Health Equity Selective Report 2008

How do stigma, myth and misunderstanding prevalent in a culture affect the presentation of patients to mental health services? –  A comparative discussion between Malay and Australian culture.

I was sure I did not want to be a psychiatrist.

So when I had chosen Mental Health Stream for my HES this semester, it was done with the intention of finding out exactly what was it I was refusing to become. All in the spirit of making an informed decision, of course.

Judgmental

When I first started my HES placement, I had an idea of what a good psychiatrist would be like. He/she would be someone with a calm, collected and unflappable manner. He/she would appear compassionate and empathetic as he/she was listening to a patient, all the while maintaining an open mind without the slightest hint of being judgmental.

Despite of the fact that I have always been fascinated by psychiatry, I had decided long ago that psychiatry was not for me.

Because I knew I was judgmental.

I have always thought that deep inside everyone is judgmental. The only difference between someone who is called judgmental and someone who is not called judgmental lies on whether or not he/she voices out loud what he/she thinks. Other than on those topics that are factual and self-evident, how could anyone not have an opinion on anything else? As long as there are 6.70 billion people on this planet, there will always be 6.70 billion unique, different or at least slightly dissimilar views on every subjective issue on earth, namely culture, religion, politics etc, etc.

Well, I am judgmental. But I am always careful not to be labeled as such. That means when I judge, my judgment is broadcasted only within my brain. Especially if the particular result of my judgment would be offensive to the person hearing it. Rest assured, I like to exercise my freedom of speech most of the time. But I do not think there is freedom of speech to offend. If there is, then there should not be. Just like there is no freedom of speech to lie. You cannot lie about something, and justify the act by saying “it’s my freedom of speech to lie.” It is just not right.

Objective

The objective of this report is to address the stigma, myth and misunderstanding in a culture that could hinder patients’ willingness, alacrity or promptness in seeking immediate help when they are faced with the burden of mental illness.

Why do I choose this topic? Because I have seen more than five patients at Mater Hospital, who have confessed that they have been dealing with their symptoms for quite some time before they finally presented for psychiatric treatment for the first time. Why the delay, I could not help but wonder.

Another objective of this report is to do a comparative study between cultural stigma in Australia and that in Malaysia, particularly in the Malaysian of the Malay race. Why do I choose to compare between Australia and Malaysia? Well, I have read many HES reports of Australian students when they went to the third world countries to do their HES. Their reports revolved around their point of view as a citizen of a developed country, on the cultures of the third world countries and how those cultures impact health care in those countries.

My report would be from the point of view of a student from a third world country about Australian culture and health system and how does it compare to my own country, Malaysia. I think it is very beneficial to understand how Australian culture and other cultures differ. This is because it would help to create better awareness and greater understanding between the Western world and the third world.

The third world countries should not be viewing Western medicine with wariness. At the same time the West should give the third world countries some empathy and understanding when they try to change what they deem as backward habits of the third world countries, bearing in mind that every tradition serves a purpose for that particular culture even though that purpose may not be important in the western culture.

I am privileged in the sense that I get to combine 5 years of study together with 5 years of traveling. Born and raised in Malaysia, I continued my tertiary study in Australia when I was 20. It feels like I am having 5 years of vacation. It feels like I have experienced the best of both worlds.

I am also able to choose which ones of the custom in both cultures I would like to adhere to, and which ones I would rather ignore. And because of that, I could get away with doing/not doing many things common to both cultures. What Australian society would find odd about me, I would explain it away by saying it is due to my being a Malaysian and of a different culture (even though sometimes it is just my own peculiarity and has nothing to do with culture at all). And when I am among my fellow Malaysians back home, I explain my lack of adherence to some objectionable Malay custom by saying: I am overseas educated, what do you expect? Needless to say, I enjoy myself immensely. And I hope what I have gained as a result of my enjoyment would be apparent in my HES report.

Limitations

When I first decided to write on this topic, I pondered hard and long on my ability to meet the objectives of this topic. Comparing two different cultures and how those cultures give impact to mental illness is not a matter to be taken lightly. I do not want to accidentally offend both cultures with my ignorance and insensitivity.

However, after reading the previous HES reports of last year students I noticed that most of them were also reporting on subjective matters; their point of views and their reflections of what they have seen and heard as they were doing their HES attachment. Naturally, understandably, you can never be all-knowing about a culture you do not spend your whole life practicing. Australian culture is like that for me too. But this report is my honest reflection of what I think of it and how it affects mental illness.

The same thing can be said about the Malay culture. I have lived and breathed the culture all my life. Yet, there are many customs within the culture; some I practice and some I only know vaguely.

So below is my summary of the limitations that could be found in this HES report:

1) It is based on my own observation while I was doing my attachment. I could be dealing with instances that are rare in the culture (but appear to me as common because only those kinds would present to the hospital) and mistake it as a common cultural thing. A lack of knowledge is a fearful thing, but I tried to minimize it by reading many books that discuss Australian and Malay culture. Any unjust views would be most unconsciously done but I would be able to say quite sincerely that everything is based on my observation and my readings.

2) I have not actually done any mental health placement in Malaysia. My only placement was at the Mater Hospital. I would try not to let this be a major compromise to my report since I am comparing on cultural stigma; not on hospital system and patients’ management. Rest assured, 22 years of being a Malay is quite suffice for me to know what the Malay culture is all about, without me having to actually do a placement in Malaysia.

3) This HES report is not a complete comparative study between the two cultures. There may be many more issues that I should have addressed on. Or there may be some issues that I have overlooked which are much more significant to be addressed on than what I have actually written. However, this report is partly about my point of view of everything that occurred in my mind while I was doing my HES placement; a record of my thoughts and reflections after having met many patients. So, I could not very well write on things that have not occurred to me, either because those things did not happen at the Mater Hospital (where my placement is) or because even if they did happen I had not thought them important due to my lack of knowledge or insight.

