Education and debate

Traditional community resources for mental health: a report of temple healing from India

R Raguram, professor of psychiatry ^a, A Venkateswaran, resident in psychiatry ^a, Jayashree Ramakrishna, additional professor of health education ^a, Mitchell G Weiss, professor and head of department ^b. 

^a National Institute of Mental Health and Neurosciences, Bangalore 560 029, India, ^b Department of Public Health and Epidemiology, Swiss Tropical Institute, CH-4002 Basle, Switzerland

Correspondence to: Dr Raguram raguram{at}nimhans.kar.nic.in

The use of complementary medicine and the traditional medicine of other cultures has been increasing in Europe and North America.³ Although less well documented, the use of complementary medicines and consultations with traditional healers is widely acknowledged in low income countries, such as India. Here too the limited availability of health services motivates the use of a wide range of alternative systems of care for various ailments, including mental illnesses⁴

In addition to herbal and other traditional medicines, healers and healing temples are seen as providing curative and restorative benefits. In India many people troubled by emotional distress or more serious mental illnesses go to Hindu, Muslim, Christian, and other religious centres. The healing power identified with these institutions may reside in the site itself, rather than in the religious leader or any medicines provided at the site. Studies of these healing sites have focused primarily on ethnographic accounts.⁵ Research has not systematically examined the psychiatric status of the people coming for help at these religious centres or the clinical impact of healing. It has focused primarily on possession and non-psychotic disorders, rather than serious psychotic illnesses.

Yet people with serious psychotic illnesses do visit such healing temples in India,⁶ and understanding the role of these institutions may help with planning for community mental health services in underserved rural areas. We describe here the work of a Hindu healing temple in South India known as a source of help for people with serious mental disorders. We also tried to measure the clinical effectiveness of religious healing at this site.

	The healing temple

The study was conducted at the temple of Muthusamy in the village of Velayuthampalayampudur, Dindugal District, Tamil Nadu. Set in the foothills of the Palani range of the Western Ghats, this temple, built over 60 years ago, has become increasingly popular as a place of healing, especially for people with serious psychiatric problems. It was built on the outskirts of the village in the middle of a graveyard, over the tomb of Muthuswamy, a man who lived in the village a century ago.

During his lifetime Muthuswamy was considered a strange person who worked little and spent his time wandering about in the village. According to local legend, towards the end of his life people noticed that a mere touch of his hand cured many ailments, especially mental illnesses, and stories spread about his healing powers.

After Muthuswamy died the villagers built the temple over his tomb, and it began to attract people with mental illnesses (figure). They are usually brought by their families to stay in the temple. They may stay without charge, and a close relative stays with them and takes care of their daily needs. In many other healing temples for agitated people physical restraints are used, but they are not used here. The ill person is encouraged to take part in the daily routines of the temple, such as cleaning the compound, watering the plants, and so forth. The temple is currently managed by the descendants of Muthusamy, who ensure its availability to those in need and maintain the tradition.

	Conduct of the study

Our research was carried out over three months from June to August 2000. Everyone who came for help and stayed in the temple was studied. The purpose and nature of the study was explained to the subjects and the family caregivers who stayed with them, and informed consent was obtained from both. During this period one of the authors (AV) stayed in the temple and carried out an in depth ethnographic inquiry into the historical background of the temple, the various popular ideas about the origin of the temple, and the process of healing that occurs. He elicited the patients' illness experience and the caregivers' views on the causes with a locally adapted semistructured cultural epidemiological interview, known as "emic." The term emic, after which these interviews are named, refers to the "internal" views of health and illness according to patients and the local population, in contrast to the "etic" or "external" views of doctors and epidemiologists.⁷

To assess the impact of their stay in the healing temple on clinically important symptoms, the severity of psychopathology was assessed with the brief psychiatric rating scale,⁸ which provides a systematic approach for assessing 18 psychiatric symptoms on a seven point scale. The subjects were assessed by a trained psychiatrist (AV) on the first day of their stay in the temple. The initial ratings were then given to the principal investigator (RR) and were not available to the rater when AV made his second assessment on the day the subject left the temple to return home. For those subjects who planned to leave the temple after the investigator's period of residence, he returned to make this assessment on the day of their departure. Scores for the total brief psychiatric rating scale, individual items, and the four major subsyndromes were analysed.

