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Culture and Mental Health: An Introduction and Overview of Foundations, Concepts, and Issues

Anthony J. Marsella Ann Marie Yamada

Department of Psychology University of Hawai'i Honolulu, Hawai'i

I. INTRODUCTION A. Overview of Foundations

1. Emil Kraepelin—Comparative Psychiatry

In the early years of the twentieth century, Emil Kraepelin (1904), the father of modern Western psychiatry, journeyed from his home in Germany to Asia and North America as part of a worldwide lecture tour. During the course of his travels, Kraepelin experienced difficulties diagnosing some patients. He noted that the patients in these lands failed to express their illness with the prototypical symptoms characteristic of his patients in Germany and Northern Europe. Puzzled by this situation, Kraepelin suggested a new specialty within psychiatry be created—Vergleichende Psychiatrie or Comparative Psychiatry—to study cultural differences in psychopathology:

Handbook of Multicultural Mental Health: Assessment and Treatment of Diverse Populations Copyright © 2000 by Academic Press. All rights of reproduction in any form reserved.

The characteristics of a people should find expression in the frequency as well as the shaping of the manifestations of mental illness in general; so that comparative psychiatry shall make it possible to gain valuable insights into the psyche of nations and shall in turn also be able to contribute to the understanding of pathological psychic processes. (1904, p. 9)

It is ironic that Kraepelin, who was, like many 19th-century psychiatrists, committed to a biological view of mental illness should be among the very first to note the importance of cultural differences in the frequency and expression of disorders. In the interim between Kraepelin's early remarks and present times, the study of cultural differences in psychopathology has progressed under a number of names within psychiatry (e.g., transcultural psychiatry, cultural psychiatry, ethnopsychiatry, cross-cultural psychiatry) and related social sciences (e.g., psychiatric anthropology, culture and psychopathology, culture and mental health) (Marsella, 1993).

2. Culture and Mental Health: The Early Struggle

Within the last few decades, psychiatry and the other mental health professions and sciences (i.e., anthropology, psychology, sociology, public health, and social work) increasingly have acknowledged the critical importance of cultural factors in mental illness. This had led to new conceptual and methodological frameworks that position cultural factors as a major determinant of the onset, expression, course, and outcome of mental disorders. Indeed, for much of the past century, the mental health professions and sciences failed to recognize or acknowledge the importance of cultural factors in psychopathology (e.g., Mez-zich, Kleinman, Fabrega, & Parrone, 1996). Indeed, it was often assumed by those in positions of power and influence that mental disorders were universal in their onset, expression, course, and outcome, and that any variations (e.g., culture-specific disorders such as koro, latah, susto) were simply minor deviations within a prototypic universal disorder (e.g., Marsella, in press,b).

There were, of course, numerous voices that were raised in opposition to this position. But, these voices were often those of minority group members or clinical scientists who were marginalized and powerless because of their different views. In fact, many Western professionals and scientists who were pioneers in the field of transcultural psychiatry (e.g., Jane Murphy, Eric Wittkower) often tended to minimize the importance of cultural differences in psychopathology even as they studied variations (e.g., J. Murphy, 1976; Wittkower, 1969). To make matters worse, even some non-Western psychiatric pioneers accepted this perspective (e.g., Pow Meng Yap, Adeyo Lambo), owing, in large part, to their training in Western medical schools and residency programs (e.g., Yap, 1951; Leighton et al., 1963). All were part of the culture of Western psychiatry, and even as they studied cultural psychiatry, they were embedded and enmeshed in a professional and scientific worldview and ethic whose assumptions argued in favor of universals and against cultural differences in mental disorders.

The situation was, and still remains today, a perfect example of the unintentional abuses of power that can occur even among persons of goodwill. Although Western medical science considered itself to be objective in its quest for truth, it failed to recognize its own cultural relativity. Western medical science failed to grasp that its assumptions and methods were deeply rooted within Western cultural traditions, and as such, were at best, a limited and restricted perspective on the nature of psychopathology beyond Western cultural borders (e.g., Jenkins, 1998; Kirmayer, 1998; Mezzich, Kleinman, Fabrega, & Parrone, 1996; Lin, Tseng, & Yeh, 1995). Members of non-Western cultures often accepted the conclusions that were rendered without question because they were, after all, coming from professionals and scientists that were from the world's leading economic and political powers—modern technological societies who dominated the world. That this was the case should not be surprising, for it has only been within recent years, as ethnic and racial minorities and non-Western cultural members have become more prominent in number and influence among the mental health professions and sciences, that the bias inherent in much of our prior mental health knowledge and practice has become widely known and criticized (e.g., Chakraborty, 1991; Lin et al., 1995; Misra, 1996).

