CF02 : Family in India

Understanding Mental Health and the Role of Family in India

Submitted by :

Neeti Prakash (M2019CF009)

Neha Nizam (M2019CF010)
Rahul Khumbalwar (M2019CF014)

Submitted to : ​Dr. Pekham Basu

Abstract : ​Mental health has become a burgeoning area of research and discussion in social
work. The centrality of the family in Indian society means that it becomes a crucial determinant
of mental health for thousands of Indians. Academicians have amply highlighted the importance
of family in recovery and support for patients of mental illness. However, when it comes to
mental health, the role of the family cannot be analysed only in terms of caregiving. The family is
a dynamic system and its impact on mental health can be both positive as well as negative. This
paper explores the various roles the family can play in compounding mental health issues as
well as mitigating them. By analysing the mental health status of India, social determinants of
mental health in India, the role of dysfunctional families in mental health and finally of
caregiving families in mental health, we highlight how individual mental health is constantly
defined and redefined through the family system and that family is a fluid context for mental
health, where its functions as cause and caretaker of mental illness can be the two sides of the
same coin.

Introduction: Defining Mental Health and Mental Illness

American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders

(2013) defines mental illness as “any condition characterized by cognitive and emotional
disturbances, abnormal behaviors, impaired functioning, or any combination of these”. Such
disorders cannot be accounted for solely by environmental circumstances and may involve
physiological, genetic, chemical, social, and other factors.

Up until the late 20th century, mental health was understood from the point of view of defining
and categorising illnesses rather than planning care and recovery. In the 1960s and 1970s, the
emphasis was on formulating a diagnosis using limited, broad categories of illnesses. However,
formal definitions of mental health have evolved considerably over the decades. There has been
a noticeable shift away from focusing on the disease to focusing on the health of the individual
(Manderscheid et al, 2010). Today, the “wellness model” of mental health, which sees illness not
in isolation but as a part of a continuum with health, has been widely accepted as the framework
for defining mental illnesses health. Within this model “health and disease are viewed as two
separate (but connected) dimensions. Recovery is the bridge between the two that builds on the
strengths of health to address the weaknesses of disease (Manderscheid et al, 2010, p. 2).

World Health Organization (WHO) (2004) defines mental health as “a state of well-being in
which the individual realizes his or her own abilities, can cope with the normal stresses of life,
can work productively and fruitfully, and is able to make a contribution to his or her
community”. Over the years, many new definitions of mental health have emerged.In 2015,
Galderisi et al forwarded a new, more elaborate definition of mental health. Through this
definition, they intended to present mental health as more than mere absence of mental illness
and as a combination of a number of physiological, psychological and social factors. They define
mental health as “Mental health is a dynamic state of internal equilibrium which enables
individuals to use their abilities in harmony with universal values of society. Basic cognitive and
social skills; ability to recognize, express and modulate one's own emotions, as well as
empathize with others; flexibility and ability to cope with adverse life events and function in
social roles; and harmonious relationship between body and mind represent important
components of mental health which contribute, to varying degrees, to the state of internal
equilibrium. (Galderisi et al, 2015, p. 231-232)”.

In India, mental health and care towards individuals struggling with mental illnesses became
formalised in 1987 with the passing of the Mental Health Act, 1987. The act, which superseded
the colonial Indian Lunacy Act of 1912, aimed at creating an organised set of provisions for the
treatment and care of individuals with mental illnesses. In 2017, the Mental Health Care Act was
passed to supersede the 1987 law. The new law focuses on enhancing the agency of those
struggling with mental illnesses and tackling the stigma around mental health. To that end, it
decriminalises suicide and restricts usage of invasive mental health procedures without informed
consent.

How mental illness is experienced and mental health is cultivated depends on a number of
factors, one of the most crucial of which is family. On the question of mental health, families can
occupy a number of roles. They can be the targets of mental illness, due to a range of
psycho-social determinants, they can be contexts where mental illness is created and exacerbated
for their members as well as wholesome environments where recovery and rehabilitation from
mental illness and the journey towards a well-rounded mental health is possible. In this paper, we
will be exploring the various roles played by families in sustaining mental illnesses as well as
holistic mental health. We begin by exploring the mental health status of India in the first
section. In the sections following that, we analyse the various social determinants of mental
health in India, how families can become dysfunctional contexts where mental health worsens,
the caregiving role played by families and its impact on their family members. In doing so, we
also explore how the experience and effects of mental health differ for different members of the
families, across the intersectionalities of age and gender. We conclude by analysing the gaps in
the present literature and making recommendations for social work practice.

Status of Mental Health in India

Mental health discourse in India witnessed a watershed moment in 2016 when the first National
Mental Health Survey was published. The survey aimed to assess the mental health issues and
areas of concern across the country. It was was the first nation-wide analysis to take stalk of the
pressing mental illnesses across various vectors such as age, gender, region and so. Headed by
the National Institute of Mental Health and Neurosciences, Bengaluru, it attempts to map the
various dimensions of mental health in India, their social determinants and their possible causes
and solutions. The following is the status of mental health in India as presented by the survey.

● Variations in Prevalence of Mental Illnesses exist at the Regional and State levels

The current general prevalence estimate was 10.6% of the population surveyed, but in the
different states surveyed significant changes in total morbidity vary from 5.8% in Assam to
14.1% in Manipur. The prevalence rates in 3 states Assam, Uttar Pradesh, and Gujarat have been
below 10%, with a prevalence of between 10.7% and 13.0% in 8 of the 12 countries.

There are also differences between urban and rural populations, and previous studies have
highlighted them. Differences in multisite sites are well recognized (World Mental Health
Survey, Indian Diabetes Survey, etc.) and may be due to natural variation, culture-based and
symptom-based reporting on mental illness, the consequences of socio-demographic differentials
and other issues. The survey modified uniform methods. (National Mental Health Survey,
2015-16)

● Mental Disorders Contribute to a Substantial Disease Burden in India

It is estimated that mental morbidity in persons above the age of 18 is currently 10.6 percent
outside tobacco use disturbance based on reliable, structured data collection methods for a
nationally reflect the population. The prevalence of mortality in the population studied was
13.7%. This percentage of the chronically mentally ill population requires active intervention.
This number covers a range in the International Classification of Disorders (ICD-10) of
psychiatric disorders F10-F49 categories. Almost 150 million Indians are in need of active
interventions in real numbers (based on weighting for different levels).

