~Ignou

~ THE PEOPLE'S
UNIVERSITY
MPC-05
Indira Gandhi National Open University Fundamentals 0
School of Social Sciences Mental Healt

Family, Culture and Mental Health

 MPC-051
Fundamentals of
Indira Gandhi
Mental Health
National Open University
School of Social Sciences

Block

4
FAMILY, CULTURE AND MENTAL HEALTH
UNIT 1
Developmental Theories 5

UNIT 2
Family and Mental Health 14
UNIT 3
Sociology of Mental Health 29
UNIT 4
Culture and Mental Health 44
Expert Committee
Prof. Vimala Veeraraghavan Dr. Rajeev Dogra Prof. M. Thirunavakkarasu
(Chairperson) Clinical Psychologist President, Indian Psychiatric
Former Emeritus Professor Dept. of Psychiatry, PGIMS Society, Prof. & Head
Discipline of Psychology Rohtak Dept. of Psychiatry
IGNOU, New Delhi Prof. Ram Ghulam SRM Medical College
Prof. T. B. Singh Head -Department of Psychiatry Hospital & Research Center,
Professor Clinical Psychology M.G.M. Medical College Indore Chennai
Institute of Behavioural Sciences M.P., Superintendent Dr. Swati Patra
Gujrat Forensic Sciences Mental Hospital Indore (Programme Coordinator)
University, Gujarat Prof. Dinesh Kataria Associate Professor
Prof. B. S. Chavan Dept. of Psychiatry Discipline of Psychology
Head, Dept. of Psychiatry Lady Hardinge Medical College IGNOU, New Delhi
Govt. Medical College New Delhi
Chandigarh Prof. R. C. Jiloha
Prof. R. K. Chadda Head, Dept. of Psychiatry
Dept. of Psychiatry, AIIMS G.B. Pant & Maulana Azad
Ansari Nagar, New Delhi Medical College, New Delhi

Programme Coordinator Course Coordinator

Dr. Swati Patra Dr. Smita Gupta
Associate Professor Assistant Professor
Discipline of Psychology Discipline of Psychology
SOSS, IGNOU, New Delhi SOSS, IGNOU, New Delhi

Course Writers Block Editors

Units 1, 2, 3, & 4 Prof. Manju Mehta
Prof. M. Thirunavakkarasu Professor of Clinical Psychology
Prof. & Head, Dept. of Psychiatry Department of Psychiatry
SRM Medical College Hospital & Research Center AIIMS, New Delhi
Chennai and
and Dr. Smita Gupta
Ms. Preethi Krishnan Assistant Professor
Head and Associate Professor Discipline of Psychology
Department of Clinical Psychology SOSS, IGNOU, New Delhi
SRM Medical College
SRM University, Chennai

Print Production
Mr. Manjit Singh
Section Officer (Publication)
SOSS, IGNOU, New Delhi

August, 2015
© Indira Gandhi National Open University, 2015
ISBN-978-81-266-6906-6
All rights reserved. No part of this work may be reproduced in any form, by mimeograph or any other
means, without permission in writing from the Indira Gandhi National Open University.
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BLOCK 4 INTRODUCTION
Block 4 of MPC-051 deals with the different influences of family and culture
on the mental health of individuals. This block will give you details of how
relationships and cultural influences can affect the mental health well-being.
Unit 1 deals with “Developmental Theories”. In the first unit, you will be
explained about the developmental theories which deals with the development
of an individual in all aspects since child hood. It is interesting to know that
human beings change with varied experiences of their life. Developmental
theories attempts to understand; explain and predict behaviour that occurs
throughout a person’s life span.
Unit 2 describes “Family and Mental Health”. This unit will explain you about
the role of family, care taker and related environments in dealing with mental
illness of a child and other related aspects. The family’s part in mental health
is inevitable and this unit will focus on understanding the role of family in
mental health issues and its role in aspects of management.
Unit 3 is on “Sociology of Mental Health”. In order to study social psychology
and its relationship to mental health we need to understand social attitudes,
social perception, attribution, social influence, communication patterns,
leadership and social power, conformity and deviance, prejudice, group process
and pro-social behaviour. The role of these aspects in mental health will be
discussed in this section. Another aspect of understanding mental health from
a sociological point of view is to understand the prevailing social conditions
that influence psychological functioning.
Unit 4 deals with “Culture and Mental Health”. In the last unit of this block,
you will be introduced about the relevance of culture on the mental health of
individuals. It is well known fact that, the differences in the way people think
and behave may also be influenced by the culture to which he/she belongs and
it has come to play a major role in the way mental health system is understood,
developed and administered.
UNIT 1 DEVELOPMENTAL THEORIES
Structure
1.0 Introduction
1.1 Objectives
1.2 Erick Erickson Theory of Psychosocial Development
1.2.1 Psychosocial Stage 1 - Trust vs. Mistrust
1.2.2 Psychosocial Stage 2 - Autonomy vs. Shame and Doubt
1.2.3 Psychosocial Stage 3 - Initiative vs. Guilt
1.2.4 Psychosocial Stage 4 - Industry vs. Inferiority
1.2.5 Psychosocial Stage 5 - Identity vs. Confusion
1.2.6 Psychosocial Stage 6 - Intimacy vs. Isolation
1.2.7 Psychosocial Stage 7 - Generativity vs. Stagnation
1.2.8 Psychosocial Stage 8 - Integrity vs. Despair

1.3 Piaget’s Theory of Cognitive Development

1.3.1 Stage I: The Sensori-motor Stage (birth to 2years)
1.3.2 Stage II: The Pre-operational Stage (2-7years)
1.3.3 Stage III: The Concrete Operational Stage (7-11years)
1.3.4 Stage IV: The Formal Operational Stage (11 onwards)

1.4 Assimilation and Accommodation

1.5 Let Us Sum Up
1.6 Unit End Questions
1.7 Answers to Self Assessment Questions
1.8 References

1.0 INTRODUCTION
As reflected from the title, this block will deal with the influence of family
environment and culture on the mental health of the individuals. The present
unit will focus on the developmental theories which deal with the development
of an individual in all aspects since child hood. It is interesting to know that
human beings change with varied experiences of their life. Developmental
theories attempts to understand; explain and predict behaviour that occurs
throughout a person’s life span. Erikson’s and Piaget theories are two such
theories.

1.1 OBJECTIVES
With the help of this unit, you will be able to:
 understand the stages of Psycho Social Development as propounded by
Erik Erikson; and
 describe the stages of Piaget’s theory of Cognitive Development.

5
Family, Culture and
Mental Health 1.2 ERIK ERIKSON’S THEORY OF
PSYCHOSOCIAL DEVELOPMENT
Erik Erikson has a significant contribution in the theories of personality
development. The theory of psychosocial development is a well-known theory
of Erikson which tries to explain the development of personality which takes
place through a series of stages since childhood. The theory of Psycho social
development describes the impact of social experience across the whole
lifespan. In the process of social interaction, a person develops a sense of
identity of oneself. Ego identity is one of the important concepts of Erikson’s
theory. This is term given to the conscious sense of self that one develops
through social interaction. According to Erikson, this sense of self changes, as
one goes through the various stages of personality development. In every
stage of life there is new information and experience that are present in one’s
life. These are the challenges one faces to the sense of self or ego identity.
The experience of facing these challenges determines one’s ego identity and
shapes one’s perception of life. There are challenges which one faces in daily
interactions in society and how one deals with it forms part of one’s personality.
In addition to ego identity, Erikson also believed that a sense of competence
motivates behaviors and actions. Each stage in Erikson’s theory is concerned
with becoming competent in an area of life. If the stage is handled well, the
person will feel a sense of mastery, which is sometimes referred to as ego
strength or ego quality. If the stage is managed poorly, the person will emerge
with a sense of inadequacy.
In each stage, Erikson believed people experience a conflict that serves as a
turning point in development. In Erikson’s view, these conflicts are centered
on either developing a psychological quality or failing to develop that quality.
During these times, the potential for personal growth is high, but so is the
potential for failure. The stages of psychosocial development have been
discussed accordingly in the sub sections below:

1.2.1 Psychosocial Stage 1 - Trust vs. Mistrust

(Approx. 0-2 yrs.)
This is the first stage of Erikson’s theory of psychosocial development. This
stage occurs in between birth to two years of age of a child. It is a significant
stage because at this phase of life, an infant is totally dependent on quality of
care given. If the proper care is given a child will develop trust. This is
considered important as this basic trust in the caregiver will make a child feel
safe and secure in most of its future interactions. If care-giving is inconsistent,
not dependable and rejecting in nature, the child develops a sense of mistrust
which is carried over in future interactions.
Thus, when the child develops basic trust in the care-giver, a sense of hope
and confidence in the world is developed. This would result in the child having
an optimistic view of the world. The opposite is true for those children who
fail to develop trust. Their sense of mistrust leads them to experience
depression and they could be withdrawn from people and may even develop
paranoia at a later point of time.

6
1.2.2 Psychosocial Stage 2 - Autonomy vs. Shame and Developmental Theories
Doubt (Approx. 2-4 yrs.)
The second stage of Erikson’s theory of psychosocial development occurs
during early childhood. At this stage, children are focused on developing a
greater sense of personal control. Erikson believed that toilet training was a
vital part of this process. He believed that learning to control one’s bodily
functions leads to a feeling of control and a sense of independence. Likewise
developing control over the choice of food, toys or clothing is important in
personality development. If a child is able to have a sense of personal control,
he/she will feel secure and confident and if they do not succeed, then it might
lead to a sense of inadequacy and self-doubt.
Thus, autonomy develops if a child is guided positively through praise, firmness,
encouragement and gentleness to become independent. This will result in the
child having a sense of will and good self esteem. If parents are too permissive,
harsh, or demanding, the child can feel defeated, and experience extreme shame
and doubt. This might result in maladaptive ways of gaining a feeling of
control, power, or competence. For instance, following strict rules and
regulations might give a false sense of competency. This could result in a form
of obsessive behaviour. If the child is given no limits or guidance, the child can
fail to gain any shame or doubt and be impulsive in its behaviour.

1.2.3 Psychosocial Stage 3 - Initiative vs. Guilt

(Approx. 3-5 yrs.)
The third stage occurs during the preschool years, when a child starts asserting
his/her power and is able to get a control over the world (his/her surroundings)
through directing play and other social interactions. Children who are successful
at this stage feel capable and able to lead others. Those who fail to acquire
these skills are left with a sense of guilt, self-doubt, and lack of initiative.
Hence, if parents are understanding and supportive of a child’s efforts to
show initiative, the child develops purpose, and sets goals and acts in ways
to reach them whereas if children are punished for attempts to show initiative,
they are likely to develop a sense of guilt, which in excess can lead
to inhibition.

1.2.4 Psychosocial Stage 4 - Industry vs. Inferiority

(Approx. 5-12 yrs.)
This stage covers the early school years and is a latency stage. At this stage
of lifespan, a child starts developing a sense of pride in their accomplishments
and abilities with the help social interactions. And if the child is encouraged
and praised by parents and teachers then he/she develops a feeling of
competence and belief in their skills. Those who receive little or no
encouragement from parents, teachers, or peers will doubt their abilities to be
successful. If caretakers do not support the child, feelings of inferiority are
likely to develop and this might lead the child to become underachiever.
Encouraging the child to feel over competent might make a child a shallow
person not being able to reflect on personal deficits.

7
Family, Culture and 1.2.5 Psychosocial Stage 5 - Identity vs. Confusion
Mental Health
(Approx. 13-19 yrs.)
The fifth stage of development occurs at the stage of adolescence. At this
stage, children explore their independence and develop a sense of self.
Those who receive proper encouragement and reinforcement through personal
exploration will emerge from this stage with a strong sense of self and a
feeling of independence and control. Those who remain unsure of their beliefs
and desires will feel insecure and confused about themselves and the future.
When an adolescent resolves this crisis, then a sense of fidelity would develop.
This is described as a sense of identity regarding who they are and what is
the objective of their life. If they are unable to resolve they develop identity
diffusion. These adolescents may have an unstable sense of self and may
need to belong to some group in order to develop a sense of identity. If this
becomes a serious issue for the adolescent then might have oppositional views
and may join hate cults etc.

1.2.6 Psychosocial Stage 6 - Intimacy vs. Isolation

(Approx. 20-24yrs. / 24-39 yrs.)
This stage covers the period of early adulthood. This is a stage in which
people start exploring personal relationships. Erikson believed it was vital that
people develop close, committed relationships with other people and have an
ability to experience intimacy. Those who are successful at this stage will form
relationships that are committed and secure. This will also depend on previous
stages of development, such as developing a strong sense of personal identity.
Persons with poor sense of self are observed to have a tendency to have less
committed relationships and are more likely to suffer emotional
isolation, loneliness, and depression.

1.2.7 Psychosocial Stage 7 - Generativity vs.

Stagnation (Approx.25-64/40-64 yrs.)
During middle adulthood, people continue to build their lives through various
ways such as building a career and bringing up or caring for a family. Those
who are successful during this phase will feel that they are contributing to the
world by being active in their home and community. Those who fail to attain
this skill will feel unproductive and uninvolved in the world. If a person has
experienced a sense of creativity and success, then the person develop a
sense of generativity. People who do not feel this develop a sense
of stagnation. They become self absorbed, do not connect easily to others
and do not offer much to society.

