Abstract

Culture guides the individuals to live their lives according to the beliefs set by the people of that culture. In order to know about the cause of any illness, the combination of knowledge and culture is considered to be a powerful tool. The study aimed to see the cultural perceptions about mental illness in Jalalpur Pirwala. This study focused on the carers of mentally ill persons by observing their perceptions regarding the mentally ill person of their families. The subject of the research was 18-60 years old mentally ill persons. Data collection methods included observation, unstructured interviews with practitioners (spiritual healers/ bhoopa), and in-depth interviews were conducted with caretakers of mentally ill persons, selected through snowball sampling. Findings showed that cultural beliefs regarding mental illness are related to supernatural or divine phenomena in which causes of mental illness are Allah’s will or punishment, witching, black magic, evil eye, curse or women’s fault.

Key Words

Culture, Mental Illness, JalalpurPirwala, Spiritual Healer, Carers, Beliefs, Cultural Perception

Introduction

Culture guides the individuals to live their lives according to the norms and beliefs set by the people of that culture. On particular issues, there are immense variations in the concepts, cultural beliefs as well as practices, rather issues are regarding religion, politics, economy or health. Health is immensely perceived according to cultural beliefs, particularly with respect to the illness. In order to make a belief or to know about the cause of any illness, the combination of knowledge and culture is considered to be a powerful tool. Each culture has its own explanations for why some kids are born with illnesses or impairments, how these people should be treated, and what responsibilities and functions family members, helpers, and other members of society should play. Because there are some cultural ideas about what causes those flaws or disabilities, this is the case. Children born with defects were traditionally thought to be a terrible sign for the family, and they were hidden or mistreated (Lamorey, 2002). Meanwhile, the concepts associated with mental illness are supernatural causes and bad omen.

A psychiatric condition defined by behavioural or psychological impairment of functioning is known as mental illness. It's frequently linked to depression, disease, or a reaction to a specific event, or it's restricted to social interactions. According to anthropological perspectives, cultural perceptions of mental illness can be rooted in social or spiritual domains. This may appear untrue and difficult to others, but the truth is that spiritual intrusion is one of the causes of illness in these spiritual or social domains. It is also true that all physical or tangible assets manifest in the spirit realm before they manifest in the physical world. Cultural and religious teachings often determine attitudes toward the person with mental illness, as well as ideas about the origins and causes of mental illness (Chikomo, 2011).

Mentally ill people are vulnerable in society when they have a severe kind of mental disease. This sensitivity gives rise to several family conceptions and beliefs about mental illness, such as, Nazar (evil eye), Jinnat ka saya (spirit possession), and Nahosaat (bad omen). Pakistan, too, is a developing country where such views predominate. Jalalpur Pirwala is a rural location where such beliefs are prevalent. The goal of this study was to learn about the cultural attitudes of Jalalpur Pirwala families about mental illness. In Pakistan, there are few studies on adults' mental illness from a personhood perspective; this phenomenological study adds to the anthropological research in a specific discipline of Anthropology, Medical and Psychological Anthropology.

Review of Literature

an explanatory model (1978). In this way, all illnesses are depicted in different cultural perspectives in different ways. Similarly, mental illness is also an explanatory model according to cultural perspectives. Where perceptions and explanations regarding mental illness change with the changes in cultures. Here mental illness is seen in the 'embodied person-hood' perspective where the focus was on the carers of mentally ill persons. How they perceive mental illness?

Ran et al. (2021) conducted an analysis comprised of forty-one papers from the Pacific Rim region that matched the inclusion criteria. In the Pacific Rim region, the rate of mental illness stigma (for example, public stigma from 25.4 to 85.2 percent) was relatively high. People's stigmatizing behaviours and attitudes toward people with mental illness, their family, and mental health professionals were influenced by cultural factors, for example, Confucianism, collectivism, familism, face concern supernatural beliefs, and religion. 

In a stratified sample of the adult population in 28 European countries, Bracke (2019) investigated the impact of cultural and personal stigma beliefs on efforts to seek professional care for mental health disorders. When stigmatizing ideas are prevalent, people are less likely to seek help from specialized mental health professionals, and they are less likely to contact general practitioners when they need formal care, regardless of their own personal stigma

beliefs.

Afaque, N. (2012) stated that people who are disabled, such as those who are mentally ill, are sometimes treated with pity or contempt. Cultural and religious beliefs have a big influence on how people react to impairments. Physical or mental illness is viewed as a divine punishment for a bad conduct committed by the person or his/her parents. Some people think of disability as a spirit trapped inside a body. Others say it is the product of bad powers or the presence of Nazar (evil eye).

