Some years ago I completed an MSc in Culture and Mental health at University College London. This was essentially a medical anthropology MSc with an emphasis on mental health. The course organiser was Professor Roland Littlewood, arguably one of the most influential people in the cultural psychiatry world. His book, Aliens and Alienists, co-written with Maurice Lipsedge, remains a core text in the cultural psychiatry cannon.
I also, around that time, took some time out of my psychiatry training scheme and worked in Southwest Uganda for a year as a psychiatrist. As well as clinical work and teaching I carried out some research for my MSc thesis on collaboration with traditional healers. The thesis is probably worth a separate post but, in short, argues for a need for collaboration, in sub Saharan Africa, between psychiatric services and traditional healers. In part for pragmatic reasons: Whether you agree with them or not people in Africa will visit the healers because they provide a culturally relevant, holistic care. Many of the healers I visited described going through psychological difficulties on their journey to become healers, so in retrospect, they could also be viewed as a sort of extended peer support network. Of course this collaboration can be generalized beyond sub Saharan Africa to any community where a plurality of healing systems exist. This, of course, also includes western cultures.
Since finishing my MSc I have not formally studied any further anthropology but with the passing of time I have noticed that I am constantly returning to these ideas to mull them over. With time, my understanding of some of the issues has developed. It is almost as if time and distance has brought the subject matter into sharper focus. Therefore, this post is an attempt to synthesise these thoughts into some sort of order.
To my mind, cultural psychiatry provides a robust critique of a biologically orientated psychiatry, and so I will discuss what cultural psychiatry is; illustrating some of the concepts by discussing, in detail, depression from a cultural psychiatry perspective.
Cultural psychiatry is still peripheral to standard psychiatric training with little space and time given over to these matters. The Shorter Oxford Textbook of Psychiatry, as an example, devotes about two paragraphs to the subject, by its own admission, claiming that this is a much neglected area of psychiatry.
It was none other than Emil Kraeplin (1904) who, having delineated syndromes which remain the basis of modern classification systems (dementia praecox and manic depressive psychosis), travelled to Java to examine whether patients in a Javanese psychiatric asylum had similar disorders to his patients in Germany. His conclusion was that they did. In discussing Amok (a ‘syndrome’ where an individual, following a period of brooding, runs about wildly assaulting people and things), which he encountered in Java, Kraeplin defined it as either epileptic or catatonic. Though much criticised for his authoritarian approach he set the tone for Trans-cultural psychiatry, which was initially comparative, that is, finding goodness of fit between Western diagnostic categories and behaviours encountered in different cultures.
Some of this comparing was wildly speculative and ridiculous in its pomposity. For example, the windigo reaction of North American Indians was, at various times, interpreted by different authors as depression, schizophrenia, hysteria or anxiety. Windigo are said to be malevolent spirits that like to consume human flesh, and because cannibalism is taboo in much of North American Indians, people who ate flesh at times of famine were said to become possessed by these spirits. Elsewhere, shamans were described as mentally ill, with diagnoses ranging from hysteria, epilepsy, fear, neurosis to veritable idiocy. Some even went further, including Freud, suggesting that primitive religion and primitive societies were themselves a form of organised psychosis.
In 1943 E.H Ackerknecht, who was both a physician and a historian, was one of the first to challenge this cultural imperialism. He suggested that we can no longer regard a person as abnormal only on the basis of certain symptoms, whilst ignoring the historical and cultural place of this person. This cultural relativism was further elaborated on by Yap (1951), himself credited with coining the term ‘culture bound syndrome,’ who stated that “if we say a man is abnormal because he departs from an average or an ideal, then we want to know; what average and whose ideal?”
It was not until 1977 that Arthur Kleinman proclaimed the arrival of a new ‘Cultural Psychiatry.’ Kleinman criticised the long-held assumption that psychiatric categories themselves were culture-free entities. In the past it had been assumed that psychological abnormality in all its forms could be delineated and each of these categories in turn represented something with a biological basis. Cultural factors, on the other hand, were merely seen as obscuring the underlying disease process. In short, biology decided the form of the illness, whilst culture determined the content.
In his seminal ‘Rethinking Psychiatry’ Kleinman (1988) pointed out that psychiatry is itself constrained by social systems, and its categories determined by history and culture as much as biology. He argues that we need to move away from reductive comparisons and interpretations and start to take account of how cultures, themselves view abnormal behaviour and illness. In his view, we need to look at the ‘illness’ (what the patient brings to the consultation) not the disease (what the doctor imagines lies beneath this suffering).