● Common Mental Disorders affect Significant Sections of Society

The large burden affects about 10.0 percent of the population is common mental disorders
(CMDs), including depression, anxiety disorders and the use of drugs. The cause and effects of
multiple non-communicable disorders (NCDs) are also closely associated with this group of
disorders and thus lead to a significantly increased health care burden. In the planning and
delivery of health care programmes, these disorders were previously disordered. Such disabilities
are also misunderstood and overlooked by individuals and families until they are severe.

● Severe Mental Disorders are Equally Important

Almost 1.9% of the population had serious mental disorders in their lives and 0.8% were found
to be affected by serious psychiatric conditions. More serious mental illnesses have been
observed among males and those living in city metro areas, including schizophrenia, other
non-affective psychoses, and bipolar affective disorder. In most states, the prevalence of serious
mental disorders in Manipur and West Bengal was less than 1 percent. Although the prevalence
is very low compared to common mental disorders, the manifestation, outcome and the effect of
severe mental illnesses are just as important as CMDs. In addition, these disorders are associated
with a significant stigma because they affect all areas of life and need long-term rehabilitation.

● Prevalence of Mental Morbidity Could be Associated with Urbanisation

The weighted prevalence in urban metro diagnosis categories was higher (less than 10 million)
than in rural and non-metro urban areas. There are, however, variations between types of
diagnosis. The prevalence of schizophrenia and other psychoses (0.64%), mood disorders (5.6%)
and neurotic or stress related disorders (6.93%)was nearly 2-3 times more in urban metros.

The contribution of several factors (fast-paced lifestyle, stress, complexities of life, the
decomposition of support systems, economic instability challenges) to this increased prevalence
can be speculated and taken into account, and further research is needed to understand the
relationship between urbanisation and mental illness. The burden is expected to increase with
constant urban planning and thus a specific urban mental health program is needed. Although the
cause, risk factors and protective factors of urban and rural populations vary, accessibility,
affordability and awareness of mental health services are important drivers of the use of service.
Therefore, it is important to provide equitable coverage of mental health services throughout
India.

● 1 in 20 people in India Suffer from Depression

The weighted rate of depression was 2.7% and 5.2% both for the present period and for life,
which showed that almost 1 in 40 and 1 in 20 suffered from the depression both past and present.
Depression in women, 40-49 year olds and in those residing in urban metros has been reported to
be higher.

● High Suicidal Risk is an Increasing Concern in India

Almost 1% of the population has indicated a high risk of suicide. The prevalence of high suicidal
risk was more in the 40-49 age group (1.19%), among females (1.14%) and in those residing in
urban metros (1.71%). Although half of this suicide risk group has a mental disorder, half of
them have not reported any mental disorder. It means that multi-sectoral efforts are essential. The
causes, risk factors, and consequences are not well known, in addition to the loss of lives (mostly
young), in India, and this requires quality research at national and state levels, as well as a
concerted, systematic study. Suicide and suicidal ideation are very sensitive issues of public
health.

● ‘Productive’ Age Groups are Affected Most

The worst affected age groups are males aged 30 to 49 years were indicative of greater morbidity
in the productive population as a consequence of mental disorders. In this age group, the
prevalence of all disorders affects productivity, earnings, and quality of life.

● Struggle with Mental Illness Exists Across Genders

There are significant differences in class in various mental illnesses. The prevalence of mental
illness in males was higher (13. 9%) than in females (7.5%). In females, there was however a
higher proportion of special psychological conditions such as mood disorders such as depression,
neurotic disorders, phobias, agoraphobia, generalized anxiety disorders, and
obsessive-compulsive disorders.

● Mental health status of Elderly

Mental disorders affect everyone, irrespective of age, gender, residence and living standards,
even though some groups are at a higher risk for certain illnesses; only the impact varies.
Amongst elderly the two most prevalent mental disorders are Depression and Dementia. The
depression rate in elderly is 3.5% which is very similar to the rate of depression in middle age
population

● Children and Adolescents are Vulnerable to Mental Disorders

In 13-17 years the prevalence of mental disorders was 7.3% and almost the same in both sexes.
Almost 9.8 million young Indians aged 13-17 need to be actively involved. The prevalence of
mental disorders in urban metropolitan areas was nearly twice (13.5%) higher than in rural
(6.9%). The main problems that occurred were: depressive episode & recurrent depression
disorder (2.6%), phobic anxiety disorder (1.3%) or psychotic disease (1.3%) (2.3%), intellectual
disability (1.7%), and autistic spectrum (1.6%). A study recently conducted in the State of
Himachal Pradesh over 15 to 24 years found that teenagers suffered from a range of mental
health conditions such as depression (6.9%), anxiety (15.5%), tobacco (7.6%), alcohol (7.2%),
suicidal ideation (5.5%) and urgency intervention13. Early recognition and intervention will
contribute to positive results (National Mental Health Survey, 2015-16).

Notwithstanding the seriousness and extent of CAMH disorders, the large population of over 435
million child and adolescent people in India does not have a comprehensive CAMH policy
(Hossain and Purohit, 2019). The state has adopted several policies to fill the gap including
National Child Policy (1974), National Education Policy (2019) and the Mental Health Act
(2017), National Nutrition Policy (2015), National Health Policy (2002, 2016) and the National
Mental Health Policy (2014). At the regional level, most states lack an explicit CAMH policy
other than Kerala which has been designed to improve young people's mental health.

The issue of mental health has also been recognized by Rashtriya Kishor Swasthya Karyakram
(RKSK) as one of the six strategic priorities of the national teenage health strategy. The
government of India launched this project in 2014 and planned to take effect through the
National Health Mission by the State Government. The program has introduced peer counseling
at the levels of schools and communities alongside other activities, such as improving food
supply and reproductive health (Hossain, & Purohit, 2019).

