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The Samples Taken Along Various Lines

A. ACCORDING TO AGE:

                          MALES        FEMALES

14-20 years           31                46
2 1-30 years          43                97
31-40 years           35                89
41-50 years           15                39
51-60 years            6                 18
                     ________    _________
                         130               89

B. ACCORDING TO CIVIL STATUS   

                MALES              FEMALES
             
Single             62                 112   
Married           66                 168
Widowed        2                    9
                 ________    ________
                     130              289

C. ACCORDING TO OCCUPATION:


MALES                        
               
Students                                           51                         
Executives                                         14                         
Businessmen                                      13                        
Skilled workers                                   13                        
Government employees                        9
Salesmen                                            5                                    
Politicians                                            4                         
Bookkeepers                                       3                           
Teachers (college and high school)         3                                       
Unemployed                                        3                          
Doctors                                               2                                                   
Lawyers                                              2              
Engineers                                            2                                                        
Clergymen                                           2                            
Farmers                                               2                            
Musicians                                             2                            
                                            ________________
                                                      130

FEMALES

Housewives                                     128
Students                                           36
Office workers                                   27
Teachers (all levels)                           22
Businesswomen                                 15
Unemployed (single)                            5
Executives                                          7
Bank employees                                  5
Dentists                                             4
Nurses                                               3
Doctors                                              3
Lawyers                                             2
Social Workers                                   2
Nuns                                                  2
Sales girl                                            1
Chemist                                              1
                                            _______________
                                                      263


D.SOURCE OF REFERRAL:

 
                               MALES                                  FEMALES

Doctor                      78                                        178
Priest                         9                                          32
Relative                    16                                          28 
School counselor         6                                           11
Friend                        5                                           12
Another patient          13                                          12
Self-referred                3                                          12
                             ___________                        ___________
              130                                        289

Eight patients, three women and five men, came from other psychiatrists. The three women felt they could not talk freely with a male doctor. The rest came because the psychiatrist was going abroad or did not have available time right away. Some of the referring doctors were friends of the patient. As such, they were consulted nor for a medical problem but to seek advice or solace. For example, not all who came from obstetricians or gynecologists had symptoms directly referable to the reproductive system. What happens is that a woman sometimes develops a great dependence on her obstetrician and in the course of a check-up or consultation may reveal to him all her emotional difficulties.

Priests, like doctors, handle a large volume of psychological problems in their office. If all of the emotional illnesses were included, those coming from the priest’s office will be much larger in number. The priest may also happen to be a psychologist, but it is more as a priest that his advice is sought. In some instances, the patient had gone to a doctor, a friend, a relative, and to the school counselor, all of whom suggested psychiatric help, but only when a priest made the same suggestion was action taken.

From conversations with colleagues and friends, one gathers the impression that there are many who do not come at all. Some patients say that a psychiatric referral had been suggested one or two years before they came. Some try other means, such as going to the province, a trip to Hong Kong or Japan, dropping out of school, changing jobs, etc., and many never get to a psychiatrist’s office at all.

Women outnumber men in the sample with the ratio of 2.2 to 1. Their preponderance might be quickly explained by the Filipino belief that women should confide their innermost frustrations and private lives only to another woman. Moreover, the Filipino male tends to feel that woman, even if she is a doctor, can never empathize with male patients on how a man really feels. He may also think that it is offensive to a woman’s sensibilities to hear a man describe in detail his most private activities. Finally, to men in this culture, who place such a high premium on masculinity, seeking help for emotional problems and from a woman at that, may threaten to dent his masculine image. The writer, however doubts that such cultural inclinations are operand to a degree sufficient to account for the greater number of women than men in this study. These figures seem to be more in keeping with trends noted in other places here and abroad. The 1966 census at the psychiatric outpatient clinic of the PGH showed that out of 214 patients 123 were diagnosed as neurotic and with personality disorders, 47 of whom were males and 76 were females.

