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How culture bound is 'cultural' psychiatry?

Dr Sushrut Jadhav
MBBS, MD, PhD, MRCPsych.,
Senior Lecturer in Cross-cultural Psychiatry
Centre for Behavioural & Social Sciences as applied to Medicine
University College London, W1N 8AA
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'Cultural Psychiatry' as a clinical speciality sprung mainly from Europe and North America, in order to respond to growing concerns of ethnic minorities in high income countries. Academic psychiatrists pursuing the comparative question in international mental health, together with clinical ethnographies conducted by medical anthropologists contributed to its theoretical basis (Kleinman, A 1987; Littlewood, R 1990). What at first appeared to be a marginal speciality is no longer so. For example, the UK alone had witnessed a steady growth: its mandatory inclusion in mental health training curricula, several taught Masters courses, academic positions in universities, three dedicated journals; and more recently, lead papers in mainstream publications that debate the cultural position of the ‘biological’ itself (Timimi & Taylor, 2004). Additionally, with a proliferation of clinical jobs for 'ethnic minority' services in Hospital Trusts across the country, there is ample scope for employment. The overall evidence indicates that ‘Cultural Psychiatry’ in the UK is now a speciality in its own right.

Stated provocatively, with a few exceptions (see Anthropology & Medicine, special issue, 2001), the discipline remains confined to the cultural boundaries of Euro-American countries, and predominantly serves the career and social interest of their scholars. In most low-income countries, the ‘speciality’ and its methods are ironically labelled as Cultural Psychiatry (rather than just plain standard local psychiatry). More over, scant teaching and research output from the latter countries is related to a more worrying scenario: psychiatry in low income nations continues for the most part to rely on inappropriate text(s), teaching and research designs imported from high income countries. The magnitude and relative ease with which ‘outsourced’ mental health professionals from low-income nations function effectively in Britain is testimony to their psychiatric training, which in turn is predicated upon received wisdom from high-income countries.

Consider for example, India: a nation of 1.4 billion people, that has produced Booker Prize winners but not yet a singular text(book) of psychiatry which is genuinely predicated on local psychology and social problems. The latter would include social suffering related to dowry, caste, marital and ethnic violence, corruption, kinship systems, famine and crop failures, and suicide. In such settings, phenomenologies of rich bodily experiences are commonly pushed into a black box of 'somatisation'. Further more, these ‘somatic’ experiences are edited and recorded in English language by local mental health professionals on (Maudsley derived) 'Mental State Examination' proformas as +++! In this situation, local worlds, their core moral and cultural values, and a rich vocabulary associated with bodily problems and expressed through a range of non-English languages (Lynch, 1990), are often glossed over or pruned to fit into conventional psychiatric nosology (ICD-10 and DSM-IV). This process of systematically acquiring a culture-blind ability is considered credible and meritorious, both locally and internationally. The exclusion of culture then systematically abolishes the ability (and sensibility) to consider the role of major social and cultural 'variables' that may well provide a phenomenological template and local forms of psychopathology to shape appropriate nosologies of distress (Kirmayer & Young, 1998). Ironically, these are precisely the very issues cited by the international community as relevant for the health and economic development of poorer nations.
To proceed further entails the following:
1) A study of lived experiences of everyday suffering and recourse to help, through local narratives and language that would identify key constructs and examine the cultural logic of constructing illness experience in both Western and non-western settings. The ‘semantic illness network’ is one such approach that revealed local distress models for the Punjabi community in Britain (Krause, 1989) and Shiite Muslims from Iran (Good et al, 1985).
2) Such local models would generate popular and locally meaningful patterns of distress to validate local experience on its own terms. These could then be operationalised and validated against western phenomenology and psychopathology for congruence or goodness of fit in form, content and quality. It is likely that some patterns of distress may not fit with western descriptions of psychopathology and disorders, and may therefore need separate and distinct class category representation. Examples of these are the Japanese concept of taijin kyofusho in the official Japanese diagnostic system for mental disorders; the qi-gong (excess of vital energy) psychotic reaction and shenjing shuairuo (neurasthenia) as represented within the Chinese Classification of Mental Disorders. Alternatively, some patterns (mainly the psychoses) may well reveal common universals (but not necessarily the same configuration) that would further enrich the debate on cultural validity.
3) Development of instruments, both quantitative and qualitative, that would measure such distress patterns and contributes towards the development of higher order categories or syndromes. Only then can such ‘categories’ be comparable with western psychiatric concepts for cross cultural equivalence and validity. For example, a study of ‘life events’ contributing to mental health problems would require at first a full picture of what a ‘life event’ means to the population under study. What is their relative perceived threat to marriage, kinship ties and integrity of the community on the one hand versus economic risks or unemployment on the other? Should a life event questionnaire not be re-calibrated by local members of the population who might chose to re-arrange the hierarchy of events? Similarly, how healthy rather than pathological are ‘expressed emotions’ such as ‘over-involvement’ in societies where extended kinship ties are valued and energetically pursued? Over-involvement in this context might well be the very ‘glue’ that bonds families with sick members together.