When it comes to the family mental health, the status has been assessed primarily as a sum of the
mental health of its individual members. The emphasis on mental health is not as concrete as it
could be in the National Family Health Survey. There is no comprehensive policy to address
family mental health. Although many policies, including the Mental Health Care Act of 2017 do
acknowledge the importance of family with respect to mental health, this importance is only
accorded in the caregiving context. In our policies, the family is only seen as a system which
helps an individual with mental illness cope with their declining mental health or as a system
whose absence is a primary cause of the mental health issue. However, the fact is that the
family’s relation to mental health is far more complex. In the following sections, we analyse
these different relations of the family with mental health.

Social Determinants of Mental Health in India

Health and illness are not only biological phenomena but also social ones. Conrad and Barker
(2010) argue that health and its experience is largely socially constructed. Social construction of
health implies that the biological and physiological processes of health come to be pinned in a
broader social framework. Therefore, while it is true that biology dictates to a large extent how
an illness is created and propagated, the experience of health and illness, the ability to access
diagnosis, treatment, and the experience and nature of recovery and rehabilitation are largely
determined by social factors and norms of culture.

Social determinants of health are defined as those social and cultural factors, such as conditions
in which people are born, grow, live, work, and age, that have an impact on our overall health
and well-being (Shim et al, 2014). Much like in other areas of health, in mental health, these
determinants allow us to understand illnesses and their impact beyond their physiological
dimensions and contextualise their diagnosis and treatment.

Over the last couple of decades, there has been burgeoning interest in the social determinants of
mental health. Lund et al (2014) argue understanding the social determinants is essential because
it helps us analyse the etiology of mental disorders from a social perspective. A social etiology of
mental illnesses expands the scope of addressing mental illnesses and paves way for
population-level interventions.

In India, mental health has unique socio-demographic determinants which determine the
experience of mental illness. In order to understand family mental health, it is crucial to locate
families in their contexts.

1. Economic Status : It is a well-documented fact that economic status and financial

liquidity plays a huge role in defining mental health for an individual as well as a family.
Economic status can be a major cause of distress which can lead to the development of a
number of mental health issues within a family. Kuruvilla (2007) highlighted that
“poverty, acting through economic stressors such as unemployment and lack of
affordable housing, is more likely to precede mental illnesses such as depression and
anxiety, thus making it an important risk factor for mental illness” (p. 274). NMHS
(2016) also highlighted the role of income in aggravating mental illnesses. According to
the survey, the prevalence of psychiatric morbidities was highest in individuals from the
 lowest income quintile (15.6% as compared to the 12.2% prevalence in the highest
income quintile). Low income affects families’ ability to seek diagnosis and treatment for
mental illnesses since mental healthcare can ​b​e expensive and limited funds are dedicated
to other priorities like food and housing.With the inclusion of mental health in the
national insurance scheme, Pradhan Mantri Jan Arogya Yojana (2018), the effects of
economic status on mental health might be mitigated to some degree.

2. Caste : Caste identity can determine the experience of other social determinants
especially economic status, education, livelihood and social norms. By that virtue, or
vice, it can be a major determinant in family mental health, especially for oppressed
castes. Humiliation, degradation and violence experienced by families from oppressed
castes has widespread mental health consequences including, low self-esteem, shame,
fear, depression, PTSD, panic disorder and generalised anxiety disorder (Pal, 2015).
Furthermore, exclusion, discrimination, stigma and the economic challenges associated
with certain caste identities can prevent families from oppressed castes from accessing
mental healthcare.

3. Religion : ​Much like caste and gender, religion as a social determinant operates by
determining the experience of other social determinants. For minority religions,
persecution, discrimination and communal violence could be major stressors which could
lead to PTSD, sleep disorders and anxiety. Minority status and the social exclusion that
comes with it could also negatively impact access to mental healthcare. However, many
theorists postulate that the religious communities play the role of providing social
support which can mitigate mental health problems. Durkheim (1912) highlighted that
one of the social functions religion plays is that of social cohesion. The cohesion and
support provided by communities rooted in religion could provide a wide range of
material and emotional resources which could prevent mental health issues. They could
be used to mitigate challenges posed by other determinants such as economic status and
livelihood. Communities are also an accessible frontier of psychological service. Rogers
and Stanford (2015) highlight the importance of church-based peer-led support groups in
enhancing access to psychoeducation, coping skills, and increased interpersonal
connections.

4. Age : Age is a key factor in determining the experience of mental health and illness
within a family. Being the key dependents, children and the elderly are also put at risk of
mental illness within the family. The NMHS (2016) states that at least 7.3% of
adolescents suffer from some form of mental illness. It also indicates that the highest
prevalence of psychiatric morbidities is found adults between the age groups of 40-49
years(18.3%) and 50-59 years (16.1%). Both ends of the age scale, by the virtue of
 having little to no bargaining power in the household, are susceptible to neglect, abuse
and even violence. The impact of poverty, lack of education and gender discrimination in
the family is also felt more acutely by these groups, who have special needs at their age
junctures which tend to be overlooked. These factors contribute to a number of mental
illnesses like depression, eating and sleeping disorders, behavioural disorders and so on.
While the vulnerability of children and associated mental illnesses is well-documented,
the vulnerability of the elderly has only recently been picked up as a crucial area of study.
Helpage India (2018) reports that of the 5014 elderly they surveyed, nearly 25%
confirmed that they had been abused by their family. Patel et al (2018) found a strong
correlation between mental morbidities in the elderly and abuse at home.