1.2.8 Psychosocial Stage 8 - Integrity vs. Despair

(65 yrs. till death)
This is a phase that occurs during late adult hood or old age and is focused
on reflecting back on life. Those who face conflicts at this stage will feel that
their life has been wasted and will experience many regrets. The individual will
be left with feelings of bitterness and despair. Those who feel proud of their
accomplishments will feel a sense of integrity. Successfully completing this
phase means looking back with few regrets and a general feeling of satisfaction.
8 These individuals will attain wisdom, even when confronting death.
This entails facing the ending of life, and accepting successes and failures, Developmental Theories
ageing, and loss. People develop ego integrity and accept their lives if they
succeed, and develop a sense of wisdom and those who do not, feel a sense
of despair and dread their death.
Table: Psycho social Stages of Development by Erik Erikson
Stage Psycho-social Approximate Important Criteria
crisis age relations dominating
at the the develop-
stage ment at
the stage
1 Trust vs. 0-2 years Mother Hope
Mistrust
2 Autonomy vs. 2-4 years Parents Will
Shame and Doubt
3 Initiative vs. Guilt 3-5 years Family Purpose
4 Industry vs. Inferiority 5-12 years Neighbour, Competence
school
5 Identity vs. Confusion 13-19 years Role model Fidelity
6 Intimacy vs. 20-24 years / Life partners, Love
Isolation 24-39 years friends
7 Generativity vs. 25-64 years/ Workmates Care
Stagnation 40-64 years
8 Integrity vs. 65 years till Humanity, Wisdom
Despair death mankind

Self Assessment Questions 1

State Whether the following statements are ‘True’ or ‘False’:
1) Fidelity is described as a sense of identity regarding who they are
and what is the objective of their life ............................... .
2) Autonomy develops if a child is guided negatively through blames,
punishments and curse become independent ........................
3) If the proper care is given a child will develop mistrust towards the
caretakes.................... .
4) Erikson believed it was vital that people develop close, committed
relationships with other people and have an ability to experience
intimacy............................ .

1.3 PIAGET’S THEORY OF COGNITIVE

DEVELOPMENT
After knowing the theory of Erikson, it is important for you to know the
significant contribution of Piaget. Piaget also tried to explain the development
that takes place at different stages of development of child but from a
9
Family, Culture and perspective of cognitive development. The Piaget’s theory of cognitive
Mental Health development focuses on the child thoughts, perception and acquisition of
knowledge at each stage. The stages of cognitive development propounded
by Piaget have been explained in the following sub sections:
1.3.1 Stage I: The Sensorimotor Stage (Birth to 2 years)
This stage of cognitive development takes place since birth to about two
years of age. At this stage the child tries to make sense of the world through
its senses and motor ability. Some abilities are innate behaviour which greatly
assists the infant. Sucking, looking, grasping, crying and listening are such
innate behaviours that enhance learning. In the beginning the infant uses only
reflexes and innate behaviour. As they become mobile, their cognitive ability
increases slowly. Towards the end of this stage, the child uses a range of
complex sensori-motor skills.
According to Piaget there are two mental representations a child must develop.
One is the concept of Object Permanence. This is an important
accomplishment for an infant in this stage, as their memory power increases.
This is the ability to understand that objects continue to exist even if they
cannot be seen or heard. As the child matures towards the end of this stage,
it develops the ability to mentally represent the object in their mind, leading
to exploration for an object even if it is moved. Another concept that Piaget
states is important to achieve in this stage is Deferred Imitation. This is
simply the imitation of behaviour a child has seen before. As child can mentally
represent behaviour they have seen, they are able to enact it through playing
and in other situations. So a child might ‘talk’ into a toy telephone or ‘steer’
a toy car around the room.
1.3.2 Stage II: The Pre-operational Stage (2-7 years)
The pre operational stage occurs in between the age of two to seven years.
During the age range of toddler hood to early child hood, there is a smooth
transition from the previous stage. The major accomplishment during stage is
language ability, memory and imagination power. A child is also able to
symbolically use one object for representing another. For example, a child
swinging their arms in a circular motion might represent the wheels on a train.
This shows the relationships children can form between language, actions and
objects at this stage.
A major characteristic of this stage is egocentrism. This is the ability to
perceive the world only in relation to oneself and how the child perceives
things. They find it difficult to see it from another person’s perspective. Another
feature of this stage is conservation. Children struggle to understand the
difference in quantity and measurements in different situations. For example,
if a liquid in one container that is broad based is poured into taller and
narrower container, the child is unable to see that the quantity of liquid is the
same. They see the taller glass as containing more liquid.
1.3.3 Stage III: The Concrete Operational Stage
(7-11 years)
This stage sees another shift in children’s cognitive thinking. It is aptly
10 named “concrete” because children struggle to apply concepts to anything
which cannot physically be manipulated or seen. Children have difficulty in Developmental Theories
understanding hypothetical and abstract concepts. However, they now begin
to understand that other people have different perspectives from them. For
example, simple Maths, such as addition/subtraction becomes much easier
but they struggle to apply any prior knowledge to abstract situations.
1.3.4 Stage IV: The Formal Operational Stage
(11 onwards)
Children at this stage acquire the ability to think hypothetically and think
about abstract concepts. For example, children begin to have the ability to
think about consequences and outcomes before taking an action. Verbal
information becomes adequate for them to come to a decision or conclusion.
They do not require “concrete” physical objects to do take a decision or
act on something. When a problem is presented to them, they can think
logically and consistently and solve the problem or come to a conclusion.
Their thinking becomes more like an adult.

1.4 ASSIMILATION AND ACCOMMODATION

It is worth to mention that, Piaget basically focussed on two processes-
assimilation and accommodation. Assimilation is a process in which with
the help of experiences an individual assimilates or fits new thoughts and
information in to an existing old thought or idea. It is a process of integrating
external elements into definite structures through experience. It is process
with the help of which an individual adapts new information. It leads to
fitting of new information into pre-existing cognitive schemas. It gradually
occurs when an individual faces new or unfamiliar information and then the
individual refers to previously learned information in order to make sense of
it. Accommodation is totally opposite of assimilation. In the process of
accommodation, an individual takes new information in one’s environment
and alters the pre-existing schemas in order to fit in the new information.
That is, when the previously existing information or cognitive schema does
not work then the individual needs to change the existing information in
order to deal with the newer object, information or experience. Amongst the
two, accommodation is more significant because with the help of
accommodation only people will continue to interpret new concepts, schemas
and frameworks. Although, he proposed that both the processes- assimilation
and accommodation work together and go in hand by hand. In order to
assimilate an object into an existing mental schema, one first needs to take
into account or accommodate to the particularities of this object to a certain
extent. For example, in order to recognize (assimilate) a car as a car, an
individual first needs to focus (accommodate) on the boundaries of this
object. To do this, one needs to roughly recognize the size of the object.
Development increases the balance, or equilibration, between these two
functions. When both assimilation and accommodation are well balanced
then mental schemas of the operative intelligence takes place. When one
process dominates over the other, they generate representations which belong
to figurative intelligence.

11
Family, Culture and
Mental Health Self Assessment Questions 2
Fill in the blanks:
1) Assimilation is a process in which with the help of .............................
an individual assimilates of fits new ................................... in to an
existing old thought or idea.
2) The pre operational stage occurs in between the age of .............
.................... years.
3) Children at ............................................................... stage acquire
the ability to think hypothetically and think about abstract concepts.
4) In the process of ............................................................ , an
individual takes new information in one’s environment and alters the
pre-existing schemas in order to fit in the new information. ..........

1.5 LET US SUM UP

In this section we have discussed about two of the major theories of
development - Erik Erikson’s theory of Psychosocial Development and Piaget’s
theory of Cognitive Development. Erikson’s stages of psychosocial
development as articulated by Erik Erikson explain eight stages through which
a healthily developing human should pass from infancy to late adulthood. In
each stage the person confronts, and hopefully masters, new challenges. Each
stage builds on the successful completion of earlier stages. The challenges of
stages not successfully completed may be expected to reappear as problems
in the future.
However, mastery of a stage is not required to advance to the next stage.
Erikson’s stage theory characterizes an individual advancing through the eight
life stages as a function of negotiating his or her biological forces and
sociocultural forces. Each stage is characterized by a psycho social crisis of
these two conflicting forces (as shown in the table below). If an individual
does indeed successfully reconcile these forces (favoring the first mentioned
attribute in the crisis), he or she emerges from the stage with the corresponding
virtue. For example, if an infant enters into the toddler stage (autonomy vs.
shame & doubt) with more trust than mistrust, he or she carries the virtue of
hope into the remaining life stages.
Piaget’s theory of cognitive development is a comprehensive theory about the
nature and development of human intelligence. It deals with the nature of
knowledge and how humans come gradually to acquire, construct, and use it.
To Piaget, cognitive development was a progressive reorganization of mental
processes as a result of biological maturation and environmental experience.
Children construct an understanding of the world around them, then experience
discrepancies between what they already know and what they discover in
their environment. Moreover, Piaget claims the idea that cognitive development
is at the center of human organism and language is contingent on cognitive
development.

12
 Developmental Theories
1.6 UNIT END QUESTIONS
1) What could be the consequences of developing a sense of mistrust in an
infant?
2) How does an infant develop a sense of autonomy?
3) How does a sense of guild develop in a child?
4) How does developing a sense of intimacy help in future interactions?
5) What is meant by ego integrity according to this theory?
6) What are the major mental representations that children develop in the
sensorimotor stage?
7) How do the mental representations in stage 1, help in the next stage or
preoperational stage in Piget’s theory of cognitive development?
8) How do young children’s ability to think in abstract terms help in problem
solving tasks given to them?

1.7 ANSWERS TO SELF ASSESSMENT

QUESTIONS
Self Assessment Questions 1
1) True
2) False
3) False
4) True
Self Assessment Questions 2
1) experiences; thoughts and information
2) two to seven
3) Formal Operational
4) accommodation

1.8 REFERENCES
Papalia, D., Olds S & Feldman R.( 2004). Human Development, 9thedition.
Tata Mcgraw Hill Education Private Limited.
Sadock B, & Sadock V, (2007). Kaplan and Sadock’s synopsis of
psychiatry, Behavioural sciences/clinical psychiatry, 10thedn.Lippincott
Williams & Wilkins, New Delhi.
http://psychology.about.com/od/psychosocialtheories/a/psychosocial.htm
accessed on 4/6/15
http://en.wikipedia.org/wiki/Piaget%27s_theory_of_cognitive_development
accessed on 4/6/15 13
Family, Culture and
Mental Health UNIT 2 FAMILY AND MENTAL HEALTH
Structure
2.0 Introduction
2.1 Objectives
2.2 Historical Aspects of Role of Family in Mental Health Care
2.3 Family Perspectives of Mental Health Issues
2.3.1 Multi-generational Transmission
2.3.2 Nature of Family
2.3.3 Structure of Family
2.3.3.1 Transition in Family Structure
2.3.3.2 Implication of Changes in Family Structure for Mental Health
Professionals
2.3.4 Strategic Approach
2.3.5 Experiential Family Approach

2.4 Role of Family in Mental Health

2.5 Role of Family in Mental Illness
2.5.1 Mental Illness and Therapists/Family Relationship Service Providers
2.5.1.1 The Interpersonal Nature of Mental Health Problems
2.5.1.2 Untreated Disorders
2.5.1.3 Managing Chronic and Recurrent Disorders
2.5.1.4 Informal Caregiving
2.5.1.5 Vulnerable Families
2.5.1.5.1 Protective Factors

2.6 Caregivers Burden

2.6.1 Living with Someone Who has a Mental Health Problem
2.6.2 Children of Parents with a Mental Illness
2.6.3 Caring for Someone with a Mental Health Problem
2.6.4.1 Particular Needs of Carers
2.6.4.2 Stigma

2.7 Let Us Sum Up

2.8 Answers to Self Assessment Questions
2.9 Unit End Questions
2.10 References

2.0 INTRODUCTION
In the previous unit, you were informed about how an individual’s psychosocial
and cognitive development takes place since childhood. In the present unit,
you will be informed about the role of family, care taker and related
environments in dealing with mental illness of a child and other related aspects.
The term family has been derived from the Latin word ‘familia’ that indicates
a household establishment, similar to ‘famulus’, which denoted a servant who
came from that household establishment. Family 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
14 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 Family and Mental Health
collectively. (iv) Those have descended from a common ancestor.
In mental health, the term 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.
Thus, the family’s part in mental health is inevitable and this unit will focus on
understanding the role of family in mental health issues and its role in aspects
of management.

2.1 OBJECTIVES
With the help of this unit, you will be able to:
 describe the nature and structure of family and their role in mental illness;
 explain the origin of family therapy;
 define family related approaches to wards illness;
 enlighten the importance of family in mental health and mental illness; and
 explicate the issues that influence management of mental illness.

