Culture and Clinical Reality Notes

Culture & Clinical Reality

Case Study: Bill, a Pediatrician

Bill, a successful pediatrician, committed suicide at 45.
He was a magna cum laude graduate of Harvard and an honors graduate from medical school.
His father, also a physician, died during Bill's fourth year of medical school, leading to a four-month depression.
He was treated with antidepressant medication and required to repeat his fourth year due to mental illness concerns.
Bill faced difficulty getting into internship and residency programs due to his mental health history.
He married during his residency and later entered private practice, having two daughters.
At 35, his wife developed terminal liver cancer and died a year later, leading to another depressive episode requiring hospitalization.
He remarried a younger, less intellectual woman interested in sports and barhopping some time later.
In his mid-forties, his second wife wanted an open marriage, leading to Bill feeling depressed again.
His wife divorced him, and Bill experienced public humiliation and arrest for public intoxication.
He was hospitalized for six weeks and treated with medications and ECT, but his medical license was temporarily suspended.
After his license was reinstated, he committed suicide, leaving behind substantial life insurance for his daughters.
Nancy Andreasen attributes Bill's suicide to a "broken brain" and advocates for greater compassion, understanding, and patience toward the mentally ill.

Clinical Reality

Clinical reality refers to the cognitive construction of reality in the clinical setting by the clinician and client, using their learned cultural schemas.
Bill's case illustrates how mental illness is cognitively constructed within a specific cultural context.
Disease-centered psychiatry, while aiming for compassion, may define a clinical reality affecting the patient's care and understanding of their condition.

Five Ways Culture Affects Clinical Reality

Culture-based subjective experience
Culture-based idioms of distress
Culture-based diagnoses
Culture-based treatments
Culture-based outcomes

The case of Bill can be analyzed using these five aspects.
Despite experiencing understandable emotional shocks, Bill was diagnosed with a brain disease, potentially denying him the necessary compassion and understanding.

Culture-Based Subjective Experience

Culture affects clinical reality through culture-based subjective experience.
Bill, as a physician, was trained to think about illness in biological terms, likely leading him to perceive his mental illness as a biological problem.
Despite the lack of laboratory findings for major depressive episodes, Bill probably conceptualized himself as having a biological problem due to his biomedical background.

Dhat Syndrome Example

Dhat syndrome in India provides cultural contrast.
The term "dhat" comes from the Sanskrit "dhatu," meaning essential element; semen is considered the most important dhatu.
In Indian culture, dhatus determine immunity, and semen loss is believed to cause physical and mental weakness.
It's believed that $40$ drops of butter produce one drop of blood, and $40$ drops of blood produce one drop of semen.
Symptoms include fatigue, weakness, body aches, headaches, depression, anxiety, loss of appetite, insomnia, heart palpitations, and suicidal feelings.
Western-trained psychiatrists in India often diagnose it as major depression.
A case study of Mr. Sinha, a clothing merchant, illustrates this syndrome, which he links to semen loss due to regular masturbation since adolescence.
Mr. Sinha associated his mental condition with excessive sexuality and masturbation habits, leading to weakness and mental illness.
In Mr. Sinha's culture, excessive semen loss causes illness characteristic of major depression in western cultures.

Culture-Based Idioms of Distress

Culture affects clinical reality through culture-based idioms of distress, which include behaviors expressing illness.
Idioms of distress include physical actions, seeking clinical care, mannerisms, figures of speech, and cognitive focus on specific symptoms.
Bill, viewing his illness as biological, sought a disease-centered psychiatrist.
Mr. Sinha's cognitive and verbal construction of illness as semen loss is a culture-based idiom of distress. He sought a folk healer (Indian guru) for treatment.

Culture-Based Diagnosis

Culture affects clinical reality through culture-based diagnosis, where clinicians assess and diagnose consistent with local culture.
Bill's psychiatrists diagnosed him with major depression, culturally schematized as a brain disease.
Mr. Sinha was diagnosed with Dhat syndrome by a Hindu guru, schematized as a physical illness caused by semen loss.
Agreement on the nature and cause of illness between client and clinician reinforces cultural meaning systems in constructing "diseases."

