Cultural Construction of Psychiatric Illness in Malaysia

The concept of the cultural construction of illness is important in terms of understanding people's behaviour. In this article, this idea is applied to psychiatric illness in Malaysia to explore how it is informed by sociocultural elements, a process that will help us understand the psychiatric expression and help-seeking behaviour of the country's population.


The History of Psychiatry
Psychiatry is a medical field that deals with behavioural, emotional and psychological disturbances. The word "psychiatry" is derived from the Greek words "psyche" and "iatros", the former meaning "soul" or "mind" and the latter "healer" or "physician". Our understanding of psychiatric concepts is not a new phenomenon; mental disorders have been described in ancient manuscripts, and were believed to be caused by a humoral imbalance that required medical treatment. Hippocrates (fourth century BC), for example, wrote that melancholia was the origin of black bile excess (2).

Contributions of Earlier Muslim Scholars in Psychiatry
The psychiatric field was later advanced in the Islamic medieval age by Muslim scientists such as Al-Razi and Ibn Sina (or Avicenna), who and treatments are being discovered, promising a higher standard of care for patients.
That said, the stigma attached to psychiatric illnesses is proving extremely persistent. The functional disorders in psychiatry render diagnoses less precise than those in other medical specialisations. The manifestation of psychiatric illness as altered behaviour carries negative connotations of madness that are not widely accepted in the community. The undertone attached to a psychiatric diagnosis carries a weighty social significance, and may result in segregation and alienation from socalled "normal" society.

A Culturally Constructed Illness
Despite the advancement of biological psychiatry, the acceptance of psychiatric diagnosis and treatment in Malaysia remains low (4). For Malays, the term psychiatric illness or sakit mental carries a highly negative connotation, and seeking help from a mental health provider would have a similar effect. The other Malay term that can be used interchangeably for sakit mental is gila (crazy or madness). There is less stigma where people recognise that an individual has experienced some form of emotional stress or when there is a known organic etiology, such as epilepsy.
Malays recognise different types of madness based on certain criteria, each of which represents a different etiology and indicates the need for a particular mode of treatment (5). There are several traits of madness and in Table 1 summarise the types of mental illnesses, their etiologies, symptoms, treatment and the probable associated psychiatric condition.
Meanwhile, the western anthropologist Laderman (6) described the humoral reasoning among the Malays as regards physical illness and neurotic phenomena. Yet, when the phenomenon is not usual, as in the case of psychosis, or when the condition does not respond to the natural course of the humoral model, the root of the illness is then attributed to supernatural elements. These beliefs are strengthened through religious teachings on the presence of genie possession and spirits, leading to alternative explanations of illnesses and causing believers to seek folk or spiritual healers.
Swami et al. (7) explored the health-related beliefs of Malay Muslims, found that they would attribute the cause of a psychiatric illness to fate and religion; such beliefs have shaped treatment-introduced the concept of a relationship between the body and mind and the need for medical treatment. Al Razi, or Muhammad Ibn Zakariya Al-Razi (or Rhazes), was the first physician to operate a psychiatric ward in eighth-century Baghdad. Even then, in a similar approach to current methods of treatment such as psychotherapy, drug medication, music therapy and occupational therapy were prescribed for the mentally ill. Ibn Sina, in his book Canon of Medicine (eleventh century), described the psychopathology of mental illnesses, such as mania, hallucinations and melancholia (depression), and their relationship with the brain. The same author also discovered the functions of the brain components responsible for psychological and behavioural disturbances, such as the frontal lobe, which controls cognitive reasoning and personality (3). Such an advanced understanding of psychiatric illnesses and treatment is not too far removed from the current field of modern psychiatry; however, since most of the Muslim texts were written in non-English manuscripts, many consider that modern psychiatry only began in the eighteenth century.
Meanwhile, in the Europe of the Middle Ages, psychiatric illnesses were regarded as originating from supernatural elements, such as devils, witchcraft or possession. They were seen as spiritual ailments, rather than medical conditions. Therefore, spiritual healers were highly sought after and treatments were based on magic and sorcery, with exorcism being a common practice.

Modern Psychiatry
The reforms in psychiatry started in the 18th century, with a key impetus being King George III's mental disorder. Thereafter, the operators of mental health institutions began to develop a more humane approach, including removing restraints and offering moral treatment in lunatic asylums. The psychiatric field was later recognised as a medical concern with the development of research and academic departments, especially in Germany. From the twentieth century to the present, the field has been in a constant state of advancement with the discovery of biological evidence such as biomarkers, neuroimaging, psychogenomics and pharmacogenetics, and the development of physical and pharmacological treatments. With the progress of biological psychiatry, new drugs

Limited Emotional Expression
Malays, in general, are reluctant to express their psychological problems. They prefer to somaticise their distress, often complaining of poor sleep, loss of appetite, loss of weight and energy rather than a depressed mood (8). Haque (9) claimed that Malays prefer to attribute psychological problems to physical illnesses, in order to avoid being stigmatised by fellow community members. Even so, Malays may use the phrase susah hati (translated in English as "heavy heart") to describe sadness or a loss of soul (semangat) or willpower that contributes to bodily weakness, while angin or wind is said to enter the stomach, nerves or blood and thereby exacerbate anxious feelings. Abdul Kadir and Bifulco (10), for example, studied the expression of depression among Malay Muslim women and seeking behaviour, meaning that they prefer folk medical treatments over psychiatric care when it comes to healing. Modern psychiatric care is believed to produce adverse side effects and to do more harm than good. Such behaviour arises from the stigma attached to a labelled diagnosis. By adopting spiritual pathways, patients' associates do not view them as mentally ill; rather, they are seen as having some form of emotional disturbance, and can therefore still be perceived as normal. Consequently, sufferers are more likely to confide in their close friends and family members over their problems, and the problem would initially be contained in this close circle until they could not cope with the symptoms. Help from the medical profession is the last resort, even among those who are professionals themselves. identified various terms for depressive feelings, such as murung (Malay) or depresi (adopted from English), which are used interchangeably. Rather than openly expressing their feelings, the authors claimed that Malays use cultural proverbs or idioms to denote the benefits of sorrow or adversity, such as "Adversity makes one a better person", "The more sorrow one encounters, the more joy one can contain" and "After falling, the ladder falls upon you", to describe the phenomenon of one bad thing happening after another, or a feeling that all bad things seem to happen at the same time; similarly, people speak of "an unlucky person who has been having an unlucky streak". Such suppressions of emotional expression are said to be associated with the Islamic values that teach followers how to handle grief and death, whereby people are not expected to cry excessively and should express emotion in moderation (11).

Constructing the Clinical Reality
In constructing the clinical reality of psychiatric illness, the cultural and spiritual elements should be integrated in the management plan. While religion may play a role in delaying the seeking of professional help, the understanding of the concept of mental health from the Islamic perspective is worthy of analysis. This includes the concept of Takziyatun nafs, or purification of the soul, which delineates the relationship between the body and soul from the Islamic viewpoint, together with the historical contribution of the ancient scholars in the field of psychiatry. Continuous discourses and collaboration with faith healers and religious scholars would smoothen the integration process. In order to penetrate resistance to the modern psychiatric interventions in the population of Muslim majority, it is high time that a psychiatric Islamic intervention to be established in Malaysia.