CULTURAL PSYCHIATRY

Editor

Dr H TATANG KARTAWAN

2006

CROSS-CULTURAL PSYCHIATRY

SOCIO-CULTURAL DIFFERENCES

(ETHNICITY, NATIONALITY, RELIGION ETC) IMPAIR COMMUNICATION (COMPLAINT, PST UNDERSTANDING OF ILLNESS AND NEED FOR TREATMENT, RAPPORT)

MISUNDERSTANDING

HUMILITY, RESPECT

ASKING, DO NOT ASSUMING

• CULTURE MEANINGS, VALUES & BEHAVIORAL NORMS THAT ARE

LEARNED AND TRANSMITTED IN THE DOMINANT SOCIETY AND WITHIN ITS SOCIAL GROUPS

A TOTALITY COMPOSED OF SUBJECTIVE DIMENSIONS (VALUES, FEELINGS, IDEALS) AND OBJECTIVE DIMENSIONS (BELIEFS, TRADITIONS, BEHAVIORAL PRESCRIPTIONS) EXPRESSOR, MEDIATOR, MODERATOR OF PSYCHOLOGICAL PROCESSES AND EMOTIONAL DISORDERS INFLUENCE COGNITION, FEELINGS, SELF CONCEPT, D/ & TH/• ETHNICITY GROUPS OF INDIVIDUALS SHARING A SENSE OF COMMON

IDENTITY, COMMON ANCESTRY AND SHARED BELIEFS & HISTORY (PREFERRED TERMINOLOGY THAN RACE THAT HAS A MORE BIOLOGICAL CONNOTATION)

• ANTHROPOLOGY THE STUDY OF HUMAN BEINGS PSYCHIATRIC RELEVANCES : SYNDROMAL SIGNIFICANCE, FORMULATING ILLNESS & RESPONDING TO IT IN CULTURALLY APPROPRIATE WAYS, IMPROVING OUTCOME AND PREVENTING ILLNESS HELPS TO UNDERSTAND NORMAL AND MALADAPTIVE BEHAVIOR IN VARIOUS CULTURE CULTURAL VARIABLES INFLUENCE BEHAVIOR HELPS FURTHER UNDERSTANDING OF NATURE VS NURTURE PHENOMENA (WHICH ASPECTS OF HUMAN BEINGS ARE INNATE, BIOLOGICAL AND WHICH ARE SHAPED BY THE ENVIRONMENT AND HOW THE CONSTANT INTERACTIONS & FEEDBACKS BETWEEN THAT TWO ASPECTS AFFECTS HUMAN BEING)

NORMALITY VS ABNORMALITY

• SOCIAL DEF OF NORMALITY AND ABNORMALITY BASED ON SHARED BELIEFS WITHIN A GROUP OF PEOPLE AS WHAT IS CONSIDERED THE IDEAL/PROPER WAY FOR INDIVIDUALS TO CONDUCT THEIR LIVES IN RELATION TO OTHERS GUIDELINES TO BE CULTURALLY NORMAL AND THE CRITERIA OF BEING TEMPORARILY ABNORMAL

• NORMALITY HAS A MULTIDIMENSIONAL ASPECT (BEHAVIOR, DRESS, HAIRSTYLE, PERSONAL HYGIENE, GESTURES, LANGUAGE, TONE OF VOICE ETC APPROPRIATENESS TO CERTAIN CONTEXT & SOCIAL RELATIONSHIPS)

• NORMALITY IS NOT A STATIC CONDITION, COULD CHANGE WITH TIME AND CIRCUMSTANCE AND ALSO DEPEND ON THE SUBJECTIVITY/PARTICULAR PERSPECTIVE OF THE ONLOOKER

Controlled Normality

Normal Abnormal

A BControlled Abnormality

(Symbolic Inversions, Religious States, Culture-Bound Syndromes)

Controlled

Uncontrolled

Uncontrolled Abnormality

(Mad)

Uncontrolled Normality

(Bad)