A review of ethnocultural beliefs and mental illness stigma by Abdullah et al. (2011) emphasises the diversity of cultural perspectives on mental health. Some American Indian tribes, for example, do not stigmatize mental illness, while others stigmatize only some mental illnesses, and still, others stigmatize all mental illnesses.

Khan et al. (2011) gave an analysis related to mental illness. People in Malaysia attributed supernatural agents, possessions by spirits, and witchcrafts as the source of mental illness, according to a survey. There are also misconceptions that mentally ill people are unpredictable, that they will never be normal, and that they are dangerous and violent.

With the passage of time and society, our understanding of mental disease evolves as well. Every culture has its own set of beliefs and practices that it uses to explain mental illness. Subudhi (2014) wanted to investigate how Indian culture influences mental illness manifestation, prevalence, and treatment techniques. It's sometimes said to be a curse or the outcome of a past life's curse or retribution. In rural India, people still think that mental illness is caused by bad spirits that are furious because the sick individual murdered a cow in a previous life.

Chikomo (2011) confirmed that the World Health Organization (WHO) has stated that understanding of the causes of mental health differs by culture and has never been positive globally, it is necessitating public education and more openness about mental illness.

Understanding illness and healing as symbolic and portrayed as a culturally relevant performance is central to the interpretive approach (Keinman 1977 quoted by Goodman & Brooke, 1994). For example, if a Shaman sings a long narrative song to calm and reassure a woman during a difficult birth, it may provide a placebo effect. When considering the findings of this study, it is clear that "cultural attitudes and beliefs characterize the mental disease." The means of healing are manipulated by these indigenous perceptions. One of the respondents, for example, saw a girl's mental illness as a possession of the fairies thus she preferred that her child be treated by a spiritual healer rather than a doctor or psychiatrist.

Goodman & Brooke (1994) said that interpretive perspective of medical anthropology describes that disease brings some meanings with it. These meanings can be social, cultural, psychological or biological. This approach documents the thoughts and experiences of sufferers, their families, and others in their communities. In the current study, it can be observed that in Jalalpur Pirwala mental illness is considered to be caused by supernatural beings or powers. So, mental illness is understood in the perspectives of supernatural phenomena.

Bhugra et al. (2021) stated that the way we comprehend our explanatory models of distress, which define who is addressed first for support, heavily influences our pathways into therapeutic care. We frequently seek aid from personal, folk, or social sources first and then turn to professional treatment once these options have been exhausted. This will also be determined by the sort of healthcare system in place and the number of funds available (which will also be decided by the culture and the society). Individuals in distress may use more than one healthcare system at the same time in some instances.

Spirit hostility and soul loss were the two main categories of animistic causation that Murdock (1980) considered. Spirit aggression is a widely held concept that illness is caused by spirits acting aggressively, such as putting something into or doing something to a person's body. Spirit possession is a form of spirit assault. When a person's soul or spirit leaves during a dream or as a result of the soul being terrified or taken by a ghost or act of sorcery, it is known as soul loss. In the context of shamanic rituals, the concept of soul loss is investigated as the lack of some crucial essence of the person.

Punishment for misbehaviour is a key aspect of supernatural theories, which Murdock (1980) defined as the "automatic result of some act or experience of the victim mediated by presumed impersonal causal linkages rather than by the participation of a human or supernatural being," also known as "mystical illnesses” (p. 17). The cause is seen to be an impersonal supernatural power rather than supernatural creatures' conscious actions.

However, psychiatric disorders have assumed natural causes and uniform progressions and results, but it has been revealed that the course and result of these disorders differ in the different social and cultural settings. Medical anthropology basically outlines the connection between psychiatric disorder and social and cultural procedures as "mediation". In this development of psychiatric illness, cultural and social procedures significantly influence the experience of illness, the reaction of the sufferer's families and societies, and the curing or healing of illness (Kleinman, 1980).

In Pakistan, the prevalence of mental health issues is on the rise. In both the rural and urban populations, common mental health problems have been discovered, and they appear to have a positive relationship with socio-economic difficulties, relationship problems, and a lack of social support. Bipolar disorder, schizophrenia, psychosomatic diseases, obsessive-compulsive disorder, and post-traumatic stress disorder appear to be the most common (Khalily, 2011). This research focuses on mental illness and provides insight into how such disorders and concepts are seen differently among cultures in Jalalpur Pirwala.

