CULTURE & MENTAL HEALTH:
WHAT IS CULTURE?
shared norms, values, beliefs, meanings, behavioural patterns of group of people
language, nonverbal expression of thoughts/ emotions (i.e. gestures/ facial expressions), religious + moral
beliefs, spirituality, family structures, life-cycle stages, customs, legal systems rituals + traditions, technologies,
etc.
CULTURAL REFERENCE GROUPS: transmitted over generations + change as individuals/ groups are exposed to
multiple other cultures
not just distinct, homogenous groups of people = ecosystems w. evolve + influence each other
Individuals don’t necessarily have all same values/ beliefs as others in their cultural group = often members of
multiple cultural groups w. different sets of values/ beliefs
Individuals choose to accept/ reject elements of their cultures throughout their lives
affects way we feel, think, behave in the world
affects expression, experience, interpretation, course, outcome of mental illness
HOW IS CULTURE RELEVANT IN MENTAL HEALTH PRACTICE?
Clinician/ patient relationships
Experiences of mental illness
Understanding of mental illness
Assessment
Diagnosis
Treatment
EARLY HISTORY OF TRANSCULTURAL PSYCHIATRY:
Are mental illnesses universal across cultures?
academic debate whether all cultures experience same symptoms has been in literature domain for a century
UNIVERSALIST: Kraepelin’s 1903 voyage to the island of Java
Kraepelin concluded t. dementia praecox (precursor to schizophrenia) was ‘very common’ w. differences in
presentation limited severity (NOT type) of symptoms
CULTURALLY PARTICULARIST: Cecil Seligman’s expedition to New Guinea in 1904
Seligman didn’t consider t. behaviours/ experiences included in rituals = activity comparable to psychosis despite
any similarities he may have noted
1970s: World Health Organisation (WHO) cultural psychiatry studies
International Pilot Study of Schizophrenia (1966–1975) = Schizophrenia is found worldwide + among various cultures
incidence of schizophrenia similar across world BUT treatment outcomes better in developing countries
CRITICISED: WHO research methods downplayed cultural differences + influences in search for universal symptoms
employed standardised questionnaires to identify core schizophrenic syndrome = cross-cultural researchers
excluded other presentations in favour of reliable (familiar) syndrome
ACADEMIC VIEWS ON WHO STUDIES RAISED 2 NB QUESTIONS:
, (Initiated by Kleinman in 1977)
1. DO PSYCHIATRIC CATEGORIES HAVE CROSS-CULTURAL VALIDITY?
CROSS-CULTURAL VALIDITY: whether measure/ category developed in one culture accurately picks up w. is
presumed to be identified in another culture
CATEGORY FALLACY: diagnostic interview schedules were consistent in picking up symptoms in other
countries (i.e. reliable) BUT weren’t valid (i.e. actually measured incidence of schizophrenia) in another
culture
Kleinman wasn’t ruling out possibility t. schizophrenia might have validity for other cultures = BUT is it an
empirical question + can’t assume this validity as WHO researchers had done
NB to know some cultures have particular ways of understanding psychological changes + fit w.
spiritual/religious explanations
‘changes’ are non-Western cultural opinions (NOT cultural signs of illness) = not published while
Western views on ‘changes’ were published + regarded as medical symptoms
Despite poor cross-cultural validity of psychiatric categories = recurring patterns of affect/ thought/
behaviour t. are similar + can be identified across cultures
some cultures, pattern called ‘depression’ or ‘schizophrenia’ + in another culture equivalent patterns
called ‘soul loss’ or ‘spirit possession’
2. HOW DOES ‘CULTURE’ INFLUENCE ‘MENTAL DISORDER’?
cultural role in constitution of symptoms = content of symptoms aren’t solely swayed by biological factors
i.e. cultural beliefs shape presentation of psychosis (e.g. hallucinated voice belongs to Satan)
cultural conceptions of t. self may impact interpretation of symptoms
i.e. some cultures are connected to ancestors/ afterlife = hallucinatory voices in head not so distressing
bc. sense of self is connected to spiritual world + other people
HOWEVER in cultures where separateness/ individuality of self is valued = hallucinatory voices very
distressing bc. it feels intrusive/ abnormal
Judgements of ‘normal’ / ‘abnormal’ differ between cultures
Cultures have different explanatory models for illnesses/ psych changes = impact person + treatments
EXAMPLE:
EXPLANATORY MODELS FOR PSYCHOLOGICAL & BEHAVIOURAL CHANGES
, SPIRIT POSSESSION BIOMEDICAL
Recognises problem Recognises problem
Allows kind of action to be taken = spirit removed Locates problem in person = something wrong w.