5. Education : ​The NMHS (2016) reports that prevalence of psychiatric morbidities is

14.6% amongst individuals who are illiterate while it is 9.5% amongst individuals who at
least have pre-university, vocational education. Education can positively affect other
socio-demographic areas such as economic status, family structure, perception of mental
illnesses and gender status and contribute in improving mental health. Fahey et al (2017)
screened 663 rural Indian women for Common Mental Disorders (CMD). 1 in 4 women
screen positive for CMDs and this was associated with, among other factors, with low
education and the perceived stress from them. They concluded that increasing education
could mitigate the association between high stress and CMDs. “Education enhances
self-esteem and autonomy of women, which might be the underlying mechanism for the
observed protective effects of increasing levels of education for the risk of CMD in the
context of elevated stress levels” (Fahey et al, 2017, p. 6).

6. Family Structure : ​The 21st century is seeing a varied number of family forms. Family
is no longer understood only in the hetronormative sense, with two heterosexual parents
and children. Family structure can determine economic status and can be dictated by
religion and social norms. Its interdependence on other social determinants that makes
family structure an important determinant of mental health. Kumar (2011) highlights that
single-parent families experience extreme stress, both at the end of the parent as well as
the child. The financial instability that accompanies single-parenthood, potential conflict
with estranged partner and the diminished attention towards the child can also lead to
mental illness issues like resentment, depression, separation anxiety and antisocial
behaviour in the family. Working-parents families, which have become the norms in
many urban centres of the country, are more stable on the financial front but can be a
context of mental illness because of lack of bonding and family time (Kumar, 2011) .
These effects can, however, be mitigated by the involvement of relatives and the
community (fictive kinship ties).
 7. Gender : Gender’s role in defining mental health experience is often that of exacerbating
the effects of other social determinants. For example, women’s mental health is
disproportionately affected by their family’s poverty because they are primarily
responsible for managing the household, which can lead to illnesses like anxiety and
panic disorder (Sharma et al, 2019). They are also often the primary targets of
frustration-driven violence perpetrated by other members of the family. Experience of
caste exclusion, discrimination and violence can be far worse for women from the
oppressed castes who are often victimised by sexual violence by dominant castes which
can lead to PTSD, anxiety, social isolation, and delusions (Pal, 2015). Certain religions
have stricter sanctions for women which can give rise to a new range of mental health
challenges. For example, the sanctions around widowhood in Hinduism can alienate and
stigmatise women, making them susceptible to ailments like depression. In India, the
literacy rate amongst women is also lower (65.5% as compared to 82.1% in males) which
can be an obstacle in their access to mental health healthcare (Census of India, 2011).
They also face unique challenges like pregnancies, childbirth and miscarriages which are
associated with mental illnesses like postpartum depression and anxiety.

8. Social Perceptions around Mental Health : Taboos and stigma attached to mental
health in India is perhaps the single most overarching social factor which impedes access
to mental healthcare and treatment of mental illness. ​I​n India, mental illnesses have
always had religious and superstitious connotations.This has affected how individuals are
socialised to perceive mental illnesses and consequently, ignore it or suppress it if they
observe it within their own family. Raina (2009) found in a survey in Madhya Pradesh
that at 7% of the sample don’t perceive mental health as a medical concern. Even when
other social factors like economic status allow access to mental healthcare, the beliefs
around mental health can be the determining factor which prevent a family from
acknowledging a mental health issue and seeking care. Education, to some degree, has
mitigated the effects of cultural norms in perception of mental health. Increased
globalisation and influx of new ideas and data around mental health has also played a role
in demystifying mental illnesses. However, even now, medical diagnosis of mental
illnesses have to be balanced with cultural perceptions of it (Raina, 2009).

Dysfunctional Families as the Contexts of Mental Illness

The family unit plays a crucial role in the overall well-being of its individual members. The unit
not only provides basic necessities of life, such as food and housing, and in some cases even
education and livelihood, it also performs other tasks such as healthy socialisation,providing
emotional support, checking negative or socially unacceptable behaviour and coping with crises
such as illness, poverty, death and so on. When a family is unable to perform its functions, the
individual members are inadequately prepared to engage or cope with life’s challenges. In the
absence of healthy coping mechanisms which a family should have ideally provided, the
individual members develop their own mechanisms to cope with these challenges, which may be
makeshift, emotionally repressive and not always healthy. A family which is unable to perform
its functions as a unit, in whatever arena or capacity, is called a dysfunctional family and can be
the gateway for unhealthy coping mechanism, maladjusted behavioural patterns which can
ultimately lead to deteriorating mental health and lifelong, unaddressed mental illness.

In 1982, Robert Beavers classified families along the dimensions of family competence and
family style in what came to be known as the Beavers Systems Model of Family Functioning.
The competence dimension described how adequately a family performed its prescribed
functions, maintained its structure and its willingly to change those structures and functions with
changing circumstances. The style dimension described the quality of family interaction and the
importance the family accords to itself vis-a-vis the possibilities offered by the outside world.
Based on these dimensions, Beavers gave the following classification of families :

● Optimal : intimacy available, empathy, opportunities for individuation, conflicts

easily resolved, mutual respect, group problem-solving, equal-powered
transactions.
● Adequate : control-oriented, problem-solving through direct force, less intimacy
and trust, role stereotyping - unemotive men with emotive, yet depressed, female
counterparts.
● Mid-range : Authoritarian control, overt power differences between family
members, children susceptible to psychological disorders, invasion of personal
boundaries.
● Borderline : overt power struggles, poor parent coalition, open expression of
anger and resentment, children learn to manipulate the weak and oscillating
parental subsystem.
● Severely Dysfunctional : limited communication and negotiation between
members, impermeable outer boundary with no non- family members allowed in
or extremely loose outer boundary with family members seeking family support
from the outside world, extreme loyalty or extreme hostility towards the family,
children develop social-emotional problems.

