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9. It is biopsychosocial. 10. It is revolutionary and progressive.

II. OVERVIEW OF CULTURE AND MENTAL HEALTH QUESTIONS, CONCEPTS, AND ISSUES

A. Some Defining Questions

Although the topic of culture and mental health is studied in a number of different academic disciplines and professional fields under such names as trans-cultural psychiatry, cultural psychiatry, ethnopsychiatry, culture and psycho-pathology, and psychiatric anthropology, the disciplines and professions are guided by a set of common concerns and questions:

1. What is the role of cultural variables in the etiology of mental disorders? How do cultural variables interact with biological, psychological, and environmental variables to influence psychopathology?

2. What are the cultural variations in standards of normality and abnormality?

3. What are the cultural variations in the classification and diagnosis of psychopathology?

4. What are the cultural variations in the rates and distribution of psycho-pathology according to both indigenous and Western categories of psycho-pathology?

5. What are the cultural variations in the expression, course, and outcome of psychopathology?

B. Some Important Concepts

1. Ethnocentrism

Ethnocentrism refers to the natural tendency or inclination among all people to view reality from their own cultural experience and perspective. In the course of doing so, the traditions, behaviors, and practices of people from other cultures are often considered inferior, strange, abnormal, and/or deviant. Ethnocentrism becomes a problem in the field of mental health when certain realities regarding the nature and treatment of mental health are imposed on people by those in power without concern for possible bias (Marsella, in press,a).

2. Culture

An older effort at compiling the different definitions of culture (Kluckhohn & Kroeber, 1952) listed more than 150 different definitions. For current purposes, a psycho-behavioral definition of culture used by the senior author for a number of years will be used:

Shared learned meanings and behaviors that are transmitted from within a social activity context for purposes of promoting individual/societal adjustment, growth, and development. Culture has both external (i.e., artifacts, roles, activity contexts, institutions) and internal (i.e., values, beliefs, attitudes, activity contexts, patterns of consciousness, personality styles, epistemology) representations. The shared meanings and behaviors are subject to continuous change and modification in response to changing internal and external circumstances.

This definition acknowledges that the meanings and behaviors shaped by culture, in both its external and internal representations, are dynamic and subject to continuous modification and change. Although the impulse is generally toward adaptation and adjustment, it should be noted that cultures can frequently become pathogenic (e.g., Edgerton, 1992) because of the values and cultural constructions of reality they impart. Culture is the lens or template we use in constructing, defining, and interpreting reality. This definition suggests that people from different cultural contexts and traditions will define and experience reality in very different ways. Thus, even mental disorders must vary across cultures because they cannot be separated from cultural experience. Marsella (1982) stated:

We cannot separate our experience of an event from our sensory and linguistic mediation of it. If these differ, so must the experience differ across cultures. If we define who we are in different ways (i.e., self as object), if we process reality in different ways (i.e., self as process), if we define the very nature of what is real, and what is acceptable, and even what is right and wrong, how can we then expect similarities in something as complex as madness? (1982, p. 363)

3. Ethnocultural Identity

Ethnocultural identity refers to the extent to which an individual endorses and manifests the cultural traditions and practices of a particular group. Clearly, what is important is not a person's ethnicity, but rather, the extent to which they actually are identified with and practice the lifestyle of that group. In groups undergoing acculturation, there can be considerable variation in the extent of ethnocultural identity with a particular cultural tradition. Thus, it is important to determine both a person's ethnicity and their degree of identification with their ethnocultural heritage. Although some individuals may be bi-cultural, others may be fully acculturated, and still others may maintain a traditional identification.

Ethnocultural identity has emerged as one of the most popular new areas of inquiry in cross-cultural research. It is the "new" independent variable in cross-cultural research, replacing the simple comparison of different ethnic groups. Today, ethnocultural identity is being assessed by a variety of methods including the measurement of similarities in attitudes, values, and behaviors of different groups (e.g., Yamada, Marsella, & Yamada, 1998). In studying cultural aspects of mental disorder, it is important that patients be evaluated for their degree of ethnocultural identification. For example, if we are studying mental illness in Hispanic-Americans, we should first determine the extent of the patients' identification with Hispanic culture. If we use Western standards for assessment and diagnosis, we may create many problems. Yamada et al. (1998) have developed a valid and reliable behavioral scale for the assessment of ethnocultural identification across ethnic groups. The DSM-IV (APA, 1994, p. 843) guidelines for the cultural formulation of a case list the cultural identity of the individual as the first criteria to be assessed when conducting a cultural formulation.

C. Cultures as Causative of psychiatric disorders

Cultural factors may play an important role in causing psychiatric disorders, via their roles as a stressor, resource/support system, definition and standard of normality/abnormality, and the concepts of self and personhood.

1. Stress and Stressors

A cultural context can be a major stressor by confronting individuals and/or groups with demands that exceed their abilities and resources to cope. A typical example of this is the rapid social change that characterizes contemporary life and the serious problems associated with urbanization and urban lifestyles (Marsella, 1998b) or modernization and change (e.g., Sloan, 1996b). Other culture-related stressors that may play a role in the etiology of mental disorders include racism, acculturation, social change, cultural abuse, and cultural disintegration.

Acculturation is a good example of the kind of stress that may be imposed on an individual or group of people. Acculturation refers to the process that occurs when an individual or group from a given culture is required to adapt and adjust to the cultural worldviews, customs, and traditions of another group. In many instances, the latter culture is a dominant culture in the interaction. Under pressures to conform, comply, and accommodate to the dominant culture's way of life, the acculturating individual or group may find their own cultural worldviews, customs, and traditions are denigrated, devalued, or denied. Thus, the acculturating individual or group may be left without the cultural anchors that defined their identity and meanings. Sometimes, the acculturation pressures are so great that they provoke burdensome and oppressive patterns of uncertainty, anger, resentment, and despair. The ways of life that had guided people for centuries are now devalued or destroyed. Languages and customs are lost, and children caught in the turmoil of change are often caught between the new and old worlds with resulting anomie and alienation. David Stannard's (1992) poignant analysis of the tragic consequences of acculturation for indigenous people in America captures the stresses of acculturation and cultural disintegration. Table II provides a conceptual model of acculturation. As Table II indicates, the acculturation process is complex and can result in a spectrum of outcomes at individual, cultural, and geographic levels. The key factors may be the circumstances of the culture contact process.

2. Resources and Supports

Culture may be implicated in the etiology of mental disorders because of the presence or absence of different resources or supports. Resources and supports include such factors as social support systems, effective communication networks, effective leaders, flexible belief systems, and the socialization of effective personality dispositions (e.g., hardiness, ego strength, sense of coherence) (Marsella & Scheuer, 1993). Consider the power of a belief. In Islamic cultures, the phrase "Inshallah" means "If Allah will it" or "It is the will of Allah." This belief is invoked to help explain and accept many life circumstances and diffi-

TABLE II Acculturation and Mental Health Model"

Culture contact variables

Individual levels

Cultural levels

Geocultural levels

Number of cultures

Interpersonal

Sociocultural ethos

Urbanization

Diversity of cultures

processes

Social structure

Environment

Culture contact

Personality

Institutions

Ecology

Circumstances

processes

A. Family

Population

(Forced, invited)

Cognitive processes

B. Religion

distribution

Extent of culture

Sensorimotor

C. Education

Disease

contact

processes

D. Politics

exposure

Culture exposure

Psychophysiological

E. Health

Pollution

(Frequency,

processes

F. Economics

duration, intensity)

Neuroanatomical

Social roles

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