Issues in Mental Health Nursing, 34:908–910, 2013 Copyright © 2013 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2013.799722
CULTURAL COMPETENCE COLUMN
Cultural Differences in Interpreting Behavior: Staring and Spitting Jacquelyn H. Flaskerud, RN, PhD, FAAN University of California—Los Angeles, School of Nursing, Los Angeles, California, USA
Edited by Jacquelyn H. Flaskerud, RN, PhD, FAAN University of California—Los Angeles, School of Nursing, Los Angeles, California, USA Several times recently I’ve been reminded of the differences in interpretation of behavior across cultures. A relative who was visiting was telling me about how, in his retirement, he mentors inner city kids. He related that among many other things, he was trying to teach them to maintain eye contact. I responded that not all cultures value eye contact; he reacted by saying that to avoid eye contact was an evasive or resistant behavior, or an insecure or inattentive behavior. A column that I edited two months ago by Scott Trueman (Trueman, 2013) focused on providing mental health services to aboriginal Australians. In the context of eye contact, he wrote that many factors determine the amount of appropriate eye contact between nurse and client, including their respective genders and ages, whether sensitive topics are being discussed, and the level of trust/relationship between nurse and client. He went on to say that what is not acceptable is fixed or intrusive eye contact. Trueman provided some techniques or mannerisms that may be employed by the nurse to avoid direct eye contact, such as staring into the distance or at the ground or hands while talking, and occasionally looking at the client. I related this information to my relative, but he insisted that in our culture it was important to maintain eye contact. I had written about this behavior earlier in my career, cautioning psychiatric nurses that direct eye contact might be considered aggressive, confrontational, and hostile by some clients, and rude, immodest, or even dangerous (e.g., “if looks could kill”) by others, particularly if there were age, gender, or ethnic/racial differences between the nurse and client. On the other hand, in some cultures, looking at someone while talking to them might be considered essential to a respectful dialogue. A friend of South Address correspondence to Jacquelyn H. Flaskerud, School of Nursing, University of California, 700 Tiverton Ave, Factor Building, Box 951702, Los Angeles, CA 90095-1702. E-mail: [email protected]
American origin related to me a story about her father driving them to the Grand Canyon when they first came to the US. Intrinsic to his nature was looking at the person he was talking to, which meant that he kept looking backwards at his mother in the rear seat while he drove, putting all of their lives in jeopardy. There are other examples of the necessity of looking at a person when talking to them. When people are hard of hearing, they compensate by lip reading; communication is difficult if they are not looking at you directly. Even those of us who think we have a consistent cultural approach to eye contact will find ourselves making incongruous statements. Consider the authoritarian admonition: “Look at me when I’m talking to you!” compared to the equally authoritative command: “Stop staring!” There are many situations and beliefs that govern how much eye contact is appropriate in any given encounter and to maintain that, in our culture, eye contact is valued is to ignore these many differences. The same observations may be made about physical space— how much space is necessary between two persons when they’re talking? Does that amount of space decrease when people are packed into a subway? Does it differ depending on one’s relationship to the person—family versus friend versus client? Does it differ by culture? Again, Trueman (Trueman, 2013) describes Aboriginal people as tending to stand side-by-side rather than face-to-face when telling a story or relating a narrative. He advises that the same configuration should be undertaken during any psychiatric interview. The nurse should be near, but not too close, so as to not impose on the client’s personal space (Trueman, 2013). There are many other examples of differing interpretations of behavior: stance and body language may denote modesty, respect, or being hip (i.e., current, trendy). The same is true of the use of hands in communication and expression—touching, dramatic gestures, and what various hand signals mean. I’ve traveled to many countries where I was warned in advance that certain uses of hands and fingers mean extremely different things from one culture to another. What really got me started on this whole idea of differing interpretations of behavior was the subject of spitting. Granted, spitting may fit into a different category, one that includes its
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CULTURAL COMPETENCE