This is the crux of the cultural psychiatry’s critique: It suggests that the very categories which are assumed to be natural occurring forms, are in fact just social and cultural constructions. It is no longer trans cultural because we are no longer making comparisons, trying to find goodness of fit between western categories and local forms of distress. All cultures divide the world up into normal and abnormal; all have some notion of madness, but the idioms used to describe these states and the causes behind them can only ever be understood in the full context of the culture where they take place.
The lens of cultural psychiatry is also turned upon us. It suggests that biological psychiatry is just that, an idiom. It also suggests that the categories we employ speak volumes about own moral and value systems more than any underlying natural pathology.
This relationship between categories and behaviour can also be conceived of as two way. That is, not only do the categories describe patterns of behaviour but the categories themselves provide culturally sanctified ways of feeling and behaving when under distress. This is something Roland Littlewood is interested in. We might say that in describing the category Anorexia Nervosa, for example, we annotate the various manifestations of this disorder; but in doing so we also make available a trope which can be used, in this case, commonly by young women, for signalling distress.
School shootings are not a disorder, but we could easily collapse the features of school shootings into a new disorder called, school shooting disorder. In doing so we provide the next potential school shooter with a template for action. Arguably we don’t even need to create a category for this to happen; it is amazing how quickly a sort of symbolism and recurring pattern has emerged following the first shootings.
The methods of cultural psychiatry are social and cultural anthropology. An example comes from John Orley, a psychiatrist and senior lecturer at Makerere University in Kampala who, in the 1960s, lived amongst the Buganda people, learning their language and customs and trying to gain an understanding of mental illness in Buganda culture. The important part was not to see mental illness as an abstracted entity that one arbitrarily measures but to gain an idea, from the inside so to speak, of what the Buganda people consider is mental illness: How it manifests? How it is managed? And how it is related to other parts of society? The ethnography that resulted from this process is what Clifford Geetrz called ‘a thick description’ in which observed phenomena are described completely in the context in which they exist. Orley’s ethnography affords us a bottom up or emic understanding of mental illness in Buganda culture, as opposed to the standard top-down etic view.
The Example of Depression
There is this an almost mantra like statement issued from the World Health Organization (WHO), which claims, depression is a worldwide epidemic second only to cardiac disease in global disease burden. But it is a statement that requires teasing apart, and to some extent resisting. What are we really claiming here? Is depression a problem that occurs everywhere? Is it the same thing where ever we look, just shaped by local idioms of distress into different presentations? And is the right response to the WHO’s claims to roll out western models of mental health care, whereever we find depression?
Let’s start with our own culture: In looking at Western depression Jadhav (1996) provides a lexical and semantic analysis of depressive terminology. He shows how the key concepts of depression have been shaped by our own history. Central are the Western notion of a bounded individuated self and the Cartesian dualism of mind and body. Cross-cultural research has shown these are not universal and indeed collective or social forms of identity are more common across the globe. Other problems encountered in cross-cultural studies of depression are differing local categories of emotions and the difficulty in translating emotion-related vocabulary. His focus is on the vocabulary of guilt, fatigue, energy, stress and depression. These vocabularies have their own unique histories and meaning; deeply embedded into European culture, literature and institutions, and so while the category of depression that arises out of these ideas may be appropriate to Western European culture it is a fallacy to assume they can be applied elsewhere.
Kleinman (1988) provides an example: ‘Neurasthenia,’ once a common diagnosis in the west, no longer remains a category in DSM-IV, where it has been replaced by major depressive disorder. In China, at least in the 1970s when Kleinman carried out his studies, the diagnosis of Neurasthenia was commonly made. The condition is characterized by a lack of energy and physical complaints such as sore stomach. In China it is seen as a neurological disorder, but Kleinman in reviewing such patients sees how they could also meet the diagnosis for major depression. He also notes a partial response to antidepressant medication (though not full until social, family and employment issues were addressed). Whilst recognizing that depression and neurasthenia probably represent a similar psychosocial process, one he calls ‘demoralization’, he argues that they ‘present’ in such markedly different ways because of the cultural conditions that favour different forms of expression. Depression, the diagnosis is as culturally constrained as neurasthenia. He advocates a focus on illness not on ‘disease.’ In his words: ‘Depression experienced as low back pain and depression experienced as guilt-ridden, existential angst are such substantially different forms of illness behaviour, with distinctive patterns of help seeking, and treatment responses that … the illness becomes the determative factor.’
