Note: My views are in Italic and Hina’s are in regular.
Our mental health is more important now than it has ever been! The detrimental effects of COVID-19 and lockdown are very well known. My good friend Hina told me about World Mental Health Day and suggested a blog post to highlight issues we have faced, and we have seen in our respective workplaces.
When I sat down to think about what I could talk about I was overwhelmed with the number of examples I could think of both from my personal and professional life. I have decided to explore my experiences of pregnant individuals from the South Asian community that I have come across.
For all of those who know me, you will know that I am a chatterbox. I can talk for days and I love making conversation with people – I could talk about anything. It is probably why I enjoy my job so much; it is great to get to know people and I have learnt so much about the struggles people face in their lives. It humbles me if anything. From reflecting on the conversations, I have had with South Asian pregnant women who are suffering from mental health related issues I have picked out a few quotes/phrases I have heard.
The Unspoken Words
I hear this a lot “you know what it is like with us guys.” This is often a reference to the South Asian community and some of the cultural attitudes and traditions that have historically been a barrier to open conversations about one’s mental health. Women have mentioned how they are told they are “overdramatic” and that there is nothing wrong with them. Those of the Muslim faith are often told they just need to pray more, and they will be fine. Others may have heard that their mental health illness is down to supernatural causes such as jinn or black magic. These women do not feel as though they are heard by those closest to them.
“Sundas, what can I do?” – upon hearing this I felt completely helpless. The words of a woman who herself felt helpless. She is struggling with her mental health. There are many expectations of a South Asian woman – she sacrifices a lot and will not always speak up about how she is feeling. I often find that these women are likely to disclose more to me compared to a non-South Asian midwife as they can relate because of the culture and sometimes faith that we share. The unspoken words that are so easily communicated and understood. I can understand what life is like for the average South Asian family and the expectations of each family member. This can be hard to explain to someone who is not from the same culture. For a community that is big on strong family relations, I would say feelings are rarely spoken about. Many children growing up in a South Asian household could probably count on one hand how many times they’ve heard “I love you” and this is not because they are not loved but it is because there is an awkwardness around saying it out loud.
Read the Room
I am not a mental health professional and I will always recommend these women seek professional help if they have not already. As a midwife I can refer these women myself (with consent). I offer the most appropriate support at the time. You must read the room and decipher what will help the woman at that point in time. Sometimes that is talking about faith and sometimes that is suggesting mechanisms to help such as writing out thoughts/feelings, podcasts, or art therapy.
This is a plea to all my South Asian followers, let it be known to close family and friends that you are there if they ever need someone to talk to without judgement. Encourage these open conversations about mental health with our parents. Encourage those who are suffering with mental health illness to seek professional help. There is no shame in it.
Within CBT (Cognitive Behavioural Therapy), we use the analogy of a vicious cycle to help people understand what they are experiencing – negative thinking patterns, behavioural patterns, emotions, and physical symptoms are maintained and exacerbated overtime if the cycle is not broken. Similarly, I feel a vicious cycle exists when it comes to seeking help in the South Asian community.
Picture a person suffering from depressive symptoms; not finding the same enjoyment in meeting friends, experiencing suicidal ideation, lack of motivation in completing day to day tasks, daily hygiene starting to seem more difficult to maintain. This person may not understand what is happening, and may ask for advice from a family member – that family member may tell them to “get over it”, or remind them of the struggles and strife that other members of the family have been through. They may also get told to keep up appearances, to not show other people that they are struggling. As a result, this person may experience increased feelings of isolation and helplessness, as they feel they have nobody to turn to, and can see no way out – the depressive symptoms become severe over time, and this person has still not been able to seek any help; the vicious cycle carries on, and the same messages are passed to younger generations.
Within CBT, we treat anxiety and depression by helping people break their vicious cycle by identifying and challenging existing negative behavioural and thinking patterns. How can we break this vicious cycle of avoidance and shame when it comes to seeking help in the South Asian community? World Mental Health Day presents the perfect opportunity to identify issues, communicate and discuss solutions.