relationship to health and public health. Listening to an interview by Terry Gross on public radio’s Fresh Air (March 26, 2013), I was struck by how cheerfully Mary Roach, the author of Gulp (2013) was talking about spit, a topic that I find generally disgusting. Roach writes about the positive characteristics of saliva and its functions in digestion, demineralization, lubrication, and the like (2013). In her interview with Gross (2013), she spoke of the anti-infective qualities of saliva. She explained that saliva renders viruses non-infective and that in it are proteins called histatins that help wounds heal. In the past, saliva was a home remedy for cuts and scrapes (Gross, 2013). A study by scientists in the Netherlands in 2008 confirmed the antifungal and antibacterial functions of histatins in saliva and found they were relevant to the rapidity of oral wound healing as compared to the slow rate of healing for skin lesions (Oudhoff et al., 2008). Roach (2013) also writes about the negative associations of saliva with bacteria, and traces the history of these beliefs to Hippocrates and Galen. Both believed that saliva and sweat were the body’s way of flushing itself of disease-causing impurities. Before physicians knew about microorganisms as the cause of infections, they would put people in “salivating rooms” to treat their diseases. Roach (2013) equates this practice with the antiquated idea that persists today of going to a sauna or steam room to sweat out toxins. However, cultural views about spitting range widely. In some ways, they mirror views on when eye contact is appropriate and are specific to gender, age, ethnicity/race, a particular situation, and beliefs about the value of spitting. Eisenberg (2004) writes about the popular Jewish superstition of spitting three times (either literally or figuratively by saying, “pooh, pooh, pooh”) in response to something exceptionally evil or good. He relates that Jews perform this ritual in response to seeing, hearing, or learning of something terrible and as a prophylactic measure to prevent such a tragedy from happening or recurring. However, it is also traditional to perform the same ritual in response to something wonderful happening—such as good news or the birth of a beautiful and healthy child—to ward off the evil eye. A similar positive attitude toward spitting is attributed to the Greeks. Roach (2013) describes the Greek practice of spitting on anything they want to protect from the evil eye or bless for good luck, including babies and brides; although most don’t actually spit but say, “Ftou, ftou, ftou.” According to Roach, the Greeks got it from the Roman Catholics whose priests baptized with spittle, and the Roman Catholics got it from the Gospels of Mark and John (Roach, 2013). Eisenberg (2004) agrees that the origin of the Jewish superstition may well have originated from the Christian Bible, which mentions the miraculous power of the spittle of Jesus. And they brought to him one who was deaf, and spoke with difficulty . . . And he took him aside from the multitude, and put his fingers into his ears, and after spitting, touched his tongue with saliva; and looking up to heaven, he sighed, and said to him, Ephphatha, that is, Be opened. And his ears were opened, and the impediment of
909
his tongue was removed, and he began speaking plainly. (Mark 7: 32–35).
In another reference, Jesus spit in the dirt and made clay and put it on the eyes of a blind man, who subsequently could see (New American Standard Bible, 1971). Eisenberg (2004, p. 586) goes on to say that because spitting was eventually viewed as a crude and messy practice, it was replaced by the more refined ritual of simply saying, “pooh, pooh, pooh.” And that brings us to crude, rude, and messy—the more negative, and common, attitudes toward spitting. In the US baseball players spit—many times because they chew tobacco or gum, or out of habit. Teenagers, often boys, spit to look cool, to conform, to show disrespect or contempt for others, or to demonstrate their manliness or toughness when feeling insecure. Boys and men used to spit on their palms before shaking hands to seal a deal. Spitting in our culture seems to be gender-associated, with boys and men behaving this way more often than females. Many people of differing cultures spit for reasons related to their health (or illness). An early association with illness occurred in New York City in 1896 when a law was passed against spitting in public (on sidewalks and in streetcars). Public health officials believed that spitting spread lethal diseases, among them consumption, diphtheria, la grippe, bronchitis, pneumonia and, especially, tuberculosis, a leading cause of death in crowded, dank neighborhoods (Ephemeral New York, 2011). New York became the first US city to outlaw expectorating, and signs went up on public transportation and other popular spitting spots, warning of arrest and a $500 fine. Citizens complained about the law, even those opposed to spitting, saying that it was unenforceable and even dangerous because the health of an individual might suffer from such a restraint (Ephemeral New York, 2011). Again, there was the belief that spitting is a way to rid the body of disease. However, reports are that the anti-spitting law (plus other public health measures) slowed the tuberculosis epidemic in New York measurably. In a much more current