Culture-Based Treatment

Culture affects clinical reality through culture-based treatment, which refers to treatments defined by the cultural meaning system or clinical paradigm.
Bill's treatment included antidepressant medications and electroconvulsive therapy because his illness was defined as a brain disease.
Mr. Sinha was prescribed sexual abstinence and meditation, aligning with the clinical reality defining the illness as excessive semen loss.
Traditional remedy for dhat syndrome is sexual abstinence to retain semen, storing energy, power, and health.
Ideas about sexual abstinence are pervasive in Hindu culture; examples include Shiva's celibacy and Mahatma Gandhi's abstinence for spiritual power.
Mr. Sinha's symptoms remit with two weeks of abstinence, illustrating the relationship between chastity and mental condition.
Appropriate treatment is determined by schemas in the culture-based clinical reality.

Culture-Based Outcome

Culture affects clinical reality through culture-based outcome, which refers to the outcome resulting from cognitive construction and treatment within a particular cultural fashion.
Bill's outcome was suicide, which is not typical for those treated for major depression in Western culture.
Bill's subculture (American medicine) had little compassion for mentally ill medical professionals.
The Promotions Committee, hospital administrators, and medical examiners acted negatively due to Bill's depression.
Instead of recognizing Bill's grieving, the medical subculture constructed his clinical reality as a chronic brain disease that's internal, stable, and general.
This cognitive construction promoted hopelessness, aggravating the problem.
Treating depression as a serious brain disease decontextualized and dehumanized Bill's emotional processes, reducing his personal and emotional problems to a brain imbalance, which Kleinman, Eisenberg, and Good (1978) refer to this as a veterinary style of clinical practice.
In this clinical reality, suicide is attributed to his "brain disease."
Mr. Sinha's symptoms recur with frequent sex, but remit with abstinence, illustrating a Hindu culture-based outcome of mental illness.

Healing and Curing

Problems in constructing clinical reality occur when the client and clinician come from different cultural backgrounds.
The client's "illness" may differ from the clinician's diagnosed "disease."
Clinicians treat "diseases" per their cultural reality or professional paradigm.
Major depression is treated with medications and ECT for chemical imbalances, while dhat syndrome is treated with sexual abstinence for semen loss.
Treating "disease" is described by Kleinman (1988a) as curing, while treating the client's subjective experience of being sick is described by Kleinman as healing. Disease and curing go together, as do illness and healing.
Poor outcomes occur when a western client with major depression is treated by a Hindu folk clinician, or vice versa, due to cultural differences.
Curing is thus likely to have a poor outcome if the disease that is diagnosed is not simultaneously the illness that has brought the client in for treatment.
Clinicians need to be aware of both illness and disease so that they can administer both healing and curing.

Four Ways Mental Illness Has Meaning

Symptom as symptom
Cultural significance
Personal and social meanings
Explanatory models

Treating the subjective experience of mental illness (healing) is important because a mental disorder is a complex system of meanings.
Cultural meaning systems create cultural entities (objects existing solely due to collective social agreement), including mental disorders.

Symptom as Symptom

Identifying a symptom as a symptom is one way mental illnesses have meaning.
A symptom becomes an indicator of illness when cognized as such, within a cultural meaning system.
The construction of an experience as a symptom, can in itself, cause further suffering.
Bill's grief after his father's death was assessed as a symptom of mental illness because cultural schemas defined it as an indicator of major depression.
Assessing grief as a symptom of mental illness is an interpretation.
Grief as a symptom of mental illness is a cultural entity, not a natural one.
The appropriate grieving period is prescribed by the cultural schemas.
Cultural differences exist in what is identified as a symptom and what the symptom signifies.
Symptoms are considered natural and independent of human intentionality.

