The study of culture and mental health is concerned with understanding the relationships of cultural factors to the etiology, assessment, diagnosis, classification, and treatment of psychopathology. Interest in the study of cultural variables is relatively new although the importance of examining and comparing psychopathology across cultures was first acknowledged in 1904 by the father of modern psychiatry, Emil Kraepelin. During the course of a world tour introducing his new psychiatric classification system which distinguished between dementia praecox and the manic-depression psychosis, Kraepelin reported difficulties diagnosing cases among Southeast Asian people and various American Indian tribes. This led him to propose the study of Vergleichende Psychiatrie (comparative psychiatry). He wrote:
The characteristics of a people should find expression in the frequency as well as in the shaping of the manifestations of mental illness in general: so that comparative psychiatry shall make it possible to gain valuable insights into the psyche of nations and shall in turn also be able to contribute to the understanding of pathological psychic processes. (Kraepelin. 1904. p. 9)
Today, numerous subdisciplinary specialties are concerned with cultural aspects of psychopathology (e.g., psychiatric anthropology, transcultural psychiatry, culture and mental health, cultural psychiatry). Marsella (1993) have traced the history of the field from its modern roots in the mid-eighteenth century to contemporary times.
The Growing Popularity of Culture and Mental Health
Ethnocentric and cultural bias in psychiatry and related mental health sciences and professions was fostered, in part, by twentieth-century beliefs that considered non-Western values and lifestyles as inferior, primitive, and unimportant, while Western science and knowledge were considered to be universally valid. However, in the last few decades, this viewpoint changed in response to social, political, and professional dynamics including:
- more international collaborative and comparative studies (e.g., the World Health Organization Pilot Study of Schizophrenia) that demonstrated ethnocultural variations in psychopathology;
- increases in the number of ethnic minority and non- Western psychiatrists and related mental health scientists and professionals;
- disaffection of ethnic minority and non-Western psychiatrists and related mental health professionals with the ethnocentrism and cultural and racial bias of Western psychiatry;
- increases in political and social awareness of the pathological sequalae of racism, sexism, imperialism, colonialism, and other “isms” producing powerlessness, marginalization, and underprivileging among sizable population sectors;
- awareness of the multiple and interactive determinants of psychopathology (e.g., biological, psychological, cultural, sociological, spiritual, environmental); and
- proliferation of scientific and professional communication networks and outlets promoting interest in the topic through societies (e.g., World Federation of Mental Health: Society for the Study of Psychiatry and Culture: World Association for Social Psychiatry), and professional-scientific journals (e.g., Transcultural Psychiatry: Culture, Medicine, and Psychiatry; Culture and Mental Health).
These changes have generated a number of critical questions: Should ethnic and racial minorities and non- Western people be evaluated according to Western (i.e., White, Anglo-Saxon, Protestant, male) standards of normality and abnormality? Should they be tested with culturally insensitive and ideologically based instruments, such as the Minnesota Multiphasic Personality Inventory (MMPI), or the Wechsler Adult Intelligence Scale (WAIS)? Should they be diagnosed according to culturally insensitive and ideologically based classification systems, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD)? Should they be treated with culturally insensitive and ideologically based therapies (e.g., psychoanalysis, cognitive behavior therapy, client-centered therapy)? Should they be treated with psychopharmacological medications that may have a multiplicity of effects, dynamics, and consequences across cultures as Lin. Poland, and Nakasaki (1993) reported in Psychopharmacology and Psychobiology of Ethnicity? These questions have increased the popularity of culture and psychopathology as a subdisciplinary specialty.
Critical Concepts and Issues
Ethnocentrism and the cultural construction of reality are key issues.
The fundamental assumption underlying the study of culture and psychopathology is ethnocentrism and cultural bias. The term ethnocentrism refers to the “natural tendency or inclination” among people everywhere to view reality from their own cultural experience and perspective. In the course of doing so, the traditions, behaviors, and practices of people from other cultures are often considered inferior, strange, abnormal, and/or deviant. Obviously, when a decision must be made regarding a person’s sanity and treatment, ethnocentrism can have destructive consequences.