incident, the belief in ridding the body of disease through spitting and the continued wide-spread practice of it became a major concern in China as they prepared for the Beijing Olympics in 2008 (BBC, 2007). The Beijing Civilization Office, in an effort to make sure that residents did not spit all over city streets and embarrass the capital city, had volunteers hand out special spit bags and fined offenders (about $33 US); they also launched a slogan campaign urging citizens to be civilized and to behave better (BBC, 2007). The Beijing Civilization Office’s efforts seemed aimed more toward “civilized behavior” than toward curbing the spread of disease. An explanation for the cultural difference in interpreting spitting behavior comes from Roach (2013). She refers to the practice of spitting among the Chinese and clarifies that it is not saliva they are spitting out but phlegm from the lungs and sinuses, with the intent of spitting out disease. Although we might view this behavior as spreading disease and perhaps disgusting, she notes that they spit because they don’t care to use handkerchiefs or
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tissues; they find our habit of collecting it in tissues held in our hands disgusting and dirty. Point taken. What about mental health and illness? Are there any connections to spitting and mental disorders? Two very different kinds of stories are associated with spitting and mental illness. One account publicizes a new test, the Genecept Assay test, which uses a patient’s saliva to look for genetic biomarkers associated with depression (Healthbeat, 2013). The test can be used for patients with a range of psychiatric conditions, including depression, bipolar disorder, and anxiety disorders. The hope is that this test might help doctors predict which anti-depressants are most likely to work with any given patient (Healthbeat, 2013). The other association of spitting and mental disorder describes spitting as one of the signs or symptoms of a particular disorder. Spitting has been associated with Tourette’s syndrome and with phonic tics. Frequently spitting is associated with obsessive compulsive disorder (OCD). Obsessions are recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress (Bio Behavioral Institute, 2009). Persons with OCD attempt to ignore or suppress such thoughts, impulses, or images, or neutralize them with some other thought or action. Compulsions are repetitive behaviors that the person feels driven to perform in response to the obsessive thoughts (Bio Behavioral Institute, 2009). The behaviors are aimed at preventing or reducing distress or preventing some dreaded event or situation. Compulsions can be divided into two types: ideational or mental, and motor. Ideational compulsions are performed in the mind and are not physically observable. Motor compulsions are urges to perform a certain physical act. Among the motor compulsions are physiological acts, including spitting (Bio Behavioral Institute, 2009). People in the US with OCD who spit describe constant spitting as a compulsive reaction to the obsession that what is being encountered (heard, seen) is so dirty, horrible, nasty, and gross that they have to spit so that it doesn’t become part of them (ADD Forums, 2012). One person wrote about seeing something like an unflushed toilet, or thinking of something bad, and then becoming fearful that he would swallow whatever he saw or thought of. The same thing was true if he heard cursing or read bad words; he would have to spit it out. He got a horrible feeling that it was in his mouth and that it would become part of him if he did not spit it out (ADD Forums, 2012). Again, this behavior seems to be gender related, occurring more frequently in males than females. This reaction has a remarkable similarity to the cultural belief that one can rid the body of disease by spitting and seems to flow naturally from it. Incorporating cultural interpretations of behavior into the symptom pattern of mental illness is very common. All persons, including those with mental disorders, express distress in culturally embedded ways, which differ by region, age, gender, and local conditions and traditions. Spitting
has a long history of association with disease—as a way to cure disease (e.g., in biblical times), a way to rid the body of disease (e.g., as Galen and Hippocrates believed), or as a superstitious rite to prevent disease or evil from occurring (e.g., in Jewish and Greek practices). The association with disease is geographically widespread and appears in association with both physical and mental disorders. Although the practice of spitting seems persistent, our attitudes toward it may be changing slowly over time. According to Traditions of the United States Senate (Baker, no date, p. 17), the Supreme Court Justices of the United States still have spittoons in their chambers, using them today as waste baskets, and the US Senate also has spittoons spread across Senate Chambers, which is considered part of Senate tradition. In conventional practice very few of us spit, and tolerance of spitting in the US, seems to be decreasing. Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
