The Journal of Nervous & Mental Disease
(C) 1999 Lippincott Williams & Wilkins, Inc.
---------------------------------------------Volume 187(8)
August 1999
----------------------------------------------
pp 465-471
Clinical Relevance of Contemporary Cultural Psychiatry
ALARCON, RENATO D. M.D., M.P.H.1; WESTERMEYER, JOSEPH M.D., Ph.D.2;
FOULKS, EDWARD F. M.D., Ph.D.3; RUIZ, PEDRO M.D.4
1 Department of Psychiatry and Behavioral Sciences, Emory University
School of Medicine
2 Department of Psychiatry, University of Minnesota Medical School,
Minneapolis, Minnesota.
3 Department of Psychiatry, Tulane University Medical School, New
Orleans, Louisiana.
4 Department of Psychiatry, University of Texas Health Science Center,
Houston, Texas.
---------------------------------------------Abstract
In recent years, the field of cultural psychiatry has gained
recognition and accumulated evidence of its clinical relevance. This
article examines the intersections of culture and psychopathology and
describes five independent but interrelated clinical dimensions that
identify and define culture as: a) an interpretive/explanatory tool, b)
a pathogenic/pathoplastic agent, c) a diagnostic/nosological factor, d)
a therapeutic/protective element, and e) a service/management
instrument. Along these lines, conceptual boundaries, clinical
findings, specific applications, and research implications for each of
the five dimensions are systematically reviewed. Cultural psychiatry
adds significantly to the comprehensiveness of psychiatric evaluation
and management and addresses prominent issues regarding understanding,
classification, diagnosis, and competent treatment of most psychiatric
disorders in every society and region of the world. Based on the
strength of these clinical dimensions, and on the related educational
and research efforts, cultural psychiatry can also contribute
decisively to the design of comprehensive mental health policies.
---------------------------------------------Culture is defined as a set of meanings, behavioral norms, and values
that determine the unique view of human groups and societies about the
world and about themselves. Culture also influences the development of
personality and individual behavioral styles through parental
attitudes, child-rearing methods, and through the use and transmission
of language (Favazza and Oman, 1978). Cultural psychiatry, in turn,
addresses the definition, description, evaluation, and management of
psychiatric conditions, as they are a reflection of cultural factors
within a biopsychosocial context (Alarcon and Ruiz, 1995). The
interactions between culture and psychopathology from a strictly
clinical perspective have not been examined systematically for almost
two decades (Beiser, 1985; Favazza and Oman, 1978). Although not free
of polemics and controversy, clinical and research evidence accumulated
throughout the same period leads to the description of five dimensions
that redefine the contemporary clinical roles of culture as: a) an
interpretative and explanatory tool, b) a pathogenic and pathoplastic
agent, c) a diagnostic and nosological factor, d) a protective and
therapeutic element, and e) a resource in the structuring and
management of clinical services. This article will explore each of
these areas by critically surveying contributions from the recent
literature.
Culture as an Interpretive and Explanatory Tool
The interpretive and explanatory role of culture emphasizes the
nonpathological nature of human behavior, thus helping the clinician
understand or "decode" observed behaviors through the use of cultural
parameters such as religious beliefs, conceptions of illness, or modes
of emotional expression. Most clinicians have occasionally labeled as
pathological behavioral expressions that have proved to be
nonpathological in the context of the affected individual's culture.
For example, in some churches or religions, group-induced hallucinatory
experiences constitute regular components of their rituals (Griffith
and Young, 1988). Likewise, the rudimentary discourse of recently
arrived immigrants could sound incoherent or "tangential" and, when
complicated by anxiety, resemble an incipient psychotic process.
On the other hand, the cultural meaning of somatic symptoms as
expressions of emotional discomfort is often ignored. This has been
observed in ethnic groups such as Hispanics in the United States (Koss,
1990), Mediterranean communities, (Fava et al., 1983), and Chinese
citizens during the Cultural Revolution (Kleinman and Good, 1985). From
a different perspective, attitudes toward illness and death are quite
distinguishable among certain ethnic groups such as American and Asian
patients. American patients view them as life disruptions inflicted
upon them, whereas Asian patients experience illness and death as part
of the normal cycle of life (Nilchaikovit et al., 1993). Similarly,
Cheung (1981) concluded that neurasthenia among the Chinese is an
instrument of destigmatization of psychiatric disorders: as psychiatric
disorders in China are often reduced to psychoses, and neurasthenia is
not a psychosis, it can then be considered a culturally determined (and
acceptable) expression of distress, and not a severe mental disorder.
