Purpose: To attempt to appreciate the cultural manifestations of low self esteem in Marzi Pura area that is a socioeconomically poor area in a third word country, though the Psychiatric Services are available, and I am presently working in the area as a mental health professional doing outpatient clinics in one of the teaching hospitals.

 Motivation: Till one month ago I had been working in The United Kingdom as a consultant Psychiatrist, after I had finished my training there and most of my learning and building blocks of understanding of human Psychology and Psychopathology developed over time in the British culture, academic and professional environment. Prior to that I have been brought and raised in Pakistan and I know well the language and culture here. Therefore, in my interactions with clients I am now observing, appreciating, relearning and experiencing manifestations of psychological and psychopathological phenomena in the Pakistani culture but from a mental health professional’s point of view. At the same time I am trying to find a way to link the the same phenomena of various psychological and psychopathological manifestations here in Pakistan that I observed and formally studied in British culture. It’s a very interesting experience and although most of the phenomena appear to have some parallels between two cultures, nevertheless, some completely unique and never observed before manifestations can also be appreciated at times. My mind says let’s learn about this and my heart says that let’s try to find the best ways to serve and support the local community incorporating their own cultural needs.  Although I am born and brought nearby, despite that my schooling and upbringing had been in a rather affluent and socioeconomically more sound environment, that implies that I have familiarity with some aspects of cultural and lingual presentations of this socioeconomically deprived area to some extent but I don’t have a full grasp of either the language or culture and I have pledged to learn and have also committed to improve me skills and expertise everyday in these two areas.

Low self-esteem:

Dr Jennifer Alison in her book “Self Esteem: Fast Proven Treatment for Recovery From Low Self Esteem” describes nine patterns (cognitive/Behavioural) that lead to developmental and perpetuation of low self esteem in an individual.

These patterns are

  • Focusing only on failures and therefore minimising or completely discounting any positives including successes
  • Unrealistic goal setting, that leads to repeat failures that are self-selected
  • Self-sabotage and self-attacking thoughts or behavioural pattern
  • Neglecting one’s physical needs
  • Constant comparison of self with others, whilst keeping own self always in an inferior position
  • Substance misuse or abuse to find immediate gratification and avoidance of emotional pain
  • Focusing on things that can’t be changed but stubbornly sticking to them
  • Focusing on past mistakes.

Cultural Manifestations in Marzi Pura:

Although I have not come across a bookish picture of all the above cognitive and behavioural patterns in a chronological order, nor I plan to comment on them one by one but there are a few repeat psychological and emotional presentations of clients that are strongly suggestive of existence of the same above patterns in a completely different form, compared to as we would expect in a Western Culture (my major comparator is British culture, in particular North West of England).

“Marzi Pura” is a small town situated in the outskirts of the city of Faisalabad, which is the third biggest city in Pakistan, based on population size. Marzi Pura is thickly populated. The area thickly populated by lower and lower middle-class people who mostly work in the factories and industries situated in this area. We also expect some blue- and white-collar people too who are mostly attached with the same industry directly or indirectly, though labourers outnumber clerical and administration staff members in industries hugely. . In the morning majority on roads can be observed riding bicycles and motorbikes carrying usually three to four kids wearing uniforms suggesting they are on their way to schools. Three-wheeler vehicles like autorickshaw and animal driven carts dominate the vehicle population on the road clearly and you come proportionately across one four wheeled cars in comparison to roughly one hundred other small vehicles (less than four wheels or four wheeled public transport vehicles) for a few hundred yards whilst driving towards the main city

Three Basic Foundations:  