REFERENCES ADD Forums. (2012, December). Anxiety Disorders, OCD, and PTSD. Retrieved from http://www.addforums.com/forums/showthread.php?t=47353 Baker, RA. Traditions of the United States Senate. Retrieved from http://www. senate.gov/reference/resources/pdf/Traditions.pdf BBC News. (2007, August 6). Olympic crackdown on China’s bad habits. Retrieved from http://news.bbc.co.uk/2/hi/asia-pacific/6927361.stm Bio Behavioral Institute. (2009, February 13). What is obsessive compulsive disorder? Retrieved from http://www.biobehavioralinstitute.com/ viewarticle.php?id=3 Eisenberg, R. L. (2004). The JPS Guide to Jewish Traditions. Philadelphia, PA: The Jewish Publication Society. Retrieved from http://www. myjewishlearning.com/beliefs/Issues/Magic and the Supernatural/Practices and Beliefs/Popular Superstitions.shtml Ephemeral New York. (2011, May 16). New York City’s novel anti-spitting law of 1896. Retrieved from: http://ephemeralnewyork.wordpress.com/tag/ new-york-city-anti-spitting-law/ Gross, T. (2013, March 26). In digestion: Mary Roach explains what happens to the food we eat. Fresh Air. Retrieved from http://www.npr.org/2013/04/ 01/175381702/in-digestion-mary-roach-explains-what-happens-to-the-foodwe-eat Healthbeat. (2013, February 11). Spit test may diagnose mental disorders. Retrieved from http://abclocal.go.com/wls/story?section=news/health&id= 8988958 New American Standard Bible. (1971). The New Testament. Carol Stream, IL: Creation House. Oudhoff, M. J., Bolscher, J. G. M., Nazmi, K., Kalay, H., van’t Hof, W., Amerongen, A. V. N., & Veerman, E. C. I. (2008). Histatins are the major wound-closure stimulating factors in human saliva as identified in a cell culture assay. The Journal of the Federation of American Societies for Experimental Biology, 22(11), 3805–3812. Roach, M. (2013). Gulp: Adventures on the Alimentary Canal. New York, NY: W. W. Norton. Trueman, S. W. T. (2013). Contextualizing mental health nursing encounters in Australian remote Aboriginal communities: Part 2, Client encounters and interviews. Issues in Mental Health Nursing, 34(10), 772–775.
Copyright of Issues in Mental Health Nursing is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
CULTURAL COMPETENCE COLUMN
Cultural Differences in Interpreting Behavior: Staring and Spitting Jacquelyn H. Flaskerud, RN, PhD, FAAN University of California—Los Angeles, School of Nursing, Los Angeles, California, USA
Edited by Jacquelyn H. Flaskerud, RN, PhD, FAAN University of California—Los Angeles, School of Nursing, Los Angeles, California, USA Several times recently I’ve been reminded of the differences in interpretation of behavior across cultures. A relative who was visiting was telling me about how, in his retirement, he mentors inner city kids. He related that among many other things, he was trying to teach them to maintain eye contact. I responded that not all cultures value eye contact; he reacted by saying that to avoid eye contact was an evasive or resistant behavior, or an insecure or inattentive behavior. A column that I edited two months ago by Scott Trueman (Trueman, 2013) focused on providing mental health services to aboriginal Australians. In the context of eye contact, he wrote that many factors determine the amount of appropriate eye contact between nurse and client, including their respective genders and ages, whether sensitive topics are being discussed, and the level of trust/relationship between nurse and client. He went on to say that what is not acceptable is fixed or intrusive eye contact. Trueman provided some techniques or mannerisms that may be employed by the nurse to avoid direct eye contact, such as staring into the distance or at the ground or hands while talking, and occasionally looking at the client. I related this information to my relative, but he insisted that in our culture it was important to maintain eye contact. I had written about this behavior earlier in my career, cautioning psychiatric nurses that direct eye contact might be considered aggressive, confrontational, and hostile by some clients, and rude, immodest, or even dangerous (e.g., “if looks could kill”) by others, particularly if there were age, gender, or ethnic/racial differences between the nurse and client. On the other hand, in some cultures, looking at someone while talking to them might be considered essential to a respectful dialogue. A friend of South Address correspondence to Jacquelyn H. Flaskerud, School of Nursing, University of California, 700 Tiverton Ave, Factor Building, Box 951702, Los Angeles, CA 90095-1702. E-mail: [email protected]
