Cultural Approach for Bipolar Disorder Self Help Groups.
Cultural Approach for Bipolar Disorder Self Help Groups
DR. Dr. Cokorda Bagus Jaya Lesmana, SpKJ (K)
Department of Psychiatry, School of Medicine, Udayana University, Bali
Bipolar Disorder
Bipolar disorder (BD) is one of the most distinct syndromes in psychiatry and has been
described in numerous cultures over the course of history. It is characterized by episodes of
depression and mania or hypomania. Most patients tend to experience predominantly chronic
depressive symptoms or recurrent depressive episodes with the result that bipolar depression
can be misdiagnosed as major depressive disorder. This can lead to inappropriate medication
choices and increased healthcare costs. It has a significant impact on quality of life, and also
on social, occupational, and cognitive functioning domains. Increased recognition of the
several burdens of BD has triggered an important change in treatment paradigms, which have
started to focus not only on symptomatic but also on causative for functional recovery.
Psychological interventions have emerged in response to studies that have shown associations
between socio-cultural environment stressors and remission–relapse cycles of bipolar
disorder.
Since Kraepelin, the importance of environmental stressors in the individual
variations of the clinical course of BD has been considered (Green et al., 2014). Among those
stressors, childhood trauma has emerged as one of the most important factors associated with
negative outcomes of psychiatric disorders (Larsson et al., 2013), including BD (Watson et
al., 2014).
Childhood sexual abuse have been reported by 24% of patients with BD (Maniglio,
2013). Specifically, emotional abuse has been reported by 37% of bipolar patients, 24%
reported physical abuse, 24% emotional neglect, and 12% physical neglect. In addition, onethird of those patients presented a combination of different types of trauma (Garno et al.,
2005).
Early life stress has been suggested to mediate vulnerability to affective disorders
(Lovallo, 2013), despite the exact mechanism of this association is not completely
understood. In line with that, a variety of studies have been relating childhood maltreatment
with disrupted neurodevelopment (Dvir et al., 2014, Sala et al., 2014, Bucker et al., 2014).
Traumatic events during childhood are associated with long-term structural and functional
brain alterations (Bremner, 2002, Haldane and Frangou, 2004) especially involving
dysfunctions in prefrontal cortex, amygdala, and hippocampus (Grant et al., 2011, Lu et al.,
2013). These changes have been taking place in the pathophysiology of BD and have been
consistently related with its severity (Frey et al., 2007).
From the pathophysiological point of view, it is postulated that BD is related to
dysfunction in brain circuits involved in emotion regulation. Considering that there are
important differences in the way emotions are experienced and expressed in different
cultures, it is natural to infer that BD diagnosis and management are influenced by cultural
factors. Thus, cultural factors should be considered in designing treatment programs,
particularly in collectivistic societies (Baek et al., 2014, Vieta et al., 2011) Combining the
above developments and considerations, we propose that an expanded, culturally sensitive,
and informed deployment-focused model may be a more effective approach to the treatment
of bipolar disorder patients in non-Western cultures.
Balinese cultural elements of relevance to BD
The Balinese culture possesses a pervasive spiritually based system that emphasizes
relationships to foster solidarity and cooperation within the nuclear family, the extended
family, and the community. In Bali, family and community are tightly enmeshed and
interdependent. Children are highly respected, a respect firmly rooted in the Balinese belief
that children are reincarnated ancestors whose souls are physically reborn into the bodies of
infants. Since the souls of ancestors are highly revered and worshipped, it follows that their
reincarnated physical form is similarity honored and worshipped. Such child worship,
embedded in religious beliefs, forms the basis for the degree of respect, sustained attention,
love and devotion shown to children and appears to be a significant contributor to the
formation of secure childhood attachments to primary caregivers. Furthermore, due to the
closeness and support of both the nuclear and extended families, children tend to attach to
more than one primary caregiver, i.e. parents, older siblings, and extended family members.
As a culture-wide value, maintaining balance and control of impulses and actions is
respected, valued, and indeed expected. Any deviation from this norm would be interpreted
as inappropriate at best and as evil spirit possession at worst. Preservation of relationships
with others takes precedence over nearly all other values in society, and the abuse of children
whether physical, sexual, or psychological, would disrupt the socioculturally defined
boundaries of a relationship with another person.