Hysteria, dissociation, and personality disorders are among the
diagnostic labels most frequently misused (Alarcon, 1996; Young, 1995).
For instance, many clinicians have diagnosed dependent personality
disorders in Asian or Asian-American individuals whose culture
advocates submissiveness to authority and adherence to what Westerners
would consider rigid hierarchical and interpersonal norms; or
histrionic personality disorders, in individuals of Latin or
Mediterranean origin who exhibit loud expressiveness and whose culture
accepts apparent violations of privacy (Fava et al., 1983); and
paranoid personality disorders in former political prisoners or members
of racial minorities who have suffered intense experiences of
persecution and discrimination (Grier and Cobbs, 1968).
The interpretive and explanatory functions of cultural psychiatry
foster a rational approach to human behavior by postulating that
manifestations such as those of the so-called "sick role" are shaped by
cultural factors. As such, the cultural approach acknowledges private
experience and public display, distinguishes self-control from
fatalism, and separates social meaning from actual symptomatology.
Its use could prevent not only diagnostic but also treatment and
prognostic errors.
Culture as a Pathogenic and Pathoplastic Agent
Culture can operate as a pathogenic agent and also be a pathoplastic
modulator of clinical symptoms. Some child-rearing practices can
decisively contribute to the occurrence of psychopathology. Neglect of
the newborn, violence within the family, and the transmission of
unrealistic expectations may generate predispositions among children
that could lead to symptoms during adult life. Societal influences can
also trigger clinical symptoms such as misdirected aggressive
tendencies in children and adolescents as a result of premature
exposure to violence through the media (Lewis, 1992). Posttraumatic
stress disorder is determined by disturbances of the political or
social order such as war (Freedy and Hobfoll, 1995). Expressed emotions
by relatives of schizophrenics could be an important determinant of
relapse and readmission (Leff and Vaughn, 1985).
Regarding the pathoplastic role of culture, Ackernecht (1983) has
discussed how the religious delusions frequently seen in the past have
been replaced by technological ones and how gender differences in
delusional context have disappeared. Other authors have also postulated
that clinical patterns usually ascribed to culture bound syndromes are
applicable to clinical conditions originated in the West such as
anorexia nervosa (Iancu et al., 1994; Littlewood and Lipsedge, 1987).
Several studies have demonstrated that the perception of illness is
intimately influenced by culturally determined beliefs, i.e., for
Italians symptoms may represent opportunities for expressiveness and
overdramatization, whereas Irishmen deny them because they depict a
life characterized by "long periods of plodding routine followed by
episodes of wild adventure" (Zola, 1966).
Among Mexican-Americans, folk diseases may help resolve interpersonal
conflicts, but value conflicts may also precipitate conditions such as
"susto" and "espanto," two forms of "fright sickness" (Rueschenberg
and Buriel, 1995). Similarly, the Buddhist background of exiled Burmese
immigrants in Australia enforces tolerance toward deviance,
nonconformity, and failure; this, however, worsens the ensuing
depression, guilt feelings, and persecutory delusions (present during
the acculturation phase) that portend abandonment and represent
punishment, according to the tenets of the old culture (Way, 1985).
Culture as a Diagnostic and Nosological Factor
The relationship between culture and psychiatric diagnosis has recently
been the subject of intensive studies. One of the main points of
contention in this area is the commission of a category fallacy that
pigeonholes clinical entities or behaviors inherent to some cultures or
societies within the diagnostic terms of DSM-IV (Kleinman, 1996). The
fourth edition of Diagnostic and Statistical Manual (DSM-IV) has
included a cultural formulation and a glossary of culture bound
syndromes that, at least in part, acknowledge the difficulties of
locating these cultural syndromes and characteristics in the
conventional nosology and realize the nonpathological nature of some of
them, as well as the value of their local explanations (Mezzich, 1995).
Another diagnostic domain with strong cultural implications is that of
the translation, adaptation, and cultural validity of assessment tools.
Throughout the 1980s, the development of instruments for cross-cultural
psychiatric research underwent both theoretical and practical
improvements. Different components of questionnaires and scales appear
to be a function of cultural differences between different ethnic
groups (Westermeyer and Sines, 1979). Flaherty et al. (1988) recognized
that cultural freedom (universality) of instruments is the exception
more than the rule, and postulated a stepwise validation of selected
instruments with five measured dimensions of cross-cultural
equivalence: content (relevant to the phenomena of each culture),
semantic (similar meaning of individual items), technical (comparable
assessment in each culture), criterion (interpretation remains the same
when compared with the norm), and conceptual (measuring the same
theoretical construct in each culture).
