Hinduism, marriage and mental illness.

For Hindus, marriage is a sacrosanct union. It is also an important social institution. Marriages in India are between two families, rather two individuals, arranged marriages and dowry are customary. The society as well as the Indian legislation attempt to protect marriage. Indian society is predominantly patriarchal. There are stringent gender roles, with women having a passive role and husband an active dominating role. Marriage and motherhood are the primary status roles for women. When afflicted mental illness married women are discriminated against married men. In the setting of mental illness many of the social values take their ugly forms in the form of domestic violence, dowry harassment, abuse of dowry law, dowry death, separation, and divorce. Societal norms are powerful and often override the legislative provisions in real life situations.

INTRODUCTION

Since time immemorial marriage has been the greatest and most important of all institutions in human society. It has always existed in one form or another in every culture, ensuring social sanction to a physical union between man and woman and laying the foundation for building up of the family – the basic unit of society.[1]

MARRIAGE AND HINDUISM

The Hindus have idealized marriage in a big way. In the patriarchal society of Rig Vedic Hindus, marriage was considered as a sacramental union, and this continued to be so during the entire period. In the Shastric Hindu law,[2] marriage has been regarded as one of the essential sanakaras (sacrament for every Hindu). Every Hindu must marry. “To be mothers were woman created and to be fathers men.” The Veda ordains that “Dharma must be practiced by man together with his wife and offspring”. “He is only perfect who consists of his wife and offspring.” “Those who have wives can fulfill their obligations in this world; those who have wives truly have a family life; those who have wives can be happy; those who have wives can have a full life.”[2] For a Hindu marriage is essential, not only for begetting a son in order to discharge his debt to the ancestors, but also for performance of other religious and spiritual duties. The institution of marriage is considered sacred even by those who view it as a civil contract.

Wife is the ardhangini (half of man) according to Satpatha Brahmana “The wife is verily the half of the husband. Man is only half, not complete until he marries.” The Taittiriya Samhita is to the same effect. Manu declared that mutual fidelity between husband and wife was the highest dharma. According to Mahabharata, by cherishing the woman one virtually cherishes the Goddess of prosperity herself. Wife under Hindu law is not only a “grahpatni,” but also a “dharma patni” and “shadharmini.” The wife is her husband's best of friends. She is the source of Dharma, Artha, Kama, and Moksha. The husband is known as bharthi. He is supposed to support his wife. He is also known as pati because he is supposed to support her.

The sacramental aspect of marriage under Hindu law has three characteristics: (1) That it is a sacrament union, which means that marriage is not to gratify one's physical needs; but is primarily meant for the performance of religious and spiritual duties; (2) a sacramental union implies that a marriage once entered cannot be dissolved on any ground whatsoever; and (3) a sacramental union also means that it is a union of soul, body and mind. It is a union not only for this life, but for all lives to come. The union is not only for this world, but also for other worlds.

Performance of certain Sastric ceremonies, which have been laid down in detail in Griha Sutras, are necessary for a Hindu marriage.

Marriage as a social institution

Marriage has been an important social institution. It is the basis for the family. The functions of marriage include regulation of sexual behavior, reproduction, nurturance, protection of children, socialization, consumption, and passing on of the race.[1]

Hindu marriage is regarded as a means to establish a relationship between two families. Free intermixing between two sexes is a taboo. Thus most marriages are arranged by parents or relatives, even in the educated class. Children are expected to accept their parents’ decision with respect to marriage unconditionally, extra-marital relationships, separations, and remarriage have been looked down upon. For most people in India, marriage is a one-time event in life, which sanctified and glorified with much social approval. Marriage is a social necessity; marrying children is the primary responsibility of parents in India. Daughters should be married as soon they become young in early twenties and sons married as soon as they start earning. Married couples are accorded respect in the community. Non-solemnization of marriage is a social stigma. Social values, customs, traditions and even legislation have attempted to ensure stability of marriage.

