Understanding Mental Illness Across Cultures: It Starts with Recognising Our Universal Humanity

by Aaron Balick

An older Indonesian woman shuffled slowly into the room, enrobed in the brightly coloured gown worn by all the residents here at Bali’s only inpatient psychiatric facility. Her head was downcast, her jaw shifting side to side conspicuously, a common side effect of some anti-psychotic medications. She was there, but hardly present, looking vacant behind the eyes. Accompanying her were about thirty women of different ages, all with serious enough conditions to be here, but widely different in terms of their levels of functioning.

Meeting them in the room were about fifteen young volunteers on mental health work-placements. All of them bright, intelligent, and bursting with knowledge from their university courses. Within minutes, volunteers, patients, and I were all standing in a large circle, about do some yoga.

These volunteers were largely, but not exclusively, from wealthy Western countries, psychology students or graduates, with English as their lingua franca. How might they be expected to communicate, let alone work effectively, with a group of people that were so profoundly different from them in almost every way: culturally, religiously, economically, and linguistically? What could they possibly offer in a country where even the concepts of mental health and its treatment are so different from their own?

I wanted to find out, so I was gratified go to Bali with SLV.Global to do just that. SLV the organisation that arranges mental health placements like this in Bali as well as other projects in Sri Lanka and India. Such projects are ethically developed in partnership with local organisations and are devised in culturally appropriate and sustainable ways. I travelled there to deliver a training to the psychiatric staff at the same facility in which the volunteers were based. This was a two-day training on “Self Care for Patient Care” based on the principles of emotional intelligence, mindfulness, and positive psychology. Once that training was complete, I joined the volunteers as a participant in their activity sessions with the patients resident there.

This brings us back to the start of the story where we are all gathered in that giant yoga circle. A volunteer gestured to herself and we all looked her way: as she began to move, we mirrored her. It was a gentle but active session intended to engage and warm up the participants. Engagement in this process ranged from reticence to gusto, with a few, like the woman I describe in the first paragraph, hardly seeming to be aware of their surroundings at all.

SLV volunteers are trained to create workshops based on psychological principles that can be deployed without the use of language. The aim is to increase patients’ psychological and emotional functioning within this unique cross-cultural, cross-linguistic context . Getting people moving, making eye contact, and engaging in basic interpersonal mirroring through yoga is a good example of this approach.

Yoga was followed by a rather more energetic dancing activity aimed at getting in touch with different emotional states. A playlist of short clips was prepared that represented different moods (sad, happy, angry, etc.), and we danced according to the feeling state of each musical clip. Volunteers and patients alike participated in these exercises – even a visiting psychotherapist like myself, who, I can assure you, is not an accomplished dancer.

After dancing, participants were split into five smaller rotating groups, giving all the participants a chance to experience a variety of activities that appeal to the physical (miming facial expressions), to the artistic (drawing emotions), to the more cognitive (matching groups of emotions together by theme), creating a highly integrated biopsychosocial programme.

What really touched me was the way volunteers used facial expression and gesture to gently guide the participants through the activities. Being a “talking therapist” I noticed myself having to fight the compulsion to speak. But of course “explaining” would have defeated the purpose. It’s not just the task itself that enhances engagement, but even more importantly, the process of communicating how to engage in that task.

Though many of the participants were able to engage easily, a minority, like the woman I introduced at the top, were less able to do so. During the yoga, she seemed not to understand what was happening. In the small group work, however, I witnessed a glint in her eye when she “got” that the task was to match images cut from magazines with feelings written on cards. I registered a sense of satisfaction and pride in her face when she dragged an image across the floor to match its card. Volunteers and other patients clapped encouragingly as she did.

The workshop closed with another yoga session, though this time everybody was more aligned with the activity. The woman I’d been accompanying was more fully engaged too, actively mirroring the poses of the leader. Seeing her transform over the course of two hours was deeply moving, and I feel sure she benefited greatly from the care and attention the volunteers put into the activities in which she participated.

While I think we can assume that most of the residents appreciated the session, I would like to briefly explore the residual effect it may have had on the volunteers. What I witnessed developing among the volunteers is what most people might call “soft skills”, but what I consider to be crucial in the field of mental health work. Though the volunteers will have arrived with an awful lot of knowledge about evidence-based medicine and clinical psychology, they will leave with something that is much more difficult to teach: how to engage, communicate, and be with someone’s essential humanity in the context of enormous personal and cultural difference, without relying on language. This is a skill that will enhance their practice for a lifetime.

The great irony is that I went to Bali to teach “soft skills” to the staff there, and found I learned more about it from the sessions with volunteers and patients. They taught me afresh how to use my face, my body, my will and intention to communicate and to be with the patients without resorting to the ease of language and explanation. What an amazing opportunity these young volunteers have, at the very beginning of their working lives, to work across such presumed difference, only to find one has to be present for something that is actually common to us all – just the need to be recognised as a human being who is struggling.

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