2.2 HISTORICAL ASPECTS OF ROLE OF FAMILY

IN MENTAL HEALTH CARE
There is no doubt that the significance of family, love and affection creates a
healthy environment for the child to grow. In order to create a positive
environment and well being of children, the movement of family therapy began
way back in the 1950’s. One of the prominent names in the emergence of
family therapy is Gregory Bateson. The central concept of family therapy
stems from the understanding of how interpersonal issues affect mental health
and also how resolving these issues can contribute in solving the problem of
the individuals. Family therapist initially understood the limitations of individual
focused interventions. The proponent of family therapy in United Kingdom
was John Bowlby and in USA it was John Dell.
Family therapy came in to importance as a result of three movements:
 In the child guidance clinics, it was found that family intervention was
essential for resolving child’s problems.
 In UK and USA, movement focused on marriage counseling eventually
saw the need for family intervention and became centres for family therapy.
 Sex therapy movement which essentially was behavioural in approach in
the 1970’s by Master’s and Johnson in the USA, later integrated with
systemic marital therapy. Theoretically, Adler and Sullivan also at the
same time pioneered the development of social psychiatry with emphasis
on the ongoing family relationships. Banduras’s Social Learning theory
also contributed to advent of family interventions (Carr, 2006).
In India, Dr. VidyaSagar in 1956 had pioneered the effort to involve family
members in the treatment and management of mental illness. He was the first 15
Family, Culture and to demonstrate that patients improve and recovered sooner with family
Mental Health involvement. This approach was followed soon after in Christian Medical
College, Velore by establishing family wards. The result of these was positive
and faster recovery, lower relapse rates was noted. Family members also
served as change agents in their community as they identified other patients
and guided their family members to approach psychiatric centers for help
(Avasthi, 2010).

2.3 FAMILY PERSPECTIVES OF MENTAL

HEALTH ISSUES
There are various viewpoints towards the contribution of family in the child
development and mental health related issues. Some of the perspectives have
been discussed in the subsections below.

2.3.1 Multi-generational Transmission

Murray Bowen suggested that the attitude of parents towards children is
influenced by how they themselves were treated as children. Family emotional
process is considered to be transmitted from one generation to another. Bowen
introduced the use of genogram which involves a pictorial representation of
the client’s family tree, normally reaching as far back as the client’s
grandparents. It is a format for drawing a family tree that records information
about family members and their relationships, spanning at least three
generations. This visual aid quickly points out the patterns and multi-generational
transmission of the family system and it helps in planning treatment for a
care-seeker.
A genogram helps in understanding several issues like:
 It helps in assessing the strength of relationship with other family members.
 It provides a complete history of the client’s significant relationships.
 It helps to identify family histories of significant health issues or mental
disorders and disturbances.
 It also gives a clue of gender role expectations of that family.
 The influence of birth order and sibling relationships on the person can
be understood.
 It helps to understand cultural and ethnic influences.
 It provides traces of specific problem issues (if any) in the family.
 It facilitates to examine the influence of traumatic events on the couple.

2.3.2 Nature of Family

The nature of the family has also been considered as a significant aspect in
transmission of mental health as well as mental disturbances. It is a well
known fact that, a family is universal, permanent and nucleus of all social
relationships. It has an emotional basis, has an influence over its members,
teaches its members about their social responsibility and the necessity for co-
operation and follows a social regulation.
16
In India the family is the most important institution that has survived through Family and Mental Health
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.

2.3.3 Structure of Family

Salvador Minuchin gave the structural approach which puts forth the idea that
in normal families every individual has specific functions to perform. The
members of the family usually have fixed boundaries of relationship.
Disturbances happen when family members are either too close or too distant
from each other. Salvador Minuchin discovered two patterns common to
troubled families: some are “enmeshed,” chaotic and tightly interconnected,
while others are “disengaged,” isolated and seemingly unrelated.
The structure of a family has subsystems with boundaries separating them. A
healthy structure of the family organism requires clear boundaries, particularly
generational boundaries. Unclear boundaries create a dysfunctional family
structure, one manifestation of which is a symptomatic family member. It is
assumed that if the structural flaw is corrected, the family organism will return
to health.
The theory of structural family has stated three essential components of family:
structure, subsystems and boundaries.
 Family structure is the organized pattern in which family members interact.
It is a deterministic concept, but it does not prescribe or legislate
behaviour.
 Families are differentiated into subsystems of members who join to
perform various functions. Every individual is a subsystem, and dyads or
larger group make up other subsystems, determined by generation, gender,
or common interests.
 Individuals, subsystems, and whole families are demarcated by
interpersonal boundaries, invisible barriers that regulate the amount of
contact with others.
Minuchin developed a theory of family process. This theory views pathology
of the family as arising out of problematic interpersonal boundaries within the
family. Interpersonal boundaries between family members can vary from rigid
to diffuse. Rigid interpersonal boundaries are categorised as disengaged
subsystems and diffuse boundaries are categorised as enmeshed/trapped
subsystems. That is, enmeshed subsystems offer a heightened sense of mutual
support, but at the expense of independence and autonomy. In disengaged
families, boundaries are rigid, emotional distance is excessive, and the family
fails to mobilize support when it is needed. Enmeshed parents create difficulties
by hindering the development of more mature forms of behaviour in their
children and by interfering with their ability to solve their own problems.
Adaptive changes in structure are required when the family or one of its
members faces external stress and when transitional points of growth are
17
Family, Culture and reached. Family dysfunction results from a combination of stress and failure
Mental Health to realign them to cope with it. The family’s failure to handle adversity may
be due to inherent flaws in their structure or merely to their inability to adjust
to changed circumstances.
In India for example, the concept of family is considered as strong, stable,
close, resilient and enduring. Since ages, the ideal and desired family in India
is the joint family. A joint family generally includes three to four living
generations, including uncles, aunts, nieces, nephews, and grandparents living
together in the same household.
Generally, when the elderly parents expire, a large joint family gets divided
because there is no longer a single authority figure to hold the family together.
However, after division, each new residential unit 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.
The major principle of joint family is to create and maintain family harmony.
Women are especially strongly socialized to accept a submissive position to
males, to control their sexual impulses, and to subordinate their personal
preferences to the needs of the family and kin group. However the conditions
are changing in recent decades as women are getting good education and
optimal exposure. 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.
2.3.3.1 Transition in Family Structure
There has been a shift in family structure with the change of time. For example,
in Indian traditional joint family structures, where family members used to stay
together with their spouses and children, have been significantly replaced in
urban areas by nuclear families. More importantly, the family system has
become a highly differentiated and heterogeneous social entity in terms of
structure, pattern, role relationships, obligations and values.
2.3.3.2 Implication of Changes in Family Structure for Mental Health
Professionals
As we have seen earlier, the strength of Indian families lie in their traditional
nature. But the emerging urbanization and industrialization has lead to a
transition. The trend to change has shifted persons from rural to urban settings
and this has resulted families to turn to nuclear kind from joint families. Due
to this they are subjected to stress more in terms of readjustments, reorientation
and the making-breaking of human ties. The populations that are vulnerable
to face this stress are elderly, children and adolescents, and women. The
range of disorders and deviancies associated with urbanization are enormous
and includes adjustment disorders, depression, sociopath, substance abuse,
alcoholism, crime, delinquency, vandalism, family disintegration, and alienation.
As a result of this, there is a worldwide emphasis on reducing the psychiatric
hospital beds and reducing admission into the mental asylums.
2.3.4 Strategic Approach
Jay Haley proposed a strategic family approach. This is also known as the
18 General system’s theory. This approach views that the main cause of disturbance
in an individual is the patterns and power structure in the family. Jay Haley Family and Mental Health
stressed upon the importance of the rules of the hierarchical structured family.
He believed that the cause of most behavioural problems lies in ineffective
parenting hierarchies, that is in a family if one parent is highly authoritative and
does not allow the other parent or children to take part in any decision
making, then this leads to psychological problems in the family. His approach
towards these problems aimed to reorganize the family structures and make
it more functional. He believed that if the boundaries of a family are clearly
defined then there is clear cut clarity in the roles and positions of the parents
and the children. The boundaries are designed primarily to help family members
experience new ways of interacting so that they will have different experiences
and feelings and therefore behave differently. For example, triangulation can
occur in a family and that might lead to family conflicts.
Triangulation occurs when a dyadic relationship becomes too stressful or
conflicted. A third person is involved as a way of diffusing the tension. This
typically occurs in families, often with a husband and wife (or two partners)
and one of the children. The more family members are differentiated, the less
likely they are to triangulate.
Transgenerational therapy typically involves helping people learn to recognize
emotional patterns that lead to triangulation, through more insight into how
they learned these patterns through transgenerational transmission.
2.3.5 Experiential Family Approach
Virginia Satir, one of the few women family systems pioneers, believed that
every human being had innate worth and that all individuals and families had
the potential to grow and flourish. Her views towards humankind were very
much similar to that of Carl Rogers’. She believed that any disturbance,
problem or similar symptoms is a blockage towards growth of a person and
for the family at large, and she was interested in what a family had to give up
or sacrifice in order to maintain this kind of negative balance.
All individuals are born into a primary survival triad between themselves and
their parents where they adopt survival stances to protect their self-worth
from threats communicated by words and behaviors of their family members.
Experiential therapists are interested in altering the overt and covert messages
between family members that affect their body, mind and feelings in order to
promote congruence and to validate each person’s inherent self-worth.

Self Assessment Questions 1

Fill in the Blanks
1) The major principle of joint family is to create and maintain .........
2) The theory of structural family has stated the following three essential
components of family : ......................... , ................................and
........................ .
3) Salvador Minuchin discovered two patterns common to troubled
families: some are..................... while others are..................... .
4) The proponent of family therapy in United Kingdom was ........
................ and in US it was ..................... . ................................

19
Family, Culture and
Mental Health 2.4 ROLE OF FAMILY IN MENTAL HEALTH
The social aspect of mental health care has become increasingly important.
Human behavior has to be understood in the context of interpersonal
relationships and environmental factors. One’s immediate environment is the
family and interaction with its members is an important influential factor in
behavior. Sethi (1989) noted that for a mental health professional family denotes
a group of individuals living together during important phases of their lives and
that their relationship is bound by biological, social and psychological
relationship. Therefore it provides scope for development of personality,
behavior patterns, interpersonal responsibility and a context for emotional
expression.
Robison, Rodgers & Butterworth (2009) mentioned that a family life provides
positive and protective factors to its members. Social support and particularly
the emotional support from a close relationship is one important protective
factor for mental health problems. Anxiety and depression is higher with families
that lack close supportive relationship. It has also been pointed out that
families also influence quality of life in an important way. The potential of
families in providing the earliest most enduring social relationships is a factor
that influences feelings of competence, ability to be resilient and influence a
sense of well being.

2.5 ROLE OF FAMILY IN MENTAL ILLNESS

In India, family is considered to be the key resource in the care of patients
with mental illness. Families are considered to have 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 lack
of trained mental health professionals and 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 traditional joint family is seen as a source of social and economic support
and is known for its tolerance of deviant behavior and capacity to absorb
additional roles in times of crisis, especially in Indian context. Leff et al
(1990) have suggested that traditional joint families allow for diffusion of burden
in families caring for the mentally ill and could be responsible for mediating
the good course and outcome of major mental disorders. Reviews of the role
of the family in relation to mental health have found that the nuclear family
structure is more likely to be associated with psychiatric disorders than the
joint family. Chandrashekar et al.(1991) reported that fewer patients from
rural families sought hospitalization when compared to urban families because
of the existing joint family structure.