The goal of marriage in Hinduism is to foster, not self-interest, but self-restraint and love for the entire family, which keeps the family united and prevents its breakdown.

Sex roles and marital adjustment

India is largely a patriarchal society. The traditional dyad is the husband with high masculinity and the wife with high femininity.[3] An important observation is that across generations, while women show less femininity, masculinity remains stable.[4] Bharat[5] reviewed the published studies relating to sex roles amongst Indians and reported as follows: Cross-culturally, the masculine stereotype remains stable, the female one changes; family-orientated traits which are seen as feminine in western culture are seen as gender-neutral and valued in India; both traditional and modern traits are valued in Indian women; and sex differences are mainly along the lines of greater autonomy for men. A recent study by Issac and Shah[3] reported a positive link between androgyny and marital adjustment, and a trend for couples to move toward gender-neutral dyads.

Dowry and Hindu marriage

Dowry is a custom in Hindu marriage since times immemorial. According to Dharmashastra, the meritorious act of “kanyadan” is not complete until the bridegroom is given a “Varadakshina.”[2] After decking the daughter with costly garments and ornaments and honoring her with presents of jewels, the father should gift the daughter a bridegroom whom he himself has invited and who is learned in Vedas and is of good conduct. The presents given to the daughter on the occasion of marriage by her parents, relations, or friends constituted her “Stridhan.” Both “Varadakshina” and “Stridhan” were given out of love and affection. These two aspects got entangled and in due course assumed the frightening name of dowry. For obtaining dowry compulsion, coercion and occasionally force had to be exercised. Ultimately most marriages became a bargain. Over the years dowry has turned into a widespread social evil. Surprisingly, it has spread to other communities, which were traditionally non-dowry receiving communities. Demand for dowry has resulted in cruelty, domestic violence, and death by homicide or suicide.

Marriage of women

The prescription of marriage is more stringent for women. Women must get married. “Doosre ki amanat hai” (She is another person's property). “Jawan ladki ghar nahin baitha sakte hain” (cannot keep a young unmarried girl at home). After marriage, her husband's home is her home. She should visit her natal home only as a guest, she should never return to her parents’ home. Parents cough out their life savings too/take loans/dispose-off their property and arrange for substantial dowry to marry their daughters.

In India, marriage and family dominate the life of women. The primary duty of the woman is to be subservient/loyal to the husband/his relatives and her children. After marriage, husband and relatives control all outside relationships. There are festivals/rituals such as “teej” and “karva chaut” in which the woman worships her husband as her God/Lord (“Patiparmeshwar”) and prays for his long life. The primary roles for the women are still “marriage” and “motherhood.” Marriage confers a positive status to the woman which is greatly enhanced by motherhood. No wonder non-solemnization of marriage of young daughters, separation or divorce is very stressful not only for the woman, but for the entire family. Marriage brings security and dignity to Indian women. Unmarried status in India is stigma especially for females.

The sociologist Susan Wadley after examining the identity of women in folklore, myths, and legends rooted in history, observed that the Indian woman is constantly made to adopt contradictory roles – the nurturing roles as daughters, mothers, wives, and as daughter-in-laws, and the stereotyped role of a weak and helpless woman. The latter is fostered to ensure complete dependence on the male sex. Consequently, the constant movement from strength to passivity leads to enormous stress placing the woman's mental health under constant threat.[6]

Reforms in Hindu marriage customs

Sati was prevalent in Ancient India. The British succeed in bringing XVII Prevention of Sati Act which declares sati illegal and punishable by courts. Raja Ram Mohan Roy, Ishwar Chandra Vidyasagar and E.V. Ramasamy Periyar paved the way for social reform. In India, the first movement of marital rights of women centered on three major problems, child marriage, enforced widowhood, and property rights of women. The Dowry Prohibition Act[7] was enacted to curb the dowry menace. It applies to all people, Hindus, Muslims, Christians, Parsis and Jews. The law was found to fail to stall this evil. Dowry Death (304B)[8] was later enacted. Where the death of the woman occurred in unnatural circumstances within 7 years of marriage and it is shown that she was subjected to cruelty or harassment by her husband or his relatives in connection with any demand for dowry, it would be presumed to be a dowry death, deemed to be caused by the husband or his relatives.