C D

NORMALITY VS ABNORMALITY

• 4 ZONES OF SOCIAL BEHAVIOR THE N/ABN BEHAVIOR IS STILL CONTROLLED BY SOCIAL NORMS/RULES OR NOT

CONTROLLED NORMALITY, MOST CULTURES HAVE A WIDE RANGE OF SOCIAL NORMS APPROPRIATE FOR DIFFERENT AGE GROUPS, GENDERS, OCCUPATION, SOCIAL RANKS, MINORITIES (A) CONTROLLED ABNORMALITY, ON CERTAIN OCCASIONS NORMS/RULES ARE DELIBERATELY FLOUTED/INVERTED ABNORMAL BEHAVIOR BECOMES TEMPORARILY PERMISSIBLE (FESTIVALS, PARADES, CARNIVALS, TOURIST DRESS-BEHAVIOR DURING HOLIDAYS, BEING POSSESSED, GLOSSOLALIA, RELIGIOUS RITUALS, CULTURE-BOUND SYNDROMES ETC) (B) UNCONTROLLED NORMALITY, NORMAL BEHAVIOR BUT SOCIALLY UNDESIRABLE, OFTEN ILLEGAL (BAD, CRIMINAL) (C)

UNCONTROLLED ABNORMALITY, STRANGE/ABNORMAL BEHAVIOR NOT CONTROLLED BY SOCIAL NORMS, HAS NO ACCEPTABLE CAUSAL FACTOR AND NO APPARENT PURPOSE (MAD) (D)

ROLE OF CULTURE AS AN ETIOLOGICAL FACTOR OF MENTAL ILLNESS

• ALL CULTURES DEVELOP PROCESSES THAT FACILITATE ADJUSTMENT & CONFLICT RESOLUTION AND PRESSURES THAT FOSTER CONFLICT, DEVIANCE AND MALADJUSTMENT

EACH CULTURE PROVIDES ITS OWN UNIQUE STRESSES & BELIEFS AND RITUALS TO REDUCE PSYCHOLOGICAL TENSION GLOBALIZATION INCREASE ECONOMIC, POLITICAL AND SOCIAL COMPETITION ADDITIONAL ADAPTIVE STRESSES FOR INDIVIDUAL/CULTURAL GROUPS• IMMIGRANTS OFTEN HAVE A HIGHER RATE OF MENTAL

ILLNESS 3 SOURCES OF (ADAPTATIONAL) STRESS : ENTRY INTO THE HOST SOCIETY, DISRUPTION OF INTERPERSONAL RELATIONSHIPS, ACCULTURATION PROCESS IMMIGRANTS, MINORITIIES, EVALUATE THE INVOLVEMENT WITH CULTURE OF ORIGIN AND HOST

• 3 HYPOTHESES TO EXPLAIN HIGHER RATE OF MENTAL ILLNESSES AMONG IMMIGRANTS :

1. SELECTION HYPOTHESES CERTAIN MENTAL

DISORDERS INCITE THE INVIDUAL TO MIGRATE

2. STRESS HYPOTHESES PROCESS OF MIGRATION

CREATES MENTAL STRESS AND MAY PRECIPITATE

MENTAL ILLNESS IN SUSCEPTIBLE INDIVIDUALS

(HOUSING, INCOME & EMPLOYMENT PROBLEMS,

LANGUAGE DIFFICULTIES, REFUGEE STATUS,

RACIAL PREJUDICE, DISCRIMINATION & HARASSMENT,

ETC)

3. NON-ESSENTIAL ASSOCIATION BETWEEN MIGRATION

AND SOME VARIABLES (AGE, CLASS & CULTURE

CONFLICT ETC)

• PREVENTIVE FACTORS FOR HAVING MENTAL ILLNESS :

GREAT DETERMINATION TO MIGRATE, MIGRATION FOR ECONOMIC REASON, AN INTENTION TO RETURN HOME, LITTLE ATTEMPT AT ASSIMILATION, HIGH DEGREE OF ENTERPRENEURSHIPS, FAMILY COHESION, RELIGION

• OTHER FACTORS THAT MAY INCREASE THE POSSIBILITY OF HAVING MENTAL ILLNESS :

RIGID DIVISION AMONG SEXES, SOCIAL ISOLATION OF WOMAN, MULTIPLE RELIGIOUS TABOOS, SEVERAL GENERATIONS OF A FAMILY LIVE IN THE SAME HOUSE, INTERGENERATIONAL CONFLICTS, PRESSURE ON CHILDREN TO SUCCEEED FINANCIALLY OR ACADEMICALLY

CULTURAL INFLUENCES ON THE CLINICAL PRESENTATION & DISTRIBUTION OF MENTAL ILLNESS

• CULTURAL AND MEDICAL ANTHROPOLOGY SUPPLIES CULTURAL PSYCHIATRY :