Cultural Significance

Mental illnesses have meaning through cultural significance, which includes meanings projected onto the mentally ill person by the surrounding society that structure the person's experience of suffering.
These meanings include societal thoughts about the ill person, their particular mental disorder, and mental illness in general, which become part of the individual's lived illness experience.
Bill dealt with the stigma of mental illness imposed by biomedicine.
Within this meaning system, Bill was seen as a person with an internal, chronic disease in his brain that would affect many areas of his life.

Personal and Social Meanings

Mental illnesses have meaning through personal and social meanings, which refer to the interpersonal relations and social life of the mentally ill person.
Interpersonal relationships, particularly family relations, can add to or shape the suffering associated with mental illness.
Mr. Sinha tries as much as possible to refrain from having sex with his wife. It is something he struggles with on a daily basis. He ideally wants his relationship with his wife to be "like brother and sister."
Bill's social and professional life was severely disrupted by his mental illness.
His professional identity and competence as a medical student and physician were compromised and ultimately spoiled because of the meanings of his illness.

Explanatory Models

Mental illnesses have meaning through the explanatory model, which explains the cause of mental illness, its effects, course, and appropriate treatments.
These meanings affect the lived experiences of people with mental illnesses, structuring their subjective illness experiences.
Mr. Sinha experiences his symptoms after "excessive semen loss." This is highly unlikely that a westerner would experience a similar illness.
The course of this illness is directly related to the amount and frequency of semen loss.
The appropriate treatment in this explanatory model is sexual abstinence, which is usually possible only by keeping the mind off sexual things.
Abstinence is thought to require a spiritual discipline to control the mind and keep it on spiritual thoughts instead of sex.
In the disease-centered psychiatry explanatory model, Bill's illness was caused by a chronic disease in the brain.
Appropriate treatment must therefore be biological: medications or electroconvulsive therapy (ECT).

Evolution of Clinical Reality

The same general process in which preexisting cultural meaning systems construct culture-specific mental disorders occurs across cultures in both space and time.
Looking at mental disorders during earlier times in western culture, the cultural meaning systems tl1at existed in those times gave meaning to the symptoms and life experiences of the people in those eras, and thus structured their illnesses.
In medieval Europe, mental illnesses were structured around demonic possession and witchcraft, reflecting the society's worldview and the influence of the Christian church.
The mentally ill were culturally schematized as either demonically possessed or tl1e victims of witchcraft.
This clinical reality wasn't merely a belief system; cultural entities like God, Satan, witches, and demons were part of daily lived experiences.
Individuals subjectively experienced demonic possession and witchcraft because of cultural learning.
Modern scientists view the medieval period as ignorant, attributing mental illness to brain diseases misinterpreted as demonic possession due to superstition.
Disease-centered clinicians are portrayed as enlightened saviors who can free them from the ravages of superstition and occult practices.
The change from a religious to a scientific view of mental illness should be viewed as the evolution of clinical reality based on an evolution of the general cultural meaning system.
Scientific and political revolutions altered European culture, leading to a shift in how the mentally ill were culturally schematized from possessed to psychotic because the subjective experience of mental illness had changed.
In medieval times, the demons were a lived reality. This medieval reality has its counterparts in many contemporary nonindustrialized societies where demons, gods, witches, and other supernatural entities still commonly exist.
Generally, it has been found that the mental illnesses existing in these societies are structured by the indigenous set of cultural schemas leading to culture-bound syndromes.
Traditional nonwestern treatments for mental illness are sometimes effective, even without diagnosing the person with a scientific diagnostic category, and without providing biomedical treatment to obtain a good outcome.
Folk healers get good clinical results by treating the "illness" (subjective experience) rather than only the "disease" (diagnosed disorder), treating with the cultural views of spirit possession, usually through some form of ritual healing.
According to the effectiveness of folk healers in today's nonwestern societies, it appears that the view of medieval folk healers as being ineffective charlatans immersed in worthless occultism is culturally biased.
Therefore, assessments of the effectiveness of folk healing are largely based on ethnographic observations rather than on rigorously controlled treatment outcome studies.
The general consensus is that traditional folk healers have much to offer in the clinical setting in cooperation with modern clinicians.