culture is mental health 

Written by Shriya Srinivasan

1957, Amritsar, India. An Indian psychiatrist called Vidya Sagar stood at the cusp of a crisis. The mental hospital he headed was being overwhelmed by the changing distribution of Punjabi patients displaced by the India-Pakistan partition. With no beds available, he made an unusual decision: he decided to invite families to pitch tents and lay mats in the hospital’s courtyard to stay with their relatives who were being treated for various mental disorders.¹ It marked the founding act of modern community psychiatry in India, a model that Western psychiatry only acknowledged after being frequently challenged by anthropologists, historians and indigenous academics. Sagar realised that recovery is rehabilitational and therefore relational, and that separating one from their social world is often counterproductive. 

More than 70 years later, Sagar’s theory struggles to infiltrate the hegemony of Western psychiatry on global mental health frameworks. This is a framework built around the Diagnostic and Statistical Manual of Mental Disorders (DSM), around individual psychoanalysis and psychopharmacology, easily replicable and scalable to address mental issues as precisely those – issues of psychology, issues of the individual, issues of ‘order’ and normalcy.²  Within the United States (arguably one of the world's most well-resourced mental health care systems)³, individuals with mental disorders from racial and ethnic minority backgrounds are only half as likely as White Americans to receive treatment.⁴ When they do access services, they are significantly more likely to drop out before completing their treatment course. Approximately half of ethnic minority patients terminate treatment after a single session, compared to a 30% dropout rate among White patients; this disparity persists even after controlling for income, diagnosis and insurance status.⁵ Immigrants face additional structural barriers: one study found that they were 15% less likely than US-born individuals to have a source of healthcare at all, with an uninsured rate three times higher.⁶ Immigrants often either come from or carry with them cultural models that are incongruent with Western individualism, and therefore Western psychiatric models of the individual. We conceptualise a self that, for much of the world's population, is not the self they actually inhabit. Our conception of mental health (as it exists medically) is based on an individualist mode of being that three quarters of the world doesn't necessarily subscribe to. That the majority of our world do not see themselves, and their wellbeing, as distinct from those around them, from their collective, their communities.  

The paradox is stark. Among all the progress and consideration medicine has made in recent decades, mental health occupies a unique and confusing place. It is routinely ‘over-diagnosed and over-treated in wealthy countries’, while being ‘catastrophically under-recognised and under-treated in low-income ones’.⁷ This binary, however, obscures the more interesting detail – societies cannot routinely and entirely ignore wellbeing. The societies with the greatest ‘treatment gaps’ are not simply lacking Western mental-health care: the school therapist, the well-being check, the well-funded rehab centre. Many have developed their own sophisticated, community embedded frameworks for understanding and managing distress that exists completely outside clinical literature.

The first step: de-individualise ‘the problem’.

"We do not challenge the belief systems that they come from. It is not about doing what is right and what is wrong. We do not try to destroy their worlds. As much as it may burn us." ⁸

This was said to me by a therapist who works across rural and urban cultures, and although it sounds like a simple-but-dramatic adherence to ethical duty, it is not. It requires a practitioner to do something that their entire training has, largely, not prepared them to do. It requires them to enter a consultation without the assumption that their diagnostic framework is something that can be accurately imposed onto the person experiencing their diagnosis.

In 1978, Arthur Kleinman, a medical anthropologist and psychiatrist, formalised this as the explanatory model. Instead of just assessing symptoms, he created a set of questions to understand how the patient, and the world around them, makes sense of their suffering. What do you call the problem? What do you think caused it? Who else is affected? Understanding the layers of relationships impacted by one’s mental wellbeing is more than a secondary problem to solve – it is often the clinical work itself.⁷ For the majority of the world’s population, distress is not experienced as a private, internal malfunction. Or at least – mental distress is not considered to be just one person’s issue. It is experienced as a disruption to relationships, to roles, to your coherence of a shared world. It is a massive disruption to how you experience meaning. 

The clinical implications are revealed through studying this paradox. In India, a significant portion of patients with mental illness are pulled by family to psychiatrists, faith healers and temple priests. The diagnosis needs to make sense in the multiple versions of ‘reality’, or meaning, that one person can exist in. This is not irrational, or simply relegated to the world of culture and mythology. It is a logical response to a plural explanatory model of suffering, one in which the biological, the spiritual and the social are not cleanly separable. The clinician who does not ask, nor care, will never know. The clinician who asks and then dismisses what they hear has learned nothing. The explanatory model framework asks the language the patient is actually using to navigate their distress.

This is the first and most actionable intervention that moves beyond DEI and ethical guidelines slapped onto a professional education. The goal is to move beyond symptoms, to understand the social world in which that individual's suffering has meaning. That social world is also, often, the only site of their recovery.

The second step: treat beyond the individual – treat the community. 

“Recovery is not something that happens to an individual. It is something a community does.” ⁸

What if the social world is where the individual can recover? What if we reconsider whether the clinical unit of care should be the individual at all?

