Dissociative Disorders in India: Cultural Influence on Psychopathology and Treatment

Dissociation is characterised by an involuntary disruption of the normal integration of conscious awareness and control over one’s mental processes. ¹ Dissociative disorder (DD) is also called ‘conversion disorder’, implying that repressed conflicts are converted into somatic symptoms. Difficulties in coping with conflicts or emotions appear to underlie dissociation. Many cultures even accept dissociation as normal if it does not exceed cultural norms. Hence, perspectives on pathology and phenomenology of dissociation could be vastly culture-centric.

Despite dissociation being prevalent in India, published studies on psychological and cultural aspects of dissociation specific to India are few and there is a lack of clinical practice guidelines worldwide. This article attempts to discuss the role of culture in the clinical presentation, psychopathology, and treatment of DDs in the Indian context. The article and the de-identified clinical material reported are part of a larger study on dissociation in a tertiary mental health institute, which the Institute Ethics Committee approved.

Culture and Clinical Presentation of Dissociation

Any single definition for the concept of ‘culture’ seems insufficient. Contemporary thinking views culture as a social matrix of experience with explicit and implicit systems. While explicit aspects denote factors such as norms, values, and customs, implicit factors refer to the systems of knowledge and beliefs. ² Cultural processes deeply impact an individual’s sense of identity and self-experience. Culture also creates social categories that directly impact social position, health status, and schemas regarding perception of events, sensations, and experiences.

Dissociation is explained by culture-centric explanatory models, such as the socio-cognitive model, which views vulnerability for dissociation as an interaction between fantasy proneness and social reinforcers, leading to maladaptive role enactments. However, DDs must be viewed against unique cultural backgrounds due to culture’s potential pathogenic and pathoplastic effects. ‘Hysteria’ appears to be more common in developing countries, and culture may have an important role in the clinical presentation of hysteria. For instance, physical symptoms are considered acceptable in many cultures as a signal of distress, while psychiatric symptoms may be stigmatised. ³

Therefore, DDs often face issues of cross-cultural validity, particularly the subtype of ‘Trance and Possession Disorder’. A study in India ⁴ noted the parallels between Trance and Possession Disorder and Dissociative Identity Disorder (DID). Studies across cultures link the aetiology and expression of DID to cultural influences on the self.^5–7 DID appear to take the form of being ‘possessed’ (often by a supernatural entity) in collectivistic societies such as Asian and African cultures, compared to Western countries. ⁸

Religion, closely interconnected to culture, has also been linked to trance-like states. Suggestibility rendered by certain religious rituals could induce dissociative states. ⁹ Participants of Indian origin scored higher than Australian participants on both religious rituals and dissociation, and rituals were a significant predictor of the dissociation phenomenon. ¹⁰ Incoming information may be deflected during certain rituals, higher-order cognitive processing may be disengaged, and an individual may unquestioningly accept stimuli consistent with one’s faith and exhibit dissociation.

The influence of culture and religion on dissociative phenomena can also be understood through an attachment lens. ¹¹ Dissociative pathology is explained by insecure childhood attachment. ¹² Interestingly, it has been suggested that attachment may be formed with a cosmic figure or deity. ¹³ In a securely attached individual, attachment with God could be a reminder of positive experiences from sensitive caregivers and may contribute to good coping in difficult circumstances. However, pre-existing insecure attachment may be further compounded when a priest or godman mediates the attachment with God, increasing vulnerability to psychopathology.

Culture Mediating Expression of Psychological Distress and Relief

Factors unique to certain cultures, such as patriarchal or hierarchical social order, low literacy levels, and lack of empowerment, may make certain demographic groups (e.g., rural populations, underprivileged castes/sections, women) more vulnerable to DD. For instance, in a study from Maharashtra, women were bound by cultural expectations to sacrifice their well-being for close male members who were mentally disturbed. Women had no means of expressing their burnout, often resulting in trance states. ¹⁴

Gender shows strong links to dissociation. Epidemiological data in India shows DD is more prevalent among females than males. ¹⁵ One explanation is that of specific gender roles which are rigidly prescribed in Indian culture, particularly in rural settings. Despite strides in increasing access to education, women still have lower opportunities for education, employment, and positions of power in the hierarchy. Conversely, higher education often may not confer advantages either—in a large extended family and patriarchal social order, women may suffer restrictions on independence and contribution to decision-making despite having higher education.^16,17 Psychological distress is often dismissed or misunderstood due to poor awareness, or psychological help may be unavailable. Hence, distress may seek forcible expression through physical symptoms perceived as deserving attention and assistance.

