Renato D Alarco´n
Culture, defined as a set of behavioral patterns, lifestyle, meanings and values, shared
and utilized by members of a given human group, includes a series of variables
from the material (diet,
housing, tools, economic practices) to the purely social or epistemological
areas such as
collective knowledge, habits, customs, beliefs, traditions, language, religion,
social relations, and ethical principles.
Culture is a dynamic phenomenon that shapes a group’s view of the
world and is transmitted from generation to generation. The concept should
be distinguished from
two others, race (based
on physical and biogenetic considerations that group individuals on the basis
of physiognomic characteristics), and ethnicity that
entails distinction and identification of groups on the basis of a
common historical or geographic origins.
Against the background of a millenarian connection between
health, disease, and culture, Cultural Psychiatry could then be
defined as the sub-discipline that occupies itself with the definition, description,
evaluation, and
management of all psychiatric conditions inasmuch as they are both object and
reflection of
cultural factors in a bio-psycho-social context.
Cultural psychiatry utilizes concepts and instruments of
social and biological sciences in an effort to advance a global understanding of
psychopathological entities and their treatment. It promotes clinically and
culturally relevant care of every patient, recognizing both his/her unique cultural legacy
and universally valid principles of the management of emotional suffering.
An inheritor of distinguished historical and anthropological
traditions, Cultural Psychiatry is a relatively young discipline. Its origins
can be located around the late 19th century
with the first description of clinical entities found in exotic
places, thanks to explorations of authors such as Deniker, Ellis, Hirsch, and Brill.
Many authors consider Kraepelin as the founder of Cultural Psychiatry (which he
called Comparative Psychiatry) when he reported in 1904 on his visits to
Java and Borneo, where
he studied presumed cases of schizophrenia. Later on, Freud’s influence, and that
of followers and
dissidents of psychoanalysis, identified definite sociocultural factors (even
though they may
have not called them so) in the genesis of behavioral maladaptations and mental
disorders.
In the last three decades, the field of Cultural Psychiatry has
expanded with
contributions from other disciplines, particularly psychology, sociology and anthropology,
that started with the
seminal bio-psycho-social concept proposed by Engel, and continued with the growth
of multidisciplinary and
multifactorial approaches to health and illness, pronouncements by international
health organizations
emphasizing the totality of the human being in the fields of health and healthcare,
significant social and political changes across the world, and the development of study
groups, social programs, and academic centers devoted exclusively to the field.
It is interesting that
this growth has taken place in the midst of another revolution led by neurobiology and
neurosciences.
Cultural Variables
The following should be considered as important cultural factors that interact among themselves and with fields beyond culture to have an impact on diagnostic, clinical, and therapeutic processes in a patient.Ethnic Identity
It includes elements such as country of origin, family structure, attitudes towards medicine, psychology and psychiatry, views of the world, crossing of systems (demographic, social, educational, economic), affiliations (familiar and religious), behaviors, expectations, and values.Language
For many, it is the most significant cultural variable, powerful in the generation of identity, and a source and a vehicle of information, expressiveness, alienation, or support, protective or risk factors, and an essential element in the outcome of every clinical intervention. A variant, the so-called nonverbal language, includes physical distance among the interlocutors, visual contact, movements, and gestures.Education
It influences notably the outcome of any clinical interaction, emphasizing the good or bad results of communication between professionals, patients, and families.Gender and Sexual Orientation
These variables preside over connections and contacts, grouping and cultural responses that generate behaviors and have an impact on prevalence and severity of most clinical conditions.Religion and Spirituality
Both are potential sources of information, support, and explanation of illness. They contribute to ‘‘make sense’’ out of symptoms and symptom-related emotions and feelings, with a subsequent beneficial effect.Age and Socioeconomic Status
The ways in which society handles different age groups in the context of health and disease have an undeniable cultural basis. Similarly, socioeconomic status, as a reflection of levels of ability, opportunities, and collaborative or alienating connections between groups with varieties of financial and political power responds to important cultural sources.Diet
At a more material level, dietary styles, although closer to biological areas (e.g., metabolic processes, food composition), reflect also a variety of collective beliefs, habits, customs, traditions, occupations and community objectives and rules of strong cultural facture, and have an even stronger impact on personality and behavior.Culture-Psychiatry Interactions
Culture plays different roles and interacts at various levels with psychopathology and therapeutics. It is an interpretive and explanatory tool that clarifies behaviors that, otherwise would be considered pathological. It is a pathogenic and a pathoplastic agent, that is, contributes to produce some clinical conditions, and shapes the symptomatic and syndromic presentation of clinical pictures, respectively.
Culture is a diagnostic and
nosological factor recognized by
official nomenclatures and utilized in instruments measuring psychopathology.
In this sense, a cultural perspective prevents the commission of so called
categorical fallacies, that is the attempt to pigeon-hole clinical entities
or behaviors with a powerful cultural basis (particularly in non-Western
societies or
ethnic minority groups) into labels sanctioned by purely Western taxonomy
parameters. Culture
has also a therapeutic and a protective role on
the basis of how families and communities deal with mental health and mental
illness.
Finally, it is an important component in the management
and provision of care influencing
interactions of the therapeutic dyad (patient and professional) as well as how society
deals with mental
illness, issues of stigma, tolerance, support and understanding, and the eventual direction
that governments and
bureaucratic structures take vis-a`-vis the
care of those with mental illnesses.