- UNDERSTANDING OF THE BEHAVIOR OF PEOPLE IN THEIR

NATURAL HABITATS

- NATIVE VIEW ON HEALTH AND ILLNESS

- DESCRIPTIONS OF INDIGENOUS HEALING SYSTEM

- ROLE OF THE HEALER AND RITUALS OF HEALING IN

DIFFERENT ETHNIC & CULTURAL GROUPS

• CULTURE BOUND SYNDROMES EXOTIC DISTURBANCES OF THOUGHT, MOOD, OR

BEHAVIOR DISPLAYING DRAMATIC PRESENTATION OCCURING IN THE SPECIFIC LOCAL CULTURES, AND AT LEAST PARTIALLY UNDERSTOOD THROUGH THE LENS OF THE PSYCHOSOCIAL FORCES, OFTEN CONLICTUAL, RELEVANT TO THAT PARTICULAR CULTURE

A GROUP OF FOLK ILLNESSES, UNIQUE TO A PARTICULAR GROUP OF PEOPLE, CULTURE OR GEOGRAPHICAL AREA, USUALLY HAVE A SYMBOLIC MEANINGS, MORAL, SOCIAL OR PSYCHOLOGICAL FOR BOTH THE VICTIMS OR THOSE AROUND THEM

RECURRENT, LOCALITY SPECIFIC PATTERN OF ABBERANT BEHAVIOR AND TROUBLING EXPERIENCES THAT DIFFER FROM CONVENTIONAL WESTERN PSYCHIATRIC DIAGNOSIS

CULTURALLY BASED SIGNS AND SYMPTOMS OF MENTAL DISTRESS OR MALADAPTIVE BEHAVIOR THAT ARE PROMINENT IN FOLK BELIEFS AND PRACTICES

• DIFFERENCES IN RACE, NATIONALITY, RELIGION & OTHER SIGNIFICANT CULTURAL ASPECTS CAN IMPAIR COMMUNICATION AND CAUSE MISUNDERSTANDING

AFFECT THE WAY THE PATIENT PRESENT THEMSELVES

TO THE PHYSICIAN, THE SYMPTOMS THEY COMPLAINTS

AND THEIR UNDERSTANDING OF THE CAUSES OF

ILLNESS AND NEED FOR TREATMENT

• EACH CULTURE PROVIDES ITS MEMBER WITH WAYS OF BECOMING “ILL”, SHAPING SUFFERINGS INTO A RECOGNIZABLE ILLNESS ENTITY, EXPLAINING ITS CAUSE AND GETTING TRETMENT FOR IT

MENTAL ILLNESS IS DUE TO SPIRIT POSSESSION,

WITCHCRAFT, BREAKING OF RELIGIOUS TABOOS,

DIVINE RETRIBUTION, THE “CAPTURE” OF THE SOUL BY

A MALEVOLENT SPIRIT

(WESTERN CONCEPT, EMPHASIZES PSYCHOLOGICAL

FACTORS, LIFE EXPERIENCES AND EFFECTS OF STRESS)

• EACH CULTURE PROVIDES A REPERTOIRE OF SYMBOLS AND IMAGERY IN WHICH MENTAL ILLNESS CAN BE ARTICULATED

• ETHNIC PSYCHOPHARMACOLOGY

- RACE, ETHNICITY METABOLISM, EFFECTS OF

PSYCHOTROPICS

- BIOLOGICAL, PSYCHOLOGICAL EFFECTS OF ANCIENT

SYSTEMS OF DIETS AND CURATIVE HERBS

SOMATIZATION AND PSYCHOLOGIZATION SOMATIZATION THE CULTURAL PATTERNING OF PSYCHOLOGICAL AND SOCIAL

DISORDERS INTO A LANGUAGE OF DISTRESS OF MAINLY PHYSICAL SYMPTOMS AND SIGNS

SWARTZ : “ A WAY OF SPEAKING WITH THE BODY” LANGUAGE OF DISTRESS (SOCIAL OR PSYCHOLOGICAL) DIFFUSE AND CHANGEABLE PHYSICAL COMPLAINTS USUALLY ARE MASKED FOR DEPRESSION (TIREDNESS, HEADACHE, PALPITATIONS ETC) SOMATIZATION IS INFLUENCE BY CULTURAL AND SOCIAL

BACKGROUND (ASIANS, BLUE COLLAR WORKERS) CULTURAL SOMATIZATION : THE ORGAN CHOSEN OFTEN HAS A

CULTURAL SYMBOLIC OR METAPHORIC SIGNIFICANCE, BESIDES SPECIFIC MEANING FOR THE INDIVIDUAL PERSON

PSYCHOLOGIZATION THE USE OF ABSTRACT PSYCHOLOGICAL TERMS OR CONCEPTS TO

DESCRIBE SUBJECTIVE MENTAL STATES IS MORE COMMON AMONG THE WHITE COLLAR WORKERS

INTERPRETATION OF SOMATIZATION (CLINICIANS, PSYCHIATRISTS, ANTHROPOLOGISTS) :