B. The "New" Culture and Mental Health

Today, as we enter a new century, voices that were long silenced because of their powerlessness within the professional and scientific culture are now speaking out with force and energy. A perfect example of this is the inclusion of the section on culture-bound disorders in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-1V) (American Psychiatric Association, 1994). This section of DSM-IV came to be included only after some ethnic minority psychiatrists (e.g., Glorisa Canino, Juan Mezzich, Frances Lu, Horacio Fabrega) and a new generation of White transcultural psychiatrists (e.g., Laurence Kirmayer, Arthur Kleinman, Ronald Wintrob) expressed the importance of culture for diagnosis, assessment, and treatment. Using knowledge from the social sciences and the "new" transcultural psychiatry (e.g., Mezzich, Kleinman, Fabrega, & Parron, 1996), changes were made in the DSM-IV, even as those in power continued to resist some recommendations (e.g., Jenkins, 1998).

A recent issue of the journal Transcultural Psychiatry (September 1998, Vol. 35) was devoted to the issue of culture in DSM-IV. The various articles provide candid statements about the cultural limitations of the DSM-IV and the struggles to reduce the ethnocentricity in the disorder categories. Kirmayer (1998), the editor-in-chief of the journal, captured the dilemma facing those supporting the "new" transcultural psychiatry and those holding traditional medical perspectives, when he wrote the following:

While cultural psychiatry aims to understand problems in context, diagnosis is essentializing: referring to decontextualized entities whose characteristics can be studied independently of the particulars of a person's life and social circumstances. The entities of the DSM implicitly situate human problems within the brain or the psychology of the individual, while many human problems brought to psychiatrists are located in patterns of interaction in families, communities, or wider social spheres. Ultimately, whatever the extent to which we can universalize the categories of the DSM by choosing suitable level of abstraction, diagnosis remains a social practice that must be studied, critiqued, and clarified by cultural analysis. (1998, p. 342)

C. The Neo-Kraepelinian Movement

But who were these people in power who rejected evidence of cultural variations? They were those who favored a biological perspective—a medical model—of mental illness. It is no secret that for the past few decades, psychiatry has sought to extricate itself from its Freudian heritage and to re-establish itself as a medical specialty. To accomplish this, it would be necessary to support a medical model of psychopathology, which sought etiological causes within reductionist levels of explanation. Klerman (1978), a staunch supporter of the efforts to establish psychiatry as a medical profession and science (i.e., Neo-Kraepelinian viewpoint) wrote the credo for the new orientation. Some key points in Klerman's credo include the following: (a) psychiatry is a branch of medicine, (b) there is a boundary between the normal and the sick, (c) There are many discrete types of mental illness, (d) the focus of psychiatric physicians should be particularly (directed toward) the biological aspects of mental illness. Blashfield (1984), a psychologist with a jaded but probably accurate view of the unfolding events of the day, referred to these efforts as a "neo-Kraepelinian conspiracy."

Regardless of the terms used to describe the situation, the fact of the matter was that psychiatrists in positions of power and authority were exercising their influence to shape the values and directions of the field. They were doing so because they believed that psychiatry was moving away from its medical roots toward a social science conception of mental illness. Their struggle for identity, purpose, and professional direction was real. Ultimately, those favoring a biomedical orientation for psychiatry won the power positions. This, too, should not be surprising since it has been the norm among the mental health professions and sciences since their emergence in the 19th century, regardless of American psychiatry's ambivalent involvement with psychoanalysis between

1920-1960 (e.g., Foucault, 1967; Rosen, 1968; Zilboorg, 1941/1967). Those in power shape the "conventional" viewpoints, and those that differ remain marginalized until they acquire power or form and alternative perspective. At present, there is no doubt that the biomedical position dominates psychiatry. But, it is also clear that the cultural psychiatry position—and related viewpoints in the social sciences such as psychiatric anthropology and cultural psychology— are acquiring a stronger voice and position.