By focusing on the illness experience in other cultures, anthropologists have viewed depression and unhappiness not just as local variations of disease but rather as rich constellations of cultural information, that guide the way loss, sorrow and demoralization are expressed. For example Littlewood (1985), in describing the Trinidadian illness Tabanka, a loss reaction in men deserted by women, shows how recasting this as depression obscures the humour, the communal values and the politics of male and female relations that Tabanka embodies. Jadhav (1996) describes the ‘cultural cleansing’ of patient narritives by psychiatrists in India. By collapsing into the diagnosis of depression, the wide variety of local idioms of distress such as pain in the nerves, sweet pain, heat in the head, twitch, pain in the body or sorrow in the heart, much of the richness of local idioms are lost.
In Post-communist Latvia, Skultans notes the recent move from a somatic to a psychological language of distress; from damaged nerves to psychobabble; from no drugs to an influx of new drugs, which she sees as an iconic representation of Western Capitalism fuelled by the lavish banquettes laid on by drug companies and the seductive semiotics in advertising of these drugs. She also notes a changed conception of agency from collective to individual and new forms of psychiatric language arising in tandem with economic development. In short, she sees how much is torn apart, and how much is lost, when western psychiatry turns sorrow and unhappiness into depression.
Western concepts of depression locate the problem firmly within the individual. It is a defect state where the individual lacks something, be it the right balance of neurochemicals, or even a lack of moral fibre. But this view neglects the wider social, political and economic factors that frequently lie behind ‘depression.’ Summerfield (2008), in discussing refugee studies, suggests that the strongest moderating factors to be social conditions after displacement. Resolution of the conflict that had affected the refugees in the first place also had positive effects. This suggests that the mental phenomena (typically diagnosed as depression or PTSD) were mostly incidental and normal reactions to their circumstances. A diagnosis like depression had little power to explain the refugees’ problems. Moreover; pathologising distress, labeling it and treating it with antidepressants, negates the urgent need for political action and social change.
To return to the World Health Organisation; the statement about the commonness of depression simply seems to indicate that human unhappiness is common. Is it not just a rehash of what the Buddha said 2500 years ago, “To be born is to suffer”? But, it is how we address this suffering that is key, and to recast all this suffering as mental disorder, located within the individual, seems blatantly wrong. Western categories of mental illness are, in the main, constructions with little cross cultural validity; they fail to address the real causes behind this suffering, causes such as war, famine, displacement, poverty, oppressive governments, etc. Adopting Western-style psychiatry quickly erodes natural healing systems, local wisdom, social support networks, and cultural knowledge.
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Ackerknecht. E. R; Psychopathology, Primitive Medicine and Primitive Culture (1943). Reprinted in Cultural Psychiatry and Medical Anthropology, an introduction and reader, edited by Littlewood. R and Dein. S. Athalone Press, new Brusnswick, NJ. (2000)
Jadhav. S; (1996) The Cultural Origins of Western Depression. International Journal of Social Psychiatry 42, 269-286.
Kleinman. A; Rethinking Psychiatry. Free Press, New York. (1988).
Kraeplin Emil; Comparative Psychiatry (1904). Reprinted in Cultural Psychiatry and Medical Anthropology, an introduction and reader, edited by Littlewood. R and Dein. S. Athalone Press, new Brusnswick, NJ. (2000)
Littlewood. R and Lipsedge. M; Aliens and Alienists. Penguin Books, London. (1982)
Littlewood. R; An Indigenous Conceptualization of reactive Depression in Trinidad (1985). Reprinted in Roland Littlewood, The Butterfly and the Serpent, Essays in Psychiatry, Race and Religion. Free Association Books. London & New York. (1998)
Orley J. H; Culture and Mental Illness—A Study from Uganda. East African Publishing House, Nairobi (1970).
Skultans, V; From Damaged Nerves to Masked Depression: Inevitability and Hope in Latvian Psychiatric Narratives. Social Science and Medicine, 2003 Vol: 56 2421-2431
Summerfield. D; How scientifically valid is the knowledge base of global mental health? BMJ 2008, Vol 36, 992-994.
Yap. P.M; A Survey of Comparative Psychiatry (1951). Reprinted in Cultural Psychiatry and Medical Anthropology, an introduction and reader, edited by Littlewood. R and Dein. S. Athalone Press, new Brusnswick, NJ. (2000)