Material and Methods

Using a phenomenological research approach, the culturally produced concepts of families on mental illness were investigated. The goal of qualitative research is to learn how individuals perceive their interactions and attitudes with mentally ill people, how mentally ill people create their worlds, and what cultural meanings are associated with mental illness. This study looked at people between the ages of 18 and 60 who had a mental illness. The study took place in the city of Jalalpur Pirwala in the district of Multan. It is made up of the UC112 and UC113 union councils. The study's participants were all residents of Jalalpur Pirwala who were concerned about adult mental illness. When taking families of mentally ill people, snowball sampling was used. Whereas the sample size of the responders was 27, 23 of them were caregivers and 4 practitioners (Bhoopa).




 

 

Table 1. Respondents Distribution with respect to Religious Sects

Religious Sects		Frequency			Percent
		Carers	Spiritual Healers	Total
Sunni	Deo-Bandi	05	00	05	18.5
	Barelvi	18	01	19	70.4
Ahl-e-Hadith	Wahabi	00	01	01	3.7
Shia		00	02	02	7.4
Total				27	100

 




The people only from the Jalalpur city were selected to demonstrate external validity (generalisation). As a result, interviews were conducted with the families of mentally ill people from Jalalpur who ranged in age from 18 to 60 years old. The researchers were able to learn the following from the interview guide: (1) What are the community's overall cultural ideas on mental illness? (2) Do they regard mental illness as a divine punishment or a curse, and if not, what do they see it as?

One focus group discussion was held in Madrassah Rehmania, Jalalpur Pirwala in which some religious responses were observed. Another discussion was held in Govt. Higher Secondary School Jalalpur Pirwala to get the views of teacher and the third discussion was held in Tehsil Headquarter Hospital to get the responses of medical specialist. Thematic analysis was used to analyze the data from the respondents.

The city's name explains the city's people's connection to spiritual Islam. This is because several Roohani (spiritual) saints have called this city home, including Darbar e Pir Qattal, Darbar Hazrat Shiekh Ismail, Darbar e Aaliya Qadria Fatehia, and Darbar Sakhi Sultan. Islam has an important role in meeting the spiritual requirements of those who follow it. Huge shrines may be found all over Punjab, where devotees go to deal with their social and psychological issues. Similarly, the majestic tomb of Sultan Ahmad Qattal is the centre of interest and a well-visited shrine in Jalalpur Pirwala regarding mental illness. Jalalpur Pirwala had a number of Islamic saints, which is why the city's second name is 'Pir,' which means'saint' in Saraiki and Urdu. Pirwala refers to a location where a saint (Pir) resides. This is why the majority of people in Jalalpur Pirwala believe in saints and superstitions. For mentally ill persons, they also apply traditional and cultural cures.

Results and Discussion

With the thematic analysis of the carers’ data led to the identification of the following sub-themes: (a) Fairies and Jinn Possession, (b) Witching and Curses, Punishment, (c) Touching the Things belong to the Supernatural Powers, (d) Gender of mental illness development under a main theme “Etiology of Mental Illness: Witches, Fairies Possession, Sickness, and Other Explanations.” Findings point to a dynamic formation of these beliefs as well as the manner in which cultural tradition has influenced psychological problem conceptualizations.

 

Etiology of Mental Illness: Witching, Fairies Possession, Sickness, and Other Explanations

Regardless of whether the source was magic or illness, all participants classified mental illness as madness. They referred to madness as bhooli (mad female) and bhoola (crazy male). They believe the person went insane as a result of a jinn possession, curse, fairies' possession, or witchcraft. “Ganna chalda hay tai houn waly pariyaan aa de meri dhi naal kheddi hein tay hou waly ay bhooli thi wendi hay" (Whenever a song is played, fairies appear and begin to play with my daughter and she became vulnerably insane at that moment).

 

Curses and Witching

In this portion of the study, seven out of twenty-three individuals mentioned the widespread notion that madness or mental illness, is caused by a person being cursed or witched. Witchcraft and curses were frequently classified as magic or magical objects by participants. “Agr kahein di dimaghi halaat khraab thi wendy hay ya oo bhoola thi wendy tay eenda kethai na kethai taluq jaado mentaar naal hondy” (When someone goes insane or becomes mentally ill, it's usually due to witchcraft) one community member said. This reflects the widespread existence of this concept in the culture of Jalalpur.

Many people in Jalalpur Pirwala still do not believe in psychic phenomena. People frequently cannot identify the cause of mental illness and instead blame it on being witched. Placing mental illness explanations in this abstracted world gives the impression that psychological issues are "magical matters and magical objects." Furthermore, these statements represent a long-held view among caregivers of mentally ill people that sickness is fully caused by these mystical matters, rather than a product of one's own lived experience or physical state.

