A culture shock to the system

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 from Manchester, spending three years learning about psychological practice as it's done in the UK, ignoring all the jokes from my home country about how I was becoming a 'whitewashed' psychologist. In truth, having spent 10 years of my life living in Pakistan, I was very much in tune with how psychological practice occurred there. Regardless, I was still thrust into what can only be described as a form of culture shock when I began my placement.

Years of practised traditions and customs have led to all major aspects of the country, including health care, being heavily structured around cultural practices and norms. Therefore, it was clear to me going into the job that psychological welfare and ethical practice, while regarded with high esteem, were overruled ultimately by traditional expectations. With emphasis on the importance of creating and maintaining a family unit at the forefront, when assigned a patient it was generally a given that you were also responsible for three or four accompanying family members. They deemed it their duty to be present at all sessions that more often than not extended beyond the recommended psychoeducation and family counselling. While being aware of this natural behaviour in mental health practice back home, I was yet to be exposed to its more sinister side.

Of course, this highly accepted family involvement could suggest a positive step towards families rallying around individuals suffering from mental health difficulties. They are expressing a deep-found interest that goes beyond a societal taboo of mental health and fanatical assumptions deep rooted in the culture, such as black magic – a prevailing belief in rural communities. Family and friends find themselves gaining firsthand knowledge of mental health issues and how to prevent or manage them. However, a more profound analysis could bring into question whether society's preference for family involvement may in fact be causing more damage than not.

When working with patients I was expected to never second guess the personal involvement of parents, siblings and even aunts and uncles, who would sit in on privileged sessions with or without the patient's consent. Whether the patient was comfortable with their grandfather sitting in on their private consultations was of little regard. All that mattered was keeping the family unit solid, even if at the cost of privacy. 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 when it was suggested that his wife may want to discuss her issues in private. She eventually stopped coming in for her therapy because her husband didn't have time for it and I was bound, both professionally and culturally, to accept this. Such instances are common and generally acceptable. 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, with much difficulty, to leave the room. When they later demanded to know what their daughter had said in their absence I was encouraged by superiors to break privilege as it was their parental right, despite their daughter being over 20 years old. It is an unspoken rule in the culture 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 during a session, received conflicting reactions of comfort from his psychologist and judgement and anger from his parents. In that situation, from a professional standpoint, you are not at a liberty to begin challenging the parents of your charge. From an ethical standpoint however, would it not have been beneficial for your patient to separate him from his parents? Or simply not have them present in the first place? In the end policy dictated the psychologist remain neutral and 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, seemed to trump mental health each and every time. Never was this more heavily ingrained into my brain 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 then 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?

I played the passive professional, submitting to the family member's wishes, which did that young man no favours. Ultimately I questioned not just the ethics of practising in Pakistan, but my own ethics and potentially compromised morality. How far should cultural practices and traditions be allowed to venture into psychological practice before a line must be drawn?