Forty-six women and twelve men in the sample come from the provinces, but all of them have at one time or another visited, studied or lived in Manila. Of those who reside in Manila not all have always lived there; some have moved to the city only within the past ten years. The majority have lived in Manila or its suburbs all their lives. The sample is, therefore, a predominantly urban one. Even those who come from the provinces have grown up or lived in an urban area. Moreover, their places of residence in the province are not on farms, although they may be proximate to them. The farmers in the sample were administrators of farms, which they visited but did not live on.

The majority are students, businessmen, government or private-firm employees and professionals who lead a busy life in Manila. These are the people who usually are the first to feel the impact of social change, particularly that which is brought on by industrialization and urbanization. They are the ones who are most likely to be forced by new standards and systems to depart from time-honored cultural practices.

The patients in this study belonged to the middle, upper middle, and a few to the upper economic class. These patients were very much involved in the economic tensions of the times. The acquisition of material comforts and the prestige that goes with money and position were leading preoccupations. Adolescents, in spite of their preoccupation with their inner emotional strife, were very much aware of rank and station in society as determined by money. The plushness of the neighborhood one lived in, the ability to afford expensive parties, association with socially and politically prominent and powerful people—all of these implied financial success and prestige in the public’s eyes.

Only depressed patients, at the height of their despair, paused to question the work-and-money ethic, wondering if the relentless pursuit of success and wealth was worth the bartering of their peace of mind. One example was a man whose creative spirit, yearning to make great artistic movies, often had to be compromised to please clients in his advertising agency. Another example was a woman who had become “by circumstance” the mistress of a rich, powerful man. She may have been motivated by love but the economic advantages were also considerable. Even as the siege of depression led her to struggle with guilt and shame, she could not remove herself from the privileges and comforts to which she had grown used. Instances of ambivalence towards money were eventually resolved in the direction of favoring the economic goal. Neurotic patients whose fear of success caused them to seek a demotion in their job might accomplish a private psychological victory but the cultural verdict would label them as dismal failures.

Ways of handling money between husband and wife differed to some extent from what is supposed to obtain in the culture according to which the wife manages the family treasury. The trend among the couples in this sample was for the husband to give his wife enough money to run the house and to indulge herself on her small luxuries. It was as if she were given a monthly allowance. Then the man decided on property purchases and investments for the family, and in some cases, without consulting the wife or letting her know, simply because he did not feel the need to let her / o know. The kind of husband who turned over his entire earnings cc’ to his wife giving himself an “allowance” for cigarettes, gasoline, and lunch money was very rare in this sample.

It was also quite common for married patients to receive regular or occasional financial help from their parents and even grandparents. This came either in the form of cash (sometimes on allowance basis) or material gifts. The latter can be anything from a household appliance, to something more expensive such as jewelry, a house and lot, a car, or even a trip abroad. In a few couple, one set of parents offered to pay the school expenses of one grandchild. Usually, however, this gesture had strings attached to it. The child was expected to spend time with the grandparents, if not actually live with them.

It was not unusual to have a single man, 25 or 30 years old, come with an elder sister, who tells the therapist that she would be responsible for the expenses incurred in psychiatric treatment. There two female students who came from poor families from the province. Each was brought in by elderly women who said they had more or less “adopted” the patients. In these cases they had taken the patients from their families during the patient’s teen years. Although the patients helped with chores in their new homes, they were treated as members of the “family” and sent to school.

The majority of the patients in the study had finished high school and gone ahead to collegiate level. There was no rigid correlation between financial success and educational achievement, however. In general, a college diploma was utilized to gain employment; to become rich, however, required other things not necessarily related to one. If one’s parents had property or if one married into a family of adequate or comfortable means, he or she would be assured of material comforts. There were many women who, despite finishing a college course, never worked a day of their lives outside the home. A conspicuous group in both sexes, in the 25-50 years age bracket , were those who had surpassed their parents in financial standing and, in fact, helped to pull their parents up to a higher financial rank in society.