The healing temple of Muthuswamy

Subjects' impressions, caregivers' perceptions of change over the course of stay at the temple, and their level of satisfaction with the quality and impact of care were also studied. Caregivers were asked to rank change in the status of the subjects as recovered, improved, no change, and worsened. Caregivers were also asked to assess satisfaction with their experience at the temple: highly satisfied, satisfied, neither satisfied nor dissatisfied, and dissatisfied.

We report here data on the impact of a stay on clinical symptoms and the perceived quality of help received judged by the subjects and their caregivers. A detailed report of the entire study, including an ethnographic account of activities at the temple and a cultural epidemiological assessment of illness experience, its meaning, and prior help seeking behaviour among the people seeking help at the temple, is provided elsewhere.⁹

	Findings

Over the course of the study 31 people sought help and stayed at the temple. Most (21) were male farm labourers from rural areas, and all were Hindu. Twenty three subjects were diagnosed with paranoid schizophrenia, six with delusional disorders, and two with bipolar disorder with a current manic episode.¹⁰ The average duration of illness was 71 weeks and the mean duration of stay in the temple six weeks (range 1-24 weeks). Only one of the subjects had received any prior medical care, and that was from a general practitioner, not a psychiatrist.

The mean brief psychiatric rating scale total score on arrival was 52.9 (SD 5.0), dropping significantly to 42.9 (SD18.6) at the time of departure from the temple (P<0.001). Changes in the four summary subscales are presented in the table. In addition to improvement in scores, subjects generally acknowledged benefits of their stay. The following comment is typical: "I feel much better now. My fears have come down, and I am able to do small jobs here. If at all I have any problems, I will come back here." According to the evaluation by family caregivers, 22 subjects had improved and three had recovered fully.

	Discussion

The help received at this temple served as an alternative to clinical psychiatric treatment for these people with psychotic illness. This therefore raises questions about the effectiveness of the help they received. The observed reduction of nearly 20% in brief psychiatric rating scale scores represents a level of clinical improvement that matches that achieves by many psychotropic agents, including the newer atypical agents.¹¹ In addition the family caregivers of these patients also thought that most of the subjects had improved during their stay.

Although ours is the first study to use a standard clinical assessment (brief psychiatric rating scale) to evaluate the effectiveness of temple healing, our findings are only suggestive owing to the limitations of our methods. There were no comparison groups, and although we endeavoured to make the second assessment by the same rater as independent of the initial assessment as possible, standards were clearly short of rigorous double blind research methods. Because of the unique cultural and linguistic skills required for such field research, however, it is hard to maximise methodological rigour and minimise the intrusiveness of the research. Furthermore, because temples operate in different ways, it would be inappropriate to generalise findings from study of one site to other regions or other healing temples in the same region. Consequently, comparison groups and randomisation would not only be difficult to incorporate in the design but would also add little to the generalisability of findings. Nevertheless, such research has a useful role to helping to assess needs and resources for developing locally relevant community mental health programmes.

Thus we have identified improvement in the symptoms of people with psychotic illnesses who received no psychopharmacological or other somatic interventions during their stay in this temple. How can we explain this change? The cultural power of residency in the temple, known for its healing potency, may have played a part in reducing the severe psychotic symptoms of these subjects. The Muthuswamy temple is not a high caste Hindu temple, but a temple of a backward caste, known as Gounders, which means that no elaborate brahmanical rituals of any kind were performed there. Furthermore, no specific ceremonies were performed to promote the recovery of these subjects. Residents merely attended the simple morning prayers (puja) at the shrine for about 15 minutes, and they spent the rest of the day in light maintenance routines of the temple. According to the legend of the temple, and an idea widely held among the people who come for help, it is the experience of residing in the temple for a period of time, rather than therapy provided by a healer, that brings relief from mental illnesses.

