Supernatural Beliefs Must be Understood to Treat Psychosis in Pakistan

In a new article published in The Cognitive Behaviour Therapist that illuminates the complex interplay between cultural beliefs and mental health treatment in Pakistan, a team of researchers has delved into the views and experiences of patients, carers, and clinicians dealing with psychosis. The findings highlight the significance of faith-driven beliefs and social factors, opening new doors for creating culturally sensitive treatment strategies.

The study led by Shanaya Rathod from the Southern Health NHS Foundation Trust and the University of Portsmouth, alongside co-authors from institutions across the UK, Switzerland, Pakistan, and the USA, takes an in-depth look at the treatment of psychosis in Lahore, Pakistan. With 45 semi-structured qualitative interviews, the researchers explored how cultural relevance affects the efficacy of psychological interventions like cognitive behavior therapy (CBT) or family intervention (FI) in the region.

Key among the findings were patients’ explanatory models for psychosis, which included religion or faith-driven beliefs such as previous wrong-doing and supernatural ideas like black magic. These elements, along with social factors such as high expectations, social stigma, and discrimination, play crucial roles in shaping both the interpretation of mental illness and the help-seeking behaviors of those affected.

This speaks to the larger need for mental health care to be accessible and acceptable across varying cultural contexts, particularly in countries where Western treatment models may not fully align with local beliefs and practices.

The study’s results are expected to inform the development of more culturally sensitive treatment methods and improve outcomes for patients and their families dealing with psychosis in Pakistan and potentially in other culturally diverse settings.

The current research explored how clinicians, service users, and carers in Pakistan view psychosis. Ultimately, the researchers’ goal is to assist in developing more culturally relevant, less Eurocentric interventions for mental illness in low and middle-income countries.

To accomplish this goal, the researchers conducted 45 semi-structured interviews at a mental health rehabilitation center in Lahore, Pakistan. To be included in the current research, participants had to have a DSM-5 diagnosis of schizophrenia, schizoaffective disorder, or psychosis, be a first-degree relative living with someone with one of those diagnoses, or be a mental health professional involved in their care. Additionally, participants had to be between the ages of 18-65 (for individuals with a diagnosis) or over 18 (for carers), be willing to participate in the interview and have the capacity to consent to and understand the interview. Criteria for exclusion included: severe psychosis with thought disorientation or being distressed by symptoms, diagnosis of drug/alcohol abuse, carers with physical or learning disabilities, or mental health diagnoses that could affect their ability to consent. The final sample included 15 people with a psychosis diagnosis, 15 carers, and 15 mental health practitioners.

The interviews were conducted between 26 January 2020 and 9 June 2020. The interviews were audio recorded and transcribed. Researchers then identified themes within the interview transcripts. After the initial coding of themes, a sample was further reviewed by a qualitative methodology expert and two research team members to increase the codes’ reliability.

Supernatural beliefs were common among service users and their families. They often understood psychosis as related to past wrong-doing, destiny/fate, possession, or black magic performed by someone that was jealous or angry about a rejected marriage proposal. Mental health practitioners were much less likely to understand psychosis as related to supernatural beliefs. Religious attribution was also common, with participants believing psychosis was punishment for sins, not respecting religion or the result of avoiding religious activities.

Service users, their families, and mental health practitioners all identified several social factors related to psychosis. Service users typically mentioned educational and financial issues. Patient families most commonly endorsed a breakdown of relationships, while mental health practitioners pointed to financial struggles and family conflict.

Mental health practitioners were much more likely than service users of families to mention psychological and genetic factors related to psychosis. Mental health practitioners also highlighted the role of untreated mental health issues and delayed mental health treatment in psychosis.

It was common for service users to first seek treatment through spiritual leaders and traditional medicine before seeking the help of mental health practitioners. Some participants reported going to general practitioners before seeking mental health treatment. Stigma and shame likely affected how service users sought help and made them less likely to go to mental health professionals until the situation was dire. Mental health practitioners blame a lack of insight and understanding for service users’ delay in seeking the help of mental health professionals.

Some participants emphasized that psychotherapy could be helpful alongside other treatment forms, such as traditional medicine and faith-driven treatment. 13 service users reported preferring talk therapy with medication. Most participants had a favorable view of mental health services.

Ultimately, the authors argue that mental health interventions in Pakistan need to develop cultural and religious competencies, an understanding of health beliefs and religious attributions, collectivism, the notion of family as both support and potential barrier to treatment, and the roles of shame and stigma in delaying treatment.

The authors acknowledge several limitations to the current study. All the participants were recruited from Lahore. Had people from other parts of Pakistan been included in the sample, the resulting themes could have changed significantly. Transcripts were translated from Urdu to English, possibly losing some meaning and nuance. The analysis was conducted by non-Pakistani researchers. The authors note that the problem of non-Pakistanis conducting analysis was mitigated to some extent by the presence of Pakistanis on the research team and communication with the research team in Pakistan. The authors conclude:

Similar to the current work, other authors have lamented the lack of research on psychosis in the non-western world. Researchers have argued that scaling up psychiatric interventions globally may be severe consequences for low and middle-income countries. Some authors believe the emerging field of mad studies can assist in dismantling the Euro-centrism so common in the psy-disciplines.

Research has found that the stigma around psychosis is likely increasing and is not helped by mental health literacy.

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Rathod, S., Javed, A., Iqbal, R., Al-Sudani, A., Vaswani-Bye, A., Haider, I., & Phiri, P. (2023). Results of a qualitative study of patient, carer, and clinician views on the experience of caring for individuals with psychosis in Pakistan. The Cognitive Behaviour Therapist, 16. https://doi.org/10.1017/s1754470x23000077 (Link)