Sophistication was difficult to gauge in ach case. If by “sophistication” one means a certain awareness anti knowledge ability about the world which leads to broadmindedness, worldliness, or modernness, more male than female patients appeared to possess this quality. With the latter, the most that was achieved was a veneer of sophistication. With the men, it was easier to differentiate the city bred, the well traveled, and those aware of the world in general from the others who had not had similar experiences. Among the women, it was difficult to correlate sophistication with upbringing, degree of education, extent of travel or nature of work.

Thus, although the stereotype of the “provinciana” (abbreviated by city folk as a derogatory nickname—”ciana”) is a woman who is naive, shy, backward in dress and manner, and inclined to be shocked at city happenings, a Manileña often had identical traits, except that she may be dressed more stylishly. Travel was no reliable guarantee for acquiring sophistication. Many of the women who had traveled and even lived abroad for a looked, talked, and reacted to events as I they never left home.

Having had college education also did not seem to add to knowledge ability about the ways of the world. More often than not, it seemed that acquiring a diploma meant little more than passing all the required objects. Some of the brightest students in school, habitually garnering honors and high grades, had little psychological-mindedness and only a limited ability to handle and understand given situations from various points of view. Similarly, a career woman could be working alongside men for years and still harbor child-like attitudes about them.

The patients were prone to form fixed images of certain women in this culture. A “society girl” was one who came from a moneyed family and had her social activities chronicled in the papers; as such, she was stereotyped as frivolous, exhibitionist and likely to be empty-headed. A woman who appeared on TV and movies as -an entertainer was strongly suspected of inclinations to sexual promiscuity. Many of the male patients felt that these women had already lost their virtue. Of late, not a few patients cited fashion modeling as likely to lead to similar directions. They felt, without basis, that a “model” made herself fair game for sexual license, in particular, voyeurism. Actually, the few “society girls,” movie and TV entertainers who came for psychiatric help turned out to be quite serious, given to worry, and sensitive to their own guilt and shame feelings.

Sophistication or “modern ness” was ambivalently regarded by the women and vaguely equated in their minds with looseness or licentiousness. Men showed a tendency to be attracted to women who work, drive a car, smoke and drink, and feel at ease with men; they are however ambivalent and, in some cases, vehemently against seeing their wives behave in such manner. It was not unusual to encounter a husband who was quite upset over the prospect of his wife going to work, In attempting to gauge the level of sophistication of the patient group it has been observed that despite their long residence in urban areas, they sometimes behaved or reacted like provincial folk.

Their attitude towards seeing a psychiatrist was more liberal than that shown by those coming from lower economic groups. Still, initial reactions ranged from surprise to disbelief. No one really felt it to be synonymous with being crazy unless the fear of losing one’s mind was originally there. Whether belonging to the upper, middle, or lower economic class, a patient if distressed enough will welcome a gesture of help. However, excursions into one’s thoughts, feelings, and reactions brought on varying degrees of chagrin, embarrassment, or resistance. In this study, the relatively more receptive attitude may be due to exposure to TV, movies, and magazines describing the practice of psychiatry. The knowledge that a friend or relative has had psychiatric assistance also brought added reassurance.

More than 90% of the patients were Catholics, the rest were Protestants. The gap between traditionalism and liberalism was wi4e. In general, the women, who were much more fervent than the men, relied greatly on prayers and seemed to do all the praying for the family. There were a few men, however, who were more religious than their wives and had quite a time urging the latter to turn to prayer in order to be relieved of their illness. Several women in therapy openly challenged certain dogmas of the Catholic Church but otherwise kept these views discreetly from others. There were searches for the right priest and passing the word to friends as to which parish the priest belonged. One woman went to the same priest-confessor regularly each week for nearly 15 years. Patients would travel several miles outside their parish to go to a priest who was more impersonal hearing confessions. At least ten women were being seen simultaneously by a priest for spiritual counseling.

Many clinical impressions accumulate from a doctor’s continuous experience with patients. These impressions are subtly registered in his mind, increasing his ability to evaluate and sharpening his skills at management. In time, he develops a certain kind of intuitive approach to a certain class of patients with a certain set of complaints.