Cultural validity apart, there is an additional reason that merits such an enquiry: mental health professionals, particularly from low-income nations have often expressed surprise at the manner in which scholarly discourses on cultural psychiatry and medical anthropology remain confined to academic institutions of high-income countries with little impact on changes in everyday clinical practice in their own settings. It is in this context that anthropologically informed methods of enquiry have potential to help establish clearer links between personal suffering and local politico-economic ideologies. Such methods can generate alternative cannons of culturally valid psychiatric theory and practice and contextualise them in both time and space. Although ambitious in its aims, research that will critique western psychiatric theory and practice, and reveal its ethnopsychiatric premise, also broadens the debate on cultural validity of psychiatric disorders in general (Jadhav, 1995). Moreover, this process could lead to local interest into indigenous taxonomies and provide a meaningful framework within which both professionals and patients from low-income countries could reclaim their local cultural and political histories. Such a framework would also inform the development of a valid ‘text’: one that is indigenously grounded and offers a concrete solution to free this speciality from its current Euro-American confines. Until then, the debt of uncritically importing an epistemology will continue to mount and worsen existing psychiatric alienation from local suffering.

References
1. Anthropology & Medicine journal (2001): Special issue on Cultural Epidemiology. 8, 1, April.
2. Good, B; Good M & Moradi, R (1985): The Interpretation of Iranian Depressive Illness and Dysphoric Affect. Pages 369-428. Chapter in 'Culture and Depression': Studies in the Anthropology and Cross-cultural Psychiatry of Affect and Disorder. Edited by Kleinman, A & Good, B (1985), University of California Press.
3. Jadhav, S (1995): The Cultural Origins of Western Depression. Special issue on cultural validity of psychiatric diagnosis. International Journal of Social Psychiatry, 42, 269-286.
4. Kirmayer, L & Young, A (1998): Culture and Somatization: Clinical, epidemiological and ethnographic perspectives. Psychosomatic Medicine, 60: 420-430.
5. Kleinman, A (1987): Anthropology & Psychiatry: the role of culture in cross-cultural research on illness. British Journal of Psychiatry, 151: 447-454
6. Krause, I (1989): Sinking Heart: a Punjabi communication of distress. Social Science and Medicine, 29: 563-575.
7. Littlewood, R (1990): From categories to contexts: a decade of the "new cross-cultural psychiatry". British Journal of Psychiatry, 156: 308-327.
8. Lynch, O (ed.) (1990): Divine Passions. The Social Construction of Emotion in India. University of California Press.
9. Timimi, S & Taylor, E (2004): ADHD is best understood as a cultural construct. British Journal of Psychiatry, 184: 8-9.

Acknowledgements: This article was first published in the Bulletin of International Psychiatry of the Royal College of Psychiatrists, London, UK, April 2004. Indianpsychiatry.com would like to thank the college for permitting Dr Jadhav to reproduce the article here.

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