Traditional healing & Western psychiatry in Bali
In Bali, two types of psychotherapists exist: the Western trained psychotherapists and
the spiritual (traditional) healers, known as Balians. Although, often psychotherapists and
Balians aim at the same symptoms and problems, important differences in treatment
premises, theories, methods, techniques and modalities exist. Balians focus on the healing of
illness based on spiritual beliefs, psychotherapists on the treatment of psychobiological
disorders. Psychotherapists tend to rely on external manipulations – such as medication,
cognitive or otherwise therapy – treat illness and symptoms concurrently, and view the
treatment goals largely achieved when symptoms disappear. Thus after the completion of a
successful course of treatment both patients and therapists may assume a complete, or near
complete, recovery. Balians may use traditional medicine, but their main aim is to ‘‘reset’’
the body systems so that they regulate themselves harmoniously, while they regard the
process as continuing for a long time and the patient as being responsible for their own health
(Suryani and Jensen, 1993).
A culturally sensitive approach to the treatment of BD
Over the past 12 years or so, we have been developing and implementing in Bali a
treatment that integrates the above approaches into a holistic model of biopsychosocial
intervention (Lesmana et al., 2009, Lesmana et al., 2010). The model recognizes and respects
the importance and interconnectedness of every person’s mind, body, and spirit, as well as
the ways these elements are influenced by and in return affect, positively or negatively, one’s
sociocultural relationships and religious/spiritual beliefs. Rather than following a singledisorder treatment approach and isolating interventional foci (such as the psychobiological
focus of the psychotherapist or the spiritual focus of the Balian), our model eclectically
combines all of them, primarily at an idiographic level, in order to treat the individual as
holistically and cultural-sensitively as possible. In essence our approach is an expanded,
culturally sensitive, and informed deployment-focused model.
Through our model, patients of BD are initially clinically interviewed (ICD or DSM
interview protocols), in order to identify the presence of potentially severe symptomatology
that may require a pharmacological intervention. However, the focus of the approach is to
bring the individual back into a state of psychological balance. This is achieved through
guiding the patients to perform intentional self-care – that is, actively pay attention to their
mind, body and spirit – and the involvement of culture-specific agents. The patients are
advised to meditate twice daily and to visit or revisit a Balian to receive further spiritual
healing and guidance. The families are encouraged to perform purification ceremonies in
order to cleanse the spiritual burden that resulted from their exposure to the illness.
Furthermore, the patients’ families, both nuclear and extended, and communities are offered
workshops, educating them on the relevant issues in a meaningful and respectful language to
their culture and local customs. Public dialogues are frequently setup, where affected families
and interested individuals are openly invited and encouraged to participate, exchange
information, and receive further advice and support. Mutual support groups are created by the
families, neighbors, counselors, and community leaders that are responsible for maintaining a
healthy communication and reporting relevant mental health state changes of community
members. The patients’ mental health state was reassessed a week after the last treatment
session, six months later, and in many instances four years thereafter. No residual symptoms
relating to their trauma have been observed in any of the patients yet.
Conclusion
Culture implementation is a potential and systematic contributor into holistic and
sensitive interventional models for the treatment of mental illness outcomes of childhood
traumatization. Mainstream psychotherapeutic approaches to BD arguably still possess
questionable levels of efficacy and external validity, which may be reduced further in the
absence of an acculturated agenda. In areas in the world, such as Bali, where a relatively
homogenous collectivistic cultural and spiritual infusion permeates all aspects of life, such
therapies need to follow an integrated, multimodal, and synergic approach to intervention.
Such an approach would mobilize modern psychotherapeutic techniques and medication,
while respecting, and responsibly utilizing the traditional health practices and religious
beliefs of the focal human geography.
In conclusion, it is our conviction that through the prudent and systematic
implementation of holistic and culturally competent strategies, a development of mental
health deployment-focused models can be achieved that offer a fair and effective service to
the population.
References
Baek, J. H., Cha, B., Moon, E., Ha, T. H., Chang, J. S., Kim, J. H., et al. 2014. The effects of
ethnic, social and cultural factors on axis I comorbidity of bipolar disorder: results
from the clinical setting in Korea. J Affect Disord, 166, 264-9.