Case Description 1

Ms A is a 19-year-old lady admitted with severe and frequent dissociative symptoms. Her symptoms involved non-epileptic seizures and sudden episodes of aggression, mostly directed towards herself through self-harm. At age 17, Ms A was coerced by her family to marry a much older man in return for financial security. On evaluation, she revealed that she was subjected to marital rape and violence over the years, which resulted in severe physical and psychological trauma. Ms A also had experienced a depressive episode during the ordeal, for which no help was sought. Her husband’s family silenced her protests and cry for help. Her husband blocked all means of communicating with anyone outside his family. She underwent a spontaneous abortion following severe sexual violence. Ms A reached out to her own family; however, they sent her back to her husband, fearing societal stigma. Once Ms A returned, she was under strict monitoring, and the abuse intensified. Soon, the patient started experiencing frequent seizure-like symptom. With the onset of severe dissociative convulsions, the husband was compelled to take her to a hospital. The intensity of her physical symptoms helped the treating team psycho-educate her parents, who supported her recovery and facilitated a divorce.

Another important concept linked to DDs, as seen from a cultural context, is the concept of ‘agency’, which refers to the ability of a person to act, or the perceived ownership of their action, which develops over time through socialization with the individual’s cultural processes and settings. In settings where an individual is deprived of agency and power, the trance and possession states may facilitate behaviour change and reduce distress while displacing agency to an external entity. Possession may also temporarily give the person a special status in society regarding powers of prediction and healing, which can sometimes become a livelihood source.

Case Description 2

Mrs B is a middle-aged lady with post-graduate education, previously employed, hailing from a religiously devout, patriarchal family. Due to certain financial constraints, Mrs B had to leave her job and live with her in-laws. During her stay, she was forced to adhere to strict religious codes, which advocated submissiveness and unquestioning obedience from women. Mrs B suffered sexual violence from a male relative. However, her circumstances prevented her from protesting or expressing her anguish. She even had to continue functioning under a strict patriarchal regime imposed by the perpetrator. Mrs B began to experience episodes where she assumed the identity of a seemingly powerful man, expressed her rage, and refused to adhere to rules. The perpetrator tried to trivialise her symptoms and subjected her to magico-religious practices. However, the symptoms increased in severity and Mrs B became more aggressive towards family members. After the episode, Mrs B would have no memory of the episodes, was guilt-ridden about her behaviour, and would engage in constant prayers to absolve herself of sin. The aggressive nature of her dissociative episodes created fear in her family. It allowed power dynamics to shift such that she no longer had to be submissive to the perpetrator and also gave her access to medical care.

Challenges Posed by Culture in the Treatment of Dissociation

Stigma and Social Accommodation Paradox

Psychiatric illnesses, especially DID, are often subjected to ‘negative evaluation’ or stigma. ¹⁸ The scepticism and stigma towards DID are related to the idea that individuals with DID are ‘attention-seeking’ and that symptom presentation is exaggerated to gain special treatment. ¹⁹ This is one premise of the socio-cognitive model of DID and is linked to the concept of ‘secondary gain’ traditionally used to understand dissociation. Unfortunately, the label of ‘attention seeking’ leads to biases even amongst mental health professionals. Often, the attention gained by dissociative patients is largely negative in terms of social and professional stigma. ¹⁸ However, some aspects of psychopathology may be inadvertently encouraged by family, society, and popular media through ‘accommodation’ or ‘facilitation’.

Case Description 3

Ms C, in her thirties, is unmarried, has completed post-graduation, and belongs to a middle socioeconomic status. She presented with episodes of possession by a powerful female entity wherein she often made predictions about family members and gave directions or courses of action to solve the family’s current difficulties. Her family attributed the episodes to paranormal powers and responded to these episodes with fear and devotion. Ms C was otherwise extremely submissive, indecisive, and diffident. Interestingly, Ms C’s solutions to everyday problems were dismissed by the family, despite being insightful and pragmatic, unless they were proposed in a dissociative state. Ms C underwent several systems of treatment for her illness, which mostly returned to magico-religious practices or systems that accepted paranormal beliefs. However, Ms C continued to relapse, and the episodes severely damaged her socio-occupational functioning, leading to the loss of her job and delaying her marriage. At this point, Ms C was admitted for psychiatric care and received structured psychotherapy. The episodes reduced considerably following clinical intervention. However, Ms C’s family commented that they missed the ‘powerful entity’ being part of the family because it had an important role in decision-making and moderating family dynamics.