Janet Kizziar (1989) built on Beavers’ model and further detailed dysfunctional families. She
provided a popular classification of dysfunctional families. Kizziar’s classification focused on
the source of dysfunction in the family :
 ● The Alcoholic or Chemically Dependent Family System
● The Emotionally or Psychologically Disturbed Family System
● The Physically or Sexually Abusing Family System
● The Religious Fundamentalist or Rigidly Dogmatic Family System

Cogner et al (1994) expanded on dysfunctional families in terms of the nature of their

dysfunction. He described such families as extremely closed systems with no empathy and
complete disregard for the individual’s agency. The needs of the individual members are ignored
for the larger good of the family. The parental unit exercises absolute control and is
authoritarian. Children in such families are susceptible to extreme anxiety, depression and
antisocial behaviour. Similarly, Neurath (2002) defined dysfunctional families as families where
the parenting is faulty. He described such parenting as “dogmatic or chaotic parenting". Such a
parenting style is categorised by showing condition-based love and affection to children, socially
isolated parents or parents with low social mixing skills, punishing children for expressing
dissent, extreme loyalty to the family, children’s needs belittled or trivialised. Children in such
families are vulnerable to bipolar disorder, anxiety and behavioural maladjustments.

Dysfunctional families, thus, directly impede the fulfillment of needs of its members and in
doing so makes them susceptible to a range of psychological disorders, ranging from mild to
severe. Families which struggle with dysfunction often end up being the cause of mental illness
for its individual members rather than

In the following section, we explore how dysfunctional families aggravate mental illnesses in
India.

● Substance Use Disorder (SUD) Families

According to the National Mental Health Survey of India (2016), psychoactive substance use
disorders include abuse of “alcohol, opioids, cannabinoids, sedatives and hypnotics, cocaine,
other stimulants, hallucinogens, volatile solvents and tobacco” (p. 95). The survey reports that
“the prevalence of substance use disorders (SUD) was reported to be the highest in the 50-59 age
group (29.4%) and among the sexes, it was higher in males (35.7%).

Changing societal values brought by urbanisation, migration and industrialisation along with
other mitigating factors like lack of affection and emotional support from the family,
unemployment and increased poverty pushes individuals in the direction of SUDs (NMHS,
2016). It is interesting to note that both Rajasthan and Madhya Pradesh, which report the highest
prevalence of SUDs also report high percentages of people below the poverty line, 14.7 % and
31.6% respectively (Reserve Bank of India, 2013). Thus, a combination of social determinants as
well as prevalence of direct lack of support from families pushes the individuals into mental
illnesses like SUDs.

Individuals with SUDs often face severe discrimination and stigma from their family members
and the community. This stigma towards their addiction can create a whole new range of mental
illnesses such as anxiety, depression and even suicidal tendencies. The stigma from loved ones is
internalised which creates a sense of self-loathing and lack of confidence. This,combined with
the family’s desire to keep these behaviours hidden from the public eye, results in fewer
individuals with SUD being taken for treatment and rehabilitation, making chances of recovery
slim.
In families with individuals struggling with SUDs, the mental health of non-addicted members is
also affected. While SUDs are a product of dysfunctional families, they can also play a role in
perpetuating the dysfunction within the family. The prevalence of SUDs is higher (29.2%)
amongst middle-aged adult men (40-49 years old), who are often the primary breadwinners of
the family (NFHS, 2016). Their incapacitation through addiction can result in decline in the
quality of life of the family, poverty, frustration and in extreme cases violence and abuse.
Omkarappa and Rentala (2019) conducted a study where they found a significant difference in
mean scores of anxiety, depression, self-esteem, separation anxiety, social phobia, obsessive
compulsive problems and physical injury between children of alcoholics (COA) and children of
non-alcoholics. The care that must be accorded to an adult with SUD can create mental illnesses
of anxiety and behavioural disorders amongst children. Women, who are often tasked with the
caregiving roles, are also severely affected by mental illnesses like depression in SUD families.
In cases where the SUD-affected individual becomes frustrated, the violence is often directed
towards dependents of the family like women and children. In a study conducted in Mumbai,
Wagman et al (2018) found that the women who lived with a husband who drank alcohol,
relative to non-drinkers, were more likely to report instances of intimate partner violence (IPV).
Similarly, Goran (2017) found in a study conducted in Orissa, that children who lived with at
least one SUD-affected parent were 17% more likely to report instances of physical violence
than those living with parents not affected by SUD.

Thus, the direct violence and the burden of care that accompanies SUDs can aggravate family
mental illness on the whole. It can create dysfunction in the family, with violence and frustration
being transferred to other members of the family, and emotional support and family bonds
becoming diluted. At the same time, strong family ties, support of extended families and support
of the community members can play a huge role in mitigating effects of SUDs for the individual
members as well as for the family as a whole (Sharma, 2007).

● Emotionally Abusive and Negligent Families

Though there is no consensus on the exact definition of emotional abuse, psychologists agree
that it involves any form of abuse which is not physical in nature and has a negative impact on
health, the psyche and behaviour of those experiencing it (Espelage, 2018). It is often
characterised with elements like humiliation, manipulation, withdrawal of emotional support as
punishment, verbal abuse like insults, constant put-downs and mockery, lack of empathy, and
intimidation (Dutton et al, 2000). Emotional trauma does not always take the form of abuse. In
some cases, it could simply be neglect, i.e failure to provide empathy, communication, safety and
affection, despite the presence of other basic necessities. Here, there may be no active abuse such
as humiliation, but there is an absence of emotional fulfillment.

In India, every second child is reported to be facing emotional abuse (Bhilwar et al, 2015).
Mishra et al (2016) studied the association between childhood abuse and psychiatric morbidities.
They found that the prevalence of child abuse in patient patients of psychiatric morbidities was
43.29% with emotional abuse (61.9%) being the most commonly reported form of childhood
abuse. Emotional abuse amongst children can result in a wide range of mental illnesses including
depression, anxiety, antisocial behaviour, cognitive and behavioural problems and interpersonal
issues (Rogen, 2015).