Bremner, J. D. 2002. Neuroimaging of childhood trauma. Semin Clin Neuropsychiatry, 7,
104-12.
Bucker, J., Muralidharan, K., Torres, I. J., Su, W., Kozicky, J., Silveira, L. E., et al. 2014.
Childhood maltreatment and corpus callosum volume in recently diagnosed patients
with bipolar I disorder: data from the Systematic Treatment Optimization Program for
Early Mania (STOP-EM). J Psychiatr Res, 48, 65-72.
Dvir, Y., Ford, J. D., Hill, M. & Frazier, J. A. 2014. Childhood maltreatment, emotional
dysregulation, and psychiatric comorbidities. Harv Rev Psychiatry, 22, 149-61.
Frey, B. N., Andreazza, A. C., Nery, F. G., Martins, M. R., Quevedo, J., Soares, J. C. &
Kapczinski, F. 2007. The role of hippocampus in the pathophysiology of bipolar
disorder. Behav Pharmacol, 18, 419-30.
Garno, J. L., Goldberg, J. F., Ramirez, P. M. & Ritzler, B. A. 2005. Impact of childhood
abuse on the clinical course of bipolar disorder. Br J Psychiatry, 186, 121-5.
Grant, M. M., Cannistraci, C., Hollon, S. D., Gore, J. & Shelton, R. 2011. Childhood trauma
history differentiates amygdala response to sad faces within MDD. J Psychiatr Res,
45, 886-95.
Green, M. J., Girshkin, L., Teroganova, N. & Quide, Y. 2014. Stress, schizophrenia and
bipolar disorder. Curr Top Behav Neurosci, 18, 217-35.
Haldane, M. & Frangou, S. 2004. New insights help define the pathophysiology of bipolar
affective disorder: neuroimaging and neuropathology findings. Prog
Neuropsychopharmacol Biol Psychiatry, 28, 943-60.
Larsson, S., Andreassen, O. A., Aas, M., Rossberg, J. I., Mork, E., Steen, N. E., et al. 2013.
High prevalence of childhood trauma in patients with schizophrenia spectrum and
affective disorder. Compr Psychiatry, 54, 123-7.
Lesmana, C. B., Suryani, L. K., Jensen, G. D. & Tiliopoulos, N. 2009. A spiritual-hypnosis
assisted treatment of children with PTSD after the 2002 Bali terrorist attack. Am J
Clin Hypn, 52, 23-34.
Lesmana, C. B. J., Suryani, L. K., Tiliopoulos, N. & Jensen, G. D. 2010. Spiritual-Hypnosis
Assisted Therapy: A New Culturally-Sensitive Approach to the Treatment and
Prevention of Mental Disorders. Journal of Spirituality in Mental Health, 12, 195208.
Lovallo, W. R. 2013. Early life adversity reduces stress reactivity and enhances impulsive
behavior: implications for health behaviors. Int J Psychophysiol, 90, 8-16.
Lu, S., Gao, W., Wei, Z., Wu, W., Liao, M., Ding, Y., et al. 2013. Reduced cingulate gyrus
volume associated with enhanced cortisol awakening response in young healthy adults
reporting childhood trauma. PLoS One, 8, e69350.
Maniglio, R. 2013. Prevalence of child sexual abuse among adults and youths with bipolar
disorder: a systematic review. Clin Psychol Rev, 33, 561-73.
Sala, R., Goldstein, B. I., Wang, S. & Blanco, C. 2014. Childhood maltreatment and the
course of bipolar disorders among adults: epidemiologic evidence of dose-response
effects. J Affect Disord, 165, 74-80.
Suryani, L. K. & Jensen, G. D. 1993. Trance and possession in Bali : a window on Western
multiple personality, possession disorder, and suicide, Kuala Lumpur ; New York,
Oxford University Press.
Vieta, E., Pappadopulos, E., Mandel, F. S. & Lombardo, I. 2011. Impact of geographical and
cultural factors on clinical trials in acute mania: lessons from a ziprasidone and
haloperidol placebo-controlled study. Int J Neuropsychopharmacol, 14, 1017-27.
Watson, S., Gallagher, P., Dougall, D., Porter, R., Moncrieff, J., Ferrier, I. N. & Young, A. H.