genetics/ brain + hereditary
Temporary affliction = possessed self/ body not self/body potentially permanently altered
permanently altered/ harmed
“Problem” located outside of the person lots of stigma since it’s incurably in brain
May reduce stigma + promote social inclusion
factors may improve subjective experience of illness/ Stigma + social exclusion + belief of incurable nature
course/ outcome of condition of disease + internalisation of problem = may worsen
course/ outcome for patient
Exorcism ceremony Psychiatric hospitalisation
CONCLUSION: UNIVERSALITY AND CULTURAL PARTICULARITY OF MENTAL DISORDERS
Despite poor cross-cultural validity of some psychiatric categories = researchers identified particular patterns of
affect/ thought/ behaviour that are cross-cultural
major mental disorders (e.g. depression and schizophrenia) are universal = can identify ‘equivalents’
various aspects of these mental disorders (i.e. expression/ experience/ interpretation/ symptom clusters/ course/
outcome) all culturally particular = influenced by + particular to culture
CULTURAL CONCEPTS OF DISTRESS:
CULTURAL CONCEPTS OF DISTRESS: ways t. cultural groups experiences, understand, and communicate suffering,
behavioural problems, or troubling thoughts / emotions
1. CULTURAL SYNDROMES: clusters of symptoms/ attributions t. tend to co-occur among individuals in specific cultural
groups, communities, or contexts + recognized locally as coherent patterns of experience
e.g. Major Depressive Disorder, Psychosis, Amafufunyane
2. CULTURAL IDIOMS OF DISTRESS: ways of expressing distress t. may not involve specific symptoms/ syndromes, BUT
provide collective, shared ways of experiencing + talking about personal or social concerns
“nerves” or “depression” can refer to widely varying forms of suffering without mapping onto discrete sets of
symptoms
3. CULTURAL EXPLANATIONS: perceived causes, labels, attributions, or features of explanatory model t. indicate
culturally recognised meaning/ aetiology for symptoms, illness or distress
vary in intensity of distress they express + in their meanings
mental disorders + criteria in DSM-5 are cultural concepts of distress
IDIOMS OF DISTRESS:
enables people to communicate their distress in way t. is recognisable in their culture
, can enable patient to communicate their distress to doctor BUT can be used by anyone
can communicate distress t. ranges in intensity = i.e. mildly stressful to trauma + incapacitating suffering
TYPES OF DISTRESS COMMUNICATED may include anger, anxiety, loss, social marginalisation, insecurity,
powerlessness
can refer to past, present, or anticipated future distress
sometimes effective ways of expressing distress to those around you + coping w. distress
can signify psychopathology in individual + cause ↑ distress in individuals/ those around them
may indicate a physical or psychological disorder BUT by not necessarily
can change over time = globalisation = different cultures mix + form new hybrid idioms of distress
EXAMPLES OF IDIOMS OF DISTRESS:
EXPANDED ON IN THE TEXTBOOK SOME OTHER EXAMPLES
can be expressed using language and/or behaviour, Visiting places and/or people valued for their healing
and can reflect values of society. powers in culture
Experiencing lower back pain associated with (i.e. doctors, sangomas, counsellors, rehab centres,
“back-breaking work” = overwork/ stress places of worship, special places in nature, religious
leaders, psychologists, chiropractors, acupuncturists,
Biomedical disease terminology (clinician/ self- homeopaths, etc.)
diagnosis) = use of psychiatric terms ‘confirm’ “I feel out of balance”
distress “The voices in my head are controlling me”
“My stomach is upset” (somatisation = physical
Taking medication = symbolises help-seeking complaints to express distress)
“God is punishing me”
Diagnostic testing = test results used to validate “I feel anxious and worried.” (psychologization=
person’s distress using psychological concepts to express distress)
“My life is going to hell”
Changing consumption patterns (e.g. smoking, “My neighbours have bewitched me”
drinking coffee/energy drinks/alcohol, eating junk Think about what idioms of distress you use!
food) = ↑ substance use suggests stress
MEANING AND VALUE OF IDIOMS OF DISTRESS:
should interpret idioms in terms of means of self-expression t. are normal/ valued by particular group
need to understand sociocultural context to understand meaning of specific idiom of distress
Understanding idioms of distress is helpful in mental health practice:
Indicators of psychopathology
Indicators of life distress (interpersonal, health, safety, finance, politics, etc)
Facilitators of rapport/ empathy
SOMATISATION AS IDIOM OF DISTRESS:
SOMATISATION: expressing psychological distress as somatic illness / physical complaint
WHAT IS CULTURE?
shared norms, values, beliefs, meanings, behavioural patterns of group of people
language, nonverbal expression of thoughts/ emotions (i.e. gestures/ facial expressions), religious + moral
beliefs, spirituality, family structures, life-cycle stages, customs, legal systems rituals + traditions, technologies,
etc.