American origin related to me a story about her father driving them to the Grand Canyon when they first came to the US. Intrinsic to his nature was looking at the person he was talking to, which meant that he kept looking backwards at his mother in the rear seat while he drove, putting all of their lives in jeopardy. There are other examples of the necessity of looking at a person when talking to them. When people are hard of hearing, they compensate by lip reading; communication is difficult if they are not looking at you directly. Even those of us who think we have a consistent cultural approach to eye contact will find ourselves making incongruous statements. Consider the authoritarian admonition: “Look at me when I’m talking to you!” compared to the equally authoritative command: “Stop staring!” There are many situations and beliefs that govern how much eye contact is appropriate in any given encounter and to maintain that, in our culture, eye contact is valued is to ignore these many differences. The same observations may be made about physical space— how much space is necessary between two persons when they’re talking? Does that amount of space decrease when people are packed into a subway? Does it differ depending on one’s relationship to the person—family versus friend versus client? Does it differ by culture? Again, Trueman (Trueman, 2013) describes Aboriginal people as tending to stand side-by-side rather than face-to-face when telling a story or relating a narrative. He advises that the same configuration should be undertaken during any psychiatric interview. The nurse should be near, but not too close, so as to not impose on the client’s personal space (Trueman, 2013). There are many other examples of differing interpretations of behavior: stance and body language may denote modesty, respect, or being hip (i.e., current, trendy). The same is true of the use of hands in communication and expression—touching, dramatic gestures, and what various hand signals mean. I’ve traveled to many countries where I was warned in advance that certain uses of hands and fingers mean extremely different things from one culture to another. What really got me started on this whole idea of differing interpretations of behavior was the subject of spitting. Granted, spitting may fit into a different category, one that includes its
908
CULTURAL COMPETENCE
relationship to health and public health. Listening to an interview by Terry Gross on public radio’s Fresh Air (March 26, 2013), I was struck by how cheerfully Mary Roach, the author of Gulp (2013) was talking about spit, a topic that I find generally disgusting. Roach writes about the positive characteristics of saliva and its functions in digestion, demineralization, lubrication, and the like (2013). In her interview with Gross (2013), she spoke of the anti-infective qualities of saliva. She explained that saliva renders viruses non-infective and that in it are proteins called histatins that help wounds heal. In the past, saliva was a home remedy for cuts and scrapes (Gross, 2013). A study by scientists in the Netherlands in 2008 confirmed the antifungal and antibacterial functions of histatins in saliva and found they were relevant to the rapidity of oral wound healing as compared to the slow rate of healing for skin lesions (Oudhoff et al., 2008). Roach (2013) also writes about the negative associations of saliva with bacteria, and traces the history of these beliefs to Hippocrates and Galen. Both believed that saliva and sweat were the body’s way of flushing itself of disease-causing impurities. Before physicians knew about microorganisms as the cause of infections, they would put people in “salivating rooms” to treat their diseases. Roach (2013) equates this practice with the antiquated idea that persists today of going to a sauna or steam room to sweat out toxins. However, cultural views about spitting range widely. In some ways, they mirror views on when eye contact is appropriate and are specific to gender, age, ethnicity/race, a particular situation, and beliefs about the value of spitting. Eisenberg (2004) writes about the popular Jewish superstition of spitting three times (either literally or figuratively by saying, “pooh, pooh, pooh”) in response to something exceptionally evil or good. He relates that Jews perform this ritual in response to seeing, hearing, or learning of something terrible and as a prophylactic measure to prevent such a tragedy from happening or recurring. However, it is also traditional to perform the same ritual in response to something wonderful happening—such as good news or the birth of a beautiful and healthy child—to ward off the evil eye. A similar positive attitude toward spitting is attributed to the Greeks. Roach (2013) describes the Greek practice of spitting on anything they want to protect from the evil eye or bless for good luck, including babies and brides; although most don’t actually spit but say, “Ftou, ftou, ftou.” According to Roach, the Greeks got it from the Roman Catholics whose priests baptized with spittle, and the Roman Catholics got it from the Gospels of Mark and John (Roach, 2013). Eisenberg (2004) agrees that the origin of the Jewish superstition may well have originated from the Christian Bible, which mentions the miraculous power of the spittle of Jesus. And they brought to him one who was deaf, and spoke with difficulty . . . And he took him aside from the multitude, and put his fingers into his ears, and after spitting, touched his tongue with saliva; and looking up to heaven, he sighed, and said to him, Ephphatha, that is, Be opened. And his ears were opened, and the impediment of
909
his tongue was removed, and he began speaking plainly. (Mark 7: 32–35).