An Overview

Below is the overview of how this discussion would progress. The basic outline is:

1) First of all, it is imperative to get a general impression of both Australian and Malaysian Culture. What do they have in common? What don’t they have in common? What are unique and significant in the respective cultures?

2) Secondly, I would talk about general stigmas present in mental illness. These stigmas are not culturally related; rather they are common stigmas of mental illness. They are present in most cultures, if not all. Only the extent of stigmas is different. For example, even though in both cultures, there is the stigma that Schizophrenic patients are dangerous, but the stigma is probably less in Australia compared to in Malaysia.

3) And then, I would address the issue of’ how cultural stigma/myth/misunderstanding contribute to the stigmas faced by mentally ill patients. This is more culturally-focused. This is where I would compare the Australian culture versus the Malaysian culture.

4) In the conclusion, there would be discussion on ways to overcome the cultural stigmas and the roles that health professionals should play in the endeavor.

My understanding of Australian Culture

“There is no better way of life than that of the Australian. I firmly believe this. The grumbling, growling, cursing, profane, laughing, beer-drinking, abusive, loyal-to-his-mates Australian is one of the few free men left on this earth. He fears no one, crawls to no one, bludgers on no one, and acknowledges no master. Learn his way. Learn his language. Get yourself accepted as one of him; and you will enter a world that you never dreamed existed. And once you have entered it, you will never leave it.” Nino Culotta – They’re a weird mob, 1957. [1]

The problem with discussing culture is that we tend to over-generalize the people into one particular way of life. But certainly, not everyone in that culture does a particular thing, and even when they do, not in every single circumstance and not every single time. It makes it quite hard for someone outside that culture to talk about that particular culture. It would be quite difficult to judge which one is just an individual trait and which one is a cultural thing.

When talking about Australian culture, it is double as hard. I have come to perceived that Australians are quite individualistic. There is not a need to follow others or acknowledge others as a leader. According to one website discussing Australian culture, “If an individual jump to take the lead, rather than follow him or her, the crowd might tell the wanker to get off his high horse. If the individual just does his or her own thing, and doesn’t expect anyone to follow, then they will be left alone.” [1]

Because of this individualistic characteristic of Australian people, I find it hard to recognize one particular custom/norm as being Australian. Yes, truthfully, in every culture there exist some people doing things differently from their culture, but when asked ‘whether or not such and such is in your culture,’ they would generally agree. So their willing confirmation of something as being in their culture, even though they themselves do not do so, would make it easier for us to definitely say “yes, such and such is definitely in your culture.”

But with Australian, there is a strong aversion to being stereotyped. [1] When faced with some stereotypical statement, an Australian would probably say “I don’t do that.” [1]. Finding myself in the dilemma of having to decide what is Australian and what is not, I approached this issue in the best way I knew how : I would only categorize something as ‘Australian’ when I have gotten the impression from books and from my conversations with Australians that something is definitely an Australian thing. So my benchmark of what is Australian and what is not is based on the willing confirmation of that fact from Australian him/herself which I could find in books or in my conversation.

1) Mateship is a significant concept of how Australians interact and communicate with each other. [2] It emphasizes egalitarianism, equality and friendship. [3]

2) The concept of ‘A fair go’ is an integral part of Australian society which could be seen by the existence of strong public health and education system in Australia. [3]

3) Australians are generally considered more relaxed than most. Hardly feel offended, Australians sometimes are not sensitive to causing offence in others. [1] This may cause them to appear blunt or rude to outsiders as Australians are used to calling a spade a spade.

4) Australians are very independent. Maybe this could be seen to go hand in hand with being individualistic. When parents get old, instead of living with their adult children and their growing grandchildren, they would still live alone on their own. They would get into a nursing home rather than living with their children. They find it distasteful to burden their children.

5) Drinking is integrated into local, social and cultural forms in Australia. [2] And according to my Australian housemate, Australians drink a lot. For men, drinking together with one’s mates reflects masculine identity. [2]

Understanding the Malays

The Malays are the indigenous race of Malaysia. It is one of the three major races in Malaysia other than Chinese and Indian. It is generally thought that the Malays are the ruling race; the Malays control the politics. Nine of fourteen states in Malaysia have their own Sultan and royal family. While the Chinese controls the economy.

Again, I could not emphasize this enough. In every custom and every culture, there are exceptions. But yes, an image of typical Malay exists. But there are many sub-types of typical Malays with many ways to categorize them. You can have country Malays and urban Malays, you can categorize them base on their social ranks (the Sultans and their relatives, the wealthy, the politicians, the working class etc), you can categorize them base on their education levels, or base on their adherence to religious practice. And for every sub-type, there are different values, different ways of living, and different outlooks in life.

Because of the many variations on what a typical Malay could be, I would only highlights on the ones that differ from Australian:

1) We are very respectful of the elders. We would not address someone older than us by their given name only, regardless of whether or not they are related to us. The social ranks are also observed.

2) To take care of the parents when they get into their old age is an honour. The parents would not feel as though they were intruding into their children’s lives. Just like every child is expected to be cared for when they were little, every parent is expected to be looked after by their children when they get older. Failing to do right by your family members is considered a disgrace. There are not many nursing homes in Malaysia. The few ones that exist are mostly occupied by the Chinese and the Indians.

3) It is generally known that the Malays do not drink alcohol due to religious reason. So, during any social events the big deal is the food. Food has to be enough, it has to be tasty and the host would urge the guests to have second helpings as a show of hospitality.

4) We are semi-independent. For example, the elderly parents do not have to live with their children, if they do not choose to do so. In some cases the parents are more well-off than the children in materials. But when they choose to live with their children, then the children must take care of the parents. Another example; daughters are not expected to support themselves. They will be taken care of by their parents and later on by their husbands. But if they choose to, they could work. However, they are not expected to provide for the family. So in other words, we are not dependent because we cannot be independent.

Those characteristic mentioned above are common in all Malays regardless of the subtypes

.