2.5.1 Mental Illness and Family Therapists/Family

Relationship Service Providers
Family relationships have been considered to be significant in the context of
mental disorders. The therapists or the agencies that tries to provide family
care services.
20
Those who seek help with regard to mental illness to the family therapist are Family and Mental Health
dealt with the following problems:
 Mental disorders impact not just on the individuals affected but also on
those around them—including immediate family and other relatives—and
may be both a cause and a consequence of family/relationship difficulties.
 Although most common mental disorders are amenable to treatment, the
majority go undiagnosed and untreated.
 Many disorders are chronic or recurrent and they often call for long-term
management, not just acute care. a turnover role in trying to balance the
relationship between the client and his/her family. The persons suffering
from mental illness are taken care of at homes, but this leads to many
difficulties for the care giver (family) and the care taker (person having
mental disorder). Some
 Much of the care provided for people with mental disorders (even very
serious disorders) is informal care provided by family members.
 Many of the “vulnerable” family groups that represent the clientele of
family relationships services have a greater risk of mental health problems
than the population average.
The role of the family therapist or family service providers helps in dealing
with these problems as mentioned below in the following sub sections.
2.5.1.1 The Interpersonal Nature of Mental Health Problems
Mental health problems are often so deeply personal in nature that:
 They are often not visible to others;
 Most of the problems are characterised and identified by emotional and
other subjective symptoms; and
 Many individuals experiencing problems attempt to conceal or downplay
their difficulties.
At the same time, mental health problems have features that are fundamentally
interpersonal. The clinical diagnosis of almost all mental disorders includes -
clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
The onset of illness can be identified by the immediate relatives and friends
by observing the changes in a person’s behaviour. Mental disorders are also
found to be linked with a range of adverse social outcomes, including marital
dissatisfaction and the likelihood of marital breakdown.
An additional interpersonal feature of mental health problems is the importance
of perceived stigma (when public endorsement of prejudice related to a
stigmatized group occurs), and self-stigma (what stigmatized people may do
to themselves, if the public stigma is internalized. Both types of stigma have
impact on the likelihood of receiving help. Individuals may be particularly
sensitive to the views or presumed views of relatives and friends about mental
health problems and this can be a factor in their willingness to disclose their
own problems or to seek professional help and then comes the vital role of
family therapist. 21
Family, Culture and 2.5.1.2 Untreated Disorders
Mental Health
The lack of professional care for mental health problems has implications for
family relationship service providers due to the following reasons:
 Untreated problems are likely to last longer and may worsen in terms of
severity.
 Inappropriate forms of self-help, such as substance use, can lead to
secondary problems (i.e. comorbidity).
 Clients with untreated disorders will be less likely to benefit from
interventions provided by family relationship services.
2.5.1.3 Managing Chronic and Recurrent Disorders
Even though we have treatment available for common mental disorders, if the
symptoms become ingrained before seeking treatment, the prognosis will be
affected. The service providers help the client to care for self and also try
to widen the role of interpersonal relationships and family responsibilities. For
some therapies (e.g., behaviour marital therapy or family therapy) the
importance of family relationships is an integral part of treatment.
This presents a challenge for both mental health services and for family
relationship services to accommodate issues arising from mental health problems
that can impact on families (just as chronic physical disease or disability affect
families as a whole).
2.5.1.4 Informal Caregiving
The care that is provided by the family members to the person/member is
considered as informal care giving. For those with mental disorders, a significant
part of the care giving burden falls on family members. This role is often
undertaken by parents when a young person or child is affected and when an
adult is affected care-giving falls upon spouses, siblings or ageing parents.
The important issues for care givers of people with severe mental disorders
include access to specialist services and therapeutic support for themselves.
2.5.1.5 Vulnerable Families
The therapists have found that it is not only the client but the family members
as whole becomes their target client group because of their susceptibility or
vulnerability to some mental health problems. The research literature on risk
and protective factors for adult mental disorders provides the evidence base
for the characteristics of individuals and families that increase the likelihood
of being affected by mental health problems. Some of research findings are
as follows:
 Unlike the vast majority of physical disorders, mental disorders are more
common in young and middle-aged adults, compared with older adults.
 Depression and anxiety disorders are more common in women than men,
whereas substance use disorders are more prevalent in men.
 Family history of mental health problems, especially of parents or other
first-degree relatives, is another important risk factor.
 The demographic and socio-economic factors that have the strongest
22 association with depression and anxiety are lone parenthood and
 unemployment (especially when the unemployment is long term). An Family and Mental Health
underlying feature in both anxiety and depression is financial hardship.
This is because of the dependence for essentials are on income alone.
 Adults with dependent children, especially mothers, are at increased risk
for depression and anxiety, with the mothers of younger (pre-school)
children having the highest risk.
 Past (own) relationship breakdown is also related to an increased risk of
depression and anxiety (as seen in stepfamilies as well as lone parent
families), as is parental separation in the family of origin even after many
years.
 Occupational skill level as such is not strongly related to risk of mental
health problems. Rather, work characteristics such as insecurity, high
demands and low control are more pertinent, and having a combination
of these poor characteristics may be worse than having no job at all.
 Stressful life events and transitions, whether expected or unexpected, or
forms of longer-term disadvantage can influence the mental health status
of one or more family members. Such life events and disadvantages
include violence, death or serious illness of a family member, other relative
or close friend, redundancy, financial crises, homelessness, incarceration,
natural and other large-scale disasters, family breakdown, criminality in
parents, and parental substance abuse.
2.5.1.5.1 Protective Factors
Social support and particularly the emotional support from a close relationship
is one important protective factor for mental health problems. Often, this
close relationship is with a spouse/partner or parent. People lacking such a
close supportive relationship are at greater risk of anxiety and depression.
Additional protective factors are self-help strategies that aid recovery from
mental health problems and may prevent difficulties progressing to diagnosable
disorders. These include psychological strategies (e.g. increasing coping skills
and cognitive approaches), behavioural strategies (e.g., exercise and relaxation
techniques) and use of complementary therapies such as meditation and yoga
groups.

Self Assessment Question 2

State whether the following statements are true or false-
1) Mental health problems are often so deeply personal in nature that
they are often not visible to others .......................................... .
2) Even though we have treatment available for common mental
disorders, if the symptoms become ingrained before seeking treatment,
the prognosis will be affected .......................................... .
3) Mental disorders impact not just on the individuals affected but also
on those around them ............................................................... .
4) Human behavior need not be understood in the context of
interpersonal relationships and environmental factors......................
.................................... . ......................................................................
23
Family, Culture and
Mental Health 2.6 CAREGIVERS BURDEN
A sufferer is not only the person who needs care from his/her family members,
but the family members who are providing care to those members also suffer
a lot. Some of the problems faced by the family or the care givers have been
mentioned in the subsections below.

2.6.1 Living with Someone who has a Mental Health

Problem
Research in many countries has shown that mental illness in married couples
co-occurs at a level far greater than expected by chance, i.e. that mental
illness in one spouse is associated with mental illness in their partner.
A number of different explanations have been suggested for this co-occurrence
(often called “spousal concordance”), including that:
 people marry partners who are similar to themselves, and this could
apply either to mental health problems or to other characteristics which
put people at risk of mental health problems in the future;
 spouses have similar environments and experiences (e.g., life events)
after marriage and these contribute to the similarity in their mental
health; and
 mental health problems in one spouse impact on the mental health of their
partner, due to difficulties in their relationship, through any consequences
on their economic or living conditions, or as a direct consequence of one
spouse having to care for the other.
 Such associations between mental health and marital relationships are
reflected in the application of marital therapy in the treatment of depression
and other mental health problems.

2.6.2 Children of Parents with a Mental Illness

There has been increasing recognition of the caring role that many children
play in supporting a parent with a mental illness. The effects of having a
parent with a mental illness may impact on children in different ways. Children
may be affected in terms of their own direct care, or indirectly through impacts
on their social and emotional health and wellbeing. Core attachment needs
such as love, physical and emotional nurturing and security may be at risk.
For example, depressed mothers may provide less stimulation, support and
responsiveness to children, which can affect children’s physical and
psychological health, attachment and social problems. Children may be at an
increased risk of developing mental health problems, either through genetic
predisposition, parenting style or learned behaviour, with one study suggesting
that approximately one-quarter of children living with a parent who has a
mental illness are in situations of moderate, high or extreme risk of future
mental health problems themselves. Poor relationships between parents and
children may or may not result, but emotional safety and, particularly in cases
of psychosis, physical safety may be compromised.

24
2.6.3 Caring for Someone with a Mental Health Problem Family and Mental Health

A “primary carer” is the person who provides the most informal assistance,
in terms of help or supervision, to a person with one or more disabilities. The
assistance has to be ongoing, or likely to be ongoing, for at least six months
and be provided for one or more of the core activities such as communication,
mobility and self-care.
Two aspects of caregiving relate specifically to mental health—first, the care
involved in looking after a person with a mental illness and the impact of
caring on the mental health of the caregiver. The second type may occur in
the caring of a person with a range of physical and intellectual disabilities, as
well as mental illness.
One of the key aspects of caring that can impact on the mental health of
carers is the level of burden involved in the caring role. Similarly to other
caring roles, two types of burden associated with caring for a person with a
mental illness are highlighted in the literature: objective burden and subjective
burden. Objective burden relates to the specific tasks associated with caring,
for example managing finances or doing housework, and subjective burden
relates to the feelings and cognitive appraisals associated with caring, such as
finding particular behaviours embarrassing, worrying about the future and dealing
with excessive demands. The degree of burden is most often related to the
degree of impairment or severity of the disability and symptoms associated
with the illness of the care recipient.
It is important to state, however, that caring has positive elements for some
caregivers and is not necessarily universally harmful to carers’ psychological
wellbeing. Caregiving can be a source of achievement, bearing in mind that
the experience of caregiving is not necessarily one-dimensional either—it can,
for example, being difficult and rewarding or burdensome and gratifying.
2.6.4.1 Particular Needs of Carers
A recent report on people suffering from mental illness has identified the
following needs from families and carers towards them:
 support, for dealing with issues such as challenging behaviours;
 education, particularly at the onset of an illness;
 understanding and empathy, for example, someone to listen to the
difficulties they face; and
 kind of short break for exhausted families, who may also need assistance
with feelings of guilt.
2.6.4.2 Stigma
Fear and stigma relating to mental health, in both professionals outside the
mental health service system and in the community, cannot be underestimated.
Many studies have indicated that stigma is the most prominent issue related
to seeking help for mental health problems. As stated previously, family
relationship services are in a good position to respond to mental health
problems as they are not necessarily directly associated with mental health
service delivery. A comprehensive discussion regarding stigma and responses
to addressing stigma is dealt in another unit, it seems timely to consider the
specific role that non-mental health services can play in ameliorating the
damaging effects of stigma related to mental illness . 25
Family, Culture and
Mental Health
Self Assessment Questions 3
Answer the following questions in a single sentence-
1) Who is a ‘primary carer’?
..........................................................................................................
2) What is ‘spousal concordance’?
..........................................................................................................
3) Who is a care giver?
..........................................................................................................

2.7 LET US SUM UP

Throughout the discussions done in this unit, we can summarize that family is
the basic unit of our society. Family teaches its members about the social
responsibilities. Thus the interaction between the family members is important
in mental health. Moreover, the changes which are taking place in the traditional
family structure due to industrialization also have the impact on mental illness.
Overall, in our country the mental healthcare needs are increasing but at same
time one of our main resources which is the family, in the care of the mentally
ill subjects is diminishing. Thus, it is important to take immediate steps to
enrich the positive role of family in mental health care. Community mental
health programs can be conducted to provide knowledge about the importance
of family members in “well-being”, identifying the symptoms, and the availability
of treatment.
It is important for the researchers to examine how the changing structure and
functioning of the contemporary Indian family would impact care giving for
people with major mental illness. Similarly, the contribution of family members
who have played an all important role in the treatment and rehabilitation of
psychiatric patients has to be recognized. Access to better treatment for
patients, including medications, psychosocial interventions and rehabilitation
services is to be ensured.
Moreover, caregivers need to be supported through active programs of support
and guidance. Family interventions should focus on expanding training to
patients and key relatives about wellness recovery, skills training, and task
sharing of household and self-care chores. An improvement in these areas is
likely to improve the quality of life of people with mental illness and their
families. Researchers recommend that in addition to focusing on the symptoms
of patients, more attention needs to be given to the mental health and well-
being of family caregivers. Adequate information and support have to be
extended to the family and caregivers.
The families need information, support, knowledge and specific suggestions
for coping with mentally ill relatives. Caregivers must be encouraged to join
such groups so that they can seek mutual help, learn from experience of
others, can share their problems etc. Hence, the mental health professionals
in India have an important role in promoting the preservation of family, if the
26 needs of mentally ill subjects are to be cared for in a better way.
 Family and Mental Health
2.8 ANSWERS TO SELF ASSESSMENT
QUESTIONS
Self Assessment Questions 1
1) family harmony
2) structure, subsystems and boundaries
3) “enmeshed,” chaotic and tightly interconnected, while others are
“disengaged,” isolated and seemingly unrelated
4) John Bowlby and in USA it was John Dell
Self Assessment Questions 2
1) True
2) True
3) True
4) False
Self Assessment Questions 3
1) A “primary carer” is the person who provides the most informal assistance,
in terms of help or supervision, to a person with one or more disabilities.
2) A situation in which mental illness in one spouse is associated with mental
illness in their partner.
3) A care giver is a person who takes care of the person suffering from
mental illness in the family.

2.9 UNIT END QUESTIONS

1) Define family.
2) Explain the structure of family and effect of changes in family structure
on mental illness.
3) Describe Bowen’s theory.
4) Explain the structural approach given by Salvador Minuchin.
5) What are the vulnerable factors and protective factors?
6) Describe about care givers’ burden.

2.10 REFERENCES
Robinson, E., Rodgers, B., & Butterworth, P. (2008).Family relationships
and mental illness-Impacts and service responses, Australian Family
Relationships Clearinghouse, issue 4.
Varghese A, (1988). family participant in mental health care: the Vellore
experiment, Indian journal of psychiatry, 30 (2).

27
Family, Culture and Avasthi, A., (2010). Preserve and strengthen family to promote mental health,
Mental Health Indian journal of Psychiatry, Volume 52, issue 2.
Sethi, B.B., (1989). Family as a potent therapeutic force, Indian Journal of
psychiatry. 31.
Leff J, Wig NN, Bedi H, Menon DK, Kuipers L, Korten A, (1990). Relatives?
expressed emotion and the course of schizophrenia in Chandigarh. A two year
follow-up of a first contact sample. Br J Psychiatry 1990;156:351-6.
Chandrashekar CR, Rao NV, Murthy RS (1991). The chronic mentally ill and
their families. In: Bharat S, editor. Research on Families with Problems in
India: Issues and Implications. Vol 1. Bombay: Tata Institute of Social Sciences;
1991. p. 113-20.
Carr, A. (2006). Family therapy concepts, process and practice. Wiley series,
NY.

