometimes people also find comfort in them too. But creating this balance through education and empowerment is crucial" Counselling Psychologist Nivendra Uduman[/caption]
Especially in rural areas, can conditions like paranoid delusions or schizophrenia be attributed to needing an exorcism, thovil, or shanthikarma as a remedy? Have you experienced this in your practice?
Nivendra: I have and not just in my practice. In many of my travels in the country, I have come across such instances and sometimes, like in the recent past, these can become abusive and aggressive towards the person who is at the receiving end. However, there is another side to this, where it can help people because of the belief systems involved, and therefore, we shouldn’t completely negate them. Instead, we can strike a balance where we can use traditional religious healing methods in combination with medical and psychological help to give the individual the best chance possible, especially for conditions such as schizophrenia.
Uttara: Even in therapy, there are individuals who openly state that religious practices, such as prayer, and going to a church or temple, can help them alleviate their discomfort. When somebody comes in with that approach, we need to acknowledge and respect it. However, some individuals can go to an extreme with such practices.
In our culture, people feel more comfortable approaching a community or religious leader for support than a mental health professional, and therefore, they have more insight about what a person could be going through. So if these leaders can work in tandem with mental health professionals, we can create a balanced system that will allow for better and all-round assistance for individuals.
A recent well-known incident was the case of the girl who underwent an exorcism. How do you create a balance that is safe?
Nivendra: We need to empower people to use their voice. People need to question when they feel the need to do so. If people are educated and empowered, we can stop such abuse from happening. There cannot be a power imbalance. While religious/cultural practices can be distressing to the person undergoing them, sometimes people also find comfort in them too. But creating this balance through education and empowerment is crucial.
Research suggests that individuals can present clinically, where they express symptoms in a religious or cultural context due to their upbringing or embedded norms. Do you agree?
Uttara: Yes, they do, and I agree. I think it’s necessary that as mental health professionals, we have a sound understanding of our cultural, religious, and societal beliefs. If we can respect these while bringing in the mental health assistance, there will be better reciprocity and rapport. Cultural sensitivity is a must to help individuals feel comfortable to speak to us.
There is a tendency, somewhat, to treat psychological or psychosomatic conditions in a textbook context. Professionals may sometimes encourage religious practices, or even the idea of ‘marriage will sort it out’ to individuals. Does this hinder psychological help?
Uttara: I think as individuals, professionals have different approaches. How a professional guides somebody or offers support can be subjective to an extent. However, as professionals, it is good if we can be objective. As a community, some of these approaches you reach may have been normalised, and a professional may be bringing in that context, because it allows them to survive within that community and help people.
Do you feel that cultural stigmas restrict professionals from helping to the actual extent that they want to?
Uttara: Yes. That’s why the method of reaching out to somebody is important. We are a multicultural nation with different religions, beliefs, and rituals. In the moments where we cannot fully provide assistance, we need to also understand that there is a limit, and in such instances, if we can connect with others in a given community so that the individual who is in need of help, may be able to find the assistance they need in one way or the other.
Where do we stand in terms of awareness and assistance in mental health?
Uttara: There is a lot that needs to be done. There needs to be education on the kind of assistance and to what extent it can have an impact needs to be present. It’s not just in the rural areas that this is lacking; in urban areas too we come across people who may lack that awareness. With regards to support and the resources available, there seems to be an improvement as compared to before. There are psychiatric units, people can get directed to base hospitals for assistance. But the extent to which these are available is a question. For example, in a rural area, people may have to travel long distances to get help.
Nivendra: It’s easy for us to sit in Colombo and say reach for help. But in rural areas, people may not have access to psychological assistance, and maybe culture and religion is all they have. They cannot stop work for the day if they are to earn, and so instead of being condescending and labelling these practices as non-pragmatic, non-empirical, and so on, we need to think about priorities of these people – is it about feeding a family or getting help? We have come a long way in the psychological aspect, but there is a long way to go still. There are awareness programmes, some of which I have been involved in too, as well as initiatives to train people to recognise symptoms, but there is a long road ahead.
We belong to an island that boasts a proud cultural and religious heritage. Colourful, rich and diverse, these various cultural and religious components are inextricably woven into our lifestyles and bound to our thought patterns. Even unconsciously, these are a part of how we process anything, whether we like it or not. Our schemas are impacted by them. That said, we cannot negate and dismiss the cultural and religious norms from all of our society. Then the way forward is clearly developing empathy, cultural sensitivity and respect along with tolerance. Normalising asking for mental health assistance, not stigmatising those who are ailing, providing empathy and support in whatever ways that we can are all things that we can do, without having to be psychology professionals. The key understanding that our words and actions may make the difference between saving a life or endangering it, and that the psychological and cultural/religious worlds need not always collide, and rather can co-exist in harmony, is the key that will unlock the doors to a mentally sound and healthy nation. PHOTOS Pradeep Dambarage and Sudarsha Lakmal