MARRIAGE AND MENTAL ILLNESS

Marriage is the greatest event in an individual's life and brings with it many responsibilities. Mental disorders can either result in marital discord or may be caused by marital disharmony. In predisposed individuals, marriage can cause mental-health problems.[1] Divorce seeking couples have higher psychiatric morbidity than well-adjusted couples with more neurotic traits. Besides, studies consistently show greater distress among widowed/separated/divorced men and women. Greater distress is seen in among married women compared to married men and greater distress in single women as compared to single men.[1] An ICMR and DST study[9] on severe mental distress also found the highest common distress was found in housewives, in both rural and urban samples. The ever married suffered more than those who were never married.

Indian society has a greater bias against women with mental illness; many of them are abandoned by their husbands and in-laws and are sent back to their parents’ homes. This causes misery and stigma and further complicates their problems by making them more susceptible to development or exacerbation of psychiatric disorders after marriage.[1011]

Anxiety disorders

Batra and Gautam[12] found a high prevalence of neurotic disorders among divorce-seeking couples. The neurotic problems encountered were either antecedents or consequences of marital disharmony. In a prospective study of 107 subjects with obsessive-compulsive disorder being married significantly increased the probability of partial remission.[1]

Depression

There is research evidence to suggest that for men, marriage confers protection against depression, while it appears to be associated with higher rates of depression in women. There is some evidence that within marriage, the traditional role of the female is limiting, restricting and even boring, which may lead to depression.[1] Moreover, in traditional Hindu families there a rigid code of conduct for women which prevents communication and expression of emotions, especially negative ones, because of which there is higher prevalence of internalizing disorders such as depression in women compared of men.

Suicide

Studies in China and India report that single individuals are not more vulnerable to suicide than their married counterparts.[1314] Cultural attitudes toward the woman's role in marriage may also partially explain the comparatively higher ratio of female to male suicides found in Asian countries as compared to Europe and the United States of America. In countries like India, Pakistan, and Sri Lanka, where arranged marriages are common, the social and familial pressure on a woman to stay married even in abusive relationships appears to be one of the factors that increases the risk of suicide in women.[15] Dowries, which involve a continuing series of gifts before and after marriage, complicate the problem. When dowry expectations are not met, young brides can be harassed to the point where they are driven to suicide.[16] In some cases families oppose the marriage of young couples, who face the unsolvable conflict of either living apart or severing ties with their families; choose suicide – either together or alone.[17] In a study of women treated in hospital emergency rooms after a suicide attempt, over 40% were young rural women 15-34 years of age; an unhappy marriage (over 60%), financial problems (over 40%), and having been beaten by a spouse (almost 40%) were the most frequently cited stressful events they had experienced.[18]

Alcohol use

Alcohol use in India on social occasions has a long-history. Social approval of alcohol use has generally been for men. Thus, rates for alcohol use are much lower in women. Alcohol intake by spouse results in marital problems. The divorce rate among heavy drinkers is high and the wives of such men are likely to be anxious, depressed and socially isolated. Besides, women admitted with self-poisoning blame the drinking habit of the husband.[16] The home atmosphere is often detrimental to children because of quarrelling and violence. Indian studies have shown that 50-60% of domestic violence is due to alcoholism.[1]

MARRIAGE AND SEVERE MENTAL ILLNESS

The WHO data, in which confounding factors such as, age, pre-morbid personality traits, and family history were controlled, married men experienced significant delay (1-2 years) in the onset of psychotic symptoms compared with single men.[19] Patients with schizophrenia are more likely to remain single and unmarried than patients in other diagnostic groups, this being particularly true of male patients.[1]