Conceptually equivalent versions of depression and diagnostic
instruments among different ethnic groups should establish pertinent
symptoms, semantic integrity, clinical consistency, and comparability
with Western concepts (Bravo et al., 1993). In this context, Kinzie and
Manson's (1987) review of the use of self-rating scales in crosscultural psychiatry included studies of the MMPI, Zung, Symptom Check
List-90 (SCL-90), Cornell Medical Index, Center for Epidemiological
Studies-Depression Scale (CES-D), Health Opinion Survey, and
Langner 22-item Symptom Inventory. These authors pointed out that no
truly etic (externally validated) self-reported measures exist because
all of these tests are ultimately based on the respondents' subjective
sense of distress, which is a function of culture and language and
requires an emic (from within) perspective. Additionally, self-rating
scales have limitations in terms of language translation. Although a
number of conventional instruments have been validated in a variety of
clinical and nonclinical populations, particularly for the assessment
of depression (Kaiser et al., 1998), the only one developed from the
outset to be fair across genders, age, and ethnic groups is the CES-D;
yet, in one study it yielded only a modest diagnostic correlation with
the Schedule for Affective Disorders and Schizophrenia (SADS;
Guarnaccia et al., 1989).
As a result of this new awareness, instruments such as the Explanatory
Model Interview Catalogue (EMIC) have been developed in order to elicit
psychiatric illness-related perceptions, beliefs, and practices in
intercultural studies, based on explanatory models of psychiatric
illness and the emic/etic dichotomy (Weiss et al., 1992). The most
important assets of these instruments are the measurement of the
cultural context of perceived causes of psychiatric disorders, the
generation of a database of explanatory models that specify
cultural norms and intercultural diversity, the testing of hypotheses
which relate anthropological data to illnesses, behaviors, clinical
outcomes, and the facilitation of cross-cultural comparisons. Along
these lines, structured instruments such as the Diagnostic Interview
Schedule (DIS) have been used for case ascertainment by the NIMHsponsored Epidemiological Catchment Area (ECA) survey, and the Taiwan
Psychiatric Epidemiological project (Compton et al., 1991). DIS was a
precursor of the Composite International Diagnostic Interview (CIDI;
Robins et al., 1988), considered now as the instrument of choice for
the next generation of cross-cultural surveys.
Guarnaccia et al. (1993) created a 12-item scale from the somatization
section of the DIS to measure the Puerto Rican idiom of distress
"ataque de nervios." This research was based on the assumption that
"cross-cultural validity can occur only when indigenous categories of
experience are incorporated into assessment schedules." These
investigators dealt with the methodological issue of normative
uncertainty, that is, the possibility of establishing a distinction
between psychiatric illness and culturally determined responses to
questions. Finally, assessing interrater reliability and validity in
cross-cultural studies is another important methodological parameter
(Draguns et al., 1970; Rohner and Katz, 1970).
Culture as a Therapeutic and Protective Element
The best known and documented example of the therapeutic and protective
role of culture is the second finding of the International Pilot Study
of Schizophrenia (IPSS): patients from developing countries or from
rural areas in developed countries were found to have a better longterm prognosis vis-a-vis schizophrenia than patients who came from
urban areas. If the patient's family or community showed more
tolerance, acceptance, and willingness to integrate patients suffering
from schizophrenia into functional levels appropriate to their
adaptability and capacities, the patients did not show a disturbing,
isolating, or alienating effect (Leff et al., 1992). The opposite
occurs in developed countries as documented by the daily scene of
homelessness in the big cities (Sosin and Grossman, 1991).
The literature on the relationship between acculturation and
psychopathology is controversial. Some studies show a direct
relationship between a thorough acculturative process and a successful
therapeutic outcome (Berry and Kim, 1988). However, others, like the
Los Angeles ECA survey site (Burnam, et al., 1987), or the Mexican
American Prevalence and Services Survey (MAPSS; Vega et al., 1998),
found that immigrant Mexican-Americans were much "healthier"
psychiatrically than Mexican-Americans born in the United States. It
is, therefore, possible for cultural factors to prevent directly or
indirectly some psychiatric disorders. Kendler et al. (1997) in a
genetic epidemiological study recognized the "buffering" effects of
religion against stressful life events and substance abuse. Similarly,
traditional therapeutic approaches such as those represented by the
Andean curanderos, the Amazon witches, the Brazilian and Puerto Rican
spiritists, the Cuban "santeros," or the "folk healers" scattered
through urban and rural areas in the United States, reflect the complex
syncretism of the mental health field.