However, no matter what type of Malays they are, every Malay would acknowledge that religion and culture is the most important thing in the Malay society, regardless of whether or not the Malay him/herself is religious. There is one very prominent saying in Malay which when translated into English sounds basically like this: “If I could either save my child or my culture, I would save my culture every time.”

To a certain extent, that idiom makes the Malays look quite heartless. What is a set of society rules to compare to the life of a child? Well, it has to be seen in a proper context. It is just an idiom as a show of our devotion to religion and culture. It is just a comparison of how important religion and culture are in our lives. Nothing comes near to them, not even our own child.

That particular expression is a testimonial of how seriously we deal with culture. We are passionate about our culture. Because when we say ‘Malay culture’ what we really mean is ‘religion’. This is because being a Malay has always been associated with being a Muslim. If you are one, you are the other. It comes in a package.

However, there is a stigma to being a Muslim now because Muslims all over the world keep confusing their own culture as something religious. They like to ‘mix and match’ cultural practice with that of religious practice. This cause many confusions and misconceptions about what Islam is all about.

“Oh, you can wear a pink Hijab? I thought you can only wear black? And why did you not cover half your face?”  My usual answer to this kind of question is, “Probably just in your culture.”

Sometimes non-Muslims confuse another country’s National Law to religion. “Oh, you mean you can drive? But you are a girl!” It was with an exasperated sigh that I said “Where is it in the Quran that says women should not drive?”

And misconception about ‘mistreatment of Muslim women’ is rife partly because when Muslim men hit their women, they justify their action with some verses from the Quran that are taken out of context. The truth is, mistreatment of women happens in every culture. Judging by the number of depressed patients I have seen at Mater Hospital, mistreatment of women occurs here too, some of them presenting with abusive partners or bad childhood due to abusive fathers. It occurs in America too, the propagator of the free world. It is just that at least, here, the men do not go around attributing their abominable actions to some religious texts. However, I could not stress enough that just because some irresponsible Muslim men say something is so, does not mean Islam says it is so.

And regarding Muslim women being forced to don on their hijab by their men, that is also a myth and a misunderstanding. To quote Sheikh Khaleed Yassin, “If anyone wants to know how a Muslim woman feel when they put on their hijab, do not ask CNN and do not ask Barbara Walters. Ask a Muslim woman who actually practices it.”

There are almost twice as much Muslims living in China than there are in Saudi Arabia.[3] The BBC gives a range of 20 to 100 million Muslims in China.[3] That kind of mess up on the stereotype a bit, does it not? In fact, the Arabs are the minority in Islam.

There are 6.6 billion people in the world.[3] 1.5 billion of them are Muslims. That is a huge number. Basically, one in four people in the world is a Muslim. Do we see one in four people in the world committing terror? With the Malays being the ruling power, I shudder to think whatever will happen to the many non-Muslims in Malaysia if that is the case. Here, people confuse between political issues and religion.

If all those bad cultural stigmas of being a Muslim are true and happen to all 1.5 billion of them for more than 1400 years now, I would imagine that we would have organized some sort of revolution a long time ago. After all, every revolution starts with oppression and injustice; the Enlightenment, the French revolution and the Russian Revolution, just to name a few.

The truth is people mistake culture with Islam. Not only the Western media that make that mistake, but also the Muslims living the culture themselves.

Fortunately, nowadays there is a positive move towards educating many Malays to recognize what is cultural versus to what is religious. This is a positive move because whenever we do something bad, we would take the responsibility ourselves.

There is also a move towards abandoning cultural practices that are against Islamic practice. Basically, we keep the Malay customs that are permissible and not opposed to Islam, but we throw away the ones that are against it. Since the early Malays were actually practicing Hindu, there were plenty of cultural practices that we have abandoned after we found out that those practices were Hinduism in origin.

So, nowadays, the generalization that ‘being a Malay means being a Muslim’is something we are trying very hard to make it true. Yes, some Malays do not practice every rule there is in Islam, but they would acknowledge the rule exists, and that it is part of their culture, regardless of their adherence to it.

However, the Malays have got a long way to go before they could really say my way of thinking is totally Islamic, rather than cultural. Yes, they have Islamized the practices, but those are mere rituals. But their judgments, their thoughts, their views and all the stigmas that come along with them are sometimes hardly Islamic in nature.

And it causes many problems and misconceptions when it comes to mental illness.

General Stigma of Mental Illness In Both Cultures.

The first patient I met on the first day of my placement had been having problem of chronic low mood ever since she was 15, but only presented for treatment  3 years later, when she was 18. Curious as to why she had been keeping things to herself, I asked her whether the stigmas associated with mental illness have anything to do with it. She nodded her confirmation.

What stigmas are there when it comes to mental illness? Why does mental illness not regarded as any other medical illness?

Usually, how people react to the difficulties of others depend on their understanding of the cause of the problems. [4] People have the propensity to be more sympathetic for conditions believed to be beyond the control of the patient. [4] On the other hand, conditions such as obesity or lung cancer due to smoking are viewed to be under the voluntary control of the patient and thus produce unsympathetic reactions. [4] Rather like a ‘you deserve it’ reaction.

So with all these stigmas of mental illness, do the majority of people in the society actually think that the mentally-ill patients could help themselves from getting the illness? Schizophrenia for example could be genetic. Depression could also be genetic. Some patients develop mental illness after being abused by family members and they certainly cannot help from which family they are born into.

After having thought about it hard and long, I have come to conclude that part of the reason why mental illnesses are so stigmatized is because people are wary of the unordinary. People generally feel comfortable with the familiar and feel threatened by differences. Differences are not normal. They are abnormal.

And abnormalities of the mind must be the worst of all. Just think about it. All animals have brain but it is the human mind that makes us special and human. Our mind is our whole personality. That, I think, is partly the reason why mental illness receive such burden of stigma. Because human beings put so much values on the mind, and it is not hard to imagine why we would do so.