Emotional abuse is also prevalent in families without children. “According to a study by the
National Centre for Biotechnology Information, suicide attempts in India are correlated with
psychological intimate partner violence. Of the Indian women who participated in the study,
7.5% reported attempting suicide” (Singh, 2015, p. 318). Psychological abuse amongst women
can take the form of verbal abuse, degradation, insults and can result in mental health issues like
depression, anxiety and suicidal ideation. The reasons behind the abuse can range from dowry
abuse to infertility to conflict to conflict with other females in the family (Singh, 2015). The
perpetrators can be women members of the family such as mothers-in-law as well as the male
members. Though most literature paints men as the perpetrators of psychological IPV, more
recent studies like the one conducted by Malik and Nadda (2019) shows that men also
experience emotional abuse in a relationship. Out of the 1000 males interviewed, 51.6% reported
emotional abuse, out of which 85% were criticized, 29.7% were insulted in front of others, and
3.5% were threatened or hurt. Men are often victimised by emotional abuse especially due to
reasons like unemployment and infertility and this can result in severe depression, anxiety,
antisocial behaviour, substance abuse, alcoholism and so on (Malik and Nadda, 2019).

One of the demographic groups which is severely victimised by emotional abuse is the elderly.
Skirbekk and James (2014) found in a study that 11% of 60+ year olds have experienced at least
one type of elderly abuse at the hands of their own family members (Physical 5.3%, Verbal
10.2%, Economic 5.4%, Disrespect 6%, Neglect 5.2%). As dependents, the elderly often lose
their bargaining power in the household. Intergenerational disagreements and changing cultural
norms around family and kinship can make the elderly victims of alienation and hostility. Verbal
abuse and neglect creates emotional trauma which makes the elderly susceptible to a range of
issues including sleep deprivation and anxiety, depression, Post Traumatic Stress Disorder
(PTSD) and even aggravation of physical symptoms such as cardiovascular issues and
neurological problems. Skirbek and James’ study also found that formal education among elderly
beyond a certain level (8 years) played a strong role in reducing violence against the elderly.

● Physically and Sexually Abusive Families

Physically and sexually abusive families can be hotbeds of trauma and extreme mental illness for
their individual members. Physical abuse, in its many forms, is one of the most pervasive forms
of family dysfunctions. It can range from mildly infuriating actions as well as potentially fatal
physical acts. Age is no barrier in physical abuse, with reports showing that individuals of all age
groups, from children to the elderly, tend to experience it (NCRB, 2018). Physical abuse often
goes along with other forms of abuse such emotional abuse and can be aggravated by a number
of factors like SUDs, socio-economic factors and so on.

Mental health consequences of violence against women include sleeping and eating disorders,
depression, anxiety, post traumatic stress disorder (PTSD), self-harm and suicide attempts, and
alcohol, and substance use (Sharma et al, 2019). Chandra et al (2009) found that there were
higher frequencies of depression, post-traumatic stress disorder (PTSD), and attempted suicide
amongst women who experienced physical domestic violence. Kumar et al (2012) found that of
the 9938 women they surveyed, 4005 (40%) reported experiencing ‘any violence’ during their
marriage, of whom 2243 (56%) had Self Report Questionnaire scores indicating poor mental
health. Here, ‘any violence’ is defined as the perpetration of any one of four physically violent
behaviours (slap, hit, kick or beat). The reasons for physical abuse can range from infertility to
conflict with partner or in-laws to dowry harassment and violence.

Indian literature shows a bias against men who are mostly seen as the perpetrators of abuse
which causes mental illness rather than victims of it. This is exemplified on very little data on
IPV against men and its effects on their mental health. This could also be rooted in the fact that
instances of IPV and DV amongst men aren’t recognised or reported as often as in the case of
other genders. A study by Save Family Foundation (Sarkar et al., 2007), which interviewed
1,650 husbands between the ages of 15 and 49 years, reported that 25.2 % of the surveyed
sample experienced physical violence. Nearly a decade later, Malik and Nadda (2019) reported
that of the 1000 males they interviewed, 6% reported instances of physical violence. Much like
in the case of women, in the case of men as well, physical violence can have severe
consequences for mental health, including extreme stress, generalised anxiety, depression and
even suicidal tendencies ( Kumar, 2012).
As dependents, children and the elderly are also common targets of physical abuse. Raman et al
(2015) found that of a sample of 300 children, over 50% of those who showed symptoms of
depression and anxiety reported instances of physical abuse. On the other end of the age scale,
Patel et al (2018) reported that 54% of elderly diagnosed with severe depression reported
instances of physical abuse at home. They also noted the bidirectional relationship between
depression and elder abuse. Illiteracy and severe depression put the elders studied at risk of
physical and mental abuse at home.

Sexual abuse is often considered to a more gendered form of physical violence. Most literature
addresses stories of sexual abuse amongst women and girls rather than men and boys.In cases of
forced incest, the result couldl be exposure to STDs and HIV, adolescent pregnancy, miscarriage,
and or birth defects in infants, which could be another source of mental illness for the survivor of
such abuse. Sexual abuse can have long terms impacts on mental health resulting in repression,
PTSD, sleep and eating disorders, anxiety and so on (Wagner et al, 2016). Sexually abusive
families can also have severe, lifelong impact on children's mental health. According to the
National Crime Records Bureau data,in 2018, 39,827 cases were reported under the Protection of
Children from Sexual Offences Act (POCSO). Shrivastava (2017) states that child sexual abuse
is associated with a wide range of psychiatric disorders in adulthood that range from depression,
posttraumatic stress disorder (PTSD), panic disorder, and substance abuse to schizophrenia and
antisocial personality disorder. There is an erasure from reportage of sexual abuse in male and it
can adversely affect how sexual abuse in males is percieved. Male sexual abuse is addressed, if
at all, mostly inthe context of children. Existing patriarchal, cultural norms which disregard
male sexual abuse, lack of discussion on the issue and underreporting of adult male sexual abuse
creates a stigma around it and discourage men from reporting such instances, hence making it
difficult to address the issue.

Family as a Protector from Mental Illness and Provider of Care

In India, family acts as the primary caretaker in most of the scenarios in which a person is
disadvantaged, it is the same in case of mental illness too. Family provides primary support and
care in most of the cases. Studies suggest that almost 90% of severely mental ill patients in India
live with their family (Pavitra, Kalmane, Kumar, & Gowda, 2019) . In most of the cases families
are the ones who bring the patient or the person with mental health issues for psychiatric care
and takes care of their medication. Families are found to be helpful in the patients rehabilitation
process too as they help them get employment and help them maintain or reestablish themselves
in society and in social life. The most important factor is the provision of psychological and
emotional support provided by family which is hard to be substituted. All these factors make
family an unique support system for persons with mental illness. Another important indicator is
the prevalence of joint family systems in india. Joint family as a system always comes in aid
while taking care of members in need. This is true for the maintenance and caregiving of
members with mental illness too (Pavitra, Kalmane, Kumar, & Gowda, 2019).