In 2006, a Zimbabwean psychiatrist named Dixon Chibanda began training grandmothers to fight at the frontlines of Zimbabwe’s mental health epidemic. Zimbabwe had twelve psychiatrists for a population of thirteen million.⁹ But what it lacked in professionals, it made up for in the community. Chibanda noticed networks of elderly women, embedded in the daily life of the neighbourhoods around primary care clinics. Chibanda trained them to deliver problem-solving therapy on wooden benches outside those clinics, using kufungisisa (literally, thinking too much) as the working idiom for anxiety and depression rather than importing DSM categories that were clinically thorough but inadequate in the narratives of his patients. After the one-to-one sessions, clients were introduced to Circle Kubatana Tose (holding hands together), a peer support group drawn from the same community, where shared experience itself became a therapeutic intervention. The results were striking: a 78% reduction in depression and suicidal ideation across 700,000 clients. This turned out to be the biggest mental health intervention in Africa, sans the medical world.¹⁰ Trained psychiatrists are absolutely crucial to serious mental health interventions,  but are usually entirely alienated from the societies they treat. The unit of care needs to expand beyond the ‘patient’. It must be – to some extent – outsourced to either building or mechanising an existing support system. 

India offers a different but complementary example. A significant proportion of those with mental illness in India consult faith healers and religious centres alongside allopathic care. Classic cases of combining theertam (holy water) with marunthu (medicine) are often found in parts of South India. Psychiatrists often call this ‘complementary medicine’, but one must acknowledge the centrality of these so-called ‘complementary’ ways of understanding mental health. A study of a temple’s ashram/short-stay programme in Tamil Nadu found measurable reductions in psychiatric symptom scores among patients with paranoid schizophrenia and delusional disorders after a meditative stay.¹¹ The temple was founded and used by ‘lower’ caste individuals, which meant no elaborate Brahmanical rituals were performed. Instead, individuals simply participated in the daily routines of cleaning, watering plants, prayer, and some spiritual rituals. Most were rural farm labourers; almost none had received any prior medical care, yet mean psychiatric symptom ratings dropped significantly. Most importantly, the way they experienced and described their symptoms were spiritual or psychosocial, not pathological. The temple was not a pharmacy, but it offered structure through ritual, and community through collectivity. The traditional Indian joint family has long functioned as the primary infrastructure for psychological health, yet utilisation of family in the formal management of mental disorders remains minimal.¹² While neither temples nor families can replace medical care, they are undeniably involved in returning people’s senses of self. 

China offers perhaps the most striking example of what community-centred mental health can look like. In 2004, faced with an estimated thirteen million people with severe mental disorders and only 1.85 psychiatrists per 100,000 people, the Chinese government launched the ‘686 Program’.¹³ In the aftermath of China’s mass outflow of migrants from rural to urban areas (constituting a floating population of more than 300 million workers), the government started a nationwide initiative to decentralise and democratise mental health care out of psychiatric facilities and into the communities themselves, linking provincial hospitals to town clinics and deploying teams into the most rural, ‘left-behind’ areas. Since the 1970s, the disparate speed of development has broken families and pulled the traditional Chinese ‘Confucian’ domestic unit apart. Recognising the inadequate sample of those that actually sought help, China recognised those who didn’t know how to medicalise their own wellbeing. What the programme found was damning. People with severe mental illness had lived largely untreated in their family homes for years, with less than 1% of the sample in regular treatment. Some were physically restrained by family members with ropes or chains, not out of malice but desperation.¹³ Over its first ten years, the programme registered 4.3 million patients with severe mental disorders in community service archives, with 3.15 million participating in community follow-up visits.¹⁴ Fundamentally the same as Amritsar, China recognised that alleviating the burden on a ‘caregiver’ did not mean picking families apart, but instrumentalising them as the unit of care. 

What medicine cannot fix. 

There is, however, a limit to this argument that must be named.

Frantz Fanon, in his famous 1961 book The Wretched of the Earth, observed that colonial psychiatry misdiagnosed and often pathologised the symptoms of oppression while leaving the oppression intact. Treatment, in his words, produced individuals adjusted to an unjust world.¹⁵ Spearheading critical theory, he pointed out how the structural violence of psychiatry names collective suffering as individual disorder, and therefore inappropriately offers individual treatment as the solution to a structural problem. 

A 2025 review of trauma frameworks applied to Arab refugees found that PTSD had been treated by humanitarian programmes as the only legitimate form of war-related suffering, reducing the horrors of war to a technical issue of individual ‘mental health’. Communities that had previously relied on family and societies, which had been violently torn apart, were offered Western-designed trauma programmes that focused on their individual ‘pain’. This critique has not aged out.¹⁶ A trained, culturally conscious, local clinician, as this article advocates, is better equipped than most. But they are still working within a framework that locates the problem and solution at the level of an atomised individual. 

The question Fanon forces us to consider is whether there are forms of suffering whose correct response is not treatment at all, but political action; by the restoration of rights, land and safety. Community health does not resolve structural violence, as no clinical model really can. It does, however, create the conditions in which structural violence becomes legible, because the community is present and aware to name it together. When the Friendship Bench grandmother sits with her client in public in their neighbourhood, suffering becomes public. When China's 686 teams arrived in villages and found patient after patient locked in their homes, they saw a sense of abandonment that could not breach even hospital rooms. Recovery, understood this way, is the restoration of an individual to their shared world. 

Read the rest of the edition here.

References

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