Most of our basic conceptual, methodological, and professional assumptions and practices regarding mental health are derived and validated within the historical and cultural contexts of northern European and North American societies. As such, they are ethnocentric and culturally biased. They are rooted within ideological worldviews that favor individualistic, materialistic, democratic, and scientific perspectives. As a result, the essential concepts of personhood, normality and abnormality, illness and health, consciousness, and personal choice and responsibility that guide Western psychological and psychiatric thought and practice bear little relevance and/or applicability to people from non- Western cultures and traditions.
This fact has been well known for many years but has only recently become a major concern for both Western and non-Western people. For example, a quarter century ago, Clifford Geertz, an American cultural anthropologist, wrote (The Interpretation of Culture, New York, 1973):
The Western conception of the person as a bounded, unique, more or less integrated motivational and cognitive universe, a dynamic center of awareness, emotion, judgment, and action, organized into a distinctive whole and set contrastively – both against other such wholes and against social and natural background-is, however incorrigible it may seem to us, a rather peculiar idea within the context of the world’s cultures. (P. 34)
More recently, Ajita Chakraborty (Lancet, 19, 337), an Indian psychiatrist, wrote:
Even where studies were sensitive, and the aim was to show relative differences caused by culture, the ideas and tools were still derived from a circumscribed area of European thought. . . . Research is constrained by this view of psychiatry. . . . Psychiatrists in the developing world . . . have accepted a diagnostic framework developed by western medicine, but which does not seem to take into account the diversity of behavioral patterns they encounter. (p. 1204)
Cultural Construction of Reality
But, most important, Western psychiatrists and mental health scientists and professionals are beginning to accept the view that culture constitutes the context in which our different worldviews are shaped and differentiated (i.e., the cultural construction of reality). Marsella noted (1982) that since our realities are culturally constructed, how can we expect universality in psychopathology? Marsella wrote:
We cannot separate our experience of an event from our sensory and linguistic mediation of it. If these differ, so must the experience differ across cultures. If we define who we are in different ways (i.e., self as object), if we process reality in different ways (i.e., self as process), if we define the very nature of what is real, and what is acceptable, and even what is right and wrong, how can we then expect similarities in something as complex as madness. (p. 363)
This new awareness of the importance of culture helped encourage the American Psychiatric Association to include an entire section on culture-specific disorders in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); American Psychiatric Association, 1994). Indeed, some psychiatrists are now proposing a new diagnostic axis for ethnocultural factors for the fifth edition of the DSM.
Key Questions in the Study of Culture and Psychopathology
The study of culture and psychopathology is concerned with the following key questions:
- What is the role of cultural variables in the etiology of psychopathology? How do cultural variables interact with biological, psychological, and environmental variables to influence psychopathology?
- What are the cultural variations in standards of normality and abnormality?
- What are the cultural variations in the classification and diagnosis of psychopathology?
- What are the cultural variations in the rates and distribution of psychopathology according to both indigenous and Western categories of psychopathology?
- What are the cultural variations in the phenomenological experience, manifestation, course, and outcome of psychopathology?
- Are all psychiatric disorders culture bound?
Some Critical Issues and Research Findings
The roles of biology and culture in psychopathology, cultural concepts of illness, equivalence in clinical assessment, and epidemiology are the main areas under discussion.
Biology and Culture in Psychopathology
The greatest ethnocultural variation is in normal behavior because this is where learning and acquired experience exercise their greatest influence. As we begin to enter the realm of severe psychopathology and biological factors also come to play an influential role, the ethnocultural variation will diminish but will still not be absent. Thus, normal behavior, though obviously a function of biological substrates, has the widest latitude of variability across cultures. As the nervous system becomes more directly implicated, as is the case in neurological diseases, cultural variability decreases. However, even in the most severe neurological diseases or disorders, cultural influences still occur since the individual’s interpretation and experience of the disorder, its behavioral referents, and the social response to these referents is influenced by culture.