Below are some of the common stigmas of mental illness that I have found out. These stigmas are present in both the Australian culture and the Malay culture. These stigmas are about mental illness in general and have less cultural influence. But in most cases, the stigmas are less intense in Australia than in Malaysia. This is due to better education and awareness of mental illness among Australian society.

Furthermore, there are very few mental illnesses being reported in the Malaysian mainstream newspapers probably because they are taboo subjects. Therefore, there are less chances of discussing them openly in Malaysia. Other than health professionals or medical students, the general public in Malaysia thought that mental illnesses consist of the psychotic ones only.

Stigma 1: Mental illness is a form of intellectual disability or brain damage.

One day I met a female patient who suffered from PTSD after she had been abducted and then raped in the park late at night. She was 26 years old, but to me she was behaving in a manner of an 8 years old. After the interview, I asked the Psychiatry registrar about her. It turned out that she also had Developmental Delay.

I just would like to make a point that unless the mentally ill patient also suffer from developmental delay, or Down Syndrome or any such intellectual disability, the patient would not be rendered less bright by being mentally ill.

Stigma 2: Mental illness is incurable and lifelong

This stigma can be seen in the experience of many patients who do not get flowers or any ‘get well’ cards from their family and relatives when they are hospitalized for their mental illness. [4]. They probably do not think the patients would ever get well from mental illness, so why send a ‘get well’ card?

The fact is mental illness is just like any other illness. The patient can present with just one episode and never get the illness again. Or the patient could have chronic mental illness, and just like any other chronic illness (e.g. diabetes or renal failure), it requires ongoing treatment so that the patient could have a normal everyday life. [6]

Kay Redfield Jamieson, who has bipolar disorder, is today Professor of Psychiatry at John Hopkins University School of Medicine. [7] She has also written extensively on mood disorders and manic depressive illness.

Stigma 3: People with mental illness are usually dangerous

I used to have that opinion myself. And I could still remember feeling that the opinion was justified. People do not go around having some opinions without any reason for having them. Certainly, some Schizophrenic patients in one movie or other have been portrayed to kill their family members. Furthermore, some of these movies are based on real stories too. And I have read in newspapers where people who are mentally ill have killed their schoolmates before killing themselves in the end.

A Finland study showed that men with Schizophrenia have 8 times higher risk of being convicted of homicide, and women with Schizophrenia have 6.5 times higher risk of being convicted of homicide. [4] A study in Germany showed that there were 13-17 times higher risk of attempted homicide by Schizophrenic patients. [4].

So maybe there are some truths to the stigma, after all?

But bear in mind that we should distinguish between risk which are relatively increased, as against the actual number of cases. There may be some truth to the stigma but it is disproportionate and discriminating. [4] Schizophrenia itself is relatively rare, so violence resulting from it must also be rare.

Furthermore, other types of mental illness like depression, bipolar and anxiety disorder are seldom dangerous. It would not be fair to lump all mentally ill patients together as dangerous. Even with patients who are severely affected by mental illness are rarely dangerous when receiving appropriate treatment. [6]

Stigma 4: People with mental illness should be isolated from the community

Nowadays, thanks to the treatment discoveries of recent decades, mentally ill patients no longer need to be confined or isolated in an institution as common in the past. [4] Most mentally ill patients can lead a very productive life especially when there are many support services and programs within the community.

Only a small number of people with a mental illness need a hospital care.

How cultural values affect the willingness of patients to access mental health services – a comparison between Australian and Malay culture

First of all, before I begin, I just would like to make certain that everyone understand that it is never my intention to offend anyone from both cultures with this comparison. I believe that you cannot judge someone from another culture base on your own culture.

For example, in my culture, drinking alcohol is a really bad behavior. Not even a drop is permissible. And yes, generally those who drink alcohol in Malaysia are also the ones with dysfunctional behavior, the ones with many problems, the ones who turn to alcohol due to family problems, and the ones who commit violence and become abusive. If they are Muslims and they drink, they are usually not happy drinkers. So, the stereotype of alcohol-drinking person in Malaysia is usually true. But here, drinking is a form of social bonding. The stereotype that is true in the Malay culture would not be true here.

Another example is freedom of speech. Australians are very outspoken, very frank and straightforward. It is one of the characteristic I like most about Australians. They generally do not understand why Malaysians seem very quiet; never talk over each other’s voices, never jump into a conversation unless they are being addressed or unless they are specifically being invited to join. It is because, we really value politeness and that includes being patient and waiting for your turn if you want to speak up. We should never seem too dominating.

But to say that Australians are impolite would be absolutely wrong. Most of the time, Australians are more polite than Malaysians. In fact, if you go to any of our supermarkets in Malaysia, you would be surprised at how impolite the cashiers are, and how unfriendly the receptionist could be. In Malaysia, the cashiers are not taught to greet you with ‘Hello, how are you?’ Basically, in Malaysia, you do not greet strangers. Most of the time, we do not bother to smile at strangers. While in Australia, I could be jogging in the morning, or walking around the campus and I can bet that at least one or two Australians would greet me with “G’day’ especially if my eyes happen to meet theirs.  My point is, different cultures have different ways and different situations of being polite, so to judge someone’s conduct base on one’s own culture would not yield accurate result. A gross injustice would be committed.

So below are some of the differences in cultural values that would hinder patients from presenting for help. These hindrances mostly occur in the Malay culture. But I thought it would be interesting to compare them with the Australian culture since my actual HES placement was done in Australia.

1) Alcohol-related cultural values.

When I first got into Australia to further my study in medicine, I was not quite comfortable asking patients about their alcohol intake or drug use. I could not help feeling as though I was prying into their affairs. Especially, since it is common knowledge that Muslims do not drink, I felt as though I would come across as judgmental. The situation is a bit like “It is okay for me to say bad things about my family because they are my family. But you should never do the same thing regardless of whether or not what you are saying is true!” I imagine, people would be less wary to answer questions about their alcohol intake to someone who they know also drinks. I had struggled to find just the right tone that meant to say “No, I am not judging you no matter what number of standard drinks you are going to tell me. I am just asking. Just asking, just doing my job.”

