Psychiatry is the branch of medicine that is concerned with the study, prevention, and treatment of mental disorder (aka mental illness and psychopathology). Transcultural psychiatry is an increasingly important specialty of psychiatry that focuses on cultural aspects of mental disorder and psychiatric practice. It has also been referred to as comparative psychiatry, cross-cultural psychiatry and, perhaps most commonly now, cultural psychiatry. Anthropologists, too, have engaged in the study of mental disorder, sometimes referring to their research as psychiatric anthropology but more commonly as ethnopsychiatry.
History
Emil Kraepelin, the founder of modern psychiatry, is also regarded as the first psychiatrist to make cross-cultural comparisons, which he did while working in a mental hospital in 1903-1904 in Java, where he conceived the idea of a comparative psychiatry. In general, however, transcultural psychiatry began with the establishment of mental hospitals in European colonies in the late 19th and early 20th centuries, leading Europeans to encounter and write about symptoms and syndromes that were exotic to them. One of the most important steps in the development of the field was the 1955 creation of a center for transcultural psychiatric research at McGill University in Canada. The center, founded by Eric Wittkower and Jack Fried, began to publish a newsletter that subsequently became the Transcultural Psychiatric Research Review. Anthropologists were regular readers of and contributors to the Review, which was replaced by the journal Transcultural Psychiatry in 1997. Transcultural psychiatry was at the margins of psychiatry for many years and is not quite mainstream even today. The American Psychiatric Association officially recognized it as a specialized field in 1969. In 1971 a Transcultural Section of the World Psychiatric Association was created through the efforts of H. B. M. Murphy, and the Society for the Study of Psychiatry and Culture was founded in 1979. National associations and university centers for transcultural psychiatry have appeared in England, Germany, Italy, China, and Japan in recent decades, attesting to the growing importance of the specialty in this era of globalization.
In the 1920s, American anthropologists began to develop psychological approaches to the study of culture, drawing on psychoanalytic theory in particular, in the “culture and personality” movement that eventually gave rise to psychological anthropology in the 1970s. One of the main issues of the movement, first raised by Ruth Benedict in her 1934 article “Anthropology and the Abnormaland” in her popular book, Patterns of Culture, was the cultural relativity of normal and abnormal behavior. Between 1933 and 1946, Abram Kardiner, a psychoanalyst, collaborated with Ralph Linton, an anthropologist, in a famous and long-standing seminar in New York on applications of psychoanalysis to the study of culture. In the process, Kardiner and Linton developed a psycho-cultural model of society that included the concept of a basic personality structure and encouraged a generation of anthropologists to study topics such as personality structure, the self, identity, ego strength, socialization, and mental disorders in a wide variety of cultures. Another important development, conceived by the Haitian psychiatrist Louis Mars in 1946 and popularized fifteen years later by the anthropologist George Devereaux in Mohave Ethnopsychiatry, was the study of indigenous conceptions of mental disorder, their causes and treatment. Since 1977, the main forum for anthropological studies of mental disorder has been the journal Culture, Medicine and Psychiatry.
There is a long history of engagement and collaboration between psychiatrists and anthropologists in the cross-cultural study of mental disorders, but there are also significant differences between the two disciplines—perhaps even more today than in the past.
Anthropology and Psychiatry
Psychiatry is a branch of medicine, western in origin, and focusing on the biology of disease. The western mind/body dualism is reflected in the division between mental and physical illnesses. American psychiatry employs a Diagnostic and Statistical Manual of Mental Disorders that was developed to identify disorders in western society but is, however, assumed to be a universally applicable or etic system. In response to criticisms from anthropologists and transcultural psychiatrists, an attempt was made to address cultural variation in the latest version, DSM-IV.
Cultural anthropology or ethnology is the scientific and humanistic study of the ways in which people construct a common framework of meaning, discourse, and institutions to guide their lives. Anthropologists seek to understand a society first of all from the perspective of its cultural knowledge, that is, from the emic perspective, and try to avoid imposing concepts that can distort cultural realities. Anthropologists offer a “thick description” of local knowledge that is essential to understanding a group of people, but the emic approach can make it difficult— some say impossible—to compare cultures and test theories. The methodology of anthropology is based largely on participant-observation and interviewing, whereas psychiatry relies on assessment instruments, experiments, epidemiological research, and statistical analysis.
There are obviously several fundamental points of contrast, if not conflict, between the psychiatric and the anthropological approaches-biological vs. cultural, etic vs. emic, universalist vs. relativist, quantitative vs. qualitative—and it remains to be seen if they can be bridged. Psychiatry is, however, becoming an increasingly diverse and international profession, with a growing number of nonwestern practitioners and centers. Some nonwestern practitioners are finding western psychiatry inapplicable, inappropriate, ineffective, or incomplete in their cultural settings and are seeking more culturally sensitive concepts and practices.
Topics and Questions
Transcultural psychiatry investigates a fascinating and important range of often controversial questions, issues, and subjects that can give us unique insights into being human, as well as meeting human needs. One of the most basic questions is how to distinguish normal from abnormal behavior—by a universal standard or according to the norms of a culture? Another issue is the classification of disorders; in particular, is the American DSM adequate for use in all cultures?