In addition to the specific healing power associated with the temple, the observed effects may have also resulted from the supportive, non-threatening, and reassuring setting. The role of a supportive, engaging environment in promoting recovery from psychotic symptoms motivated the development of institutional care for seriously mentally ill people in the late 18th and early 19th centuries in Europe and North America. In effect, this temple provides the refuge suggested by the term asylum in its most positive sense. Instead of a lengthy, if not a lifetime, stay in hospital that became characteristic of asylum treatment, in this study it was notable that a stay of only five weeks could bring notable improvement, indicating the value of a brief stay in a supportive milieu.

Healing temples thus may constitute a community resource for mentally ill people in cultures where they are recognised and valued. At a time when deinstitutionalisation has brought about uneasy changes in the management of severe mental illness in high income countries, the absence of analogous institutions providing community support in Euro-American settings is noteworthy. Without them, patients may be denied needed refuge that facilitates healing. Access to local institutions providing such refugeas in the case of the Muthuswamy templemay even help to explain the better outcomes for schizophrenia reported in low income traditional societies.¹²

Despite a mean duration of illness of one year in the people we studied, only one of them had ever consulted a doctor in the government primary health centre, which is located in the same village as the temple. Although government primary health centres are designated as care providers for mental illness in rural areas,¹³ the lack of use of these facilities has important implications. Other observers in India have long noted the need to find an appropriate role for the various indigenous practices in community mental health.¹⁴ The potential for effective alliances involving indigenous local resources needs to be considered, and at the very least, their particular role in local community settings needs to be understood and acknowledged to aid policymaking and planning for mental health.

	Acknowledgments

We thank the trustees of the Muthuswamy temple, especially Mr Ramaswamy and Mr Muthuswamy, a former priest of the temple, for their help in enabling us to carry out this study. We also thank the people and their families seeking help at the temple for their cooperation.

Contributors: RR and JR supervised the fieldwork and RR wrote the paper with the help of AV, MW, and JR. AV conducted the fieldwork and RR and MW revised the manuscript. RR is the guarantor.

	Footnotes

Funding: Self funded by the investigators from personal resources.

Competing Interest: None.

	References

1.	Fisher P, Ward A. Complementary medicine in Europe. BMJ 1994; 309: 107-111[Free Full Text].
2.	Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, et al. Trends in alternative medicine use in the United States, 1990-1997. Results of a follow-up national survey. JAMA 1998; 280: 1569-1575[Abstract/Free Full Text].
3.	Ernst E. The role of complementary and alternative medicine. BMJ 2000; 321: 1133-1135[Free Full Text].
4.	Kapur RL. The role of traditional healers in mental health care in rural India. Soc Sci Med 1979; 13B: 27-31.
5.	Pakaslahti A. Family centered treatment of mental health problems at the Bajaji Temple in Rajasthan. In: Parpola A, Tenhunen S, eds. Changing patterns of family and kinship in South Asia. Helsinki: Finnish Oriental Society, 1998.
6.	Raghu TM. Cultural aspects of schizophrenia: an exploratory study. MD Thesis. National Institute of Mental Health and Neuro Sciences, Bangalore, 1999.
7.	Weiss MG. Cultural epidemiology: An introduction and overview. Anthropology and Medicine 2001; 8: 5-29.
8.	Overall J, Gorham D. Brief psychiatric rating scale. Psychol Reports 1962; 10: 799[Web of Science].
9.	Venkateswaran V. A clinical and ethnographic study of temple healing in South India. MD Thesis. National Institute of Mental Health and Neuro Sciences, Bangalore, 2001.
10.	World Health Organization. ICD-10 classification of mental and behavioural disorders, diagnostic criteria for research. Geneva: WHO, 1993.
11.	Umbricht D, Kane JM. Risperidone: efficacy and safety. Schizophrenia Bull 1995; 21: 593-606.
12.	Jablensky A. Epidemiology of schizophrenia: the global burden of disease and disability. Eur Arch Psychiatry Clin Neurosci 2000; 250: 274-285[CrossRef][Web of Science][Medline].
13.	Government of India, Director-General of Health Services. National mental health programme for India: report. New Delhi: Ministry of Health and Family Welfare, 1982.
14.	Kapur RL. Mental health care in rural India: a study of existing patterns and their implications for future policy. Br J Psychiatry 1975; 127: 286-293[Abstract/Free Full Text].