Back in Malaysia, I have never been asked that question whenever I went to see a doctor. I could not imagine practicing medicine in Malaysia where I would have to ask about my Muslim patients’ alcohol intake. Probably if the patient present with really bad cirrhosis or hepatitis or some other related disease, only then the questions would be asked. While in Australia, asking about alcohol intake is done regularly with all patients. I could imagine the kind of death stares I would get were I ever that insolent as to assume that my Muslim patients drink. I could expect them to feel thoroughly insulted.

But why?

Well, basically, drinking alcohol is the worst of the prohibition regarding alcoholic drinks. Not only you should not drink alcohol, you also cannot invest in a company who makes alcoholic drinks. You cannot buy shares in a company which invests in a company that makes alcoholic drink. You cannot buy an alcohol for your non-Muslim friend as a gift. You cannot help to buy alcoholic drink for your friend even if it is using her/his own money. You cannot serve alcoholic drink. You cannot work at a place or receive a salary from an establishment that serves alcoholic drinks. In other words, you are to have nothing to do directly or indirectly with alcoholic beverages or promoting the drinking of them to others. The reason is because it would be such a hypocrite thing to do; you abstain from alcohol yourself because of its negative effects, yet you have no compunction whatsoever in helping people drinking it. That would translate as having no compunction whatsoever in letting people get the negative effects as long as you are not affected yourself. It is as inconsistent as saying “I might wear furs, but that does not mean I do not love animals. It certainly wasn’t me who kill them in the first place. It is the manufacturer who did that. I am not responsible.”

So to assume that my patient actually drinks alcohol, not just indirectly involved in it, but actually drinks it, is a grave insult.

However I am not so naïve as to assume that all Muslims do not drink. I remember talking to an African friend of mine who looked very surprised when I told her that I did not drink due to religious reason. She actually laughed out loud and said, “I have an Arab friend and he drinks like a fish.”

So yes, some Muslims drink. And I daresay, they would never admit it to other Muslims who do not drink themselves because of the stigma. So, for Muslim patients with alcohol-related psychiatric problems, seeking help for it would be a dreadful thing to contemplate. To admit that you not only drink alcohol, but you are actually addicted to it is a huge step to take. And to deal with the society’s negative views on alcoholism is also another problem altogether.

In fact, it was very hard to find any statistics on Malays drinking habit. One obscure Malaysian website cited that the Malays spent one billion a year for alcohol alone. [8] However, there is no appropriate statistic available to see how many Malays actually did that. The article only mentions the amount spent on alcohol. Therefore several assumptions could be made here; either very few wealthy Malays had spent all those money on alcohol, or there are actually many Malays (wealthy or otherwise) that had spent all those money on alcohol.

The lack of statistic here could even suggest just how much of a taboo this topic is among the Malays.

Even though most Muslims practice abstinence from alcohol and only very few isolated cases of alcohol-induced psychiatric illness involving Muslims exist but the de-motivating effects of the stigma should be dealt with to encourage people with alcoholic problems to present for help.

On the other hand, in Australia there are no such stigmas regarding alcohol. Drinking alcohol is a normal cultural thing. Since there is no cultural or religious restriction of drinking alcohol, the stigma of being an excessive drinker, even if it is considered bad, would only be just a little bit worse than someone who eats excessively, thus become obese.

I do not know if the impression I got is accurate. But my impression is: doctors here would treat patients with alcoholic problems, thinking of these patients in the same manner that they would think of diabetic patients with poor diet control. Sure, the doctor would probably disapprove, but there is no stigma attached there. Even if there is some sort of stigma, certainly not as much as there is in Malaysia.

Almost all patients I have seen at the Mater Hospital have some sort substance-dependence. Most patients here are under toxicology patients and are referred to the Psychiatric team for assessment. They would present with deliberate self-poisoning or overdose. Many of them abuse alcohol or are dependent on it. Treating alcohol-dependence is done on a daily-basis and almost seem monotonous to a certain extent.

In Malaysia, patients with alcoholic problems would probably get a ‘you deserve it’ reaction that I talked about earlier. It is because alcoholic problems are conditions thought of as something stemmed form your own fault rather than through no fault of your own.

2) Regarding suicide and attempted suicide.

Suicide among Malays is almost unheard of. If there are any cases involving suicides in the Malay society, they are certainly not widely reported in the mainstream newspapers. Probably only the health workers are much more in the position to really know just how many Malays have committed suicide. Reports about suicide are much more common among the Indian community in Malaysia.

There is a definite taboo to being suicidal in the Malay culture. This is admitted by the former Health minister himself, Dr. Chua Jui Meng:

“In Malaysia, death by suicides is generally despised by our conservative society, and is considered a crime under our Malaysian Penal Code. Moreover, beneficiaries of people dying from suicide face problems making life insurance claims. In such scenario, suicides are likely to be under-reported, with some being categorized as accidental or undetermined deaths, especially where the deaths are not medically inspected and certified. Nevertheless, it has been estimated that suicide rate in Malaysia is around 13 per 100,000 population.” [7]

We Muslims believe that if you commit suicide, you will not die a Muslim. It would also bring such shame for the family of the deceased. So, for Malays, suicidal ideation is inversely related to religious adherence. The more religious he/she is, the less likely he/she would commit suicide. It is not even bear contemplating.

Just like in the case of alcohol, I would be very nervous to ask a Muslim psychiatric patient whether or not he/she has any suicidal ideation. I could never win asking such question. If I happen to ask such question to a very religious and pious Muslim (which is usually the case since there are more religious Malays than not), he/she would be offended that I could ever have thought that of them.