Three factors need to be appreciated and kept as a common foundation upon which I would expect to see any presentation, whatever this might be. First is the huge stigma towards mental health difficulties in general that is extended as a courtesy stigma to one’s own mental problems and to mental health professionals and nearly anything that is related to mental health. “Pagal”. “Sudai”, “Jhalla”, “Majnu”, “Saeen”, “Allah Lok”, “Bawa Log” are common expression, they all carry pejorative connotations attached to them and have humiliating and derogatory meaning inherently incorporated. The second foundation is the denial of mental illness itself. I had an opportunity to talk to my medical colleagues, including those specialists in Internal Medicine, in Cardiology and in Neurology and they all had a shared understanding that they are regularly assessing and reviewing psychiatric patients in their clinics, however despite being encouraged or even pursued, patients are completely reluctant to attend the mental health professional. This kind of presentation continues in Psychiatrist’s consultation room, however the presentation is a bit changed in that scenario and environment, Nearly all psychiatric consultations begin with denial of any mental health issues at all, most of them start with psychosomatic complaints or in a different scenario with psychosexual complaints that mostly have been explored by the medics or other set of professional from multiple disciplines in the past and  mostly patients have been told that there are no physical health grounds for such complaints and that they need to see a Psychiatrist for further discussion. The third (predictably) unusual, unique but extremely common (almost exceeding 95%) presentation is the expression of very unusual symptoms that defy any possible anatomical or physiological structural or functional explanation. For example, that a ball of gas (Gas Ka Gola) emanates from the stomach but had the potential to move across the body regardless of the boundaries of the gut, it can travel into muscles, can have access to brain and of course has some special attraction towards heart as well. Medically unexplained pain that has been usually assessed in described as pain in the brain and the pain can have very unusual and sometimes interesting course and radiation for example emanating from knee and moving to brain or at times categorically not affecting the skull or neck muscles but emphasized by the client that it is the content matter of brain that is affected here.

For sake for my ease (that might help my reader too) I shall call them ‘three basic psychiatric patients presentation foundations in Marzi Pura’

Low Self Esteem Manifestations:

A very common theme that is readily identifiable behind somatic, sexual or dissociative symptoms expression by patient is that prescribed pills are not helping me. When asked what you would like to achieve from the prescribed medications the usual answer is to find solution to one of three foundation presentations as described above. Now if we explore and understand individual expressions more in detail a common denominator identified behind many of expressions is that of low self-esteem. Consider the following examples and scenarios for example. Let me clarify that in following examples low self esteem is not the primary or the only reason/factor that would be considered as a major causative factor or the only essential outcome.  I appreciate and acknowledge the complex multi factorial, socio-ethno-cultural-financial influences that contribute and interact with innumerable other reasons eventually leading to the development of a psychopathology and my description here is neither a simplification and nor a reductionism but instead a general appreciation of a commonly observed theme and phenomena.

  • Psycho-sexual problem in males expressed as dissatisfaction with nature and quality of erection or that of orgasm or ejaculation. All medical causes have been ruled out already.
  • There has been some spirit, black magic, amulet or jinn that has deprived me of my control and as a result I undergo phases that I don’t want to engage in. Locus of responsibility is completely externalised, and the eventual outcome is overridden control by external factors that are neither psychotic nor dissociative in nature.
  • My body stays in trouble and difficulty (Medical reasons or relevant psychiatric reasons ruled out) because I want to take revenge for an insult that I underwent long time ago. In culture of village if I don’t take revenge then I am belittled, denigrated and insulted all the time. Although symbols and some pillars of righteousness, nobility, peace, forgiveness and altruism exist in local culture, but I don’t want to tap into them and the only thing that will restore my honour or self-esteem would be revenge.
  • I don’t know what my problem is, these (my relatives) have brought me here that’s why I have comes. (Disassociation, Psychosis or other major causative factors ruled out).
  • You are the doctor, you should tell me what my problem is, that’s why I have come here.
  • You gave me useless medications last time. It is yours and medications’ failure that I haven’t improved. You as a doctor have failed to address my problem.

I hope I shall be able to find more points on the list as my practice grows in current culture.

Note for you:

The intention behind this write up is not to discuss solutions about these cultural presentations but share some reflections about the current experiences in my practice that I am going through. Kindly share your thoughts in the comments section below, especially if you have a similar kind of experience in your domain, family, circle of friends or area of practice.


(Marzi Pura, Faisalabad, Pakistan 29/11/18)