Faith and Mental Health
About faith, in particular Islam, I have noticed that many will hold onto it. The daily 5 prayers in Islam and regular recitation of the Quran provides some with a focus which may be lost in other aspects of their lives. Being of Muslim faith myself I find these to be particularly important. However, I do feel that it is totally ignorant of people to ignore when individuals need more than spiritual aid – they need professional help, and they need to speak of the issues they are. I have this analogy I would like to share for those who ignore the importance of professional help.
If a loved one had an accident which left them with a fractured ankle, the most common reaction is to seek medical help. You may pray for a faster recovery however you will also ask a professional for their advice. The same rule applies to those suffering from mental health illness – they will need your prayers and the support to access professional help whether that be the GP, counsellor, or mental health specialist.
As Pakistani Muslims, both Sundas and I have observed how the blurred lines between religiosity and culture have resulted in a common misconception that Islam does not recognise mental health. The opposite is true – there is a very good article in The Psychologist magazine which discusses in depth how The Qur’an recognises mental wellbeing, and ways to achieve this (I will include the link in the bottom of this post). The Qur’an mentions the nafs, which refers to soul, heart and mind, the inner self. It delineates 3 different forms of the nafs;
▪️ The nafs al-lawwama (accusatory self)
▪️ Nafs al-ammara (commanding self)
▪️ Nafs al mutmainna (peaceful self).
When the nafs al-ammara becomes prominent, our way of thinking can become distorted, which leads to us automatically perceiving things a negative light (for any CBT practitioners who may be reading this, clear parallels can be drawn between this and the rationale behind the intervention ‘Cognitive Restructuring’).
The Qur’an highlights ways to practice relaxation techniques to weaken the impact of the nafs al-ammara. The article linked provides a lot more detail on this topic, but the above is just one of the examples of how Islam does recognise that mental wellbeing fluctuates, and how important it is to address it and look for ways to progress.
In my own practice, I have found that being able to address spiritual and religious beliefs and incorporating this into existing CBT treatments has resulted in much better outcomes.
There is no shame
Mental ill health and its acknowledgment is often something that is shrouded in secrecy and shame in the South Asian community. People fear repercussions, which results in them not seeking the help they need. Early intervention is key in ensuring better outcomes, but this is often something that is not possible for most in the South Asian community; it takes for their condition to become debilitating to be able to recognise that help is needed.
So much of these mental barriers to accessing treatment stems from a dread of the future – what if word gets out? What my family start to treat me differently? What if this affects my marriage prospects? These ‘what ifs’ will often exacerbate the existing anxiety and depression, which can create a visceral sense of being trapped, of there being no way out. Coupled with difficulty in seeking help, this can lead to self-harming behaviours, or suicide.
The South Asian community values the family unit and collectivism – decisions and actions are often determined upon what benefits others, not just yourself. Whilst this creates barriers when it comes to accessing mental health treatment, it is important to recognise that family involvement can also do great things in supporting somebody’s recovery. The hypothetical scenario I mentioned earlier when discussing vicious cycles – if that person were able to approach a family member and be met with support and encouragement to seek out ways forward, how different would the outcome be?
Being able communicate freely about mental health, the same way we do physical health, should be the norm. Acknowledgment precedes support. We ask people how they are, but do we ask how they really are? How uncomfortable do those conversations make us, and why? It is important to ask ourselves these questions, as well as the elders within our community, to seek out ways forward.
You do not need to be suffering from severe symptoms to seek help. If you find that you are struggling with symptoms of common mental health problems, such as anxiety, depression, or panic, research local IAPT services. These services offer low intensity and high intensity interventions to treat symptoms by supporting and teaching you coping strategies and techniques that you can utilise in day to day life. You can self-refer online or request a referral from your GP. Consider telling friends and family about these services.
There is no shame in seeking help – a lot of people in the SA community have been convinced that there is, due to existing stigma and misconceptions. Like Sundas has already said, it is so important to have open conversations with the people around you. So many people report that being able to talk to family and friends transparently gives them some hope for the future, and acts as a protective factor against self-harm and suicide. If you know someone who is struggling, let them know that there is always help available; whether it be lending an ear yourself, or directing people to the right places to seek help – there is always a way to show support.
* The Qur’an and Mental Health (Frankie Samah for The Psychologist): https://thepsychologist.bps.org.uk/volume-31/june-2018/quran-and-mental-health