28
UNIT 3 SOCIOLOGY OF MENTAL HEALTH
Structure
3.0 Introduction
3.1 Objectives
3.2 Social Attitudes and Mental Health
3.3 Social Perception and Mental Health
3.3.1 Communication
3.4 Attribution Theory
3.4.1 Problems with Attribution
3.4.2 Attributions in Clinical Setting

3.5 Social Influence

3.5.1 Conformity and Deviance
3.5.2 Prosocial Behavior

3.6 Group Process

3.6.1 Prejudice Towards Members of A Group
3.6.1.1 Types of Prejudice
3.6.1.2 Prejudice and Stereotyping
3.6.2 Stigma

3.7 Leadership and Social Power

3.8 Sociological Theories Related to Mental Health
3.8.1 Sociological Aspects of Mental Health
3.8.1.1 Social Causation
3.8.1.2 Critical Theory
3.8.1.3 Social Constructionism
3.8.1.4 Social Realism
3.8.2 Structural Strain Theory
3.8.2.1 Effects of Poor Neighbourhoods on Mental Health
3.8.2.2 Survivors of Disaster
3.8.3 Implications of Applying Sociological Theories in the Field of Mental
Illness

3.9 Let Us Sum Up

3.10 Answers To Self Assessment Questions
3.11 Unit End Questions
3.12 References

3.0 INTRODUCTION
You might wonder that what is the need of studying the aspects of sociology
in this block? Let us first tell you that, sociology is a study of understanding
social systems and relating various aspects of social structures to the pattern
of human behaviour. The people who are part of the social system are
29
Family, Culture and essentially interdependent for various reasons. This interdependence
Mental Health produces interaction between people. In the course of interaction influence
is exerted on each other. Therefore social behaviour is a result of
interdependence, interaction and influence and social psychology is a
scientific study of this process.
Allport (1985) has defined social psychology as “the study of the way in
which people’s thoughts, feelings, and behaviours are influenced by the real
or imagined presence of other people.” This influence on a person’s thoughts,
feelings and behaviour involves various processes. For example, the formation
of attitudes is an important aspect that has to be understood. How these
aspects are connected to mental health is the focus of this section.
In order to study social psychology and its relationship to mental health we
need to understand social attitudes, social perception, attribution, social
influence, communication patterns, leadership and social power, conformity
and deviance, prejudice, group process and pro-social behaviour. The role
of these aspects in mental health will be discussed in this section.
Another aspect of understanding mental health from a sociological point of
view is to understand the prevailing social conditions that influence
psychological functioning. In other words, it is connecting social experiences
to mental health through psycho-social process that needs to be studied.
The assumption that is made is based on the fact that social conditions that
people live in influences their emotions, behaviour and thinking patterns.
The social conditions are noted to vary across different social groups,
societies and historical eras.

3.1 OBJECTIVES
With the help of this unit, you will be able to:
 understand the concept of social attitude in mental health;
 understand the concept of social perception and its influence in mental
health;
 understand the role of group processes in mental health;
 understand the role the process of attribution and its role in mental
health; and
 analyze the social situations that affect mental health process.

3.2 SOCIAL ATTITUDES AND MENTAL HEALTH

The formation of social attitudes is of great interest in the field of social
psychology as it has a major role in how people behave in social situations.
It is defined as a tendency to think, act and feel consistently in a favourable
or unfavorable manner towards entities in the environment. These entities can
be abstract ideas, one’s behaviour, ideologies, ideas or concrete objects. For
example, one might have a favourable or unfavourable attitude towards
immigrants, mentally ill people or alcohol drinking behaviour. These attitudes
are learned. They are usually acquired from parents, family, friends and society,
30 to some extent from cultural predispositions.
An attitude refers to a subjective judgment or evaluation of an entity made by Sociology of Mental Health
an individual. For example, people may have a negative or positive attitude
towards a condition or behaviour, such as all those who consume alcohol are
irresponsible. It can be sometimes activated automatically and the processing
may be at the preconscious level.

Attitudes are relatively persistent and stable and can be changed with effortful
means. For example health promotions are aimed at changing people’s attitude
towards exercising, smoking and drinking. However, two important areas
pertaining to attitude change are cognitive dissonance and persuasive
communication.
Cognitive dissonance is about inconsistencies in cognitions or beliefs and
behaviour. It refers to two contradictory attitudes which leads to conflict in
the mind of an individual by various means. Cognitive dissonance occurs
when an individual holds two cognitions that are inconsistent with each other.
For example, a smoker or a drinker generally holds two contradictory beliefs
or cognitions which can contradict one against the other. One example is a
person who consumes alcohol believes that alcohol relaxes his mind but at the
same time knows that it is bad for his physical condition. This leads to an
unpleasant state of mind or dissonance that has to be changed. Instead of
changing the behavior (drinking), he tends to change the dissonance by either
refusing to acknowledge the negative outcome of alcohol consumption or
wanting to believe that consequence are not so severe that one cannot cope
with.
Another way of changing attitude is through persuasion. This is a conscious
attempt to change attitude through communication of some message with the
help of power, language, expertise, creating likeability or appealing the individual
or mass to change an existing attitude.

3.3 SOCIAL PERCEPTION AND MENTAL HEALTH

Social perception is the part of perception that allows people to understand
how the other people think about themselves in their social world. This sort
of perception is defined as a social cognition which is the ability of the brain
to gain, store and process information. Social perception allows individuals to
make judgments and impressions about other people. It is primarily based on
observation, although pre-existing knowledge influences how we perceive an
observation.
Social perception gives individuals the tools to recognize how others affect
their personal lives. It helps individuals to form impressions of others by
providing the necessary information about how people usually behave across
situations. The social perception provides information needed for impression
formation by approaching the behavior with an implicit personality theory
outlook. Implicit personality theories state that, if an individual observes certain
traits in another person, s/he tends to assume that his or her other personality
traits are concurrent with the initial trait. These assumptions help us to make
quick judgments about the character of an individual. It also helps us to
“categorize” people so that we can infer additional information about them
and predict their behavior. For example, if someone observes a drunken
person being aggressive and violent towards people, then she/he generalizes
such behaviour that most people in a drunken state would behave similarly. 31
Family, Culture and Consequently, s/he avoids people who are drinking or would always perceive
Mental Health him to have other negative traits etc., such as being irresponsible, useless,
good-for-nothing person.
Social perception is one of the initial stages of processing information in order
to determine any other individual’s mind-set and intentions. It is combined
with the cognitive ability to pay attention to and interpret a range of different
social factors that may include: verbal messages, tone, non-verbal behavior,
and knowledge of social relationships and an understanding of social goals.
Any social interaction or social skill to deal with persons is influenced by
social perception. A key aspect of social interaction is the process of figuring
out what others are thinking and feeling which is also referred to as Theory
of Mind (ToM). The Theory of Mind proposes that the ability of the mind to
attribute mental states, such as beliefs, desires, emotions, perceptions, and
intentions to self and others in order to understand and predict behavior. It
involves making the distinction between the real world and mental
representations of the world.
In the clinical setting, For example children with autism are assumed to have
deficits in the theory of mind ability. That is, they lack the ability to understand
that others have needs, intentions, desires that are different from their own.
This is also true of some schizophrenic and some alcohol dependent persons

3.3.1 Communication
As discussed earlier also, that our social perception influences our interaction
with society and form an attitude. It must also be understood that social
perception cannot take place without communication. In order for people to
perceive one another, information must be transmitted. This happens with the
process of communication. Communication serves as the basis for social
relationships of all kinds. Infact, a social system may be considered as a set
of positions interconnected with communication channels. Communication is
referred to as a two way process of transmission and reception of all kinds
of data. Most people would probably think of communication primarily in
terms of what it does for them. In the process of communication information
is exchanged, demands are made, and people understand that events have
occurred, will occur or may occur.
Attempts at communication may be guided and oriented by feedback. This is
the information available to the communicator that comes back to him through
various channels. Our monitoring of our own behaviour also provides a kind
of feedback that tells how we are responding to various situations. Feedback
needs to be associated with empathy that is trying to understand why people
behave in such a way is also part of the interaction process. People attribute
various causes to their own and other’s behaviour. The next section discusses
the theories based on attribution

3.4 ATTRIBUTION THEORY

Attribution theory is concerned with how individuals interpret events and how
this relates to their thinking and behavior. This theory explains the causes of
our own behavior or the other people’s behavior. Attribution theory assumes
that people try to determine the cause of an act. A person seeking to understand
32 why another person did something may attribute one or more causes to that
behaviour. Seligman et al., in 1979 established several important dimensions Sociology of Mental Health
of attribution, that is while attributing or analyzing an act of an individual we
take certain dimensions in to account. They are:
 Locus – Internal vs external: If we consider an individual responsible for
an act or behavior, we are emphasizing on internal attributions, such as
ability, effort, personality trait, mood, and so on. For example, depressed
individuals believe that they have no control over what happens to them
in their own lives. This concept is based on the learned helplessness
model of depression put forth by Selligman, 1975). External attribution
refers to causes outside the person, situational factors, actions of others,
difficulty of the task etc.

 Stability – Stable vs unstable (permanent vs temporary) – stable causes

are relatively permanent, unchanging and lasting, for example, people
tend to attribute solely to genetic causes or personality traits for addiction;
while unstable attributions are temporary and fluctuating, here people
attribute the causes of drinking to the current stressor.

 Generality – Global vs Specific – global causes are perceive as applicable

to most actions of the person for instance there is a belief that all girls
are submissive and less assertive, whereas specific attributions pertain to
those that are restricted to certain domains or situations for example a
person may attribute his smoking behavior to peer pressure.

 Controllability – Controllability vs uncontrollability – attributions that

are uncontrollable are perceived as beyond one’s effort, autonomous and
independent (example- a person is depressed because he has a strong
family history of depression), whereas controllable causations are seen as
manageable and prone to containment or mastery (example – attributing
depression to negative life events such as failure in examination).

These insights into attributional processes have been usefully applied to clinical
situations, especially to depression. The best-known and most studied
attributional phenomenon is that of learned helplessness.

3.4.1 Problems with Attribution

Attribution leads to a number of cognitive biases and errors. Our perceptions
of events are often distorted by our past experiences, our expectations and
our own needs.

There are many common types of errors in attribution: One is attributing

causes for behaviour that serves a purpose to the self. The process of
attributing their success to internal causes and attributing failures to external
causes is known as Self-Serving Bias.

Examples for internal attribution: Attributing your success to internal factors “I

did well because I am smart” or “I did well because I studied and was well-
prepared” are two common explanations you might use to justify your test
performance. The tendency of attributing causes to internal factors such as
personality characteristics and ignore or minimize external variables when it
comes to other people is called fundamental attribution error.

33
Family, Culture and 3.4.2 Attributions in Clinical Setting
Mental Health
Person who accesses clinical facilities usually comes with certain complaints.
These complaints are usually attributed to an underlying cause according to
his/her belief system. They would have their own theories about the origin of
the symptoms and go about making efforts to think and collect information in
an attempt to make sense of their difficulties. Very often these attributions
may not be expressed openly, however, it is essential for the clinicians to
understand and bring it out in the open and discuss about it, thereby dealing
with problems and misattributions. This process is called explanatory model.
These beliefs profoundly influence care seeking behaviour and adherence to
recommended interventions.

3.5 SOCIAL INFLUENCE

Social influence is a common tendency of people to behave differently when
others are present than when they are on their own. In any social context
there is a pervasive influence on behaviour when others are present. Studies
in social psychology have demonstrated this. Social influence is said to occur
when one’s emotions, opinions, or behaviors are affected by others. Social
influence takes many forms and can be seen in conformity, socialization, peer
pressure, obedience, leadership, and persuasion. Below, some of the more
important social influences are mentioned.

3.5.1 Conformity and Deviance

Conformity is a kind of influence in which people change their behaviour or
belief towards that of a group’s majority view or belief, as a result of real or
imagined pressure from a group. Several explanations have been put forward
to account for the process of conformity. They may be because of social
comparison, avoidance of conflict and increased self awareness. Different
mechanism may be operative in different situations.

For example, in any culture customs leads to conformity of behaviour. Customs

are transmitted from generations to generations. Conformity reduces cause
and increases outcomes and thus reduces deviation. In sociological terms,
“conformity” simply means to not stray from social expectations, while
“deviance” means to stray from social expectations. This can be positive or
negative depending on the circumstance. Without conformity it would not be
possible to form a social group. Conformity makes social cohesion
possible. Deviance can cause an individual to suffer physical and/or emotional
suffering from others. But within deviant sub-cultures there is also the
opportunity for social ties, new identity formation, and high status.

3.5.2 Prosocial Behaviour

Prosocial behaviour is voluntary behaviour intended to benefit another. It
consists of actions which benefit other people or society as a whole which an
individual may involve in to even without getting any personal benefit. For
example, helping, sharing, donating, co-operating, and volunteering behviours
are prosocial in nature. These actions may be motivated by empathy and by
concern about the welfare and rights of others, as well as for egoistic or
34
practical concerns. Empathy is a strong motive in eliciting prosocial behaviour.
Demonstrating such social norms is likely to get admiration from other people. Sociology of Mental Health
There are factors that influence prosocial behaviour. People who are in a
good mood are more likely to help others as they simply feel like doing so.
So also with people who are feeling guilty, as a compensation for their guilt
feelings. People in small towns are more likely to help than those who are
together in cities.
Self Assessment Questions 1
State whether the following statements are ‘true’ or ‘false’-

1) Conformity is a kind of influence in which people change their

behaviour or belief towards that of a group’s majority view or belief,
as a result of real or imagined pressure from a group ............
.................... .

2) Attributions that are controllable are perceived as beyond one’s effort,

autonomous and independent .............................................
................... .

3) Social perception is one of the initial stages of processing information

in order to determine any other individual’s mind-set and intentions
................................ .

4) Social perception can take place without communication

....................... .

3.6 GROUP PROCESS

A group is a collection of two or more people, who are engaged in a functional
relationship with each other and have a common goal. The members interact
through communication process. They develop a structure as members occupy
positions, acquire status, and play roles.

Group processes occur at least in three contexts: 1. Interpersonal behaviour,

2. Intra group (within -group) behaviour and 3. Intergroup (between-
group) behaviour.

Group members interact over a period of time and therefore they go through
a process of development that involves being accepted, resolving conflicts,
attaining consensus and ultimately adjoining. During this process people form
an identity, they perceive themselves as members of group and adopt a unique
identity. They begin to get to know one another and form emotional bond.
They usually have a sense of purpose and shared goals. Very often groups
have standards of conduct such as rules that could be implicit or explicit.