CULTURAL REFERENCE GROUPS: transmitted over generations + change as individuals/ groups are exposed to
multiple other cultures
not just distinct, homogenous groups of people = ecosystems w. evolve + influence each other
Individuals don’t necessarily have all same values/ beliefs as others in their cultural group = often members of
multiple cultural groups w. different sets of values/ beliefs
Individuals choose to accept/ reject elements of their cultures throughout their lives
affects way we feel, think, behave in the world
affects expression, experience, interpretation, course, outcome of mental illness
HOW IS CULTURE RELEVANT IN MENTAL HEALTH PRACTICE?
Clinician/ patient relationships
Experiences of mental illness
Understanding of mental illness
Assessment
Diagnosis
Treatment
EARLY HISTORY OF TRANSCULTURAL PSYCHIATRY:
Are mental illnesses universal across cultures?
academic debate whether all cultures experience same symptoms has been in literature domain for a century
UNIVERSALIST: Kraepelin’s 1903 voyage to the island of Java
Kraepelin concluded t. dementia praecox (precursor to schizophrenia) was ‘very common’ w. differences in
presentation limited severity (NOT type) of symptoms
CULTURALLY PARTICULARIST: Cecil Seligman’s expedition to New Guinea in 1904
Seligman didn’t consider t. behaviours/ experiences included in rituals = activity comparable to psychosis despite
any similarities he may have noted
1970s: World Health Organisation (WHO) cultural psychiatry studies
International Pilot Study of Schizophrenia (1966–1975) = Schizophrenia is found worldwide + among various cultures
incidence of schizophrenia similar across world BUT treatment outcomes better in developing countries
CRITICISED: WHO research methods downplayed cultural differences + influences in search for universal symptoms
employed standardised questionnaires to identify core schizophrenic syndrome = cross-cultural researchers
excluded other presentations in favour of reliable (familiar) syndrome
ACADEMIC VIEWS ON WHO STUDIES RAISED 2 NB QUESTIONS:
, (Initiated by Kleinman in 1977)
1. DO PSYCHIATRIC CATEGORIES HAVE CROSS-CULTURAL VALIDITY?
CROSS-CULTURAL VALIDITY: whether measure/ category developed in one culture accurately picks up w. is
presumed to be identified in another culture
CATEGORY FALLACY: diagnostic interview schedules were consistent in picking up symptoms in other
countries (i.e. reliable) BUT weren’t valid (i.e. actually measured incidence of schizophrenia) in another
culture
Kleinman wasn’t ruling out possibility t. schizophrenia might have validity for other cultures = BUT is it an
empirical question + can’t assume this validity as WHO researchers had done
NB to know some cultures have particular ways of understanding psychological changes + fit w.
spiritual/religious explanations
‘changes’ are non-Western cultural opinions (NOT cultural signs of illness) = not published while
Western views on ‘changes’ were published + regarded as medical symptoms
Despite poor cross-cultural validity of psychiatric categories = recurring patterns of affect/ thought/
behaviour t. are similar + can be identified across cultures
some cultures, pattern called ‘depression’ or ‘schizophrenia’ + in another culture equivalent patterns
called ‘soul loss’ or ‘spirit possession’
2. HOW DOES ‘CULTURE’ INFLUENCE ‘MENTAL DISORDER’?
cultural role in constitution of symptoms = content of symptoms aren’t solely swayed by biological factors
i.e. cultural beliefs shape presentation of psychosis (e.g. hallucinated voice belongs to Satan)
cultural conceptions of t. self may impact interpretation of symptoms
i.e. some cultures are connected to ancestors/ afterlife = hallucinatory voices in head not so distressing
bc. sense of self is connected to spiritual world + other people
HOWEVER in cultures where separateness/ individuality of self is valued = hallucinatory voices very
distressing bc. it feels intrusive/ abnormal
Judgements of ‘normal’ / ‘abnormal’ differ between cultures
Cultures have different explanatory models for illnesses/ psych changes = impact person + treatments
EXAMPLE:
EXPLANATORY MODELS FOR PSYCHOLOGICAL & BEHAVIOURAL CHANGES
, SPIRIT POSSESSION BIOMEDICAL
Recognises problem Recognises problem
Allows kind of action to be taken = spirit removed Locates problem in person = something wrong w.
