There was an interesting article in the Healthcare Network section of yesterday’s Guardian by Yasir Abbasi, a British south Asian Muslim psychiatrist working in the NHS, regarding the importance of recognising and understanding different cultural beliefs and how these can become intertwined with mental health problems. 1
Abbasi gave two examples of patients he had worked with where culture was an important consideration in diagnosing and treating a person’s mental health problems. The first was a young south Asian girl who believed that she was already dead and spent hours online searching for her grave. She told Abbasi that she could ‘feel the worms crawling inside my body’. Abbasi concluded that the patient was suffering from a severe depression with Cotard syndrome, which is a rare mental illness in which the patient believes that he or she is already dead.2
The girl’s family, on the other hand, thought she was possessed by a jinn (a demon) and that she should be taken to a spiritual healer. Abbasi explains that he spent many hours explaining to the family the need for medical treatment whilst trying to gain an understanding of how they viewed the problem.
As mental illness is a taboo in so many cultures, it is easier to see it as a spiritual problem rather than a medical one. I agreed to talk to the spiritual healer, so that he could explain to the family the serious nature of her mental health problems. We finally came to an agreement whereby the girl would continue to have treatment in hospital and the family would place spiritual amulets around the room. There was a good outcome and the young girl was discharged after recovery.
The second example concerned a middle-aged woman of African descent who had developed a painkiller dependency. Her initial complaint had been that she was suffering from aches all over her body and the patient’s daughter explained to Abbasi that these aches were expressions of lethargy and lack of energy; in other words, her somatic symptoms were cultural expressions of low mood and depression.
Once we helped the person detoxify from the painkillers, we started treating her for depression which dramatically improved her life.
One thing that strikes me about this article is that Abbasi seems to applying a different type of logic to the first patient than he does to the second. In the first case, although he acknowledges that the girl and her family hold a particular set of beliefs, which include demonic possession, and obviously spent some time trying to understand these ideas, ultimately his own (psychiatric) belief system override that of the girl and her family’s.
In the second case, however, Abbasi seems quite prepared to accept the idea that a person’s psychological problems can be expressed somatically; in fact, he seems to be going even further than this, by arguing that somehow her depression and low mood were ‘culturally mediated’ through her body. Psychosomatics is a fascinating field in its own right, and is something I have explored elsewhere on this site.
Going back to the first example, I think it’s important to be clear that this is not an ‘either/or’ situation; in other words (and I think Abbasi recognises this to some extent) this need not necessarily be either a case of demonic possession or a case of severe depression with Cotard syndrome. The key point here, I would argue, is that it’s critical not only to acknowledge and appreciate where the family is coming from regarding their beliefs, but to work within this belief system itself. What I mean by this is that it is essential to ‘follow the patient’ (and in this case to ‘follow the family’ as well), rather than trying to convince them that this is ‘not really’ a case of demonic possession but rather a psychotic illness. Leaving aside the question of whether demonic possession actually exists, the key point here is to recognise that it does for the girl and her family.
Leading on from this, I think the key thing is to explore how such a belief system operates for both the girl and her family. Regarding the ‘delusional’ belief that she is already dead, the important point about delusions is that they are a way for the individual to try and make sense of their experience; in fact Freud even argued that delusions were the subject’s attempt at cure. Bearing this is mind the last thing one should do is to attempt to ‘rid’ the individual of their ‘delusional’ beliefs. Rather it is a case of exploring them in more depth and how they function for the individual. It might also be helpful to look at how the ‘clash’ of cultures (in this case Western and south Asian) might be exacerbating the problem.