The extensive review of gender differences in the epidemiology of schizophrenia has been reviewed by Picinelle and Homen.[20] It included three studies from India. The 5-year follow-up study[21] of patients attending a teaching hospital, reported a better clinical and social outcome for women. The better outcome could be because it was an out-patient sample with lesser degree of impairments. At the end of 10 years, however, there were no significant difference in the outcome.[22]

A 10-year follow-up study of a cohort of 76, first episode patients with schizophrenia,[23] found that marital outcome in Indian Patients as good with no gender difference. A high marital rate (70%) (before the onset of mental illness) was reported with more men remaining single and more women facing broken marriages. Being married before the onset of illness, presence of children, a shorter duration of illness at inclusion and the presence of auditory hallucinations at intake were all associated with a good marital outcome. Being unemployed, experiencing a drop in socioeconomic level and the presence of flat affect and self-neglect for 10 years were all associated a poor marital outcome.

A Schizophrenia Research Foundation (SCARF) study[6] showed that women were brought in for treatment much later. The ratio of male:female service seekers registered at SCARF Out Patient Department (OPD) was 2:1. A greater number of female patients were in the category of patients who had been untreated for a long-time. The main reason attributed for these findings was the low-priority is given to the mental-health of women compared to men. The fact that women generally are presented at a later age with schizophrenia raises issues about the losses these women sustain with regard to established relationships, careers and children.[24]

In a pilot study of 783 patients with mental illness registered with SCARF[6] to study the patterns of marriage and divorce, the salient findings were: More women with mental illness got married; more women were deserted and abandoned, separated and divorced by their spouses; more men continued to be married, with their spouses taking on the wage earning role; the women abandoned by their spouses, did not receive any financial support/maintenance from their spouses, the parents had to bear the responsibility of looking after them; and most women complained of ill-treatment by their in-laws.

Another study[6] of 75 divorced/separated women in comparison to 25 married women living with their care givers provided interesting information. All except eight lived with their parents. Twenty children were taken care of by the patients themselves or their parents. Only six children were cared by the husbands. Lack of awareness and the widespread belief that marriage is a panacea for all evils prompted some parents to get their daughters married even when they were symptomatic. Several needs were expressed for the separated women including to simplify the legal measures.

It is noteworthy that women with severe mental illness are discriminated in a big way. While wives are more tolerant, husbands are not and many of the marriages women with the mental illness end sooner or later. The women with severe mental illness are ostracized on three accounts. First, the female status, second the psychoses and third, marital status (divorced/separated). These three together constitute the “triple tragedy.” Most disturbing is the observation that they are abandoned more often because of the negative attitude toward mental illness, rather than the illness per se. The observations of other workers are in the same line. The stigma of being separated/divorced was more often more acutely felt by families and patients than the stigma of mental illness per se.[6]

The relationship between marriage and mental illness has been examined by Nambi.[1]

Several studies show low marital rates for schizophrenic patients compared with controls and other groups of mentally ill patients; lower rate in women than in men, a poor clinical course and lower socioeconomic status among the divorced, and a clear evidence for selection of schizophrenia among those never married.

From the analysis of records of 272 outpatients of the Institute of Mental Health at Chennai,[1] it emerged that majority of treatment seekers were males (3:2); nearly 26% males and 6% females were single; 30% of males and 23% females were married and 10% were divorced/separated/widowed.