 

Jinn and Fairies Possession

Fairies and jinn possession are also recognised as a sort of spiritual sickness by eleven out of twenty-three carers of mentally ill people in Jalalpur Pirwala. Fairy possession was a common theme in Jalalpur Pirwala's unusual cases. In Jalalpur Pirwala, the majority of carers blame Paariyoun da saya (fairy possession) for their pain or mental illness. "Paariyaan (fairies) are mythical beings who are fun and have magical powers," the caregiver says. There was a 23-year-old man in the field who was burned by the stove fire. Because her mother had tied him to the stove while she was cooking, this was the case. The purpose of binding him was to keep him away from playing with fairies, but the son was unexpectedly trapped in a fire, and he burnt and even he did not cry. “Meda potar paariyan dy saaye which hay taan hi ay khamosh thi gaya hai” (My son is in the grip of fairies, and the fairies have rendered him speechless), her mother (carer) said.

Jinn, according to Hussain and Cochrane (2002), are a separate race that may take on various forms and can harm humans if they possess them. Jinn can also make you sick, make you angry, or make you sad. Victims of evil jinn possession can exhibit incredible strength and agility, as well as self-destructive behaviour. Hallucinations, fainting, and epileptic-like episodes are also common, as are a change in the possessed’s personality, physique, and voice.

 

Punishment

It is another component that has been identified

as a contributing factor to mental illness. Retribution is felt for crimes done in this life; hence the birth of a mentally sick child could be seen as a punishment for one or both parents. This idea was proposed by participants. "A family may have done wrong or not contributed to the clan, thus a baby may be born with mental disease," one responder remarked. God is the one who imposes these penalties.

 

Touching the Things belong to the Supernatural Powers

Touching or stealing items that could belong to supernatural creatures appears to be another method to comprehend the onset of mental illness. Cultural beliefs require that one should not touch another person's property without dire repercussions since the property could be possessed by spirits or other supernatural beings, causing the individual to be witched. Participants expressed anxiety that if they touched another person's 'things,' they would go mad. Surprisingly, this curse from touching other people's stuff can be passed down through generations, as individuals "who are cursed" are "simply getting cursed since their family was cursed a long time ago," because one family member had touched something belonging to another family.

 

Gender of Mental Illness Development

In terms of spirit possession and gender, there is a belief that "males are usually possessed by a witch (churrhail) or fairies, while females are possessed by jinn." Males are more likely to incur psychological stress, according to those who believe as masculinity prevents men from expressing their thoughts therefore they are more distress.

Throughout these explanations, numerous reasons for mental illness surfaced, but thoughts about fairies, witches, and curses remained prevalent. However, there is an intriguing concept embedded in each of these explanations: the distinctiveness of mental illness in Jalalpur Pirwala society. Participants recounted the progression of madness instead of delving into specific diseases that might be addressed by Western practices or thinking.




 

Table 2. Perceptions of mental illness according to psychologist, carers and Physicians and Homoeopathists

Cases	Name of the Mentally ill person	Symptoms (Diagnosed by a psychologist through researcher)	Carers’ Perception about their Mental Illness	Physicians and Homoeopathists’ Perception about their sufferance
01	Respondent A	Post-traumatic stress disorder	Fairies’ possession	Never went to a doctor
02	Respondent B	Delusions and hallucination and high fever continuously	Jinn possession	Meningitis Fever
03	Respondent C	Dissociative identity disorder	Fairies’ possession	Never went to a doctor
04	Respondent D	Mood disorder	Victim of black magic	Never went to a doctor
05	Respondent E	Schizophrenia	Fairies’ possession	Meningitis Fever
06	Respondent F	Hallucination and just a chest pain due to any medical issue	Jinn possession	Stomach burning
07	Respondent G	Delusions and hallucination	Fairies’ possession	Never went to a doctor
08	Respondent H	Down Syndrome	Will of Allah	(Mota dimagh) Brain is not working by birth
09	Respondent I	Muscles Dystrophy	Fairies’ possession	Muscles Dystrophy
10	Respondent J	Bipolar disorder	Being witched by ex-husband	Deficiency in haemoglobin
11	Respondent K	Mania (Suddenly get overly hyper)	Fairies’ possession	Never went to a doctor
12	Respondent L	Delusions and Muscles pain	Being witched by supernatural forces	Muscles Pain
13	Respondent M	Delusions and Hallucination	Fairies’ possession	Never went to a doctor
14	Respondent N	Dissociative identity disorder	Victim of black magic	Meningitis Fever
15	Respondent O	Schizophrenia	Fairies’ possession	Never went to a doctor
16	Respondent P	Neuro-developmental disorder	Punishment by Allah because of parents sins	Never went to a doctor
17	Respondent Q	Down Syndrome	Fairies’ possession, Play with fairies	(Mota dimagh) Brain is not working by birth
18	Respondent R	Mania	Victim of black magic	Never went to a doctor
19	Respondent S	Dissociative identity disorder	Touched stone of a jinn’s path and being cursed	Effects of typhoid
20	Respondent T	Intellectual disability	Punishment by Allah	(Mota dimagh) Brain is not working by birth
21	Respondent U	Post-traumatic stress disorder and panic disorder	Being witched by a family member (did not specify)	Slight fever every evening
22	Respondent V	Mania	Being witched by supernatural forces	Never went to a doctor
23	Respondent W	Bipolar disorder	Once stolen watermelon and being cursed by supernatural beings	Severe feverc

