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The Cultural Experience of Depression Amongst White Britons in London THE CULTURAL EXPERIENCE OF DEPRESSION AMONGST WHITE BRITONS IN LONDON SUSHRUT SHANKAR JADHAV Thesis submitted in partial requirement for the Doctor of Philosophy Department of Psychiatry and Behavioural Sciences University College London 1999 ProQuest Number: U642819 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. uest. ProQuest U642819 Published by ProQuest LLC(2016). Copyright of the Dissertation is held by the Author. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. Microform Edition © ProQuest LLC. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 Table of contents Abstract Preface Acknowledgements I Introduction and a brief ethnopsychology of western depression 1 n Cross-cultural epidemiology of Depressive Disorders 28 a) Epidemiology and classification b) Cross-cultural issues in diagnosis and classification n i Methods for the Study of Folk Models of Mental Illness 51 a) Review of literature b) The Explanatory Model Interview for Classification IV Present Study: The British EMIC 86 a) Objectives b) Rationale c) Method V Developing the British EMIC 92 VI Results 107 V n Discussion 159 Vrn Conclusion 198 Notes Bibliography Appendices Appendix A; Depression: brief history of the idiom Appendix B: Hamilton Depression Rating Scale Appendix C: The UK EMIC for Depression, Version 2.T ABSTRACT This thesis reviews the cultural history of western depressive symptoms and critically examines the epidemiology of Neurotic Depression world wide. It argues that such studies and vocabularies are deeply embedded within “white British and western European” institutions; and predicated on a western epistemology. This is followed by an overview of major research methods to study folk models of mental disorders. Using established clinical anthropological methods, a clinical ethnographic instrument, the EMIC, initially developed in India, is culturally adapted for white Britons in London (the UK EMIC for Depression). 47 white Britons with a diagnosis of Neurotic Depression (ICD-9), attending psychiatric services for the first time, are interviewed for their experience of illness; presenting idioms of distress, perceived seriousness and outcome, experience of stigma, ideas of causation, and help seeking. The study also examines the relationship between such personal meaning of suffering with objective professional biomedical assessments: Results reveal that the expression of illness features, including symptoms, are governed by both popular and professional ideas of depression: Women present considerably later for help, with predominant somatic symptoms whilst men report more psychological idioms. 55 discrete models of causation are elicited. Although there is considerably stability of causal explanations over time, subjects hold multiple contradictory and overlapping ideas of causation suggesting a high degree of pluralism. These results challenge the current methodology of national public mental health campaigns. The development of a culturally sensitive stigma scale is an additional result of this^ study. Idioms of sadness together with psychological explanations are associated with high stigma, those of anxiety together with somatic explanations with less stigma. The thesis concludes that the concept of a universal psychopathological model for Neurotic Depression is problematic. PREFACE The excitement of examining a facet of white Britons and their culture was kindled several years ago when walking with Roland Littlewood through the streets of London’s West End, we discussed the absence of any research that systematically detailed the cultural psychological experience of white Britons. To be a participant observer in another culture required apart from the practicalities of access, time-and money, a position of relative power and sheer confidence in locating one self as an observer. I had little of this when I first arrived in Britain, and it took time and effort to understand and umavel tliis though a personal journey that involved interacting with local culture at different levels; simply living and participating, earning relevant credentials, engaging in frequent dialogues and intimate experiences including personal psychotherapy with a white analyst; and above all, this piece of research. As a trainee psychiatrist in India, I had watched several anthropologists study the local culture and ofi:en wondered why they bothered to know what seemed fairly trivial and uninteresting, and what drove them to endure such hardship. I also admired their tenacity. Several years later, in London, having stepped outside my own culture,, and removed in time and space from my own country, I had the opportunity to participate in seminars on medical anthropology at Bloomsbury. I was amazed,, shocked at some ethnographic observations they had made, and the conclusions they had drawn. At the time, although deeply impressed by their scholarly accounts, I had felt they violated a basic premise of empirical research: sweeping generalisations that lacked quantitative observations and hypothesis testing. Some did not even bother to examine how language skills affected major inferences they had drawn. But it took me a while, attending the same seminars to come off my own ethnocentric position which became clearer when I began field work for tliis study. Just as I had initially felt uncomfortable about narratives, I gradually appreciated the limitation of ‘numbers’ and ‘hard’ data. This led to choosing a method that married numbers with narratives; I am unsure if this has indeed resolved the conflict. My greatest difficulty has been the attempt to simultaneously hold on to dual perspectives across several dimensions: the etic and emic, enumeration and meaning, psychiatric and ethnographic, and deductive and inductive reasoning. These issues are central to the concluding sections of this thesis. I also had a great worry: what if people were unwilling to speak and share their experiences with a person of non-European origin? Tliis was dismissed at the very outset: indeed my major concern turned into managing a huge data sets, large parts of which I have yet to analyse. Nevertheless, I hope the reader will appreciate the effort to juggle the balance between the quantitative and qualitative, and empirical with theoretical. There is one major drawback in this research. It is customary to retreat from the field to one’s own culture to theorise further and then write up the research: the process of cultural distancing. These I have not done for several reasons that I consider are a matter of pragmatics. If it were possible, I would have written tliis study in Hindi or Marathi, and in a manner that would have been closer to my personal style and culture. However, this is a thesis written for London University, and to the extent that it reveals a style and method acceptable and familiar to a western academic, it conceals the Other. Someday I do hope it is possible in future to do it the other way round. And like my shock at listening to research seminars in Bloomsbury on Indian cultures; if the conclusions of this study do not ring true to native Britons, that would just go to show how impossible it is for an ‘outsider’ to know insiders (of any culture), or for that matter to decode ‘their’ syntax.. During the period of this research, Britain and Europe have undergone tremendous changes: redrawing of national boundaries, devolutions, emergence of new economic and political paradigms, violence and etlinic cleansing, changes in health seiwices, training of health professionals, professionalisation of complementary healing systems, and the advent of newer reproductive technologies, designer drugs, spare^ part surgery, etc. I have no doubt all of these matters have and will continue to influence European and British peoples’ experience of health and sickness; Tliis would also suggest that conclusions of my research are only part of a wider dynamic process and will require continuing replication over time and place, in order to better appreciate changes in folk models of Depression and other illnesses across cultures. ACKNOWLEDGMENTS I would like to thank all subjects who participated in this study and shared their experiences, and numerous English informants who gave useful tips and facilitated entry to various British social cultural institutions. Several endearing experiences with both subjects of this study and numerous colleagues have left a deep impression. If it was not for their help, patience and trust, it would have been difficult to complete this study. My immense gratitude to Roland Littlewood, supervisor for this thesis and a key informant for this research, for his intellectually rigorous yet generous mentorship. Arthur Kleinman, whose ideas and work echo throughout this thesis, facilitated my meeting with Roland Littlewood in 1990. This work is a continuation of the spirit of that encounter. I am also indebted to the senior author of the original EMIC, Alitchell Weiss, with whom I have been through the ‘thick’ and ‘thin’ of this approach, from the time I was a trainee psychiatrist in Bangalore: His continuing assistance with both methodological problems and statistical conundmms on tliis study
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