Global Psychiatry

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Writing generally, in its approach to the study and treatment of mental disorders, Western psychiatry has tended to ignore socio-cultural factors, preferring instead to conceptualize the illnesses with which it is concerned as having a biological basis and a single aetiology and presentation.  Mental disorders as seen by the West are universal and those elsewhere marginalized and considered culture bound.  All cultures do have recognised human behavioural breakdowns – sustained anomalous behaviours judged negatively and regarded as disruptive to organized social life – but this does not mean that there is a single ‘true’ psychiatry.

Whilst there are likely to be some universal – biological – processes involved in the aetiology of mental disorders, to conceive human behavioural disturbance simply in terms of chemical processes is simplistic.  Their causes are multi-determined, with socio-cultural factors playing a crucial role.  Human beings and their cultures are not separable but interdependent and reflective of one another.  The culture of individuals will interact with biological, psychological and environmental variables to determine the causes and manifestations of mental disorder.  The symptoms, meanings and appropriate treatments of mental disorders are then likely to vary across cultures.  That the dividing line between the sane and insane is culturally determined is clear, as it is being constantly readjusted even in Western medicine; homosexuality for instance crossed over from mental disorder to normal behaviour in 1974*.  A behavioural disturbance seen in another culture may resemble that identified by Western medicine, and a Western treatment may even be of assistance in its resolution, but to disregard a local viewpoint and impose a Western one risks medical imperialism.

Concepts of mental illness in non-Western cultures can be markedly different.  Non-western cultures for instance appear often to emphasize somatic symptoms when presenting with a depression-like illness, perhaps because of beliefs about the integration of body and mind.  Furthermore, emotional states that appear quite fundamental from the perspective of an English speaker are not always mirrored in the lives and languages of other cultures.  It is often very difficult to find words or phrases for ‘depression’ in the non-Western lexicon.  Such difference is even plainer when we consider that whilst the English language contains over 2000 emotional words, most languages contain fewer than 200.

Of course the reality is much more nuanced than this ‘West vs. the rest’ scenario and in any one place or culture explanatory models that are used to account for disease and illness often vary between different social groups occupying the same location at a point in time.  For example there may be differences in explanatory models between townsfolk, traditional healers and Western trained professional elites.  Western ideas, however have great influence not least in scientific inquiry where much cross-cultural psychiatric research has been undertaken by academic psychiatrists using Western psychiatric concepts to explain behaviour in non-Western people.  Such activity often uses definitions of mental illness as stated in DSM and ICD-10 manuals.  These are supposedly objective accounts, but are in fact in themselves culture bound documents, representing the attempts of one particular group of people to make sense of human behavioural breakdowns.  It is social anthropologists rather than psychiatrists who have been interested in exploring concepts of normality and abnormality in different cultures.

Ideas of the universality of the Western psychiatric model are extremely powerful, but we cannot assume that because Western mental phenomena can be identified in non-Western settings, they mean the same as they do in the Western world.  This is an important topic, as the WHO has said that, within a decade, depression will globally be second only to cardiovascular disease in terms of disease burden.  A more culturally relativistic approach would find this concerning, as ‘depression’ is merely a description syndrome and is highly heterogeneous and socially shaped.  It is therefore unsuitable to be regarded as a universally valid mental health disorder.  Framing people’s difficulties as being in the realm of mental health raises a familiar concern that to act in this way is to draw attention away from other causes of their distress, for instance poverty or lack of rights.

Consider then that despite its prominence, Western psychiatry is simply one of a number of ethno-psychiatries.  It possesses however one important difference: it is the only psychiatric paradigm with the power to project its conclusions onto the rest of the world.

* According to the American Psychiatric association who decided to remove homosexuality from the DSM following a vote

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Links:

There chapters in these two books touch on this subject
Madness Explained By Richard Bentall / Malignant Sadness Lewis Wolpert

Also:

Are mental disorders caused by universal processes that create recognisable symptoms regardless of the culture in which they occur?

How scientifically valid is the knowledge base of global mental health?

3 Responses to “Global Psychiatry”

  1. “Concepts of mental illness in non-Western cultures can be markedly different. Non-western cultures for instance appear often to emphasize somatic symptoms when presenting with a depression-like illness, perhaps because of beliefs about the integration of body and mind. ”

    It seems to me that where we have progressed in understanding some of the complexities of the mind, many cultures still think that all “mad” people have been cursed by the devil, and that there is no hope for them other than feeding them some herbs. Not so much somatic as just delusion on a grand scale. Whether their government is to blame or not is another question, but many highly educated people still believe in the most stupid things when it comes to the mind.

  2. NiroZ says:

    Psychiatry, to my understanding, is mainly based around treating (sometimes neurological or) psychological disorders that cause harm to either themselves, others or both. Granted, some do try to zealously swat down any sign of any incoming deviation from the norm, I’ve been to one of them, but that doesn’t’ mean they all do it. Sure, they don’t always get things right, like with homosexuality, and undoubtedly there’s a cultural bias, but you could say that of all medicine, I mean, remember the 4 humours and blood-letting? I think that they’re willing to change is a powerful argument in favour of them.

    The problem is not that western psychiatry is projecting it’s standards onto the world, but that the rest of the world’s psychiatric services are so far behind that they have to borrow from the west, which I suppose is better than nothing, and even if the symptomatology isn’t the same, at least they can borrow the framework, allowing them to develop theirs faster than the west did.

  3. PJ says:

    I’m not sure that ICD is totally Western dominated – it has neurasthenia (which is, admittedly, now considered a culture bound syndrome in DSM).

    You could also, I think, make a good case for things like IBS, ME, and fibromyalgia being largely Western cultural specific somatisation syndromes.

    In fact I’m not convinced that actually we’re not hiving off some of those somatising symptoms we talk about as prevalent in non-Western cultures into these conditions rather than accepting that they’re actually part of depression and anxiety. This is a highly culturally bound activity all due to ideas of what is socially acceptable.

    Working in non-psychiatric medicine at the moment I’m really struck by how much of medicine and surgery is made up of people with at least a very large psychological component to their symptoms if not a full blown and highly recognisable psychiatric disorder. And yet these people are laparascoped and CTed and have their uterus whipped out, with nary a psychiatric opinion to muddy the waters.

    Of course the really interesting question about the cultural-bound nature of psychiatric illness concerns psychosis and false beliefs. Why is it ok for someone from Nigeria to believe in evil spirits but not Surrey? Why is a belief in little black helicopters or 7ft lizard men a sign of mental illness when it is seemingly so widespread in the population?

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