The structure of the group varies such as–family members, friends, colleagues
etc. group is based on the functions and specialties. Group members generally
have a sense of loyalty towards the group. For a group to function together
they need to be cohesive. Although there might be a difference in behaviour
of group members towards their own group and how they behave towards
the outer group.

There is evidence from studies that group behaviour is characterized by the

following features: 35
Family, Culture and  Accentuation effect: It refers to a tendency to magnify or overestimate
Mental Health the differences between groups in terms of their beliefs, preferences and
behaviours. In spite of objective finding from studies showing that there
are more differences in these aspects within the group than between
groups, members tend to emphasize more on between group differences.

 Intergroup competitiveness: There is a tendency of groups to be more

competitive than individuals

 Intergroup bias: This refers to the tendency of group members to

systematically evaluate their own group members more favorably than
members from an outer group. They tend to discredit or derogate outer
group members.
 Out group homogeneity effect: This is the tendency of groups to minimize
differences between the members of the out-group and perceive them as
homogenous and undifferentiated. This leads to higher chances of prejudice
and discrimination.
3.6.1 Prejudice Towards Members of A Group
Prejudice is an attitude (usually negative) towards members of a specific
group, based solely on their membership on that group. It is important to
distinguish between prejudice and discrimination. Prejudice is a negative attitude
directed towards people simply because they are members of a specific social
group. Discrimination is a negative action towards members of a specific
social group.
Prejudice is a judgment based on previous information or feelings and it is not
based on present experience exclusively. It stands for an unfavorable attitude
towards a person or group. The judgment is not based on adequate facts.
Often based on stereotypes, it involves a certain amount of hostility against
others. Sometimes it is shared by the group as a whole and therefore it is
almost seems like a social norm. One of the conspicuous features of every
society is prejudice towards minority. The minorities for example could be
based on the race, creed or caste. The consequences of prejudice are
discrimination and inequitable treatment.
Prejudice is most likely to develop under certain social conditions: firstly,
Intergroup competition – this occurs when there are group conflicts especially
when the resources are scarce. Another situation where it may occur is when
there is unusual power distribution. Prejudice may even occur if a person or
group of persons enhances their self identity and self esteem by having
favourable opinion of their own group and putting down others. Apart from
this, a person with authoritarian trait tends to be hostile and hold prejudices
towards other groups. There is also a strong association between religion and
prejudice.
3.6.1.1 Types of Prejudice
Prejudice can be based upon a number of factors including sex, race, age,
sexual orientations, nationality, socioeconomic status and religion. Some of
the most well-known types of prejudice include:
 Racism
36  Sexism
 Classicism Sociology of Mental Health

 Homophobia
 Nationalism
 Religious prejudice
 Ageism
3.6.1.2 Prejudice and Stereotyping
Prejudice may further result in to stereotyping and discrimination. In many
cases, prejudices are based upon stereotypes. A stereotype is a simplified
assumption about a group based on prior assumptions. Stereotypes can be
both positive (“women are warm and nurturing”) or negative (“teenagers are
lazy”). Stereotypes can lead to faulty beliefs, but they can also result in both
prejudice and discrimination.
It has been found that, prejudice and stereo types occur simultaneously. In
order to make sense of the world around us, it is important to sort information
into mental categories. However, researchers have found that while when it
comes to categorizing information about people, we tend to minimize the
differences between people within groups and exaggerate the differences
between groups. Some examples of stereotypes are ‘teenagers are
irresponsible’. Stereotypes are resistant to change and persistent even though
there could be evidence contrary to the current belief system and therefore
it leads to discriminative behaviour or prejudiced mind set. Prejudice and
stereo typing affect those who have mental illness equally.

3.6.2 Stigma
Mental illness has often the burden of stigma attached to it. The word stigma
means ‘a mark placed on slaves so as to identify them.’ Earlier, when ever
a person’s behavior was found to be different or deviated from normal then
those persons were marked and were devalued or discriminated from the
society. Mentally ill patient were assumed to be violent and people tried to
avoid them and excluded them from main stream activities. The people suffering
from mental illness lack insight, decision making and are dependent on others
and therefore others need to take decision for the behavioural component of
stigma by discrimination. This can take place by a tendency to avoid them in
social interactions such as in a marriage. Maybe withheld from help such as,
providing housing facility, or even showing lack of interest in providing
professional help to mentally ill people when comparing to people with physical
illness
People come together in groups to satisfy both task and social needs. To able
to satisfy these needs depends on several factors, which include an important
aspect of the behaviour of leadership. The following section discusses the
influence of leadership process in group changes or social activity.

3.7 LEADERSHIP AND SOCIAL POWER

Leadership is regarded as a crucial factor for success or failure of any social
activity. Leadership may be defined as a process in which an individual
influences a group of individuals to achieve a common goal. The importance
37
Family, Culture and of leadership is that it can influence a reform in social norms or perceptions.
Mental Health It involves three main elements-

 Power: It refers to an ability to influence others and it specifically refers

to ability of the leader to get others to adopt common goals. There are
various types of power vested on a leader like providing rewards or
punishment.

 Persuasion: This is the ability to motivate people to follow a certain

goal.

 Vision: Leadership implies having a vision of future and leading the team
accordingly.

Leadership arises only where there is group with norms striving to reach a
goal. The main objective of leader is to make the followers act or behave
accordingly in order to reach to a common goal. In such collectivism, leaders
play a very important part in bringing about group cohesion. Irrespective of
the size of the group, the essential feature is in the narrower sense of the team
is that, there is group structure with status and role relationships and a hierarchic
organization. The leader- follower relationship involves social interaction, face
to face, as well as indirect, by means of communication.

Gibb (1969) has given the following list of seven aspects of leadership
behaviour:

 Performing professional and technical specialty.

 Knowing subordinates and showing consideration for them.

 Getting channels of communication open.

 Accepting personal responsibilities and setting an example.

 Initiating and directing action.

 Training men as a team.

 Making decisions.

Thus a successful leader is persuasive, manipulative, charismatic and can

easily influence others. A leader is desired to be an expert in problem solving,
decision making. Based on the qualities of leadership, the leaders have been
classified in to the following types:

 The institutional leader

Such a leader may maintain authority, and build up a thoroughly coherent

group. The danger with this group is that it inevitably tends to become
rather narrowly self-contained and non-adaptable. If, by force of
circumstances, it is thrown into close contact with groups of another
type, it may show itself rigid and unfriendly. Nevertheless, to exalt the
symbol is the only way in which the leader whose power is in his post
rather than in himself can consolidate his authority. Such a leader, since
he must emphasize rank, has to maintain an attitude of aloofness in general,
so far as his followers are concerned.
38
 The dominant leader Sociology of Mental Health

The dominant leader is one who impresses, commands, shapes, and

sways his men, presents a number of extremely interesting psychological
problems. It seems certain that the hereditary basis of this type of character
is so strong, that nobody who does not possess it can by training learn
to control men in the dominant manner. It is in reference to the second
and third classes of leaders that it is more or less true to say that a leader
is born and not made.
 The persuasive leader
The persuasive type of leader is, in many respects, psychologically the
most interesting of all. He is, as a rule, very much the most complex and
subtle character. He has always played an important part in social life,
but tends to come more and more to the front as society develops. This
is the political type of leadership, the civil type, the administrative type.
In conclusion, studies have shown that effective leadership styles are situation
specific. The most effective leaders are those who can develop a range of
leadership styles and those who know when to apply each style.

3.8 SOCIOLOGICAL THEORIES RELATED TO

MENTAL HEALTH
3.8.1 Sociological Aspects of Mental Health
The sociological perspectives of mental health and illness are mainly based on
theoretical. For example, mental disorder has been viewed to be related to
the existing culture and the society to which the person belongs. The following
sub sections briefly points out the various views of mental health and illness
from a sociologically based perspective.

3.8.1.1 Social Causation

Theories have been put forth to explain the role of socially derived stress in
the etiology of mental illness. This social approach to understand the causes
of mental illness puts emphasise on the relationship between social
disadvantage and mental illness. Sociologists have considered low social class
and/or poverty as the main indicator of disadvantage and study the relationship
between mental health and social class. However, social class has not been
the only variable investigated within this social causation perspective.
Disadvantages related to race, gender and age have also been studied.

3.8.1.2 Critical Theory

The relationship between socio-economic structure and the inner lives of

individuals has been of interest for many writers during the twentieth century.
For example, attempts have been made to understand people’s biography in
relation to their social context and vice versa. Freud and his associates
attempted to use insights which they had from an individual’s psychoanalytical
process and extended this process to understand the societal processes. In
the Frankfurt Institute of Social Research the members of the institute were
known as the critical theorists. They explored the inter-relationships between
the material environment of individuals and their cultural life and inner lives. 39
Family, Culture and 3.8.1.3 Social Constructionism
Mental Health
Social Constructionism is a branch of sociology that questions the prevailing
commonly held views on the nature of reality. It touches upon the themes
underlying what is considered as normality and abnormality in a particular
society within the context of power and oppression in societal structures of
that society. For example, the concept of a social construction of schizophrenia
denotes that the label of ‘schizophrenia’ is one that has been socially
constructed through ideological systems. These ideological systems are often
not empirically defined as there is no definitive evidence for the causes of
schizophrenia currently.
3.8.1.4 Social Realism
Social realism, in sociology, refers to the assumption that social reality, social
structures and related social phenomena have an existence over and above
the existence of individual members of society, and independent of our
conception or perception of them.
The sociological perspectives of mental illness hold the view that it is essential
to consider the social phenomena in contributing to the causal process of the
illness.
3.8.2 Structural Strain Theory
Structural strain theory locates the origins of disorder in the broader
organization of society. In order to prevent or reduce mental illness, society
should be restructured to reduce levels of stressors or to enhance coping
capacity. Some social structures that cause stress are the effects of poor
neighbor hoods on mental health and disaster situations.
3.8.2.1 Effects of Poor Neighbourhoods on Mental Health
In a study by Faris and Dunham in the mid 1930’s, in Chicago, previous
residences of all patients admitted to hospitals for schizophrenia and other
psychoses was recorded. They found that schizophrenic patients had lived in
poor areas of the city, concentrated in the inner urban core, with high population
turnover, a high percentage of rental apartments and boardinghouses, and a
high percentage of foreign-born (probably immigrant) residents. Thus, they
observed a pattern. Schizophrenic tended to live in neighbor hoods in which
few people knew one other or formed lasting ties. This study concluded that
schizophrenia was caused, in part, by social disorganization and the prolonged
or excessive social isolation that it produced.
This conclusion was later not acknowledged. In 1965 Dunham suggested that
disorganized neighbor hoods do not produce mental health problems in
residents. Instead, disturbed persons selectively migrate into such neighbor
hoods because their poor mental health prevents them from having the jobs
or money needed to live elsewhere. However, the bulk of the evidence from
studies favors the causal influence of disorganized neighbor hoods on mental
health. This is because poor neighborhoods are characterized by high rates of
racial segregation, unemployment, single-headed families, residential instability,
crime, and physical decay, among an array of other disadvantages. These
features of neighborhood organization have distressing and depressing influences
in them selves. Neighborhoods, in short, are contexts or structures that generate
chronic strain as well as magnify community members’ personal difficulties.
40
3.8.2.2 Survivors of Disaster Sociology of Mental Health

In 1976, a study was conducted by Kai Erickson on the survivors of a

disaster. After a heavy rain fall, early one morning in 1972 in West Virginia,
a dam constructed poorly by the Buffalo Mining Company crumbled and
released tons of floodwater, which washed out 13 small coal mining communities
in the valley below. Many were still fast asleep and were caught by surprise.
Many were injured, 125 people were killed, and literally everything in the
floodwater’s path was destroyed or swept away. The survivors were then
taken by the federal to house them in scattered locations. Through in-depth
interviews with survivors, Erikson and other researchers found that the shocks
of destruction and damage caused by the flood were compounded by the
sudden and permanent loss of community. Connections with kin and long-
term neighbours and friends were cut by the survivors’ placements in haphazard
emergency housing. Almost all of the survivors suffered from at least some
symptoms of post traumatic stress disorder, which took years to dissipate.

Therefore, it can be noted that there are harmful consequences of social

isolation or the lack of social integration. Social isolation can also take place
at the individual level in terms of holding social roles.

3.8.2 Implications of Applying the Sociological Theories

in the Field of Mental Illness
Studies have reflected that mental illness has been prevelant among those who
are socially and economically disadvantaged or low in power and influence.
The idea of the organisational role in the aetiology of mental illness is unique
to this approach and may be neglected in other approaches to mental illness.
In order to understand the complex and multiple causes of mental illness, it
is necessary to study the stress caused by social systems, social institutions,
and community contexts. Structural strain theory suggests that to prevent or
reduce mental illness in society one must intervene in fairly large-scale ways,
for example, by combating racial segregation, bolstering access to college
education, buffering spikes in the unemployment rate, and expanding services
for the elderly.

Self Assessment Questions 2

Fill in the blanks :

1) ........................................ refers to the assumption that social reality,

social structures and related social phenomena have an existence
over and above the existence of individual members of society.

2) ........................................ is one who impresses, commands, shapes,

and sways his men, presents a number of extremely interesting
psychological problems.

3) Prejudice is ............................................................................... .

4) Social Constructionism is a branch of sociology that ................... .