Domestic violence and mental illness

Domestic violence means violence that occurs within the family. Domestic violence is considered as one of the burning social problem of the present day in India. The married women with major mental illness form an extremely vulnerable population at high-risk for various forms of abuse. The incidents of wife battering, harassment by husband and in-laws, dowry deaths, suicides, kitchen accidents occur on a large scale. Many cases go unreported. The victims are unable to raise their voice, nor protect against violence.[25]

Domestic violence is an age-old phenomenon. In the past, it was mainly hidden behind the four walls of the house. Those within did not wish to speak about it. Those outside did not want to hear it. Social practices, customs, beliefs, myths, and patriarchy are the important causative factors for domestic violence in India.[25]

Harassment by in-laws on issues related to dowry is characteristic of the Indian setting. It has emerged as a risk factor for poor mental health. This age-old practice continues to survive and has been a significant factor that has driven many women to suicide.[26]

In a study on domestic violence, the International Centre for Research on Women (ICRW)[25] in multiple centers in India, reported that 85% of men admit that they had indulged in violent behavior against their wives; physical, emotional or sexual, at least once in the last 12 months. 57% of men admitted to have committed sexual abuse with their wives. 32% of men admitted to committing violence on their pregnant wives.

Risk-factors for domestic violence include alcoholic husbands, illiterate or poorly educated couple, poor socioeconomic status, women with no income of their own, and dowry problems.[25] Unfortunately, the cycle of domestic violence continues from one generation to another. An abused boy/boy witnessing his father beating his mother grows to be an abusive husband. Likewise, an abused girl/girl child witnessing her mother being battered grows to be a battered woman herself.

It is very important to identify and treat domestic violence in those with mental illness. In half of all murders committed by domestic partners, serious mental illness contributes to the risk.

The mental health problems related to domestic violence are varying in nature. Many women accept it as normal in India and suffer in silence. A few react with physical aggression. The psychological symptoms emerge as subsyndromal or diagnosable disorders.[25]

There are a number of international instruments to prevent violence against women including the Convention on Elimination of All forms of Discrimination Against Women.[27] Several legislations have been enacted with the same purpose: Dowry Prohibition Act,[7] Section 305 IPC (abetment of suicide of a mentally insane person), Section 306 IPC (abetment of suicide); Section 304B IPC (dowry death), Section 498-A IPC (of cruelty of husbands or relatives of husband),[8] the Protection of Women from Domestic Violence Act (PWDVA),[28] etc.

The protection of women from domestic violence act[28]

PWDVA defines the expression “domestic violence” to include actual abuse or threat of abuse that is physical, sexual, verbal, emotional, or economic. It provides for more effective protection of the rights of women in a domestic relationship, guaranteed under the Constitution who are victims of violence of any kind. Harassment by way of unlawful dowry demands to the woman or her relatives is also covered under this definition. This act has the following important features:

The respondent has to be an adult male.

It appreciates that the marital relation is a delicate, personal and private relationship.

It appreciates the fact that victim of domestic violence is often unprivileged in many ways.

It provides various reliefs such as a protection, residence, maintenance (monetary relief), custody and compensation orders and emergency help.

It provides necessary help in lodging the report.

It provides free legal aid to the woman.

It assumes that the woman would always safeguard the relationship.

It adopts a reconciliatory approach.

It empowers the woman. Criminal proceedings would be initiated only when the woman requests for the same.

The PWDVA has been perceived by many as an anti-male Act. It is a double-edged weapon. It should be used to protect women, not to take revenge on men.

Marriage of women with psychotic illness and Hindu Marriage Act (HMA):[29] The Indian paradox

There is a wealth of data showing the effect of Indian culture on marriage of patients with mental illness. This has been described by Sharma and Tripathi[30] as the “Indian paradox.”

The Indian paradox can be described under four headings:

Despite the presence of severe mental illness parents are determined to marry their mentally sick daughters.

Parents often succeed in marrying daughters with mental illness/active symptoms. This is possible because in India arranged marriages and giving/offering dowry are the norm.

Besides, most boys prefer arranged marriages because they fetch good dowry.

The woman with mental illness, who is ill-treated and abandoned by her husband and in-laws, seeks restitution of conjugal rights rather than divorce.

