Ethical aspects of mental health 31.10.2011
MARJA TIILIKAINEN
PhD, Postdoctoral Researcher
University of Helsinki
Cultural views of mental distress: examples on Somali migrants
In this presentation, first, I will briefly refer to some of the discussions and notions related to culture
and mental illness that have been done in the field of medical anthropology and transcultural
psychiatry. Second, I would like give some examples on the topic from my own research on Somali
migrants. Third, I aim to raise a few ethical questions in particular related to migrants and mental
health.
Cross-national epidemiologic research has shown that mental diseases such as schizophrenia, major
depression and anxiety disorders exist worldwide and in all cultures. What differs, however, are
cultural expressions for mental distress as well as cultural explanations and meanings given to
symptoms or emotions. Hence, also the understanding on proper treatment for mental distress varies
across cultures. I will come back to this later through the empirical Somali data.
In psychology and psychiatry, culture is often connected to migrant patients that are seen to be
culturally somehow different from ordinary patients. Culture has often been understood in a static
way to emphasize basic and lasting differences between migrant patients and mental health
professionals in the mental health field. Researchers, however, have also reminded that apart from
culture also other factors such as power structures, class, gender and race have to be recognized and
considered in multi-cultural mental health encounters. Furthermore, the concept of culture is
increasingly understood as something ever-changing, hybrid and flexible.
The role of culture is also present in the recognition of so called culture-bound syndromes. Culturebound symptoms or syndromes refer to well-known categorizations of disease in a certain cultural
area. They are localized categories that frame coherent meanings for certain repetitive, patterned,
and troubling sets of experiences. DSM-IV (Diagnostic and Statistical Manual of Mental Disorders)
classifies several culture-bound syndromes, for example susto in Latin America and arctic hysteria
among Eskimo populations. Culture-specific terms can be understood us “idioms of distress” and as
meaningful, culturally relevant inter-personal communication.
Medical anthropologists have maintained that psychiatry itself is a cultural institution which is
based on certain cultural assumptions on, for example, individual and autonomous self. For example
Anna-Maria Viljanen who has researched Roma people in Finland has said that dependency
between family members, for example in the Roma culture natural closeness between a grown-up
daughter and a mother, may be seen as pathological from outside.
This leads to a key question on what is seen as normal or abnormal. We can say that biomedicine
and Western psychiatry are defining the “normal”. Moreover, behavior gets its meaning from the
social and cultural context in which it is done. For example, a typical Finn who is silent and socially
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reserved is seen as abnormal and strange in Southern Europe or Africa, whereas an African child in
Finland who is energetic and lively may easily gain an ADHD diagnosis or a status as a child who
needs special care and guidance. Moreover, research from the UK has shown that black people, for
example, Afro-Caribbeans more easily than the White patients are given psychosis diagnosis. The
high rate of psychosis among the Afro-Caribbeans in the UK has partly been explained by a
tendency of Western psychiatry to pathologize ethnic and racial minorities.
One of the widely used concepts is Post-traumatic stress disorder (PTSD) which has its origins in
the experiences of the Vietnam war veterans. Since then, PTSD diagnosis has been commonly used
to frame experiences of people in war as well as experiences of refugees. Derek Summerfield is one
of the researchers who has strongly criticized the focus on PTSD, for example by international
organizations in complex post-war situations like in Ruanda, for medicalization of social suffering
and for trying to transform the social into the biological. Medicalization takes place not only in
relation to social suffering, but also to other dimensions of refugee and migrant lives that used to be
part of normal life cycle; for example, migrant women may not consider menopause as a medical
condition which requires hormonal treatment.
In many cultures, disturbances in mood, anxiety or emotional problems are not viewed as mental
health problems, but as social or moral problems that are to be solved by a family member, elder,
religious leader or a traditional healer. Moreover, in most societies mental disease is stigma and to
become labeled as mentally ill is to be avoided – hence, treatment and medication of mental disease
may also be rejected. It has been argued that somatization of mental distress would be particularly
common among Asians, Africans and other “non-Western” populations (e.g. Arthur Kleinman).
However, for example Laurence Kirmayer has shown that somatization of mental distress is
common in all population groups. Pain and fatigue are the most common somatic symptoms of
depression and anxiety.
Next, I move to experiences of Somali migrants, especially those who return to Somalia to search
for treatment for mental distress.
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