2014. Childhood trauma in bipolar disorder. Aust N Z J Psychiatry, 48, 564-70.
DR. Dr. Cokorda Bagus Jaya Lesmana, SpKJ (K)
Department of Psychiatry, School of Medicine, Udayana University, Bali
Bipolar Disorder
Bipolar disorder (BD) is one of the most distinct syndromes in psychiatry and has been
described in numerous cultures over the course of history. It is characterized by episodes of
depression and mania or hypomania. Most patients tend to experience predominantly chronic
depressive symptoms or recurrent depressive episodes with the result that bipolar depression
can be misdiagnosed as major depressive disorder. This can lead to inappropriate medication
choices and increased healthcare costs. It has a significant impact on quality of life, and also
on social, occupational, and cognitive functioning domains. Increased recognition of the
several burdens of BD has triggered an important change in treatment paradigms, which have
started to focus not only on symptomatic but also on causative for functional recovery.
Psychological interventions have emerged in response to studies that have shown associations
between socio-cultural environment stressors and remission–relapse cycles of bipolar
disorder.
Since Kraepelin, the importance of environmental stressors in the individual
variations of the clinical course of BD has been considered (Green et al., 2014). Among those
stressors, childhood trauma has emerged as one of the most important factors associated with
negative outcomes of psychiatric disorders (Larsson et al., 2013), including BD (Watson et
al., 2014).
Childhood sexual abuse have been reported by 24% of patients with BD (Maniglio,
2013). Specifically, emotional abuse has been reported by 37% of bipolar patients, 24%
reported physical abuse, 24% emotional neglect, and 12% physical neglect. In addition, onethird of those patients presented a combination of different types of trauma (Garno et al.,
2005).
Early life stress has been suggested to mediate vulnerability to affective disorders
(Lovallo, 2013), despite the exact mechanism of this association is not completely
understood. In line with that, a variety of studies have been relating childhood maltreatment
with disrupted neurodevelopment (Dvir et al., 2014, Sala et al., 2014, Bucker et al., 2014).
Traumatic events during childhood are associated with long-term structural and functional
brain alterations (Bremner, 2002, Haldane and Frangou, 2004) especially involving
dysfunctions in prefrontal cortex, amygdala, and hippocampus (Grant et al., 2011, Lu et al.,
2013). These changes have been taking place in the pathophysiology of BD and have been
consistently related with its severity (Frey et al., 2007).
From the pathophysiological point of view, it is postulated that BD is related to
dysfunction in brain circuits involved in emotion regulation. Considering that there are
important differences in the way emotions are experienced and expressed in different
cultures, it is natural to infer that BD diagnosis and management are influenced by cultural
factors. Thus, cultural factors should be considered in designing treatment programs,
particularly in collectivistic societies (Baek et al., 2014, Vieta et al., 2011) Combining the
above developments and considerations, we propose that an expanded, culturally sensitive,
and informed deployment-focused model may be a more effective approach to the treatment
of bipolar disorder patients in non-Western cultures.
Balinese cultural elements of relevance to BD
The Balinese culture possesses a pervasive spiritually based system that emphasizes
relationships to foster solidarity and cooperation within the nuclear family, the extended
family, and the community. In Bali, family and community are tightly enmeshed and
interdependent. Children are highly respected, a respect firmly rooted in the Balinese belief
that children are reincarnated ancestors whose souls are physically reborn into the bodies of
infants. Since the souls of ancestors are highly revered and worshipped, it follows that their
reincarnated physical form is similarity honored and worshipped. Such child worship,
embedded in religious beliefs, forms the basis for the degree of respect, sustained attention,
love and devotion shown to children and appears to be a significant contributor to the
formation of secure childhood attachments to primary caregivers. Furthermore, due to the
closeness and support of both the nuclear and extended families, children tend to attach to
more than one primary caregiver, i.e. parents, older siblings, and extended family members.
As a culture-wide value, maintaining balance and control of impulses and actions is
respected, valued, and indeed expected. Any deviation from this norm would be interpreted
as inappropriate at best and as evil spirit possession at worst. Preservation of relationships
with others takes precedence over nearly all other values in society, and the abuse of children
whether physical, sexual, or psychological, would disrupt the socioculturally defined
boundaries of a relationship with another person.