Interesting observations were made in South India. Many of the separated/divorced women (30 out of 75), whether or not they wished to rejoin their husbands, still continued to wear their mangalsutras.[6] The reason given for this ranged from “I am still married,” “as long as my husband is alive I must wear it” or “It gives a sense of security and protection.” The women who did not wear mangalsutra were either Christians or Muslims. Similar observation was made by Sharma and Tripathi[31] in Northern India, where the separated women continued to put vermillion on their heads.

The Dowry Prohibition Act[7] sometimes promotes dowry rather than curbing it.

A handsome dowry glamorizes the marriage proposal, so as to distract the other party from the deficiencies in the daughter. After marriage, when marital problems arise because of mental illness in the woman, gifts are offered to pacify the husband and his relatives. At other times, husband themselves might demand money/gifts; the price for putting with a ‘mad’ woman.

The paradoxical situations cited above can be understood in light of the prevailing deep rooted social value systems relating to marriage in India.

The Hindu Marriage Act (HMA)[29] provides the conditions for a valid Hindu marriage. It also provides for four matrimonial reliefs: Nullity of marriage, judicial separation, divorce, and restitution of conjugal rights. The legal provisions are often violated in the marriages of patients with mental illness because of the strong impact of Indian culture. They are mentioned below:

Remarriages of husbands and wives, separated because of mental illness take place without formal divorce.

In a series of 124 marriages of 118 married women with mental illness from Varanasi at a tertiary care hospital, it was observed that 91.9% were first marriages of both patients and their spouses. 10 (9%) were second marriages (6 of patients, and 4 of spouses). Only one second marriage of the patient was solemnized after divorce, the remaining took place without divorce from previous marriages.[32] Such marriages are void as per section of HMA. However, because of social approval they continued. Likewise, in a series of 75 mentally ill divorced/separated women from Chennai legal separation occurred only in 16 instances. However, 13 of the husbands were remarried.[6]

Women with frank psychotic illness are married.

In the series from Varanasi evidence for mental illness, in the form of taking psychotropic medication or mild psychiatric symptoms/side-effects was present about half (48%) of the women. In five marriages mental illness was present in both wives and their husbands at the time of marriage.[32] It is difficult to say as to how many of them were fit to give consent at the time of marriage.

Consent to marriage is often by proxy, force or fraud.

In the series from Varanasi[32] proper consent was present in only 14 marriages. In 110 marriages consent was by proxy from either of the patient/husband/both partners. Consent by fraud by concealment of past history of psychiatric (partially or fully) of the women with mental illness was present in 87.7% of the cases. Besides, five wives and two husbands with mental illness were coerced into marriage.[32] Thus, valid consent to marriage was not given importance.

Dowry Prohibition Act[7] is often abused in the setting of mental illness.

Very often parents paid a substantial dowry at the time of marriage.[6] Dowry is usually a non-issue in marriages of women with mental illness as the giver and the receiver are usually in agreement. However, when marital problems erupt after marriage because of mental illness, allegations of dowry demand/harassment are made and complaints are lodged at police stations. Sometimes these cases landed up in courts, leading to animosity and worsening the mental disorder. In these petitions the usual plea from the woman's side that she is normal and the husband has rejected the woman because he is greedy and wants more dowry.[32]

No maintenance was given to the women even when they had children. Only in four cases, a one-time meager amount as maintenance was given.[6] Similar observations were made by Sharma and Tripathi.[32] Besides, the decision with respect to custody of the child was made by the husband.[32] The above observations are reflective of the deep rooted patriarchal social norms and values relating to marriage.

Concealment of history of mental illness during marriage is rather common in the Indian community. Often it is a no-win situation. When the truth is discovered there is a lot of animosity, the marriage often breaks or there are petitions for nullity of marriage under Section 12 of HMA. The President of the Indian Psychiatric Society, Dr. S. Nambi, suggested that “an express legislative provision should be incorporated, which states that a past history of mental illness will be no bar to marriage; failure to disclose such past history or the fact of treatment would not amount to the suppression of a material fact,” i.e., should not be a ground for nullity of marriage.[1]