 




The Table 02 depicts the perceptions of carers, doctors and psychologist comparatively. 23 families of mentally ill persons were interviewed and in which 09 families stated that the causes of mental illness is fairies’ possessions, according to them fairies are controlling the minds of mentally ill persons and make them silent. However, 02 families said that cause of mental illness is Jinn’spossession. 07 families stated that mental illness is the result of witchcraft. According to them, black magic or curse by supernatural forces makes the man mentally ill for the whole life till they do not go to Bhoopa for its treatment. 03 families associated mental illness with religion and stated that mental illness of their family members is the result of their parents’ sins. Allah is punishing parents by giving them disabled and vulnerable child. 02 families said that their family members became mentally ill by touching or unconditionally stealing the things of supernatural beings.  These respondents had never gone to psychiatrist or psychologists for the treatment of mentally ill persons. 14 of them went to doctors (physicians or homoeopathist) but only for once and then preferred spiritual healers. While 10 of them never went to a doctor and preferred spiritual healers. 06 doctors related sufferance with fever, 03 said that brain is not working (Mota Dimagh) by birth, 02 of them related mental disorders with muscles problems, one of the doctor said that perhaps because of stomach infection hallucinations and chest pain is occurring and one of the doctors related fits of bipolar disorder with deficiency in hemoglobin.  In the other side responses of psychologist (Ms. Fozia Hamid) is documented who helped researcher and diagnosed the mentally ill persons.

Conclusion

The research's original question was meant to guide an investigation into participants' perceptions of mental illness and its treatment in Jalalpur Pirwala. Individuals in this study held a variety of ideas on mental illness and its onset. Traditional explanations of disease as a curse were recognised by participants throughout the populations. The onset of mental illness is commonly explained by cultural tradition in terms of some feeling of mysticism and spiritual links to supernatural phenomena, which is grouped into a single category of mental illness (i.e., bhoolapan). In the Jalalpur Pirwala context, understanding this culturally produced illness can aid psychological healing and management. Furthermore, mental disease ideas and treatment approaches (both ancient and modern) reflect broader cultural dynamics.

Recommendations

This research situates Pakistan's mental health needs and perspectives within the context of indigenous and culturally distinct psychological and anthropological knowledge. In anthropology, indigenous and cultural perspectives help academics and practitioners shift away from imposing Western methodology, beliefs, and practices (Greenfield, 2000). It is critical to raise public awareness and encourage people to use modern mental health care. In our society, research on the impact of culture on mental health or sickness receives minimal attention. It is also necessary to disseminate this information from ordinary people to policy planners as well as educationalists in order to develop concrete plans and programs for mental health.

References

• Abdullah, T., Brown, T.L. (2011). Mental illness stigma and ethnocultural beliefs, values, and norms: an integrative review. Clinical Psychology Review, 31, 934-948.
• Afaque, N. (2012, November 16). Defeating Disability.
• Bhugra, D., Watson, C., & Wijesuriya, R. (2021). Culture and mental illnesses. International Review of Psychiatry, 33(1-2), 1-2.
• Bracke, P., Delaruelle, K., & Verhaeghe, M. (2019). Dominant cultural and personal stigma beliefs and the utilization of mental health services: A cross-national comparison. Frontiers in Sociology, 4, 40.
• Chikomo J. G. (2011) Knowledge and attitudes of the kinondoni community towards mental illness. Dissertation presented to the university of Stellenbosch in South Africa. URL:
• Goodman, & Brooke, T. R. (1994). On Seeking Common Ground between Medical Ecology and Critical Medical Anthropology. Medical Anthropology Quarterly, 7, 202- 207.
• Greenfield, P. M. (2000). Three approaches to the psychology of culture: Where do they come from? Where can they go? Asian journal of social psychology, 3(3), 223-240.