41
Family, Culture and
Mental Health 3.9 LET US SUM UP
It can be summed up from the above discussion that social behaviour is a
result of interdependence, interaction and influence exerted between the
members of a particular society. Further, a person’s behavior is influenced by
social attitudes, social perception, attribution style, social influence and group
process. This is particularly applicable to the field of mental health. In addition
sociological theories explain the causes and consequences of social structures
and situations that affect mental health. Social attitude towards mental health
maybe favorable or unfavorable as it involves evaluation of an entity. Therefore
the understanding and management of mental health issues are affected by
social attitude. Secondly, how people perceive themselves socially can explain
certain conditions in mental health. Also, communication plays a significant
role in the process of social perception. Social influence such as conformity,
deviance and prosocial behaviour explains the way in which people behave
and change behaviour in the presence of others. The factors that influence
group membership and behaviour helps in understanding important issues such
as prejudice, stereotyping and stigma. Leadership and social power allows us
to predict how they can be used to change social behaviour and attitude.
Finally, the sociological theories explain social phenomena in contributing to
the causal processes of mental illness.

3.10 ANSWERS TO SELF ASSESSMENT

QUESTIONS
Self Assessment Questions 1
1) True
2) False
3) True
4) False
Self Assessment Questions 2
1) Social realism
2) The dominant leader
3) an attitude (usually negative) towards members of a specific group,
based solely on their membership on that group
4) touches upon the themes underlying what is considered as normality and
abnormality in a particular society within the context of power and
oppression in societal structures of that society.

3.11 UNIT END QUESTIONS

1) Write in detail about social attitudes and the ways to change them.
2) What is attribution?
3) What are all the dimensions of attribution?
4) What is attribution error?

42 5) How is attribution applicable in clinical setting?

6) Write about group process and the concept of prejudice in group Sociology of Mental Health
members.
7) Describe Stigma.
8) Write about the concept leadership and its role in sociology of mental
health.

3.12 REFERENCES
Lindgren, H. C., (1973). An Introduction to Social Psychology, 2nd Edn.
Wiley Eastern Private Limited, New Delhi.
Pennington, D. C., Gillen, K. & Hill, P. (1999). Social Psychology. Oxford
University Press, New York.
Seligman, M.E.P. (1975). Helplessness: Ondepression, Development, and
Death. San Francisco: W.H.F reeman.
Seligman, M,E.P. (1978).Comment and integration. Journal of Abnormal
Psychology, 87,165-179
Seligman, M.E.P., Abramson, L.Y., Semmel, A, & vonBaeyer, C. (1979).
Depressiveat tributional style. Journalof Abnormal Psychology, 88, 242-
247
Thambirajah, M.S., (2005), Psychological Basis of Psychiatry. Elsevier
Churchill Livingstone.

43
Family, Culture and
Mental Health UNIT 4 CULTURE AND MENTAL HEALTH
Structure
4.0 Introduction
4.1 Objectives
4.2 Culture and Mental Health
4.2.1 Meaning of Culture
4.2.2 Role of Culture in Mental Health
4.2.3 Indian Family, Culture and Mental Health System

4.3 Cultural Context of Understanding Mental Illness

4.3.1 Culture and Mental Illness
4.3.1.1 Cultural Identity
4.3.1.2 Cultural Explanation of Mental Illness
4.3.1.3 Psychosocial Environment and Level of Functioning
4.3.1.4 Cultural Elements of Relationship Between the Individual and the
Clinician
4.3.1.5 Overall Cultural Assessment for Diagnosis and Care
4.3.2 Culture-bound Syndromes
4.3.3 Culture and Stress

4.4 Immigration and Acculturation

4.4.1 Immigration
4.4.2 Acculturation
4.4.3 Fourfold Model
4.4.4 Cultural Factors Related to Immigration and Mental Health

4.5 Let Us Sum Up

4.6 Answers to Self Assessment Questions
4.7 Unit End Questions
4.8 References

4.0 INTRODUCTION
By now you must be well aware of the significance of family and environment
on the mental well being of an individual. In the last unit of this block, you
will be introduced about the relevance of culture on the mental health of
individuals. It is well known fact, that the differences in the way people think
and behave may also be influenced by the culture to which he/she belongs and
it has come to play a major role in the way mental health system is understood,
developed and administered. On basis of cultural differences, now individuals
are differentiated on basis of people who belong to a culture which gives
importance to belongingness to society (socio-centric cultures/ collectivistic)
and those cultures which give importance to individual independence
(individualistic). This kind of categorizations helps in understanding the need
of individual with mental health issues. It also helps in deciding what kind of
mental health care facility is to be provided for people with such needs. For
44
example, if people come from collectivistic communities it is essential to Culture and Mental Health
incorporate the social support systems (e.g., family) in the treatment process.
Specific behaviours that are considered to be deviant and classified as illness
are dependent on cultural values and norms. Cultural beliefs about deviant
behavior provide information to the cause of the illness, the views about cure
and predict access to the nature care system. For example, if schizophrenic
symptoms are believed to be caused by supernatural elements, the first choice
of treatment would be a faith healer and an underlying hope of complete cure
of the illness.

Culture formulates the expression and recognition of psychiatric problems.

Culture influences the meanings that are given to symptoms. Culture also
impacts the interaction between the patient and the health care system, as well
as between the patient and the physician and other clinicians with whom the
patient and family interact. Many people may not express their problems in
front of clinicians as it would be shameful act in a particular culture.

4.1 OBJECTIVES
With the help of this unit, you will be able to:

 define the concept of culture;

 explain the cultural aspects of mental health and mental illness;

 describe the different types of culture bound syndromes; and

 point out the specific issues related to immigration and acculturation.

4.2 CULTURE AND MENTAL HEALTH

Before we try to explain you the impact of culture on mental health, it is
necessary for you to understand the concept of culture. In the following
subsections, you will be explained about the concept and role of culture in
shaping up the mental health of individuals.

4.2.1 Meaning of Culture

Culture refers to a set of meanings, norms, beliefs, values, and behavior
patterns shared by a group of people. These values include social relationships,
language, nonverbal expression of thoughts and emotions, moral and religious
beliefs, rituals, technology, and economic beliefs and practices, among other
items.

Culture has six essential components: (1) Culture is learned. (2) Culture can
be passed on from one generation to the next. (3) Culture involves a set of
meanings in which, words, behaviors, events, and symbols have meanings
agreed upon by the cultural group. (4) Culture acts as a template to shape
and orient future behaviors and perspectives within and between generations
and to take account of novel situations encountered by the group. (5) Culture
exists in a constant state of change. (6) Culture includes patterns of both
subjective and objective components of human behaviour.
45
Family, Culture and 4.2.2 Role of Culture in Mental Health
Mental Health
Some of the role of culture towards mental health can be discussed as follows:
 Defines mental health- In any culture, in order to define mental health,
it is vital to identify the state of physical, mental and social well being of
an individual. Every culture has an ideal type of role an individual plays
and expectations based on cultural norms that define a sense of well
being. For example, cultural norms determine whether being submissive
or assertive is associated to well being in women. Men who are
competitive may be appreciated in one setting (e.g., corporate places)
but not in other setting. Therefore, in order to define mental health, it is
necessary to consider the context and cultural norms and values of the
sub group to which the individual belongs.
 Influences social competence- A culture also influences the social
competence among individuals. For instance, research indicates that cultural
norms and values effect the development of social competence in children,
particularly with respect to the meaning and evaluation of behaviors such
as sociability, shyness-inhibition, cooperation-compliance, and aggression-
defiance.
 Influences emotional expression- Culture can also have an impact on
the way one expresses emotions. The manner in which one experiences
depression and its expression is affected by the culture to which he/she
belongs, for instance, women in India are known to express their
depression through their body functions, such as headaches or body
pains rather than verbally expressing it.
 Influences behavior- The way one explains one’s own actions is also
influenced by culture. In fact, attribution of one’s own behavior is
considered as an important factor in the field of mental health. For example,
few cross cultural researches have shown that in cultures that stress upon
interdependence on each other, people tend to explain others’ actions in
terms of situational factors rather than internal or personal factors.
Therefore, deviant behaviour among people suffering from mental illness
may be attributed to external factors and less on individual factors. These
cultural differences in attribution may have a positive or negative impact
on individual’s responses to mental illness and different prognoses in
various parts of the world.
 Provides self identity- An individual’s existence of self and identity is
based on the culture one belongs to. Individual characteristics also interact
with social roles in specific cultural contexts. Throughout the world,
characteristics such as socioeconomic status, gender, age, color, ethnicity,
religion, sexual orientation, minority status, or, in some places, tribal/
caste status or immigration status affect not only role definitions but also
self-evaluations, employment opportunities, and quality of life. These social
perceptions clearly interact with the preexisting strains and stigmas of
mental illness. In any culture abuse to one’s mental health may adversely
affect an existing vulnerability or dysfunction.

46
4.2.3 Indian Family, Culture and Mental Health System Culture and Mental Health

Keeping in view the present scenario, researches have emphasized on the

need to preserve and strengthen family life in India as it provides support to
the person suffering from mental illness. As discussed in the previous unit also,
facts and findings have suggested that the traditional Indian joint families have
helped the clinicians to deal with mental health issues of their family members.
In Indian context, family is observed to be one of most important social
institution that has survived through the ages. Indian society deeply values
family integrity, family loyalty, and family unity. Further, in all the events of
significant decision makings like career choice, mate selection and marriage
are made by the family members collectively. Indian family is described to
basically patriarchal in its ideology. The hierarchy, roles and the rules of
conduct are clearly drawn. As discussed earlier also that the family members
in traditional joint family kind have strong emotional bonding, interdependence,
empathy, loyalty for each other. This is considered as the source strength for
the family to cope with major life events. There has also been a long tradition
of involving families in the treatment of mentally ill relatives. Therefore, the
need to preserve and involve families in treatment of mental illness has been
pointed out as being important.