Families play a major role in treatment and management of mentally ill patients. They provide
relevant and important information which is needed for diagnosis, treatment planning and
management of the individual.They also provide a conducive atmosphere where a patient can
share and ventilate their feelings. Families often play an important role in motivating and guiding
the patient to engage in rehabilitative activities and also help to adopt coping
mechanisms(Kumar & Tiwari, 2008).

Evidences proving the relation between family involvement and positive patient outcomes can be
traced back to 1950s with the experiments and studies took place in Amritsar Mental health
hospital, vellore mental health centre and ​National Institute of Mental Health and Neurosciences,
Bangalore (Ballal, Navaneetham, & Chandra, 2019). These studies serve as milestones in the
history of family intervention and provide strong evidence for stating that family involvement is
closely linked with positive patient outcomes. While looking into families as protectors from
mental illness it is necessary to go back to these studies and their findings

1. Study in amritsar mental health hospital :

The study was initiated by Dr.Vidya Sagar who was the superintendent of Amritsar
mental hospital. He studied the outcomes of family involvement in treatment by ensuring
their maximum involvement in the treatment process. He let the family of the patients
stay with the patients within the hospital campus while the treatment was going on. The
results of this intervention stated that patients’ whose family stayed with them had faster
recovery and was taken back to home.

2. Family wards in vellore christian medical college:

The outcomes from Vidyasagar's experiments paved the way for several other studies
and interventions. One such was the setting up of family wards in vellore christian
medical college where the patient’s family can stay with them. Outcomes of this
intervention suggested that involvement of family in treatment will fasten the recovery of
the patient and reduce the rate of relapse. Another observed benefit was that these
families acted as a change agent in the community by identifying other patients and
guiding their families. This intervention also brought out another merit of involving
 family in treatment. This model proved to reduce the need for services from staff like
nurses and attendants.

Another milestone in the history of family involvement in mental health care is the establishment
of general hospital psychiatric units in 1933 and their spreading during the 1960s and 1970s. The
GHPUs promoted patients staying with family and also helped in the integration of mental health
into the general health system​(Avasthi, 2010).

Traditional joint family system in India has been proved to be beneficial in the caregiving
process of mentally ill patients as they can provide more economic resources for the treatment as
well joint families provide with more number of people for taking care of the ill member of the
family ensuring that the burden of caregiving will not become a single persons responsibility.
Studies show that nuclear families are more associated with mental illness which also suggests
the role of joint family as a protector from mental illness. Studies also discuss the transition that
happened from joint family to nuclear family have in a way impacted the mental health status of
people too. Studies also relate this transition to the increased burden of caregiving on family
members(Avasthi, 2010).

‘Burden of Care’ : Impact of Caregiving on Families

As family remains to be the primary care giver in mental health care in India, so does family or
family members remain to be the ‘silent sufferers’ of mental illness. The caregiving process
often creates a ‘burden of care’ on the caregivers in terms of financial burden, psychological
burden and impacts, physical efforts for caregiving, coping and stigma. Burden of care is defined
as the problems and difficulties created by the caregiving process for the caregiver.

This burden of care care constitute of two components:

1. Objective : objective burden includes the quantitatively measurable effects such as
disruptions in household, financial burden, loss of employment for caregiver, caregivers
time spent managing the ill person etc
2. Subjective : subjective burden looks into burden from the caregivers individual
perspective. It focuses on the caregivers perceptions on the caregiving process. It includes
the negative psychological consequences on the caregiver such as feelings of stress,
anxiety, anger, frustration, uncertainty, guilt, depression, or even shame and
embarrassment which all creates suffering and distress in the caregiver(Avasthi, 2010).

However the caregiving is also connected to positive outcomes in the caregiver. This includes a
sense of gratification or satisfaction being developed and felt by caregivers (Avasthi, 2010).
Another important feature of the burden of care is the intersectionality of gender in it as studies
have proved that in the majority of the incidences female family members are the ones who take
up the role of caregiver (Souza, 2017). This was associated with the family structure, family
traditions, family and societal expectations, gender role conceptions and presumed role of
women in indian families. This scenario is also associated with the female caregivers’ feelings
and emotions and sense of responsibility. The female caregivers have said to have felt connected
to the patient, obliged to take care of them, love etc (Avasthi, 2010).

Understanding Mental Health in Family from an Intersectional Lens

From the literature analysed above, it is evidence that the experience of the same mental illness
and health concerns within a family can vary vastly from member to member, depending upon
the position they occupy, their role expectations and the power they wield in the household.
Social determinants of mental health operate differently for different members of the family.
Imbalanced power dynamics make way for negligence and abuse which in turn create mental
health illnesses. Depending upon how disadvantaged a family member is by the virtue of their
positioning, the experience of mental health could differ.

A concept that comes in handy to analyse to this difference in experience is the intersectionality
theoretical framework. Intersectionality is a concept that makes visible `the multiple positionings
that constitute everyday life and the power relations that are central to it’ (Phoenix and
Pattynama, 2006, 187). First introduced by Kimberly Crenshaw (1989), the theory highlights that
various social determinants of power like race, class, gender, caste and so on “intersect” in our
life experiences. In other words, experiences of our life, may they be of discrimination, power,
poverty, health or so on, are affected by a number of factors all at the same time. So, the
experience of mental health for two individuals would be vastly different depending upon how
their social determinants intersect. For a dalit woman who is dependent upon her husband for
financial support the mental health concerns would be far more severe than those for a woman
from an “upper” caste living independently in an urban metro. Our position, defined by these
axes, can define the nature of our mental illnesses as well as our ability to acknowledge them,
legitimise them and seek treatment and recovery.