Dissociation, which represents an altered state of consciousness, may not be considered pathological in certain forms of behavioural expression. Non-possession trance states, which are kinetically induced using rhythmic music and dance in several non-western cultures, are seen as an expression of devoutness and being one with nature. It may facilitate a communal expression of one’s ethos, giving the individual an accepted restorative mechanism. The religious art form of ‘Theyyam’ in North Kerala is an example of culturally approved trance states that the community uses for psychological relief. Understanding the meaning of the dissociative symptoms as having cultural acceptance in attenuated forms enables therapists to devise alternate methods of coping and self-expression that fit the patient’s narrative of their world.

Providing a patient with a medical dissociation model without factoring in the cultural context can lead to non-acceptance and even defensiveness. Also, even if the patient accepts the medical model of the illness during a clinical setting, returning to a culture that strongly and unitedly advocates a magico-religious model may lead to isolation, more stigma, and even ostracism of the patient.

Such a culture-sensitive approach is particularly crucial from the attachment perspective. As discussed previously regarding the link between attachment and religion, if religious beliefs are centred around relating to ‘God’ or a deity as an attachment figure, prescribing a medical model may translate to replacing an attachment figure. Such attempts could be considered threats to the attachment system, and supplanting an attachment figure could be traumatic for the patient. Hence, a culture-sensitive approach is needed for persons presenting with dissociation.

Considerations for a Culturally Sensitive Intervention for DD

Stigma and facilitation of dissociation symptoms can present subtle hurdles to treatment and recovery. Being mindful of socio-cultural aspects contributing to the individual’s symptoms is critical and may help tackle the insidious forces affecting recovery. If therapy weaves in cultural meaning, there is a higher chance of acceptance because the patient’s socio-cultural beliefs are not ‘replaced’. Sensitivity during care preserves the patient’s dignity, self-efficacy, beliefs, and sense of agency and stands a better chance of gaining acceptance at the community level.

The ‘Dawa-Dua project’ in Erwadi, Tamil Nadu, is one such initiative that complements mental health treatment with the patient’s religious sentiments. Medical practitioners and faith healers coordinated this project by starting a clinic run by the District Mental Health Programme within the premises of the Dargah, increasing the patient’s access to treatment for psychiatric illnesses. ²⁰ Systemic changes are indispensable for achieving treatment success in health conditions strongly rooted in cultural context. ¹⁷ Building community awareness through mental health education and an open, inclusive, culturally sensitive approach from the mental health system would help manage persons who manifest dissociation.

Treatment programs often end with symptomatic functional recovery rather than continuing to resolve the underlying psychological conflicts that precipitated the psychopathology. Owing to non-consensus and heterogeneity among contemporary models and a lack of clear practice guidelines for treatment, ²¹ clinicians are often compelled to work largely by intuition and anecdotal evidence, focusing on reducing symptoms. However, DD has a high relapse rate despite quick functional recovery, ²¹ necessitating a focus on underlying conflicts for a full recovery. The field of ‘psycho-traumatology’ emphasises culturally sensitive practices when developing psychotherapies focusing on treating trauma-related disorders, to address the personal meaning given to trauma memories. ²² As trauma has a crucial role in dissociation, addressing the personal meaning of traumatic memories, which may be influenced by macro- and micro-culture, becomes important.

Treatment of dissociation requires an integrated format, which is culturally sensitive, that unifies elements of dominant models of dissociation. Such an integrated model that respects the patient’s cultural context could open doors to gaining engagement in further treatment and achieving a longer remission. With mutual trust and respect, there may be better dialogue regarding psychological explanations for symptoms and engagement with psychotherapy techniques, such as skills training to reduce maladaptive coping or avoidance strategies. When the medical model speaks the language of the patient’s cultural milieu, the journey to recovery becomes unencumbered.