Cultural Aspects of Specific Clinical Entities Cognitive and Substance Use Disorders
In spite of strong biological components, these disorders
respond to undeniable social, cultural, economic, and ethnic factors. Poverty,
low industrialization, strong or weak restrictive rules related to the use of
alcohol and drugs, or
sexual practices, and levels of acceptance and tolerance of behavioral disorders
secondary to cognitive problems, are all culturally-based areas. As in the case of
substance use and abuse disorders, their weight and impact vary from culture to
culture.Schizophrenia and Other Psychoses
Schizophrenia and other psychotic conditions show differences in prevalence and even outcome and prognosis in highly industrialized societies when compared with less developed, rural or agricultural communities. Similarly, their phenomenology varies on the basis of cultural complexities.Mood Disorders
These disorders have clear symptomatic differences in different cultural settings. Conceptualization, symptom presentation, severity, and impact of acculturation are factors that distinguish depression and bipolar mood disorders in different cultural areas.Anxiety Disorders
The high index of phobias in some ethnic groups (for example, African Americans in the United States) has been explained on the basis of stress resulting from discriminatory practices. The levels of anxiety and acculturative stress in newly-arrived immigrants and even in second or third generation of immigrant families, has a definite cultural basis related to adaptability, learning new cultural clues, educational and occupational opportunities, among other variables.
Somatization and Dissociative Disorders
These two types of disorders are, for many, the end result of what is called
‘‘idioms of distress,’’ a peculiar and unique way in which members of different societies
externalize stress, or express a variety of personal and social predicaments
through means more acceptable than gross pathological presentations.
If mood and anxiety disorders are considered manifestations
of characterological weakness, then pain or seizures can be better defined
as ‘‘medical’’ or ‘‘physical’’ conditions without the associated stigma or
social criticisms
of shame and guilt.
Posttraumatic Stress Disorder
A relatively new disorder in contemporary classifications, posttraumatic stress disorder has significant cultural connotations in terms of political oppression, response to natural disasters, war, interethnic conflicts, social isolation, migrations, international politics, and other factors that put to a test the way in which individuals or groups face adversity.Other Disorders
Finally, eating disorders, psychosexual problems, adjustment and personality disorders do all have a strong cultural basis. Religion, life events, racism, resilience, creativity, and features such as individualism and competitiveness versus socio-centrism and altruism are cultural factors that play a role in the occurrence and presentations of these and many other conditions.
Cultural Aspects of Psychiatric Treatment
Patients and treating professionals do have cultural baggages that are
non-transferable. Therefore, one must make an effort to
understand the other’s cultural background and agenda, eventually presiding over
the very essential
nature of the relationship. In this context, the topics of transference and
countertransference in psychotherapy have a cultural basis, much stronger than unprovable unconscious
phenomena.
Since the use of language may be a source of comfort or conflict, interpreters may
be extremely useful in several circumstances. Therapists play the role of
cultural brokers, and the adequate connection between patient and therapist should
prevent both unfillable gaps or the phenomena of fusion and over-identification
or enmeshment, that would prevent a good therapeutic outcome.
There are numerous cultural models of psychotherapy. For
instance, Morita therapy in Japan, for the treatment of moderate
cases of obsessive-compulsive disorder, is based on periods of isolation and socio-cognitive
retraining. The use of heroes and heroins from the patient’s culture of
origin has been successful with minority patients in the United States.
Art therapy, variants of psychodrama, game therapy, cuento
therapy (story-telling) and other techniques are
important considerations. Some authors postulate the possibility
of standardized
psychotherapists in multicultural contexts. This is certainly an area that, in
the current climate of globalization, may
deserve specific research.
Ethno-psychopharmacology is a growing field, based on the study of genetic
profiles and the metabolic properties of enzyme sets over different groups
of medications. Slow,
intermediate, expansive (normal), and rapid and ultra-rapid metabolizers vary
among different ethnic
groups, with clear implications for the choice of medicines, doses, time and length
of administration, and
production of side effects.
Similarly, the so-called non-pharmacological factors in pharmacotherapy do have a
cultural basis, very closely related to the
issues of doctor-patient relationship, beliefs and expectations, and social
customs and habits
analyzed above.
Conclusion
Culture has a multitude of implications in the theoretical and practical areas of psychiatry. Its consideration is critical for the translation of diagnostic categories and explanatory models into codes understandable across the globe. Its adequate use will attenuate potential discrimination and stigma.
Culture and therapy with special subpopulations such as children and adolescents,
couples and spouses, families, aging persons,
and medically-ill patients are areas of growing importance. Social phenomena such as political and
social changes, migration, refugee issues, minority groups, intercultural
marriages, and the many different
theories regarding etiology and pathogenesis of mental illness make of Cultural Psychiatry one of the
most important areas of development in the future.
These and other topics such as cultural epidemiology,
cultural psychiatry and education, cultural formulation in the Diagnostic
and Statistical Manual of Mental Disorders: Text Revision, culture-bound syndromes, and
the bio-cultural connections in psychopathology must be priority subjects
of research.
of research.
Suggested Reading
Alarco´n, R. D., Foulks, E. F., Westermeyer, J., Ruiz, P. (1999). Clinical relevance of contemporary cultural psychiatry. Journal of Nervous Mental Disease, 187, 465–471.Kermeyer, L. J. (1989). Cultural variations in the response to psychiatric disorders and emotional distress. Social Science and Medicine, 29, 329–339.
Kleinman, A. (1988). Rethinking psychiatry: From cultural category to personal experience. New York: Free Press.
Tseng, W. S. (2001). Handbook of cultural psychiatry. San Diego, CA: Academic Press.
References
C. S.
Clauss-Ehlers (Ed.), Encyclopedia of
Cross-Cultural School Psychology, DOI 10.1007/978-0-387-71799-9, Springer
Science+Business Media LLC 2010
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