Traditional healing & Western psychiatry in Bali
In Bali, two types of psychotherapists exist: the Western trained psychotherapists and
the spiritual (traditional) healers, known as Balians. Although, often psychotherapists and
Balians aim at the same symptoms and problems, important differences in treatment
premises, theories, methods, techniques and modalities exist. Balians focus on the healing of
illness based on spiritual beliefs, psychotherapists on the treatment of psychobiological
disorders. Psychotherapists tend to rely on external manipulations – such as medication,
cognitive or otherwise therapy – treat illness and symptoms concurrently, and view the
treatment goals largely achieved when symptoms disappear. Thus after the completion of a
successful course of treatment both patients and therapists may assume a complete, or near
complete, recovery. Balians may use traditional medicine, but their main aim is to ‘‘reset’’
the body systems so that they regulate themselves harmoniously, while they regard the
process as continuing for a long time and the patient as being responsible for their own health
(Suryani and Jensen, 1993).
A culturally sensitive approach to the treatment of BD
Over the past 12 years or so, we have been developing and implementing in Bali a
treatment that integrates the above approaches into a holistic model of biopsychosocial
intervention (Lesmana et al., 2009, Lesmana et al., 2010). The model recognizes and respects
the importance and interconnectedness of every person’s mind, body, and spirit, as well as
the ways these elements are influenced by and in return affect, positively or negatively, one’s
sociocultural relationships and religious/spiritual beliefs. Rather than following a singledisorder treatment approach and isolating interventional foci (such as the psychobiological
focus of the psychotherapist or the spiritual focus of the Balian), our model eclectically
combines all of them, primarily at an idiographic level, in order to treat the individual as
holistically and cultural-sensitively as possible. In essence our approach is an expanded,
culturally sensitive, and informed deployment-focused model.
Through our model, patients of BD are initially clinically interviewed (ICD or DSM
interview protocols), in order to identify the presence of potentially severe symptomatology
that may require a pharmacological intervention. However, the focus of the approach is to
bring the individual back into a state of psychological balance. This is achieved through
guiding the patients to perform intentional self-care – that is, actively pay attention to their
mind, body and spirit – and the involvement of culture-specific agents. The patients are
advised to meditate twice daily and to visit or revisit a Balian to receive further spiritual
healing and guidance. The families are encouraged to perform purification ceremonies in
order to cleanse the spiritual burden that resulted from their exposure to the illness.
Furthermore, the patients’ families, both nuclear and extended, and communities are offered
workshops, educating them on the relevant issues in a meaningful and respectful language to
their culture and local customs. Public dialogues are frequently setup, where affected families
and interested individuals are openly invited and encouraged to participate, exchange
information, and receive further advice and support. Mutual support groups are created by the
families, neighbors, counselors, and community leaders that are responsible for maintaining a
healthy communication and reporting relevant mental health state changes of community
members. The patients’ mental health state was reassessed a week after the last treatment
session, six months later, and in many instances four years thereafter. No residual symptoms
relating to their trauma have been observed in any of the patients yet.
Conclusion
Culture implementation is a potential and systematic contributor into holistic and
sensitive interventional models for the treatment of mental illness outcomes of childhood
traumatization. Mainstream psychotherapeutic approaches to BD arguably still possess
questionable levels of efficacy and external validity, which may be reduced further in the
absence of an acculturated agenda. In areas in the world, such as Bali, where a relatively
homogenous collectivistic cultural and spiritual infusion permeates all aspects of life, such
therapies need to follow an integrated, multimodal, and synergic approach to intervention.
Such an approach would mobilize modern psychotherapeutic techniques and medication,
while respecting, and responsibly utilizing the traditional health practices and religious
beliefs of the focal human geography.
In conclusion, it is our conviction that through the prudent and systematic
implementation of holistic and culturally competent strategies, a development of mental
health deployment-focused models can be achieved that offer a fair and effective service to
the population.
References
Baek, J. H., Cha, B., Moon, E., Ha, T. H., Chang, J. S., Kim, J. H., et al. 2014. The effects of
ethnic, social and cultural factors on axis I comorbidity of bipolar disorder: results
from the clinical setting in Korea. J Affect Disord, 166, 264-9.
Bremner, J. D. 2002. Neuroimaging of childhood trauma. Semin Clin Neuropsychiatry, 7,
104-12.