Within families that create and mitigate mental illnesses, different members will feel the burden
of a mental illness differently. Within the same dysfunctional family, marred by physical abuse
and substance abuse, the mental health consequences could vastly differ. While an elderly, might
go silent and slip into depression, an adolescent might “act out” and indulge in anti-social
behaviour. Similarly, in caregiving families, “the burden of care” is borne differently
differentially. Here, gender could be the dictating factor. Women are often cast in caregiving
roles due to gendered role expectations. Children might also be cast in caregiving roles as a part
of their socialisation process. This transfers the burden of care on them and away from the males
and the elderly. Unequal distribution of burden of care can also create a staunchly imbalanced
power dynamic which can further affect the emotional and psychological experiences of different
family members.

Various factors which compound mental illness can also intersect from time to time. Negligence
can expand to include violence. Physical and sexual abuse often intersect with emotiona abuse
and negligence. Coping mechanisms to deal with these abuses could include substance
dependence , which could restart the cycle of mental illness all over again. Intersections do not
take place only between social determinants of mental health but also between a family’s role as
caregiver as well as a dysfunctional unit which worsens mental health. Caregiving and
dysfunction can often be two sides of the coin. A family where the burden of care is
disproportionately distributed or mismanaged can easily fall into dysfunction out of frustration
and stress. In this case, the family could continue giving basic care but pent-up resentment may
eventually lead to negligence and abuse. The switch between caregiving and dysfunction could,
thus be dynamic and contingent upon how effectively the mental health of caregivers is also
addressed.

Recommendations for Social Work Practice

The social work implications for family’s relation to mental health span over multiple areas,
from research to policy to practice. Mental health in India is still a relatively new area of
research. This is especially true if one takes into consideration research from the perspective of
the wellness model which focuses on destigmatising mental illness rather than simply diagnosing
it.Present research also shows a tendency of analysing mental illness as an “additional
vulnerability” and not as a vulnerability sui generis. There is a pattern of analysing mental illness
issues within vulnerable groups and associating the presence of the illness with their
vulnerability. The literature review shows that the social determinants of mental health are
emphasised to the point where mental illness is only seen as an added, albeit debilitating and
necessary to address, consequence of their pre-existing vulnerability. The downside of such an
approach is that traditionally non-vulnerable groups, whose only vulnerability comes from the
existence of mental illness, are often overlooked. Limited social work research on the mental
health of men is a good example of this.

In the arena of policy, the recommendations of the National Mental Health Survey should be
taken into account to guide the implementation of the Mental Health Care Act, 2017. A
comprehensive policy should be developed to address family mental health. The ambit of the
National Family Health Survey should be expanded to include mental health, not merely mental
illnesses, more concretely. Finally, the scope of the Mental Health Care Act, 2017 can be
expanded to enhance the rights of caregivers. The Act understanbly focuses on the agency of the
individual with the illness and scholars have argued that overpowering the caregivers can often
be detrimental to the independence of those with illness. We argue that while the independence
to decide their treatment and course of recovery should ultimately rest with those with the illness,
the caregivers and the responsibilities they take on should not be overlooked by the law. Pavitra
et al (2019) argue that that the Act should empower, not overpower, the family to care for the
individual with mental illness. Provisions should be put in place to empower the family as a
caregiving system.

Finally, in the arena of practice, mental health services and interventions should be made more
inclusive. Social workers should work towards detaching the stigma around mental health within
families and make mental health of the family an essential aspect of general family counselling,
regardless of the issue for which counselling is being sought. Through public sessions, awareness
campaigns and activities, social work practitioners should devise mechanisms to first tackle the
deep-rooted stigma in the community they are working in before devising specialised
interventions. This means normalising not only mental illnesses but also general mental
well-being and self-care.

As we have seen, dysfunction and caregiving can be connected aspects within a family. While
addressing a family’s mental health, social workers must be careful of this intersection and its
impact on family dynamics. Mental health of those members of the family who are often
overlooked, like the elderly, should be given special consideration in social work practice in
mental health. At the same time, social workers should devise interventions which also take care
of those who are “visibly” vulnerable but are victimised by mental health concerns and stigma.

Social workers should also plan more interventions for caregivers of those with illnesses. This
trend in mental health social work has been gaining momentum and we believe that focus on the
mental health of the caregivers can prevent them from falling into dysfunction and perpetuating
the toxic consequences of mental illnesses within the family. Social work practice can become
instrumental in mitigating the impact of ‘burden of care’ on caregivers and in fact reduce the
burden itself. While working with individuals with mental illness specific attention should be
given to family members’ especially caregivers’ wellbeing and mental health. Attention should
be given to assess how the caregiving process is affecting them emotionally, psychologically and
physically and interventions should be made to promote caregivers’ wellbeing and to foster a
healthier and constructive caregiving process. Focus should also be directed towards the
diffusion of caregiving burden among the family members to make sure that the responsibility of
caregiving doesn't burden a single person which largely happens with women. Finally, while we
do argue that family mental health, and not merely the sum of its members, should be researched
and focused on in social work practice, social workers should also be mindful of the
intersectionalities that operate within a family system and how they differently empower
different family members.

Conclusion

In conclusion, the family plays a complex role in sustaining and mental health. It can be the
context where mental illness is created, where care for battling illness is provided or where
individual illnesses, in combination with multiple social factors, compound to create an illness
which is unique to the family. These roles, much like the experience of mental illness within the
family constantly intersect with one another. The lens of intersectionality allows us to see how
social determinants position and power different members of the family differently and how this
can affect their experience of mental illness and health.

Social work practitioners in their analysis and planning of interventions must be wary of the
complexities that exist when families deal with mental illness and mental health. Given the
importance accorded to the family system in India, it is essential that social work practitioners
keep in mind that when it comes to mental health, the family can play multiple roles at once. It
should be our aim, in our research and interventions, to balance these roles and prevent the
perpetuation of mental illnesses and foster promotion of wholesome mental health.

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