Abstract
Sir,
We read the article ‘What constitutes recovery in schizophrenia? Client and caregiver perspectives from South India’ (Gopal et al., 2020) with interest. It provides important insights into cultural nuances of the recovery model.
Recovery in the context of Western societies emphasises on quality of life despite the presence of symptoms. The authors point out that in the Indian context, recovery is perceived as being symptom free. Patients and families feel that being symptom free enables the individual to be gainfully employed. This is a pragmatic approach especially given the lack of social security benefits in India.
In Western societies, recovery model is largely perceived to be an individual journey (Anthony, 1993) and forms the basis of a lot of community care models. In the West, this ‘responsibility’ is divested to the state and families step back a bit and sometimes completely. However, recently, there has been a focus on the ‘relational recovery’ (Price-Robertson et al., 2017) and there is recognition of role of relationships in recovery from mental illnesses.
Unlike Western countries, India has a collectivistic society. Families feel a sense of ‘responsibility’ to provide care and the ‘relational recovery’ model is very relevant. Including perspectives of caregivers, who are usually family members in the Indian setting, is commendable because it highlights the importance of their role and provides a cultural nuance to the recovery model.
Having worked in both India and Australia, we feel that the input of families caring for people with severe mental illness in India is often taken for granted. The importance of families in management of people with mental illness has been highlighted in the National Mental Health Survey of India (Gururaj et al., 2016). In India, family members often provide services that are otherwise organised through paid workers like case managers in Australia. Families are involved in identification, help-seeking, managing medications, staying with the patient in hospital when they need admission and providing psychosocial support.
While the involvement of family is an enormous and irreplaceable resource, it has not been recognised or acknowledged adequately. Families often have very little say in designing services or planning for mental health programmes. There is no provision of funds to compensate family members for providing services which should have been provided by the state in the first place. The Mental Health Care Act also appears to have ignored the central role of families. The Act focusses on individual autonomy, which may be helpful, but it does not balance the realities of involvement of families in care of the patient. There is no scope for informal involvement of families in decision-making about treatment in the Act. The Act risks erosion of family support which could be detrimental to people suffering from severe mental illnesses.
Given this background, the article rightly lays emphasis on the views of caregivers. Professionals have a responsibility to advocate for recognition of family as important stakeholders in the recovery of patients and ensure their participation in formulating the response to mental illnesses.