The relationship between culture and treatment is solidly demonstrated
by the findings of psychotherapy and ethnopsychopharmacology research.
In psychotherapy, the topics of transference and counter-transference
related to the ethnic and cultural background of therapists and
patients are a matter of intense debates (Carter, 1995; Foulks et al.,
1995). Comas-Diaz and Jacobsen (1991) described the vicissitudes of
intraethnic and interethnic dyads, and the relevance of culture as a
catalyzer of major therapeutic issues. Devices of strong cultural
origin such as time splitting and suppression of the past are
considered adaptive strategies to mitigate the risk of depression among
Southeast Asian refugees in Canada (Beiser and Hyman, 1997). Some
authors (Lin, 1986) maintain that psychotherapy should not necessarily
follow the Western/Freudian emphasis on reconstructing the past. In
some cultures where the past is highly valued, psychotherapy's aim may
well be to reintegrate the patient with his/her history rather than to
overcome it. In this context, important areas in interdisciplinary
psychotherapy research are the selection of culturally congruent
treatments, and the role of the therapist as a competent "cultural
broker" (Lefley and Peterson, 1986).
Ethnopsychopharmacological issues are increasingly recognized in
clinical practice and research. Pharmacokinetic and pharmacodynamic
differences between ethnic groups could help to explain high
interethnic variability in responses and adverse effects to medications
(Lin et al., 1995). These concepts also apply to the recently described
isoenzymes of the P450 cytochrome type (Nemeroff et al., 1996), which
are centrally involved in the metabolism of many psychotropic agents.
From a different perspective, clear differences have been found in the
diagnostic and medication prescription patterns among different ethnic
and national groups (Fisch et al., 1982). American psychiatrists, for
instance, prescribe higher doses of psychotropic agents than Swiss and
other European psychiatrists. This phenomenon is only descriptive but
touches on cultural factors probably related to the "pill culture"
embraced in the United States by a population increasingly concerned
about longevity and perpetuation of youth.
Also, in the United States the tendency to diagnose schizophrenia among
African-American patients or personality disorders among Hispanic
patients is higher than among Caucasians (Boxer and Garvey, 1985;
Wright et al., 1984). These ethnic minority patients are given higher
amounts of neuroleptics and are more likely to receive depot
neuroleptics than oral medications when compared with white patients,
even though they have the same diagnosis (Lin et al., 1995; Segal et
al., 1996). Differences in the pharmacological approach to female
patients have also been documented (Steen, 1991). Stress levels,
quality and quantity of social support, and personality styles are
factors under strong cultural influence that decisively affect the
assessment, course, and outcome of a variety of psychopathologies
(Lopez and Hernandez, 1986), as well as the response to psychotropic
agents (Segal et al., 1996).
Culture as a Management and Service Instrument
Some cultural factors have been found to be extremely relevant and
beneficial to the provision of mental health services in the community
(Berry and Kim, 1988). The current popularity of managed care, with its
primary objectives of cost containment and efficient use of resources,
makes the role of culture in clinical practice even more relevant. This
is reaffirmed by the principles of adaptability, cultural sensitivity,
and cultural competence of services (Ruiz et al., 1995).
Cultural considerations need to be taken into account when making
clinical decisions such as office or clinic schedules to accommodate
patients' needs, professional staff assignment, and delineation of
tasks in multidisciplinary teams. Additionally, participation by former
patients in the design and monitoring of treatment programs, patients
and family education, and related preventive efforts reflect and
enhance an undeniable cultural component (Lefley and Peterson, 1986).
In this context, Gaviria and Stern's (1978) examination of the
underutilization of mental health services by Latino communities
concluded that the difficulties in the definition and implementation of
such services stem from the different perspectives provided by: a)
governmental funding agencies stressing geographic proximity to
services, b) academic and social scientists pointing out the need to
recognize indigenous belief systems, and c) practitioners and Latino
community activists stating that the provision of bilingual and
bicultural staff is essential for the cultural relevance of services.
Other investigators have advocated a bicultural effectiveness training
to foster the ability to negotiate both old and new culture systems
(Szapocznik et al., 1986).