D. Postmodern Views

The emergence of postmodernism and related changes in intellectual thought have taught us in recent years that our realities, including our scientific realities, are all culturally constructed. Knowledge in psychiatry and the social sciences is culturally relative, and as such, it is ethnocentric and biased. What passes for truth is, in fact, a function of who holds the power. Those who are in power (e.g., Western psychiatry) have the "privilege" of determining what is acceptable, and those who are not, are marginalized in their opinion and influence. This is not a pleasant reality for many, but it is an accurate portrayal of the situation. It is difficult for professionals to work within a context that questions the validity of their decisions and that suggests that "truths" may be little more than relativistic assumptions supported by data that are themselves questionable. Yet, it is now evident that many mistakes have been made in the care of the mentally ill. This is especially true for ethnic minority patients and for patients in non-Western countries who have been assessed, diagnosed, and treated by culturally insensitive approaches.

Today, the situation is changing (see Marsella, 1993, for a discussion of the convergence of factors that have contributed to new views) and ethnic minority and non-Western professionals and scientists are speaking against the ethnocentric biases of Western psychiatry and social sciences. Chakraborty (1991), an Asian Indian psychiatrist, writes:

Even where studies were sensitive, and the aim was to show relative differences caused by culture, the ideas and tools were still derived from a circumscribed area of European thought. This difficulty still continues and, despite modifications, mainstream psychiatry remains rooted in Kraepelin's classic 19th century classification, the essence of which is the description of the two major "mental diseases" seen in mental hospitals in his time—schizophrenia and manic depression. Research is constrained by this view of psychiatry. A central pattern of (western) disorders is identified and taken as the standard by which other (local) patterns are seen as minor variations. Such a construct implies some inadequacy on the part of those patients who fail to reach "standard." Though few people would agree with such statements, there is evidence of biased, value-based, and often racist undercurrents in psychiatry Psychiatrists in the developing world... have accepted a diagnostic framework developed by western medicine, but which does not seem to take into account the diversity of behavioral patterns they encounter, (p. 1204)

Similarly, Misra (1996), an Asian Indian psychologist, writes:

The current Western thinking of the science of psychology in its prototypical form, despite being local and indigenous, assumes a global relevance and is treated as a universal mode of generating knowledge. Its dominant voice subscribes to a decon-textualized vision with an extraordinary emphasis on individualism, mechanism, and objectivity. This peculiarly Western mode of thinking is fabricated, projected, and institutionalized through representation technologies and scientific rituals and transported on a large scale to the non-Western societies under political-economic domination. As a result, Western psychology tends to maintain an independent stance at cost of ignoring other substantive possibilities from disparate cultural traditions. Mapping reality through Western constructs has offered a pseudounder-standing of the people of alien cultures and has had debilitating effects in terms of misconstruing the special realities of other people and exoticizing or disregarding psychologies that are non-Western. Consequently, when people from other cultures are exposed to Western psychology, they find their identities placed in question and their conceptual repertoires rendered obsolete, (p. 497-498)

E. Individualism and Scientism

It is time for Western mental health professionals and scientists to reconsider their assumptions, methods, and conclusions within the culturally pluralistic context of our world. The current world population now exceeds six billion people. Of this number, only one billion are of European and North American ancestry. However, because their nations are the dominant economic and political powers, their cultural tradition—their worldview—exercises a disproportionate influence on our approaches to mental health theory and practices. Sloan (1996a) noted the following:

Psychological theory and practice embody Western cultural assumptions to such an extent that they primarily perform an ideological function. That is, they serve to reproduce and sustain societal status quo characterized by economic inequality and other forms of oppression such as sexism and racism. The core operative assumptions that produce this ideological effect both in theory and practice are individualism and scientism. (1996a, p. 39)

Sloan's observations on individualism and scientism address two basic cultural assumptions of Western mental health professionals and scientists: (a) problems reside in individual brains and minds, and thus, individual brains and minds should be locus of treatment and prevention; (b) the world in which we live can be understood objectively through the use of quantitative and empirical data. Both of these assumptions stand in direct opposition to the postmodernist views that currently characterize and inform the study of culture and mental health relationships. These views emphasize the importance of the social context of psychological problems (i.e., powerlessness, poverty, marginalization, inequality) in understanding the etiology and expression of psychopathology. They point out that the individual psyche comes to represent and reflect the struggles and conflicts in our cultural environment and the subjective nature of our knowledge about the world in which we live. This has led to an increased emphasis on qualitative research (e.g., Marsella, Purcell, & Carr, 1999).

