My first intensive clinical placement was for three months in the psychiatric department of a government hospital in Pakistan. I had just completed my bachelor’s, ignoring all the jokes about how I was becoming a ‘whitewashed’ psychologist. Regardless, I was still thrust into a form of culture shock when the placement began.
Years of traditions and customs have led to major aspects of the country, including health care, being structured around culture. Therefore, it was clear to me that psychological welfare and ethics, while regarded with esteem, were overruled by traditional expectations. With emphasis on the importance of maintaining a family unit at the forefront, when assigned a patient it was a given that you were also responsible for family members. They deemed it their duty to be present at sessions, extending beyond the recommended psycho-education and family counselling. Though I was aware of such occurrences in mental health practice back home, I had yet to be exposed to its more sinister side.
Family involvement can be positive – families rallying around individuals suffering from mental health difficulties. They’re expressing a deep-found interest that goes beyond a societal taboo of mental health, challenging fanatical assumptions deep-rooted in the culture, such as black magic. Family and friends find themselves gaining firsthand knowledge of mental health issues and how to manage them. However, a more profound analysis could question whether society’s preference for family involvement may be causing more damage.
When working with patients I was expected to never second guess the involvement of relatives, who would sit in on privileged sessions with or without the patient’s consent. What mattered was keeping the family unit solid. In the UK this would be a serious breach of ethics but in Pakistan, where tradition means to be family oriented as opposed to self-oriented, this conduct is par for the course. One woman would have her husband accompany her to every session, and it did not seem conceivable to him that his wife may want to discuss her issues in private. She eventually stopped attending because her husband didn’t have time for it and I was bound, both professionally and culturally, to accept this.
Such instances are common. Another young woman, dressed conservatively and displaying an unassuming demeanour, was only able to discuss her active and secret sex life and how it was affecting her after her parents were persuaded to leave the room. When they later demanded to know what their daughter had said I was encouraged by superiors to break privilege as it was their parental right, despite their daughter being over the age of 20. It is an unspoken rule in Pakistan that being a legal adult hardly means anything when it comes to parental emancipation.
One’s own professional conduct is often called into question when dragged into these political games. One patient, upon confessing he had been raped by his cousin, received conflicting reactions; comfort from his psychologist and judgement from his parents. In that situation, from a professional standpoint, you are not at a liberty to begin challenging the parents. From an ethical standpoint however, would it not have been beneficial for your patient, to separate him from his parents? In the end, policy dictated the psychologist remain impartial, even if that meant letting the parents force their son into forgiving and further interacting with his rapist.
Family values, whatever those values may be, seem to trump mental health every time. Never was this more heavily emphasized than when I saw my severely depressed, catatonic patient being yelled at by his mother for bringing shame to the family and ruining his chances at becoming a doctor. She had her son removed from the ward without his consent, despite the fact that he was legally an adult and a high risk for suicide. To this day I do not know what became of him. Should I have called his mother out on being the stressor in her son’s life? Instead, I played the passive professional, submitting to the family member’s wishes, which did that young man no favours.
Such regulations that are dictated by social constructs ultimately made me question, not just the ethics of practicing in Pakistan, but my own ethics and potentially compromised morality. It truly brings into question how far cultural practices should be allotted favour and allowed to venture into psychological practice. Whether these experiences of mine and my perception of them leaves me being regarded as “whitewashed” holds little significance.