Discussion
Many authors have long sought to delineate the clinical usefulness of
contemporary cultural psychiatry concepts. A clinically based cultural
psychiatry is relativistic, nondogmatic, and extremely sensitive to the
similarities and differences of patients and professionals. It attempts
to prevent the unnecessary "pathologization" of numerous behaviors and
emotional responses. The five clinical dimensions discussed in this
article provide a conceptual and a pragmatic anchor to the knowledge of
cultural factors in mental health and mental illness. Conceptually, a
clinically relevant cultural psychiatry should warn the clinician
against the "overculturalization" of the clinical phenomena (i.e.,
notions such as "cultural peculiarities" or "respect for the
uniqueness of human groups") that might trivialize true clinical
situations and thus deprive individuals and groups of an appropriate
diagnostic assessment and treatment. Practically, we submit that this
multidimensional approach would allow the clinician to systematically
address the cultural components of his/her patient's plight in all
existing diagnostic categories and in all kinds of populations. When
evaluating any patient, the clinician must attempt to delineate the
extent to which culture can explain the behavior being examined or,
conversely, contribute to the production of symptoms, and to their
accurate diagnosis, treatment and overall management.
Our review of the literature of the last two decades shows that
additional research is needed to further substantiate the clinical
value of the contributions of cultural psychiatry to the psychiatric
field at large. The etiopathogenesis of mental illnesses is
multidimensional and, therefore, cultural factors are as important as
biological, psychological, or behavioral factors in the shaping of
pathological behavior. Poverty, for instance, is assumed to have a
strong and complex pathogenic influence. From a cultural vantage point,
however, the issue is whether poverty generates adaptive mechanisms
such as low aspiration levels to reduce frustration or the
legitimization of a short range hedonism, which makes possible
spontaneity and enjoyment under certain adverse circumstances
(Rogler and Cortes, 1993). The latter view claims that a devalued selfimage in a culture of poverty leads to a "painful compromise" rather
than a "complacent adjustment." Also, topics such as migration,
violence, adaptation to urban/social/technological
changes, and the influence of ecosystems, all fall within the field of
cultural psychiatry practice and research.
Patient and provider relations, as well as social/behavioral
epidemiology, are areas of utmost importance for culturally based
research in the assessment, diagnosis, treatment, and prognosis of
psychiatric disorders and conditions. Its clinical applications would
certainly strengthen the five dimensions, particularly in ethnic
minorities, special age groups, and women. Among women, for instance,
the unique patterns of psychopathology vis-a-vis the changing cultural
perspectives of their role, as well as issues related to sexual
harassment and abuse, are extremely pertinent (Comas-Diaz and Greene,
1994). Likewise, outcomes research related to therapeutic and
preventive interventions helps to test and refine the principles
advocated by cultural psychiatry with respect to the
provision of mental health services (Mirin et al., 1991).
The ultimate goal of a culturally informed clinical psychiatrist is to
maximize the quality of life of the mentally ill via effective
diagnosis and humane treatment. The cultural study of the organization
and meaning of behavior borrows from the psychoanalytical perspective
but deepens and broadens it (Frank and Frank, 1993). An illness is a
"cultural trait of a society" (Fabrega, 1992), and the effective
application of biomedical knowledge requires dealing with
neurobiological, as well as social and cultural factors in a
complementary way.
It is, therefore, important to acknowledge the clinical role of
cultural interventions in order to integrate them in a truly
comprehensive approach to the realities of a suffering human being.
Education and training in the field of cultural psychiatry will
certainly expand in the future. The current focus on and growth of
primary care will also help to pay attention to the cultural factors
associated with medical and psychiatric disorders. Specific clinical
case discussions, literature reviews, and experiential group activities
should be important components of the cultural psychiatry curriculum in
medical schools and in psychiatric training programs (Foulks, 1990;
Shore, 1996).
Conclusions
Culture has a powerful impact in the diagnosis, formulation, treatment,
and prognosis of medical/psychiatric illnesses. This is the arena in
which cultural psychiatry, a discipline based on principles of clinical
and anthropological relevance and with agreed upon methodological rules
of general applicability, has gained recognition. Yet, it is important
to point out that this approach to cultural psychiatry differs in
purpose, scope, and methods from that influenced by the social
anthropology of the 1970s and 1980s (Kleinman, 1977; Littlewood,
1990). The current international social climate and the realities of
multiculturalism across the globe require a concerted effort by
psychiatrists and other mental health professionals to emphasize the
practical issues involved in the interrelationship of culture and
psychopathology. All patients, irrespective of geographical areas or
societies, carry a cultural legacy as indivisible a part of their being
as the brain pathways specified in their genome (Eisenberg,
1995). The resurgence of national identities, ethnic conflicts, and
religious polarizations are all cultural phenomena with mental health
and mental illness connotations that deserve sound clinical,
educational and research efforts, (Desjarlais et al., 1995).
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Accession Number:
00005053-199908000-00002
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