In another reference, Jesus spit in the dirt and made clay and put it on the eyes of a blind man, who subsequently could see (New American Standard Bible, 1971). Eisenberg (2004, p. 586) goes on to say that because spitting was eventually viewed as a crude and messy practice, it was replaced by the more refined ritual of simply saying, “pooh, pooh, pooh.” And that brings us to crude, rude, and messy—the more negative, and common, attitudes toward spitting. In the US baseball players spit—many times because they chew tobacco or gum, or out of habit. Teenagers, often boys, spit to look cool, to conform, to show disrespect or contempt for others, or to demonstrate their manliness or toughness when feeling insecure. Boys and men used to spit on their palms before shaking hands to seal a deal. Spitting in our culture seems to be gender-associated, with boys and men behaving this way more often than females. Many people of differing cultures spit for reasons related to their health (or illness). An early association with illness occurred in New York City in 1896 when a law was passed against spitting in public (on sidewalks and in streetcars). Public health officials believed that spitting spread lethal diseases, among them consumption, diphtheria, la grippe, bronchitis, pneumonia and, especially, tuberculosis, a leading cause of death in crowded, dank neighborhoods (Ephemeral New York, 2011). New York became the first US city to outlaw expectorating, and signs went up on public transportation and other popular spitting spots, warning of arrest and a $500 fine. Citizens complained about the law, even those opposed to spitting, saying that it was unenforceable and even dangerous because the health of an individual might suffer from such a restraint (Ephemeral New York, 2011). Again, there was the belief that spitting is a way to rid the body of disease. However, reports are that the anti-spitting law (plus other public health measures) slowed the tuberculosis epidemic in New York measurably. In a much more current incident, the belief in ridding the body of disease through spitting and the continued wide-spread practice of it became a major concern in China as they prepared for the Beijing Olympics in 2008 (BBC, 2007). The Beijing Civilization Office, in an effort to make sure that residents did not spit all over city streets and embarrass the capital city, had volunteers hand out special spit bags and fined offenders (about $33 US); they also launched a slogan campaign urging citizens to be civilized and to behave better (BBC, 2007). The Beijing Civilization Office’s efforts seemed aimed more toward “civilized behavior” than toward curbing the spread of disease. An explanation for the cultural difference in interpreting spitting behavior comes from Roach (2013). She refers to the practice of spitting among the Chinese and clarifies that it is not saliva they are spitting out but phlegm from the lungs and sinuses, with the intent of spitting out disease. Although we might view this behavior as spreading disease and perhaps disgusting, she notes that they spit because they don’t care to use handkerchiefs or
910
J. H. FLASKERUD
tissues; they find our habit of collecting it in tissues held in our hands disgusting and dirty. Point taken. What about mental health and illness? Are there any connections to spitting and mental disorders? Two very different kinds of stories are associated with spitting and mental illness. One account publicizes a new test, the Genecept Assay test, which uses a patient’s saliva to look for genetic biomarkers associated with depression (Healthbeat, 2013). The test can be used for patients with a range of psychiatric conditions, including depression, bipolar disorder, and anxiety disorders. The hope is that this test might help doctors predict which anti-depressants are most likely to work with any given patient (Healthbeat, 2013). The other association of spitting and mental disorder describes spitting as one of the signs or symptoms of a particular disorder. Spitting has been associated with Tourette’s syndrome and with phonic tics. Frequently spitting is associated with obsessive compulsive disorder (OCD). Obsessions are recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress (Bio Behavioral Institute, 2009). Persons with OCD attempt to ignore or suppress such thoughts, impulses, or images, or neutralize them with some other thought or action. Compulsions are repetitive behaviors that the person feels driven to perform in response to the obsessive thoughts (Bio Behavioral Institute, 2009). The behaviors are aimed at preventing or reducing distress or preventing some dreaded event or situation. Compulsions can