Bucker, J., Muralidharan, K., Torres, I. J., Su, W., Kozicky, J., Silveira, L. E., et al. 2014.
Childhood maltreatment and corpus callosum volume in recently diagnosed patients
with bipolar I disorder: data from the Systematic Treatment Optimization Program for
Early Mania (STOP-EM). J Psychiatr Res, 48, 65-72.
Dvir, Y., Ford, J. D., Hill, M. & Frazier, J. A. 2014. Childhood maltreatment, emotional
dysregulation, and psychiatric comorbidities. Harv Rev Psychiatry, 22, 149-61.
Frey, B. N., Andreazza, A. C., Nery, F. G., Martins, M. R., Quevedo, J., Soares, J. C. &
Kapczinski, F. 2007. The role of hippocampus in the pathophysiology of bipolar
disorder. Behav Pharmacol, 18, 419-30.
Garno, J. L., Goldberg, J. F., Ramirez, P. M. & Ritzler, B. A. 2005. Impact of childhood
abuse on the clinical course of bipolar disorder. Br J Psychiatry, 186, 121-5.
Grant, M. M., Cannistraci, C., Hollon, S. D., Gore, J. & Shelton, R. 2011. Childhood trauma
history differentiates amygdala response to sad faces within MDD. J Psychiatr Res,
45, 886-95.
Green, M. J., Girshkin, L., Teroganova, N. & Quide, Y. 2014. Stress, schizophrenia and
bipolar disorder. Curr Top Behav Neurosci, 18, 217-35.
Haldane, M. & Frangou, S. 2004. New insights help define the pathophysiology of bipolar
affective disorder: neuroimaging and neuropathology findings. Prog
Neuropsychopharmacol Biol Psychiatry, 28, 943-60.
Larsson, S., Andreassen, O. A., Aas, M., Rossberg, J. I., Mork, E., Steen, N. E., et al. 2013.
High prevalence of childhood trauma in patients with schizophrenia spectrum and
affective disorder. Compr Psychiatry, 54, 123-7.
Lesmana, C. B., Suryani, L. K., Jensen, G. D. & Tiliopoulos, N. 2009. A spiritual-hypnosis
assisted treatment of children with PTSD after the 2002 Bali terrorist attack. Am J
Clin Hypn, 52, 23-34.
Lesmana, C. B. J., Suryani, L. K., Tiliopoulos, N. & Jensen, G. D. 2010. Spiritual-Hypnosis
Assisted Therapy: A New Culturally-Sensitive Approach to the Treatment and
Prevention of Mental Disorders. Journal of Spirituality in Mental Health, 12, 195208.
Lovallo, W. R. 2013. Early life adversity reduces stress reactivity and enhances impulsive
behavior: implications for health behaviors. Int J Psychophysiol, 90, 8-16.
Lu, S., Gao, W., Wei, Z., Wu, W., Liao, M., Ding, Y., et al. 2013. Reduced cingulate gyrus
volume associated with enhanced cortisol awakening response in young healthy adults
reporting childhood trauma. PLoS One, 8, e69350.
Maniglio, R. 2013. Prevalence of child sexual abuse among adults and youths with bipolar
disorder: a systematic review. Clin Psychol Rev, 33, 561-73.
Sala, R., Goldstein, B. I., Wang, S. & Blanco, C. 2014. Childhood maltreatment and the
course of bipolar disorders among adults: epidemiologic evidence of dose-response
effects. J Affect Disord, 165, 74-80.
Suryani, L. K. & Jensen, G. D. 1993. Trance and possession in Bali : a window on Western
multiple personality, possession disorder, and suicide, Kuala Lumpur ; New York,
Oxford University Press.
Vieta, E., Pappadopulos, E., Mandel, F. S. & Lombardo, I. 2011. Impact of geographical and
cultural factors on clinical trials in acute mania: lessons from a ziprasidone and
haloperidol placebo-controlled study. Int J Neuropsychopharmacol, 14, 1017-27.
Watson, S., Gallagher, P., Dougall, D., Porter, R., Moncrieff, J., Ferrier, I. N. & Young, A. H.
2014. Childhood trauma in bipolar disorder. Aust N Z J Psychiatry, 48, 564-70.