One of the first major subjects of research in this field was cross-cultural variations in the rate of mental disorders, which gave rise to numerous epidemiological studies. The rate of disorder among immigrant, minority, and refugee groups has also been examined extensively. Cultural influences on symptoms are another important topic. Depression, for example, is typically experienced as psychological or existential and associated with feelings of guilt and suicidal ideation in western societies, whereas it is more commonly somatized as a physical condition in nonwestern cultures.
A major cross-cultural study on schizophrenia was conducted by the World Health Organization in the 1970s. The main conclusions were that core symptoms of the disease are identifiable cross-culturally, and that there is little cross-cultural variation in the incidence of the disorder. On the other hand, the study determined—perhaps surprisingly—that the outcome of schizophrenia is more favorable in less developed countries than in more developed countries.
Abnormal thoughts, feelings, and behaviors that correspond to mental disorder are probably recognized in most, if not all cultures, but there are many different ways of conceptualizing and explaining them. The largely anthropological study of ethnopsychiatry focuses on folk or indigenous nomenclature and classifications of disorders, recognized symptoms, beliefs about etiology or cause, and expectations about the course of a disorder. Indigenous explanations may include biological or physical factors such as hard work or fright and psychological explanations such as envy or excessive worrying, as well as moral, social and supernatural causes such as infractions of norms, conflicts in social relationships, soul-loss, demonic possession, witchcraft and sorcery. Ethnopsychiatric conceptions provide the framework for the subjective experience of an illness, which should be distinguished from the clinician’s biomedical knowledge of disease.
Another important topic is how mental disorders are treated in nonwestern societies. Are shamans, priests, and traditional healers “folk psychiatrists,” as E. Fuller Torrey suggested in his 1986 Witchdoctors and Psychiatrists? How does traditional healing differ from psychiatry? What do they have in common? How do they compare in efficacy? What can psychiatry learn from traditional healing? In addition, is participation in some cultural practices, customs, and institutions—such as trance and possession, shamanism, and other altered states of consciousness—cathartic, protective, or therapeutic, as many have suggested?
Much of the research in transcultural psychiatry has been primarily theoretical, but more attention is now being paid to clinical applications. Does successful therapy require a shared worldview, as Jerome D. Frank argued in Persuasion and Healing in 1974? If so, then can western psychiatry be effective in nonwestern settings? How much cultural knowledge does one need to know and use to properly diagnose and treat a patient?
Another prominent topic of interest in the field is the so-called Culture-Bound Syndromes: over 186 mental disorders that are believed to be unique to particular cultures. They include susto in Central America, amok in Indonesia, ataque de nervios among Hispanics in the U.S., latah in Malaya, pibloktoq or Arctic hysteria among the Inuit, koro in China, and anorexia nervosa in the U.S. Opinion is divided on whether they are truly unique or whether they are culturally elaborated forms of universal diseases. In any case, they demonstrate that culture can and does significantly shape the appearance of mental disorders, if it does not cause them.
Anthropologists are particularly interested in how communities respond to mental disorder. Does mental disorder carry a stigma in all cultures? How common is ostracism or abuse? Are some cultures more tolerant or supportive than others? How do individuals with mental disorders seek help? To what extent is illness behavior, including mental disorders, a social role that follows a cultural script that has been learned, once a person has been assigned a label? Does a disorder follow a particular course because of the disease process or because of cultural expectations?
Many topics of research in transcultural psychiatry require expertise in psychiatry, but there are at least three subjects where anthropological expertise is more important. Two of the subjects are ethnopsychiatry and traditional healing practices, as discussed above; the third is the ethnographic study of psychiatry itself as a subculture and as a social institution, which was pioneered in 1958 by William Caudill in The Psychiatric Hospital as a Small Society. Anthropologists have also conducted participant-observation studies of a suicide ward and a psychiatric out-patient clinic in the U.S. Roland Littlewood and Maurice Lipsedge explored racism in the practice of psychiatry in Britain in Aliens and Alienists, published in 1997, and in 2000, T. L. Luhrmann offered an ethnographic examination of American psychiatry based on participant-observation in Of Two Minds.
Transcultural psychiatry began as the study of mental disorders in “other” cultures—namely, non-western and often colonial societies—from the perspective of western psychiatry. The fact that the western psychiatrist and the western patient also have a culture was largely ignored, perhaps because it is harder to perceive your own culture than another.
However, western patients and doctors also think and act according to the schemas of their cultures; they learn to feel and express their thoughts and emotions in culturally constituted ways, and these ways of thinking and feeling are often institutionalized, even in science and medicine. Studying the cultural context of mental disorders in all societies can give us new perspectives on mental disorder as well as the culture and practice of psychiatry, possibly leading to a truly global psychiatry.
References:
- Kirmayer, L. J. & Minas, H. (2000). The future of cultural psychiatry: An international perspective. Canadian Journal of Psychiatry, 45, 438-446.
- Kleinman, A. Rethinking psychiatry: From cultural category to personal experience. (1988). New York: Free Press.
- Kleinman, A. & Good, B. (Eds.).(1985). Culture and depression: Studies in the anthropology and cross-cultural psychiatry of affect and disorder. Berkeley: University of California Press.
- Simons, R. C. & Hughes, C. C. (Eds.). (1985). The culture-bound syndromes: Folk illnesses of psychiatric and anthropological interest. Dordrecht: D. Redel Publishing.
- Tseng, W.-S. (2001). Handbook of cultural psychiatry. San Diego, CA: Academic Press.