And if I happen to ask such question to a non-practicing Muslim with suicidal ideation, he/she would be wary to answer it truthfully, knowing that I am a Muslim and I could not help myself from thinking about the religious implication of it. I may be a medical student, but I could never separate my religion from myself. I would never wish to. The only thing I could do is to refrain from acting judgmental and to keep myself from giving religious lectures, but we both (the patient and I) know what my thoughts are about suicides. I do not have to make a verbal statement of it. Indeed, it would be almost redundant to make a verbal statement, were I ever inclined to do so. My point is, even without health professionals ever acting judgmental, to admit to a suicidal ideation would still be a huge leap for patients.

This would present a huge problem because without them admitting to suicidal ideation, how would we know when and how far to intervene?

However, among Muslims in Malaysia, suicide attempts are still considered low, and when present are mostly due to psychotic disorders rather than affective disorders (suicides due to psychotic disorders are less of a stigma because the patient is thought to be in a situation beyond his/her control). Malaysian News Agency, Bernama, has reported that the suicide rate among Malays is 2.6 per 100, 000 populations, which is the lowest rate among all other races (Chinese: 8.6 per 100,000. Indian: 21.1 per 100,000). [9]

At the Mater hospital, there are at least two or three patients weekly who present with suicide attempts. The health professionals do not seem to be uncomfortable asking the patients whether or not he/she has any suicidal ideation. They also ask in a straightforward manner whether or not the patients would want to do it again. Depending on the answer to that question and the impression that the doctor has obtained during the interview plus the corroborating history from friends or family members, the doctor would then decide whether or not the patient is safe to go home. Stigma about suicides, though still present in the community and still considered taboo in the Australian society, is not really felt in the hospital environment.

3) Regarding depression

My supervisor once said to me: “Do you know that until very recently, the Japanese do not know what depression is? There was no word in Japanese for depression. They did not understand depression” I thought that was a very peculiar fact, so I asked him, “Surely they could just imagine depression as a form of ‘exaggerated sadness’? I do not understand depression myself, but that’s how I’d think of it.” My supervisor shook his head as he said, “They do not understand sadness too. There are words in Japanese for shame, guilt and lost of face…but not sadness.

I found that fact fascinating. It just shows how mental illness cannot be considered separately from the patient’s culture.

Another fact that I found fascinating when I had first learned about it is clinical depression.  It seems like what you feel and do not feel is determined by the balance of chemicals in your brain. I used to marvel at how anti-depressants are effective simply because they alter the levels of serotonin and noradrenalin in the brain. I imagined, if I were depressed due to a death in the family, only by having that person come back alive would make me feel happy again. I could not believe any amount of medications would change how I would feel. And I called myself a medical student.

The implication seems to point that even without any psychosocial events, even without any devastating events in your life, even without any distressing precipitants whatsoever, you could feel depressed for no reason? I could imagine how a conversation about this would take place:

A:   I feel depressed.

B:   Why?

A:   I just do.

B:   But why? Is there a death in the family? Or did you fail a uni course?

A:   No.

B:   Then, why?

A:   I do not know

B:   But why don’t you know? There must be a reason why you feel somehing.

I have learned about clinical depression, I have seen patients with it, but truthfully, I still could not grasp it. I guess, like many affective disorders, you have to experience it yourself to really know what it is all about.

I would like to quote one paragraph from a website which sum up how depression is not just any sort of sadness:

Sadness is a part of being human, a natural reaction to painful circumstances. All of us will experience sadness at some point in our lives. Depression, however, is a physical illness with many more symptoms than an unhappy mood. The person with clinical depression finds that there is not always a logical reason for his dark feelings. Exhortations from well-meaning friends and family for him to “snap out of it” provide only frustration for he can no more “snap out of it” than the diabetic can will his pancreas to produce more insulin. Sadness is a transient feeling that passes as a person comes to term with his troubles. Depression can linger for weeks, months or even years. The sad person feels bad, but continues to cope with living. A person with clinical depression may feel overwhelmed and hopeless.” [10]

So, looking at this quote, I could see that my example of how ‘the only way I would feel happy again is by having my dead relative brought back to life’ is all about sadness. And  looking back at the short dialogue above, the insistence of B to find a reason for A’s feeling, is because B is ignorant in thinking that depression is just like sadness. That it has got to have a reason. And the reason should not be trivial ones but it should be devastating enough to justify for such intensity of feelings. Or else A would say, “That’s it? You are crying just because you have broken your nail?”

I guess, what B has to learn is that depression is a mental illness, and not just feelings. Petty reasons for having depression are not actually ‘reasons’ but ‘triggers’, so no justification is needed for such intensity of reaction. Such intensity of reaction is called depression. If the reaction is not such, then we would not call it depression now, would we? We would call it sadness.

I was B before I learned psychiatry last semester. I was B even after I have learned it, and even after my HES placement at the Mater was about to come to an end. And many Malaysians (not just the Malays but also other races) are like B to a certain extent. Only after reading one particular part from the quote above did some semblance of understanding come to me: “he can no more ‘snap out of it’ any more than the diabetic can will his pancreas to produce insulin.” Until now, I could not figure out why that sentence has produced in me an understanding of depression that one semester of learning had failed to give me.

In Australia, depression is widely recognized and acknowledged as a type of mental illness. And this is not just acknowledged by medical professionals and health workers but also by the general public in Australia. The society generally has an idea how difficult it is to be in the shoes of someone with depression. There is more empathy and understanding about depression in Australia.

I think part of the reason why Australian society is much better-educated about depression is because there have been a lot of extensive exposure of depression and the issue has been discussed quite freely in the media. Also, depression is one of the commonest conditions in young Australian and increases during adolescence.[6] And almost all patients I have seen at the Mater have been diagnosed with depression. Seeing how common the condition is, it would certainly be to the benefit of the society to be educated about it. And that’s what the society has done.

On the other hand, depression is not widely recognized as a mental illness in Malaysia. Certainly, doctors, nurses, medical students and other health workers would recognize depression as a psychiatric illness. But if you ask the general public in Malaysia, most people would think that depression is just a form of ‘exaggerated sadness’ that would go away if you just pull yourself together and motivate yourself to snap out of it. It is thought to be a matter of ‘strong willpower and determination’.