genetics/ brain + hereditary
Temporary affliction = possessed self/ body not self/body potentially permanently altered
permanently altered/ harmed
“Problem” located outside of the person lots of stigma since it’s incurably in brain
May reduce stigma + promote social inclusion
factors may improve subjective experience of illness/ Stigma + social exclusion + belief of incurable nature
course/ outcome of condition of disease + internalisation of problem = may worsen
course/ outcome for patient
Exorcism ceremony Psychiatric hospitalisation
CONCLUSION: UNIVERSALITY AND CULTURAL PARTICULARITY OF MENTAL DISORDERS
Despite poor cross-cultural validity of some psychiatric categories = researchers identified particular patterns of
affect/ thought/ behaviour that are cross-cultural
major mental disorders (e.g. depression and schizophrenia) are universal = can identify ‘equivalents’
various aspects of these mental disorders (i.e. expression/ experience/ interpretation/ symptom clusters/ course/
outcome) all culturally particular = influenced by + particular to culture
CULTURAL CONCEPTS OF DISTRESS:
CULTURAL CONCEPTS OF DISTRESS: ways t. cultural groups experiences, understand, and communicate suffering,
behavioural problems, or troubling thoughts / emotions
1. CULTURAL SYNDROMES: clusters of symptoms/ attributions t. tend to co-occur among individuals in specific cultural
groups, communities, or contexts + recognized locally as coherent patterns of experience
e.g. Major Depressive Disorder, Psychosis, Amafufunyane
2. CULTURAL IDIOMS OF DISTRESS: ways of expressing distress t. may not involve specific symptoms/ syndromes, BUT
provide collective, shared ways of experiencing + talking about personal or social concerns
“nerves” or “depression” can refer to widely varying forms of suffering without mapping onto discrete sets of
symptoms
3. CULTURAL EXPLANATIONS: perceived causes, labels, attributions, or features of explanatory model t. indicate
culturally recognised meaning/ aetiology for symptoms, illness or distress
vary in intensity of distress they express + in their meanings
mental disorders + criteria in DSM-5 are cultural concepts of distress
IDIOMS OF DISTRESS:
enables people to communicate their distress in way t. is recognisable in their culture
, can enable patient to communicate their distress to doctor BUT can be used by anyone
can communicate distress t. ranges in intensity = i.e. mildly stressful to trauma + incapacitating suffering
TYPES OF DISTRESS COMMUNICATED may include anger, anxiety, loss, social marginalisation, insecurity,
powerlessness
can refer to past, present, or anticipated future distress
sometimes effective ways of expressing distress to those around you + coping w. distress
can signify psychopathology in individual + cause ↑ distress in individuals/ those around them
may indicate a physical or psychological disorder BUT by not necessarily
can change over time = globalisation = different cultures mix + form new hybrid idioms of distress
EXAMPLES OF IDIOMS OF DISTRESS:
EXPANDED ON IN THE TEXTBOOK SOME OTHER EXAMPLES
can be expressed using language and/or behaviour, Visiting places and/or people valued for their healing
and can reflect values of society. powers in culture
Experiencing lower back pain associated with (i.e. doctors, sangomas, counsellors, rehab centres,
“back-breaking work” = overwork/ stress places of worship, special places in nature, religious
leaders, psychologists, chiropractors, acupuncturists,
Biomedical disease terminology (clinician/ self- homeopaths, etc.)
diagnosis) = use of psychiatric terms ‘confirm’ “I feel out of balance”
distress “The voices in my head are controlling me”
“My stomach is upset” (somatisation = physical
Taking medication = symbolises help-seeking complaints to express distress)
“God is punishing me”
Diagnostic testing = test results used to validate “I feel anxious and worried.” (psychologization=
person’s distress using psychological concepts to express distress)
“My life is going to hell”
Changing consumption patterns (e.g. smoking, “My neighbours have bewitched me”
drinking coffee/energy drinks/alcohol, eating junk Think about what idioms of distress you use!
food) = ↑ substance use suggests stress
MEANING AND VALUE OF IDIOMS OF DISTRESS:
should interpret idioms in terms of means of self-expression t. are normal/ valued by particular group
need to understand sociocultural context to understand meaning of specific idiom of distress
Understanding idioms of distress is helpful in mental health practice:
Indicators of psychopathology
Indicators of life distress (interpersonal, health, safety, finance, politics, etc)
Facilitators of rapport/ empathy
SOMATISATION AS IDIOM OF DISTRESS:
SOMATISATION: expressing psychological distress as somatic illness / physical complaint