F. American Psychological Association Guidelines

In response to the changing context of our times, the American Psychological Association (1992) adopted a set of guidelines for psychologists working with patients from different ethnocultural groups. These guidelines are clear and unambiguous in their assertion that psychologist should refrain from working with people from different ethnocultural traditions if the psychologist has no knowledge, experience, nor training with the group. These guidelines were enacted when it was pointed out that there was a bias in the APA Code of Ethics and that many ethnic minority patients were being inaccurately diagnosed and inappropriately treated (e.g., Pedersen & Marsella, 1982).

G. The Maturation of the Field

It is noteworthy that the study of culture and mental health has greatly matured in recent years, and many publications now provide a substantial theoretical, methodological, and clinical basis for the field. Numerous books have been published on the following:

1. Disorders (e.g., depression—Kleinman & Good, 1985; posttraumatic stress disorder (PTSD)—Marsella, Friedman, Gerrity, & Scurfield, 1996; and culture-bound disorders—Simons & Hughes, 1985)

2. Ethnocultural groups (e.g., Chinese—Lin et al., 1995)

3. Risk populations (e.g., refugees—Marsella, Bornemann, Ekblad, & Orley, 1994)

4. Issues (e.g., classification—Mezzichet al., 1996)

5. Pathological cultural processes (e.g., modernization—Sloan, 1996b; urbanization—Marsella, 1998b).

In addition, there are a score of readily available general texts (e.g., Al-lssa, 1995; Castillo, 1997; Gaw, 1993; Leff, 1988), and a growing number of specialized research and clinical journals (e.g., Transcultural Psychiatry; Culture,

Medicine, and Psychiatry; Cultural Diversity and Ethnic Minority Psychology) that publish rigorous and scholarly articles reflecting the new orientation.

The "new" culture and mental health professional and researcher believes individual and societal mental health are inextricably linked—that we must understand the ecology of mental health. Thus, mental health is not only about biology and psychology, but also about education, economics, social structure, religion, and politics. There can be no mental health where there is powerless-ness, because powerlessness breeds despair. There can be no mental health where there is poverty, because poverty breeds hopelessness. There can be no mental health where there is inequality, because inequality breeds anger and resentment. There can be no mental health where there is racism, because racism breeds low self-esteem and self-denigration; and lastly, there can be no mental health where there is cultural disintegration and destruction, because cultural disintegration and destruction breed confusion and conflict.

In brief, the roots of despair, hopelessness, anger, low self-esteem, and confusion reside in the ecological relationships among human biology, psychology, and sociocultural and environmental millieus and contexts. This does not mean our biological (e.g., genetics, neurotransmitters) nature is unimportant. Rather, this view repositions biology as one of many interactive determinants of mental health, and it acknowledges the importance of socioenvironmental demands. The "new" culture and mental health professional and researcher must be skilled and adept at diagnosing and treating individual and sociocultural problems within an ecological framework. This will often require him or her to initiate economic, political, and community actions. Table I presents the emerging array of challenges and possibilities within this ecological framework.

It is clear from Table I that the "new" culture and mental health professional will need to be versed in a broader spectrum of conceptual approaches to diagnosis and treatment. Concern for the ecology of mental health will require training in multicultural, multidisciplinary, and multisectoral areas. It is time, perhaps, for a "new" professional code for culture and mental health clinicians and researchers, a code that affirms that being a culture and mental health professional is a way of life and not simply a job, because the work we do has serious moral and political implications. The following characteristics are offered as a foundation for the "new" culture and mental health:

1. It is a worldview.

2. It is committed to diversity.

3. It is committed to social justice and activism.

4. It is concerned with optimizing communication.

5. It is concerned with empowering individuals, groups, and nations.

6. It is concerned with offering hope, optimism, and opportunity.

7. It is multicultural, multidisciplinary, and multisectoral.

8. It is ecological, historical, interactional, and contextual.

TABLE I Ecological Spectrum of Concerns for the "New" Culture and Mental Health Professional

Level of interest

Individual level

Cultural level

Sociopolitical level

Sample negative concerns

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