be divided into two types: ideational or mental, and motor. Ideational compulsions are performed in the mind and are not physically observable. Motor compulsions are urges to perform a certain physical act. Among the motor compulsions are physiological acts, including spitting (Bio Behavioral Institute, 2009). People in the US with OCD who spit describe constant spitting as a compulsive reaction to the obsession that what is being encountered (heard, seen) is so dirty, horrible, nasty, and gross that they have to spit so that it doesn’t become part of them (ADD Forums, 2012). One person wrote about seeing something like an unflushed toilet, or thinking of something bad, and then becoming fearful that he would swallow whatever he saw or thought of. The same thing was true if he heard cursing or read bad words; he would have to spit it out. He got a horrible feeling that it was in his mouth and that it would become part of him if he did not spit it out (ADD Forums, 2012). Again, this behavior seems to be gender related, occurring more frequently in males than females. This reaction has a remarkable similarity to the cultural belief that one can rid the body of disease by spitting and seems to flow naturally from it. Incorporating cultural interpretations of behavior into the symptom pattern of mental illness is very common. All persons, including those with mental disorders, express distress in culturally embedded ways, which differ by region, age, gender, and local conditions and traditions. Spitting
has a long history of association with disease—as a way to cure disease (e.g., in biblical times), a way to rid the body of disease (e.g., as Galen and Hippocrates believed), or as a superstitious rite to prevent disease or evil from occurring (e.g., in Jewish and Greek practices). The association with disease is geographically widespread and appears in association with both physical and mental disorders. Although the practice of spitting seems persistent, our attitudes toward it may be changing slowly over time. According to Traditions of the United States Senate (Baker, no date, p. 17), the Supreme Court Justices of the United States still have spittoons in their chambers, using them today as waste baskets, and the US Senate also has spittoons spread across Senate Chambers, which is considered part of Senate tradition. In conventional practice very few of us spit, and tolerance of spitting in the US, seems to be decreasing. Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
REFERENCES ADD Forums. (2012, December). Anxiety Disorders, OCD, and PTSD. Retrieved from http://www.addforums.com/forums/showthread.php?t=47353 Baker, RA. Traditions of the United States Senate. Retrieved from http://www. senate.gov/reference/resources/pdf/Traditions.pdf BBC News. (2007, August 6). Olympic crackdown on China’s bad habits. Retrieved from http://news.bbc.co.uk/2/hi/asia-pacific/6927361.stm Bio Behavioral Institute. (2009, February 13). What is obsessive compulsive disorder? Retrieved from http://www.biobehavioralinstitute.com/ viewarticle.php?id=3 Eisenberg, R. L. (2004). The JPS Guide to Jewish Traditions. Philadelphia, PA: The Jewish Publication Society. Retrieved from http://www. myjewishlearning.com/beliefs/Issues/Magic and the Supernatural/Practices and Beliefs/Popular Superstitions.shtml Ephemeral New York. (2011, May 16). New York City’s novel anti-spitting law of 1896. Retrieved from: http://ephemeralnewyork.wordpress.com/tag/ new-york-city-anti-spitting-law/ Gross, T. (2013, March 26). In digestion: Mary Roach explains what happens to the food we eat. Fresh Air. Retrieved from http://www.npr.org/2013/04/ 01/175381702/in-digestion-mary-roach-explains-what-happens-to-the-foodwe-eat Healthbeat. (2013, February 11). Spit test may diagnose mental disorders. Retrieved from http://abclocal.go.com/wls/story?section=news/health&id= 8988958 New American Standard Bible. (1971). The New Testament. Carol Stream, IL: Creation House. Oudhoff, M. J., Bolscher, J. G. M., Nazmi, K., Kalay, H., van’t Hof, W., Amerongen, A. V. N., & Veerman, E. C. I. (2008). Histatins are the major wound-closure stimulating factors in human saliva as identified in a cell culture assay. The Journal of the Federation of American Societies for Experimental Biology, 22(11), 3805–3812. Roach, M. (2013). Gulp: Adventures on the Alimentary Canal. New York, NY: W. W. Norton. Trueman, S. W. T. (2013). Contextualizing mental health nursing encounters in Australian remote Aboriginal communities: Part 2, Client encounters and interviews. Issues in Mental Health Nursing, 34(10), 772–775.
Copyright of Issues in Mental Health Nursing is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
