Cultural Aspects of Pain

1
Cultural Aspects of Pain Suffering

• Dr Cecil Helman
• Professor, Medical Anthropology Programme,
• Brunel University
• Senior Lecturer, Department of Primary Care
  Population Sciences,
• Royal Free University College Medical School

2
Background to general practice in modern Britain

• Increasing diversity of UK population
• Language
• Religion
• Culture
• Lifestyle
• Beliefs about health illness

3
The New Population Diversity

• In the UK
• Only two-thirds of London school children speak
  English as a home language
• They speak a total of 307 languages
• 7.5 of the total population (4.3 million
  people) were born outside the UK
• In 2002 over 100 000 people entered the country
  to seek asylum

4
People born outside the UK (2001)

• Ireland 494, 850
• India 466, 416
• Pakistan 320, 767
• Germany 262, 276
• Caribbean 254, 740
• USA 155, 030
• Bangladesh 154, 201
• South Africa 140, 201
• Kenya 120, 356
• Italy 107, 002

5
Global Diversity

• 175 million people now live outside their country
  of birth
• The number of migrants has doubled in the past 25
  years
• 60 of migrants live in the developed world
• United Nations Population Division, 2002

6
Implications of this new diversity

• There are now multiple views of what is meant by
  health, illness, medical treatment
• There are now multiple notions of body and
  self
• Many minority refugee communities feel in a
  vulnerable and disadvantaged position
• In medical treatment, health policy, and
  medical research the one size fits all approach
  is no longer appropriate

7
What is culture?

• It is an inherited lens of shared concepts,
  rules and meanings, through which the members of
  a group or society perceive the world they live
  in, and which guides their behaviour in their
  daily lives.
• It is a set of guidelines - both explicit and
  implicit - which every individual inherits as a
  member of a particular human group. It tells him
  or her how to view the world, how to respond it
  to it emotionally, and how to behave in it in
  relation to other people, to the natural
  environment, and to supernatural forces or gods..
• Culture is transmitted from generation to
  generation by the use of language, symbols and
  religion. Without it, neither the cohesion nor
  the continuity of the group would be possible.

8
Limitations of culture

• Culture influences many different aspects of
  daily life including perceptions, emotions,
  belief systems, and behaviours. It has an
  important influence on religion, family
  structure, gender relationships, and social
  organisation - as well as on diet, dress, body
  image, and perceptions of illness and medical
  treatment.
• But
• it is rarely the only influence on health
  beliefs and behaviour

9
Health Beliefs and Behaviours are influenced by-

• Individual factors (gender, age, experience,
  personality, physical state, psychological state)
• Educational factors(formal informal)
• Cultural factors (including Religion)
• Socio-economic factors (poverty, discrimination,
  housing, employment)
• Environmental factors (population density, rural
  or urban, physical habitat, climate,
  infrastructure)

10
Languages of distress

• Can be-
• 1. Verbal
• 2. Non-verbal
• 3. Mixed

11
Languages of distress.1

• VERBAL
• the Presenting Complaints, the History
• I feel depressed, doctor, Im not sleeping

12
Languages of distress.2

• NON-VERBAL
• 1. Symptom patterns - Somatization
• a. Individual somatization
• i. Localized (headache)
• ii. Generalized (tired all the time)
• b. Cultural somatization
• i. Localized (my heart is
  sinking)
• ii. Generalized (pains everywhere)

13
Languages of distress. 3

• 2. Behavioural changes (withdrawal, violence,
  non-attenders, frequent attenders, theatrical)
• 3. Dress (black clothing, provocative clothing)
• 4. Self-neglect (hair, skin, nails, clothing)
• 5. Substance abuse (alcohol, drugs, tobacco)

14
Dealing with somatization

• Exclude physical pathology
• Explore meaning of symptoms
• Explore context of symptoms
• Treat with a bio-psycho-social approach
• Accept that treatment may not work

15
The meaning of symptoms

• Disease the medical perspective
• Observable, measurable changes in the bodys
  structure or function
• Illness the patients perspective
• The subjective response to what has happened of
  the patient, and those around them, including the
  meaning that they give to that event

16
The patients perspectiveExplanatory models (EMs)

• What has happened?
• Why to me?
• Why now?
• What would happen to me, if nothing were done
  about it?
• What would happen to other people, if nothing
  were done about it?
• What should I do about it?

17
Talking about trauma

• For some individuals and cultural groups, the
  idea of talking to a stranger about past traumas
  may seem
• 1. Inappropriate
• 2. Embarrassing
• 3. Humiliating
• a. Losing face, being shamed (washing dirty
  linen in public)
• b. Losing caste, masculinity or status
  (stiff upper lip)
• 4. Dangerous
• a. Authorities (especially refugees,
  asylum-seekers etc)
• b. Evil Eye (envy)

18
Concepts of Body and Self. 1

• Patients views of the structure and function
  of their bodies may differ widely from those
  of their doctors
• (e.g. location of internal organs, mechanisms of
  menstruation or fertilization)

19
Concepts of Body and Self. 2

• The body is not only a physical object, but also
  has powerful symbolic and cultural dimensions
• Different parts of the body such as the heart,
  kidneys or liver - may have special cultural
  significance for the patient

20
Concepts of Body and Self. 3

• Body and Self are not necessarily the same
  thing
• Some patients may feel that their sense of
  self incorporates other people such as family
  or kinsfolk or even physical objects

21
Concepts of Body and Self. 4

• The borders of the Body (and of the Self) are
  not necessarily the skin
• Each Body is surrounded by a series of symbolic
  skins, which extend it in space
• These skins can include clothing, walls,
  fences, other people (family, community or ethnic
  group), physical objects, animals, or even a
  piece of land (e.g. in refugees from agrarian
  cultures)

22
What is Cultural Competence?

• Theory - understanding the role of culture, and
  of other social factors, in health and illness,
  and especially their effect on peoples beliefs
  behaviours
• Facts - a knowledge of the cultural
  characteristics of certain groups of patients
• Reflexivity - self-knowledge, and an
  understanding of the doctors own social
  cultural background, and how it may influence
  diagnosis and treatment. i.e. cultural
  counter-transference

23
Cultural Competence

• In understanding health, illness and medical
  care, always consider the role of context,
  including-
• Economic factors
• Gender issues
• Power relationships
• Discrimination
• Physical setting

24
Strategies for Cultural Competence

• Focusing on the individual patient, using a
  bio-psycho-social approach
• Understanding that illness, and health beliefs,
  are always multi-causal
• Understanding that illness always takes place in
  a particular context which can influence its
  aetiology, presentation, severity and treatment
• Understanding the patients health beliefs
• Understanding the patients languages of distress