Concepts of Illness and Disease
In a survey of concepts of health and illness across cultures, Murdock (1980) identified Western and non-Western views of disease causality. He reported that Western scientific views were based on naturalistic views of disease causation including infection, stress, organic deterioration, accidents, and acts of overt human aggression. In contrast, many non-Western societies believe in disease causation models based on supernatural causes (i.e., any disease which accounts for impairment of health as a consequence of some intangible force) including (I) theories of mystical causation because of impersonal forces such as fate, ominous sensations, contagion, mystical retribution: ( 2 ) theories of animistic causation because of personalized forces such as soul loss and spirit aggression: and ( 3 ) theories of magical causation or actions of evil forces including sorcery and witchcraft. Although a patient’s conception of the causes of their disorder is critical for treatment because it implicates cooperation and treatment compliance, non-Western notions of disease causality are seldom used by professionals.
Equivalence in Clinical Assessment
If cross-cultural studies are to be valid, there must be linguistic, conceptual, scale, and normative equivalency of the instruments. This means the instruments will not be biased against certain populations because of their cultural differences. Clearly, the use of Western diagnostic instruments and clinical assessment methods (e.g., interviews) in which the language, content, scales, norms, and expectations are based on Western culture constitutes a serious validity problem for both research and clinical practice.
The distribution of disorders is referred to as epidemiology Typically, the emphasis is on identifying the number of people who have a particular disorder at a specific point (i.e., prevalence) and/or the number of people who are likely to develop a disorder in a given time period (i.e., incidence). Cross-cultural psychiatric epidemiological studies have been reviewed for many disorders including posttraumatic stress disorder (PTSD) (e.g., DeGirolamo & MacFarlane, 1996), depression and anxiety disorders (e.g., Kleinman & Good, 1986), and schizophrenia (e.g., Marsella et al., in press). However, major problems in case definition and identification, cultural bias in diagnosis and classification, and lack of familiarity with the population make it difficult to compare findings. Future cross-cultural epidemiological studies should (1) use relevant ethnographic and anthropological data in designing a study, especially in determining what constitutes a symptom or category: (2) develop glossaries of terms and definitions for symptoms and categories: (3) derive symptom patterns and clusters using multivariate techniques rather than relying on a priori clinical categories; (4) use similar or comparable case identification and validation methods: (5) use culturally appropriate measurement methods which include a broad range of indigenous symptoms and signs that can be reliably assessed: and (6) establish frequency, severity, and duration baselines for indigenous and medical symptoms in both normal and pathological populations.
Research Strategies for Studying Culture and Symptomatology Relationships
One of the most important research areas in culture and psychopathology is the study of symptomatology differences across cultures. Marsella (1982) recommended a variety of research strategies for this task including (1) matched diagnosis studies (i.e., comparing patients from different cultures with similar diagnoses): (2) matched sample studies (i.e., comparing patients from different cultures who are similar in age, social class, religion, etc.); (3) international surveys (i.e., profiling symptoms across large samples from many different countries): (4) culture-bound disorder studies (i.e., investigating culture-bound patterns of disorder such as Zatah, koro, susto, mali-mali, shinkeishitsu, amok); and (5) multivariate studies (i.e., generating symptom clusters based on statistical analyses rather than clinical perceptions and experiences).
Regardless of the research strategies that have been used to study the expression of psychiatric disorders across cultures, results have consistently indicated variations in the experience, manifestation, and prognosis of psychiatric disorders across cultures.
Ethnocultural Parameters of Psychopathology
Research findings have revealed that there are ethnocultural variations across many parameters of psychopathology including perceptions of the causes, nature, onset patterns, symptom expression, disability levels, idioms of distress, course, and outcome. This has been true for even the most severe forms of psychopathology including depressive disorders (e.g., Kleinman & Good, 1986). PTSD (e.g., Marsella, Friedman, Gerrity, & Scurfield, 1996), and schizophrenic disorders (e.g., Marsella et al., in press).