4.3 CULTURAL CONTEXT OF UNDERSTANDING

MENTAL ILLNESS
It is very interesting to know that even for same kind of mental illness the
expression of deviant behaviour is not uniform across the various cultures.
Therefore, even though the prevalence of syndromes such as schizophrenia is
universal, the manifestations of the symptoms may differ and need to be
understood in their cultural contexts. The interpretations of symptoms will
differ based on their meaning, source, temporal nature, and curability. These
symptoms may evoke different social reactions, which affects treatment seeking
behaviour, compliance with treatment, functioning of the support system, stigma
attached to the illness etc. The major mental illnesses are characterized by
impairments of cognition and affection. Research findings show that there is
an underlying vulnerability for many of the categories of mental illness. However,
there are certain indicators to show that there may a relationship between
stress and mental illness and mental health.
4.3.1 Culture and Mental Illness
Research and experience in the treatment of mental illness shows that culture
affects mental health care and services in many ways. The significant influences
of culture on mental illness have been discussed in the subsections below.
4.3.1.1 Cultural Identity
A clinician’s treatment process can be influenced by the characteristics of the
person’s cultural group such as language use, religious belief, ethnicity, etc.
Cultural identity emerges throughout the individual’s life and in social context.
It is not a fixed trait of an individual or of the group of which the individual
is part. An individual may have several cultural reference groups. The clinician
needs to encourage the patient to describe the various elements like beliefs 47
Family, Culture and of the culture to which he/she belongs. Evaluating the cultural identity of the
Mental Health patient allows identification of potential areas of strengths and supports that
may enhance treatment effectiveness, as well as vulnerabilities that may obstruct
the process of treatment.
With the help of the awareness of the patient’s cultural identity the clinician
may be able to,
 Avoid the misconceptions based on inadequate background information
or stereotypes related to race, ethnicity, and other aspects of cultural
identity.
 Develop a better rapport with the patient, as it enables the clinician to
understand the patient in a better way.
 Enhance effectiveness of treatment and
 Understand the vulnerabilities that can interfere with progress of treatment.
4.3.1.2 Cultural Explanation of Mental Illness
There may be a difference in the opinions of the clinician and the patient
regarding the nature and causes of his/her illness and the treatment options
they would consider. The explanatory model defines that such differences will
occur due to the differences in their culturally acceptable means of expression
of the symptoms of the illness and their behavioral response. Conflicts between
the patient’s and the clinician’s explanatory models may lead to diminished
rapport or treatment noncompliance. Conflicts between the patient’s and the
family’s explanatory models of illness may result in lack of support from the
family. Conflicts between the patient’s and the community’s explanatory models
could lead to social isolation and stigmatization of the patient. Few examples
of the more common explanatory models are as follows:
 The moral model implies that the patient’s illness is caused by a moral
defect such as selfishness or moral weakness.
 The religious model suggests that the patient is being punished for a
religious failing or transgression.
 The magical or supernatural explanatory model may involve attributions
of sorcery or witchcraft as being the cause of the symptoms.
 The medical model attributes the patient’s illness primarily to a biological
etiology.
 The psychosocial model infers that overwhelming psychosocial stressors
cause or are primary contributors to the illness.
Culture has both direct and indirect effects on help-seeking behavior. In many
cultural groups an individual and his or her family may minimize symptoms due
to stigma associated with seeking assistance for psychiatric disorders. Thus,
culture influences the patient’s expectations of treatment.
4.3.1.3 Psychosocial Environment and Level of Functioning
In order to understand the patient’s psychosocial environment, it is important
48 to know about their family dynamics and cultural values. Even in the case of
immigrants, where one person moves out from his society, it is important to Culture and Mental Health
know how the individual and family perceive the openness of the host society
toward people of their country and region of origin, their racial, ethnic, religious,
and other attributes. For instance, when a person from India immigrates to a
western country, how he views the perception of people from that particular
country about Indians is important. The mental health also depends on how
the individual identifies the cultural support of the host country when comparing
to their region of origin. The patient and family may identify strongly or weakly
or at the same gradient with communal sources of support in the host culture.
4.3.1.4 Cultural Elements of Relationship between the Individual and
the Clinician
The cultural identity of the clinician and of the mental health team has an
impact on patient care. Lack of recognition about patient’s cultural identity
may lead to unintentionally biased treatment. Culture influences the relationship
between the patient and the clinician. When the patient and clinician are of
different genders, culturally ingrained role assumptions may create difficulties.
For example, male patients from cultures where men are assumed to have
higher status , the male patient may feel that expressing their emotional problems
to a female therapist is evidence of weakness and is culturally humiliating.
Conversely, females may view it as culturally inappropriate to discuss with
male clinicians interpersonal issues and emotions that are only considered
proper to talk about with females of their age group and within the setting of
their extended family. Thus, it is important for the clinicians to examine their
assumptions about other cultures in order to give better service.
4.3.1.5 Overall Cultural Assessment for Diagnosis and Care
In order to successfully deal with the patient, the clinician includes the use of
culturally appropriate health care and social services. The clinician may include
the family and social levels in their interventional plan. In making a psychiatric
diagnosis the clinician should not use classification systems developed for one
culture to another culture where its relevance may not be comparable. As
discussed earlier also, many psychiatric disorders show cross-cultural variation.
The evaluation of cultural factors on psychopathology can be a challenging
task for the clinician.
4.3.2 Culture-Bound Syndromes
The cross-cultural literature has shown that certain disorders or psychotic
behaviors are found only in specific cultural settings. Therefore the cultural
and belief systems influence the presentation of illness. The following are
examples of some of the culture-bound syndromes/symptoms:
Koro: More Prevalent in Southern China, Southeast Asia, India. This is a
mental disturbance characterized by a man’s belief that his penis is shrinking
into his abdomen. It is now considered an acute anxiety state associated with
sexual dysfunction.
Windigo psychosis: Usually found among Cree Eskimos and Ojibwa of
Canada. This disturbance is characterized by cannibalistic delusions. The victim
believes he has been transformed into a giant monster that eats human flesh.
This delusion is possibly derived from tribal mythology and reflects the survival
struggle in the Arctic.
49
Family, Culture and Arctic hysteria: Prevalent in Polar Eskimos. The person may scream for
Mental Health hours, imitating animal cries, while thrashing about on the snow in the nude
or partially undressed. Some attribute the condition to diet, to hypo-calcemia,
or hyper-vitaminosis-A.
Latah: Found among Southeast Asians. This syndrome appears most commonly
among women who break into obscenities and echolalia after an event that
startles them. They may also follow commands automatically or repetitively
imitate another person. It has been suggested that latah is an arousal state
(possibly located in the amygdala) that may have developed as an adaptive
response to snakes. Seeing a snake is a common precipitant of the startle
response in Malayan and Filipino cultures, where snake bite is a major cause
of morbidity.
Susto or Espanto: Found among Latin American Indians. It is a fear state or
sudden fright attributed to loss of soul by the action of spirits, the evil eye,
or sorcery. Symptoms include weakness, loss of appetite, sleeplessness,
nightmares, and trembling, and their frequency in this population has sometimes
been attributed to hypoglycemia. Susto may be diagnosed as a brief reactive
dissociative disorder, but it is unlikely to be healed by modern psychiatry. Its
cure requires a traditional healer whose ministrations will influence the spirits
to release the soul and return it to the host body.
4.3.3 Culture and Stress
According to the stress-diathesis hypothesis, stressful environmental events
lead to biological vulnerability towards a specific condition. Many experts
today tend to accept the diathesis-stress hypothesis in the case of major
psychiatric diagnoses with known biological and genetic parameters, such as
schizophrenia, bipolar disorder, or obsessive-compulsive disorder. Thus, it is
important to know the interactions of the social and cultural environment of
an individual before implying treatment towards mental disorders.
Self Assessment Questions 1
State whether the statements are ‘true’ or ‘false’
1) Susto or Espanto is a fear state or sudden fright attributed to loss
of soul by the action of spirits, the evil eye, or sorcery ...................
2) Research and experience in the treatment of mental illness shows
that culture affects mental health care and services in many ways
............................... .
3) The cultural identity of the clinician and of the mental health team
does not has an impact on patient care ............................................
4) In order to understand the clinician’s treatment, it is important to
know about their family dynamics. ............................................... .

4.4 IMMIGRATION AND ACCULTURATION

The process of immigration and acculturation also has an impact on the mental
health of individuals because it involves adaptation and adjustment towards
50
another culture. In order to make it more clear to you let us deal with both Culture and Mental Health
the processes and their outcome one by one:
4.4.1 Immigration
Refers to the movement of people into a country or region from their native
place. Immigration is made for many reasons, including temperature, breeding,
economic, political, family re-unification, natural disaster, poverty or the wish
to change one’s surroundings voluntarily.
4.4.2 Acculturation
Refers to the process of cultural and psychological change that results following
meeting between cultures. The effects of acculturation can be seen at multiple
levels in both interacting cultures. At the group level, acculturation often results
in changes to culture, customs, and social institutions. Noticeable group level
effects of acculturation often include changes in food, clothing, and language.
At the individual level, differences in the way individuals acculturate have
been shown to be associated not just with changes in daily behavior, but with
numerous measures of psychological and physical well-being. As enculturation is
used to describe the process of first-culture learning, acculturation can be
thought of as second-culture learning.
4.4.3 Fourfold Model
The four possible outcomes of immigration and acculturation are separation,
integration, assimilation, and marginalization.
1) Separation- When an individual shifts to a new culture, then the individual
may wish to maintain his/her cultural integrity, whether by actively resisting
the incorporation of the values and social behavior patterns of another
cultural group or groups with whom they have regular contact, or by
disengaging themselves from contact with and the influence of those other
cultural groups. Some religious cults are examples of separation.
2) Integration- It is an outcome of acculturative stress faced by an individual
which is derived due to the desire to both maintain a firm sense of one’s
cultural heritage and not abandon those values and behavioral
characteristics that define the uniqueness of one’s culture of origin. At the
same time, such individuals are able to incorporate enough of the value
system and norms of behavior of the other cultural group with which they
interact closely, to feel and behave like members of that cultural group,
principally the majority host culture. Accordingly, the defining feature of
integration is psychological: It is the gradual process of formulation of a
bicultural identity, a sense of self that intertwines the unique characteristics
of two cultures.
3) Assimilation is the psychological process of the conscious and
unconscious giving up of the unique characteristics of one’s culture of
origin in favor of the more or less complete incorporation of the values
and behavioral characteristics of another cultural group, usually, but not
always, the majority culture. Examples include involuntary migration, during
war for survival purpose. However, there are many other life
circumstances, including racial, ethnic, and religious discrimination, that
motivate people to overlook, suppress, or deny aspects of their cultural 51
Family, Culture and heritage in an attempt to have a seamless fit within another group. The
Mental Health price of such an effort, in terms of intrapsychic conflict, can be high.
4) Marginalization is defined by the psychological characteristics of rejection
or the progressive loss of valuation of one’s cultural heritage, while at the
same time rejecting, or being alienated from, the defining values and
behavioral norms of another cultural group, usually that of the majority
population. This is the psychological outcome of acculturative stress that
is closest to the concept of identity diffusion. As such, it is most often
exemplified by the angry, lost, and anguished youth and young adults of
many groups, those whose intense intrapsychic conflicts are reflections of
substantive intrafamilial, intergenerational, intracommunal, and
intercommunal conflict. Part of their search for psychological meaning
and self-esteem is reflected in their turmoil about their ethnic identity and
in their formation of a negative identity.
The literature on acculturation and acculturative stress emphasizes the need
for long-term study of the process. With the help of an understanding towards
stress due to acculturation, clinicians can take account of its complex influence
on the clinical presentation of the very large numbers of people affected by
it and thereby improve the quality of their treatment.
Studies suggest that individuals’ respective acculturation strategy can differ
between their private and public life spheres. For instance, an individual may
reject the values and norms of the dominant culture in his private life
(separation), whereas he might adapt to the dominant culture in public parts
of his life (i.e., integration or assimilation).
4.4.4 Cultural Factors Related to Immigration and
Mental Health
By now you must have understood that culture influences the health belief
system and has an effect on the diagnosis and treatment of mental disorders.
However, there is tremendous cultural variability among groups and
heterogeneity within groups.
Several key cultural factors that are relevant to this process are as follows:
 Language: language is one of the important factors influencing access to
health care. When a person immigrates to another country/state wherein
the language of communication is different, the communication between
the clinician and the person could be problematic.
 Level of acculturation: Studies towards immigration in western countries
have shown that generally it takes three generations for immigrants to
fully adopt the lifestyle of the dominant culture. Therefore the feelings of
alienation, disconnectedness would lead to mental health issues.
 Age: In general, the younger people can easily adapt to a different culture
when they migrate than older people.
 Gender: There are higher chances for men to adapt to another culture
than women because of exposure to the other culture.
 Traditional beliefs about mental health: The belief system about mental
illness differs from one culture to the other. This can influence the access
the mental health care; this in turn will affect the compliance with treatment
52 and the prognosis.
These factors will have differing effects, depending on the individual’s degree Culture and Mental Health
of acculturation, socioeconomic status, and immigration status.
Many studies conducted among the immigrants at different countries showed
that the immigrants showed above-average levels of admissions for
schizophrenia to psychiatric hospitals. This could mean that immigrants face
stressful situations while living in an alien country and culture. It might be
suggested that for persons suffering from mental illness, appropriate education
of caregivers or others in the person’s social network, can help in minimizing
stress.

Self Assessment Questions 2

State whether the statements are ‘true’ or ‘false’
1) Immigration refers to the process of cultural and psychological change
that results following meeting between cultures ........................... .
2) Marginalization is defined by the psychological characteristics of
rejection or the progressive loss of valuation of one’s cultural
heritage, while at the same time rejecting, or being alienated from,
the defining values and behavioral norms of another cultural group,
usually that of the majority population .................................. .
3) Language is one of the important factors influencing access to health
care .................................. .
4) The younger people can easily adapt to a different culture when they
migrate than older people .................................. .

4.5 LET US SUM UP

It can be summed up from the above discussion that culture plays a significant
impact on the mental health and belief system of individuals. The assumptions
of role of culture in psychological processes and the application of this in
understanding cultural issues in mental health and mental illness is significant.
Culture is no more a stable unchanging aspect, as there are wide spread
political, demographic and economic changing taking place globally. Therefore,
cultural aspects have become increasingly important in view of the diversity
that exists in a given society, specifically in terms of mental health issues. It
should also be understood that the therapists need to be sensitive to the
cultural background of the clients. When dealing with clients from different
backgrounds, treatment should incorporate three components: awareness,
knowledge and skills. Further, immigration has also resulted in mental illness
due to the process of acculturation with the change of time.

4.6 ANSWERS TO SELF ASSESSMENT

QUESTIONS
Self Assessment Questions 1

1) True

2) True 53
Family, Culture and 3) False
Mental Health
4) False

Self Assessment Questions 2

1) False

2) True

3) True

4) False

4.7 UNIT END QUESTIONS

1) Define culture. What are the components of culture?

2) Describe the important cultural factors that have to be considered by the

therapist in the management.

3) Write briefly about culture-bound syndromes.

4) Write in detail about immigration and acculturation.

5) What is cultural identity?

6) What is cultural stress?

4.8 REFERENCES
Sadock B, & Sadock V, (2007). Kaplan and Sadock’s synopsis of
psychiatry, Behavioural sciences/clinical psychiatry, 10th edn. Lippincott
Williams & Wilkins, New Delhi.

Kramer E, Kwong K, Lee E, and Chung H (2002). Family culture and

mental health, Western journl of medicine, September, 176(4).
Cooper C R., & Denner J (1998). Theories linking culture and
psychology: Universal and Community-Specific Processes, Annu Rev.
Psychol. 49:559-8.
Lefley, H.P., (2010). Mental health systems in cross cultural context, in A
handbook for the study of mental health- social contexts theroies and systems,
eds. Scheid, T. L., Brown, T.L, Cambridge university, NY.

54
 MPC-051 : FUNDAMENTALS OF MENTAL HEALTH

Block 1 : Concept of Mind

Unit I : r~1entalHealth
Unit 2 : Mind: Constituents of Mind
Unit 3 : Biological Basis of Mind
Unit 4 : Psychological Basis of Mind
~------------------------------------------------------------4

Block 2 : Schools of Psychology

Unit I : Behavioural Theories
Unit 2 : Biological Theories
Unit: 3 : Humanistic and Existential Psychology
Unit 4 : Psychoanalytical and Related Theories
------------------------------------------------------------

Block 3 : Normality and Abnormality

Unit 1 : Historical Perspectives of Mental Health
Unit 2 : Definition of Normality and Abnormality: Criteria and Measurement
Unit 3 : Conative Functions-Normal and Pathological
Unit 4 : Cognitive Functions-Normal and Pathological
~-------------------------------------------------------------

Block 4 : Family, Culture and Mental Health

Unit 1 : Developmental Theories
Unit 2 : Family and Mental Health
Unit 3 : Sociology of Mental Health
Unit 4 : Culture and Mental Health
SOSS-IGNOU/P.O. 3T/August, 2015

ISBN: 978-81-266-6906-6