Because of how the Malaysian society confused sadness and depression, not surprisingly there are stigmas attached to those afflicted by this illness. Within the Malay society, we are taught the concept of fate and destiny and the virtue of being moderate in your emotions and feelings. Whenever something bad happens to you, there should be an understanding that the life of this world is a test, that the outcome of every event has been pre-determined. So, the outcome does not matter as much as the process. We always put emphasis on the process. For example, you can try very hard to succeed in an exam, sometimes you study even harder than everyone else, yet fate has decreed that you will still fail. But we believe that God will reward you on your effort rather than on the outcome of it. God will also reward you on how you face the outcome. Do you deal with your failure by being frustrated and angry or do you deal with failure by being patient, by rationally and critically analyzing what is it that you have done wrong in the exam so that you can improve yourself for the next exam? The thing is, no matter what you do you still cannot change the outcome anyway, but depending on how you react to it, you can choose whether or not you will gain God’s pleasure or His displeasure out of the outcome.

So basically, we believe that; come what may, good or bad, it is not the outcome that matters; your reward lies on how righteously you deal with it. Success/good outcome would still be bad if you react with arrogance. And bad outcome would still bring happiness if you deal with it in the right way.

So when someone has been troubled by some sort of catastrophe, most Malays would go to him/her and say, “Be patient. Surely something good must come out of this if you be patient, and believe in God’s will. Be strong.”

Those words are really soothing words to the Malays. When we deal with sadness, those words are the reminders that we need in order to stay calm and put us back in track. I could vouch for its efficacy, at least in our culture.

But we have already established the fact that depression is not sadness.

It is an illness. No logical reasoning, religiously put or otherwise, would automatically cause the patient to ‘snap out of it’.

But some Malays who may be depressed and do not know the difference between sadness and mental illness, would feel as though they are not being strong, or they are not being a good Muslim by having such chronic low mood. They would have no idea that what they are going through could be medically treated and have nothing to do with the strength of their faith. I would not be surprised if there are actually many Malays who have depression but they do not actually realize it. Or if they realize it, they are probably afraid of the stigma that is attached to it.

I would like to emphasize that Islam do not cause the stigma to be attached to depression. It is the lack of understanding of the Malays about mental illness that cause the stigma to be present. In fact, it is adherence to religion that prevents most depressed patients from being suicidal, and this is true for any other religion as well.

A research in Poland showed that ”religious coping strategies are an integral part of coping with the stress process, especially among individual religiously engaged, for whom religion is an accessible and important alternative in solving negative situations in lives.”  [11]

That statement is certainly true for the majority of the Malays dealing with depression.

4) The tendency of the Malays to trivialize psychosocial stresses especially in dealing with partner-relational problems

“Oh, you mean, partner-relational problem is a diagnosis?” was my very naïve question to the Psychiatric registrar.

One day, a patient came presenting with deliberate self-poisoning with wart-killers. He took it with the intention of killing himself. After he had become well enough to talk to the psychiatric team, we found out that he was still very suicidal. We categorized him as a ‘high risk’.

When I looked at his history, I thought that his life was a walk on the beach. He had a good job, came from a good family, great childhood, no other medical illness, and never been treated for any psychiatric illness before. Of all patients that I had seen before, he had the least reason to kill himself.

Except that his girlfriend of 5 years had wanted to break up with him.

I could understand how that would be a very devastating experience, but I had seen a female patient who had undergone a bad divorce after 20 years of marriage, and at the same time was trying to fight for custody of her child, and at the same time dealing with her problems at her workplace as well as some financial problems. And on top of everything else, she had always had a psychiatric illness. And yet her risk of suicide was low.

Comparing these two scenarios together with their paradoxical suicide risks, I was left puzzled. I told the nurse consultant about that and she smiled at me even as she admonished me with “You may not realize it, but you are being judgmental. What is trivial to you may not be trivial to others.”

I was being typical Malay, of course. I did not actually have any reference to say that “yes, Malays are typically like me, always going around trivializing matters and being judgmental.” Enough to say, I am brought up in this culture and I hope it is as good a reference as any.

To trivialize matters has always been my parents’ way of trying to make me feel brave. Whenever something is distressing me, my parents would point out exactly why that situation should not have distressed me. It works with me.

I could still recall feeling very anxious after I have finished my primary school and was about to get into a new high school. My best friend would further her studies at a different high school than me. I was nervous about being alone in that school without my best friend. But one sentence from my father had calmed me down where my mother’s soothing words had failed.

“I have never heard of anyone drop dead from anxiety just because her best friend is not around for the first day of high school. I expect, my daughter will survive.” He said, with a pat on my shoulder.

I could imagine what my parents would say if they hear someone try to kill himself/herself over a broken relationship. They would probably say something like this: “The last time I checked, there is no such a phenomena where people become oxygen-deprived after being left by their boyfriend or girlfriend.”

It would make us come across as less understanding than we really are. I am sure my parents must have endured one or two broken relationships before they met each other and they probably understood how painful it could be but you would never know it by the way they come up with their comments.

In that sense, we do seem as though we are devoid of all empathy. But most of the time, we are just trying to make the other person feel better by pointing out the ridiculousness of feeling stressed out over something. It is our way of being supportive. In our own culture, it works.

But not here.

I have thought very carefully before I decided to write this. But base on my observation, a lot of teenagers here would present with suicide attempts due to broken relationship. I would say almost all teenagers who attempted suicide did so after a broken relationship. There seems to be a great dependency on another person for one’s happiness. Judging from the many cases I have seen, this great dependency is far from healthy.

So far, I have discussed about how stigma in alcohol, suicide and depression among the Malays have greatly disadvantaged the Malays from presenting for help in comparison to Australians. But the Malays’ tendency of ‘trivializing matters’ is the one trait that I think gives advantage to the Malays when it comes to partner-relational problems. We do not break down from partner-relational problems. Probably because we believe that “your husband and wife, and how you meet someone and how long your relationship would be are predetermined.” So if you break up from any relationship, that means he or she is not the one who is meant to be with you. You have not found ‘the one’ yet. So, why destroy yourself over someone who is not meant for you when you know one day in the future you will finally meet your mate?