Ethnocultural variations in basic symptom patterns of depressive disorders are evident, including a relative absence of guilt, suicidal tendencies, withdrawal, and negative self-image. Although extreme sadness and grief are present in non-Western cultures, the situations that elicit them, their perceived meaning and implications, their expressions, and the social response to them often varies. Sometimes the distress is expressed in somatic symptoms rather than existential and/or cognitive-symbolic complaints since the latter modes of expression may be alien to non-Western experience.
In the case of schizophrenic disorders, often considered to be the most universal of the psychoses in expression and clinical parameters, research conducted by the World Health organization (WHO): Jablensky et al., 1992) reports some similarities in core symptoms, but also considerable variations in secondary symptoms, the course and outcome of the disorders, and the rates of the disorders. Marsella et al. (in press) identified a number of ethnocultural determinants of schizophrenic disorders.
Posttraumatic Stress Disorder (PTSD)
In a review of the cross-cultural studies on PTSD, Marsella, Friedman, Gerrity, and Scurfield (1996) concluded that while there appears to be a universal biological response to extreme stressors and traumas (e.g., arousal of the hypothalamic-pituitary adrenal axis with associated biological and psychological changes) and elicitation of the general adaptation syndrome (GAS: i.e., arousal, resistance. and exhaustion), there are considerable cultural variations in the perceptions of a traumatic event and in the expressions and experience of the disorder.
PTSD can be diagnosed across cultures, but only if considerable care is taken to contextualize the problem within the cultural milieu of the patient. One reason for this is that many ethnic minority and non-Western people have been exposed to multiple traumas as a result of daily life problems (e.g., poverty, exposure to crime, violence, natural disasters) and collective group traumas (e.g.. wars). These problems are often exacerbated because of the absence of mental health services. It has been suggested that the term complex: PTSD may be a more appropriate diagnostic term across cultures because of its inclusion of multiple traumas and dissociative and somatization symptoms.
Cultures as Causative of Psychiatric Disorders
It is important to recognize that cultural factors may play an important role in causing psychiatric disorders. This can occur via a number of mechanisms including the following:
Culture can be a source of stress by confronting individuals and/or groups with environmental demands that exceed their ability to cope. A typical example of this is the rapid social change that characterizes contemporary life and the serious problems associated with urbanization and urban lifestyles. Other culture-related stressors include institutional racism, cultural disintegration, cultural dislocation, cultural abuse, and industrial developments that introduce toxins and environmental pollution. The massive social changes accompanying technical and industrial development can be both sources of stress and sources of positive change (Desjarlais, Eisenberg, Good, & Kleinman, 1995).
2. Normality and Abnormality.
Culture determines the standards for normality and abnormality. Problems in defining the limits in these areas can lead to serious problems regarding deviancy and conformity. The main issue here is the balance between tolerance and suppression. There can be no doubt that certain cultures insist on absolute conformity while others permit acceptable levels of deviancy One of the continuing challenges facing the study of culture and psychopathology is the identification of “universal” normal and abnormal behaviors, as well as culture-specific normal and abnormal behaviors (Ackerknecht, 1942).
3. Coping and Resources.
Culture determines rates of certain disorders such as depressive dysfunctions by posing certain stressors and limiting certain supportive mechanisms. For example, politically repressive cultures may limit individual or group choice and may punish certain behaviors resulting in learned helplessness. Further, certain cultures may have few or ineffective coping resources to mediate stress ( e g , religious beliefs, social support networks, personal predispositions).
The causal relationships between culture and psychopathology are far more complex than can be discussed in the present entry. However, the prior examples help demonstrate the many impacts that culture can have upon mental disorders by virtue of the stressors it fosters, the resources it offers, and the particular concepts of personhood, normality, and social process it socializes.
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- Marsella, A. J., Suarez, E., Leland, T., Morse, H., Scheuer, A., & Digman, B. (in press). Cross-cultural studies of schizophrenia: Issues, research, and directions. British Journal of Psychiatry.
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