While one cannot dispute the value and indispensability of clinical experience, the knowledge gathered there from, unless systematically studied, is based on empiricism. As such, whatever deductions or conclusions are derived from such impressions will have to be explained by further assumptions. In psychiatric practice, the factor of uniqueness of personality intrudes very often into the formation of reliable clinical impressions. A psychiatrist has to be always ready for surprises. Since no two people are psychologically identical, predictability of behavior must necessarily be poor. Furthermore, the doctor’s emotional reactions, no matter how well- controlled and understood, enter into his assessment and management of the patient’s problems. His clinical impressions may reflect in varying degrees his own psychological responses and will therefore be even less reliable.

A careful analysis of recorded though multifarious clinical impressions may lead to identification of patterned phenomena. Hypotheses may then be formulated for further clarification and verification which may lead eventually to more scientifically based explanations for the occurrence of these behavior phenomena.

In the Philippines, it was only recently that the emotionally or mentally disturbed person has been given the status of “a patient” needing psychiatric investigation and help. The techniques employed toward this end are largely borrowed from the West. Their application has yielded a body of information about Filipino psychiatric patients. This study hopes to record and present some of this information, in a more systematized form. The writer herself benefits primarily from this study but hopes that this work will invite Filipino colleagues in the field to carry out comparative studies. The integration of insights derived from such investigations will ultimately lead to increased understanding and improved techniques of managing psychiatric disorders in the Philippines.

The choice of this particular sample of patients is motivated by other considerations. The writer feels that the focus on neurotic and personality disorders will provide greater Information as to the relevance of social and cultural factors in emotional illnesses. Any behavior is always the sum total of the individual’s biochemical, physiological, psychological, and cultural. In the psychoses and in organic syndromes, ere is a body of evidence which suggests that in the causation of illness the first two factors are largely at work to a greater degree than in other illnesses of less malignant nature. In the neurotic and personality disorders, the psychological experiences of hepauentpreominare and, at different levels of functioning, interact with the culture and society where he lives and functions.

One can look at the pathways between culture and psychiatric disorder in two directions and ask the following questions:

From the individual’s point of view, does the culture support him in his psychological struggle, providing him with room and facilities to render his defenses effective and his goals attainable? From the other end, how has the culture contributed to the shaping of the patient’s personality, notably with respect to goals, ideals, values, and the patterns by which these things can be achieved? In Leo Simmon’s (1942) pithy words, “Man functions as creator, creature, manipulator and transmitter of  clues as to what aspects of the ongoing social and cultural changes in the Philippines, particularly Manila, are brought to bear on the genesis of emotional conflict in the Filipino. What constitutes stress for hi& and in what manner he attempts to cope with it, are some of the questions this study will try to answer.
In each case the diagnostic impression ‘was made after one or two interviews. Only in one case was a revision made when subsequent interviews yielded additional information from the patient. The initial interviews generally revealed enough of the pathology to warrant the original diagnosis.

As in all patients, each of these cases presented an admixture of symptoms; the diagnosis then depended on what type of symptomatically was more prominently displayed. The Diagnostic and Statistic Manual of the American Psychiatric Association (First Edition) was used as principal reference. This manual gives brief clinical descriptions of each diagnostic entity. Some psychiatry textbooks follow more or less the classification in the APA Diagnostic and Statistic Manual; the clinical descriptions of each disorder are detailed and comprehensive. The writer therefore will not go into a description of criteria used in establishing diagnoses, which may be found in any of these books. Rather, some aspects of diagnosis-making which appeared peculiar to this group of patients, most likely because of cultural idiosyncrasies, will be pointed out.

A breakdown of the patients in this study according to diagnostic categories shows the following distribution:


PSYCHONEUROSIS            MALES            FEMALES

Anxiety Reaction               28                    58
Depressive Reaction          17                     38
Conversion Reaction           6                     25
Phobic Reaction                 8                     15

Inadequate Personality

 

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