Honour, pride and izzat: mental illness as a Pakistani medical student

When Usama Ali developed severe depression at medical school, the idea of family honour was deeply damaging

Location: UK
Last reviewed: 10 May 2021

In the TV series Avatar: The Last Airbender, we see Prince Zuko desperately trying to regain honour to please his evil father. Those familiar with the series will know this desperation leads to Zuko doing some truly villainous things. Yet Zuko remains morally conflicted, knowing that what he’s doing is wrong but often feeling too trapped to act differently in his need to maintain honour. Welcome to the concept of izzat.

If, like me, you were born in the subcontinent, you may have rolled your eyes at reading that word. Izzat refers to someone’s honour or pride. In many South Asian communities, there is often nothing more important than izzat or family image. Sadly, one thing that is often seen as damaging to izzat is mental illness.

It was this concept that initially stopped me from getting help from my family when I suffered from mental illness. In my first year of medical school, I developed severe depression with psychosis. Despite being told by various healthcare professionals to tell my family, I remained reluctant. I’d heard stories of people suffering from mental illness back in Pakistan being shunned from society, locked away in their houses to protect family honour. I did not want the same to happen to me.

When I tried to voice these concerns to healthcare professionals, I was often met with incredulity. Some thought it was my psychosis that was making me think this way. Others suggested that my unwillingness to tell my family showed that I didn’t truly want to get better. The overall result was that I ended up mistrusting these healthcare professionals as well. This played a role in my mental health further deteriorating, with me eventually being made into a patient in a psychiatric facility.

Cultural barriers are often mistaken by healthcare professionals for patients being ‘difficult’.

Whilst in the facility, I initially lied to my parents over the phone and pretended everything was fine. But then one day, it became too much. To my horror, I burst out crying over the phone and told them everything. I told them about my depression. About how I no longer wanted to live. About how I found myself in a psychiatric facility. Then… there was silence. I held my breath, waiting for the response.

At last, came the voice at the other end.

‘That’s OK. How can we help?’

I sort of laughed and cried at the same time. For my parents to overlook the stigma that exists within the South Asian community meant the world to me. My Dad flew to the UK just so that he could be there with me. Then my 20th birthday came and I found myself still locked in the unit. Imagine my delight when my parents surprised me by bringing a cake into the unit, smiles on their faces as they ensured I didn’t feel cut off from the outside world.

In Avatar, Zuko was eventually able to find his way by having a supportive uncle willing to overlook cultural norms. As I discovered, having supportive family like that is a true blessing. But I am one of the lucky ones. Currently, mental health campaigns focus on telling people to ‘be open and ask for help’. While these phrases are well-meaning, they are overly simplistic. We need to instead focus on why people are unwilling to ask for help and strive to address these barriers.

Cultural barriers like the ones I faced are often mistaken by healthcare professionals for patients being ‘difficult’. It is important to listen to the voices of those from minority ethnic backgrounds suffering from mental illness. Only then can these cultural barriers be better understood and addressed.