So, this particular trait of trivializing matters in our culture serves a purpose for the Malays but the same trait would be counter-productive and stigmatizing were it to be applied here in Australia. Again this has proven how culture would affect the pattern of presentation of patients to mental health services. I imagine, a lot of Malaysians would be surprised if I say ‘partner-relational problem’ could be a psychiatric diagnosis.

Here, I have come to know how much more productive it would be to just listen to the patient without making any trivializing comments. I could not recall the exact words that my supervisor had said but the essence is this: “Mental illness like depression can happen to anyone. Where significant stress would not normally break you down, even something trivial can break you down if it happens at a wrong time.”

Apparently, sometimes being trivializing can come across as something very similar to arrogance. Things are only trivial until it happens to you.

Removing the stigmas

Stigmas regarding mental illnesses are still present even though mental illnesses has been around since the great civilization of ancient Egypt.[3] The strategies that could be done to address the stigmas are:

1) To know that the key step in the generation of stigma is the perception of difference in which the difference is linked to an undesirable trait. [12]. Therefore in order to tackle the stigma, the process of normalization should begin. [12]. Mental illness should be  portrayed as just like any other medical illness, with its own sets of medication and with its own intervention program that would help the  patients to live ‘just like us’.

2) The media, especially those in Malaysia, should start to play a part in discussing mental illnesses openly. Statistics of mental illnesses should be revealed to the public openly. More films and novels portraying mentally ill protagonist living like normal people do (not institutionalized) should be produced. [12]

3) We should also organize a movement that would promote the rights of those who are mentally ill.  There should be some right-based protests in monitoring and enforcing equal access to health care, housing and employment. [12]

4) Provide more information and education to the public regarding mental illnesses.

Conclusion

After seven weeks of going to the Mater, after having seen many psychiatric patients, and after having discussed many interesting cases with the two psychiatric registrars and the nurse consultant who I always went around with, I have gained many insights into psychiatry.

The psychiatry registrars I went around the hospital with are very good with patients. The interviews seem very relaxed, natural and non-threatening, almost like they were chatting with the patients.

Throughout the seven weeks of my HES placement, I had only seen one aggressive patient who had called names at us and was being verbally abusive. The rest of the patients were very well-behaved, non-aggressive and certainly not dangerous. Even in the presence of that one aggressive patient that I had seen, I could not recall being afraid for my safety. The myth that mentally ill people are dangerous is really just a myth.

All in all, psychiatry is a really interesting field. It makes me reflect more on the society and the role of family in general. After seeing how a lot of mental illnesses can be traced back to really bad childhood experience, it makes me appreciate my family members even more for making my childhood a great one. It makes me learn more about myself too. Sometimes, I found myself thinking too much on whether or not I have some sort of psychiatric disorder. Some of the characteristics certainly seem to match with my own personality. I have become the classic example of the famous ‘medical student syndrome’. So far, I have diagnosed myself with obsessive-compulsive disorder and generalized anxiety disorder and paranoid personality disorder.

I began my placement feeling sure that I did not want to be a psychiatrist. I thought at the end of my HES placement, I would be able to confirm my suspicion that psychiatry was not for me and I would then be able to cross out psychiatry from my list of future specialty options.

I have looked at my list again. And the word ‘psychiatry’ remained uncrossed.

References

1 Convict Creations.Com [homepage on the Internet]. Australia: Convict Creations [updated 2008; cited 2008 March 29]. Available from: http://www.convictcreations.com/index.htm.

2 Ernst T. Mates, Wives and Children: An Exploration of Concepts of Relatedness in Australian Culture. In: Marcus J, editor. Writing Australian Culture. Adelaide: The University of Adelaide, Department of Anthropology; 1990. p. 110-8.

3 Wikipedia [homepage on the Internet]. [updated 2008; cited 2008 April 1]. Available from : http://en.wikipedia.org

4 Thorncroft, G. Shunned: Discrimination against People with Mental Illness. United States: Oxford University Stress; 2007.

5 Dr. Sam Vaknin. Philosophical Essays & Musings: Topics In Current Philosophy & Culture Studies [homepage in the Internet]. United States:[updated unavailable; cited 2008 April 1] Available from http://samvak.tripod.com/mediakit.html.

6 Department of Health & Aging [homepage on the Internet]. Australia: Department of Health and Aging; [updated 2007 May; cited 2008 March 31]. Available from : http://www.health.gov.au.

7 Malaysia Psychiatric Association [homepage on the Internet] Malaysia: Malaysia Psychiatric Association; [updated 2006 July 6; cited 2008 March 31].Available from: http://www.psychiatric-malaysia.org/article.php?aid=67

8 Mstar online [homepage on the Internet].Malaysia: Star Publication (Malaysia) Bhd; [updated 2006 June 1; cited 2008 April 1]. Available from: http://www.mstar.com.my/cms/content.jsp?id=com.tms.cms.article.

9 Bernama [homepage on the Internet]. Malaysia: Bernama (Malaysian National News Agency); [updated 2005 September 12; cited 2008 April 1]. Available from: http://www.bernama.com

10 About.com [homepage on the Internet]. United States: The New York Times Company. [updated 2003 December 11; cited 2008 April 2]. Available from: http://depression.about.com/cs/amidepressed/a/sadness.htm

11 Szewczyk L, Weinmuller E. Mental Health, Religion & Culture: Religious Aspects of Coping with Stress Among Adolescents From Families With Alcohol Problems. [Academic Journal on the Internet]; September 2006; 9(4): 389-400. Available from: http://0-www.tandf.co.uk.library.newcastle.edu.au:80/journals/titles/13674676.html

12 Smith M. Stigma. Advances In Psychiatric Treatment (2002)8: 317-323

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