• INDEX OF DISEASE OR DISORDER

• SYMBOLIC EXPRESSION OF INTRAPSYCHIC CONFLICT

• INDICATION OF A SPECIFIC PSYCHOPATHOLOGY

• IDIOMATIC EXPRESSION OF DISTRESS

• METAPHOR FOR EXPERIENCE

• “ACT OF POSITIONING” WITHIN A LOCAL WORLD

• FORM OF SOCIAL COMMENTARY OR PROTEST

MUMFORD, LEVELS AT WHICH CULTURE SHAPE THE EVOLUTION OF SOMATIC SYMPTOMS

1. LANGUAGE AND IDIOM

2. CONCEPTS OF HEALTH AND DISEASE

3. CULTURALLY SANCTIONED ILLNESS BEHAVIOR

CULTURAL INFLUENCES ON RECOGNITION, LABELLING, EXPLANATION AND TREATMENT CONCEPT OF MENTAL ILLNESS

• MEAD, BEHAVIOR IS RELATIVE, SOCIETY CAN CREATE DEVIANCE BY EITHER CONDONING OR CONDEMNING CERTAIN BEHAVIOR PATTERN

• EACH HUMAN SOCIETY HAS AN INDIGENOUS BODY OF BELIEFS AND PRACTICES TO EXPLAIN AND TREAT DISEASE AND DISORDER DISTRESS DEALS THROUGH COMMONLY UNDERSTOOD SYMBOLS AND MEANINGS

• IT IS IMPORTANT TO UNDERSTAND THE SOCIAL AND CULTURAL DIMENSIONS OF MENTAL ILLNESS, SINCE CULTURAL FACTORS INFLUENCE THE CLINICAL PRESENTATION AND RECOGNITION OF MENTAL ILLNESS EVEN IT HAS AN ORGANIC BASIS

• CULTURALLY, ABNORMALITY OF MENTAL FUNCTION IS OFTEN SEEN MORE AS AN ABNORMAL SOCIAL BEHAVIOR

ABNORMAL ACTION RATHER THAN MISTAKEN BELIEF (DELUSION)

• D/ OF MENTAL ILLNESS DEPEND NOT ONLY TO THE EVALUATION OF CLINICAL PRESENTATION AND RESULT OF PSYCHOMETRIC TESTS, BUT ALSO TO HOW THAT PERSON BEHAVIOR PERCEIVE BY HIS COMMUNITY

• LABELLING MENTAL ILLNESS BASED ON THREE APPROACH

BIOLOGICAL APPROACH

APPLY WESTERN PSYCHIATRIC MODEL UNIVERSALLY BECAUSE THE MENTAL ILLNESSES HAVE THE SAME BIOLOGICAL BASIS, ONLY THE CONTENT OF THE SYMPTOMS MAY INFLUENCE BY CULTURE

CATEGORY FALLACY, SOME MENTAL ILLNESS MAY

PLAY DIFFERENT SOCIAL ROLES AND MEANINGS

SOCIAL LABELLING

SOCIETY DECIDES WHAT SYMPTOMS/BEHAVIOR PATTERNS ARE DEVIANT AND WHICH OF THAT DEVIANCES CAN CALLED MENTAL ILLNESS, SO IT IS RELATIVE TO THE SOCIETY IN WHICH IT IS FOUND CULTURE SPECIFIC, AND THE PATIENT LEARNS HOW TO BE SICK IN THE WAY HIS SOCIETY UNDERSTANDS

DE-LABELLING IS THEN ALSO DEPEND ON THE EVALUATION OF THE SOCIETY AT LARGE

DENIES BIOLOGICAL ASPECT OF MENTAL ILLNESS AND

UNIVERSALITY OF CERTAIN MENTAL DISORDERS

COMBINED BIOLOGICAL-SOCIAL APPROACH

THERE ARE CERTAIN UNIVERSALS IN ABNORMAL BEHAVIOR WHILE THE CLINICAL PRESENTATION MAY INFLUENCE BY THE LOCAL CULTURE

D/ MAY DIFFER BUT SYMPTOM PATTERNS CAN BE COMPARED

• POLITICAL AND MORAL CONSIDERATIONS (LAWBREAKERS, DISSIDENTS)

• SOCIAL CONTROL, ESP TOWARDS MINORITIES, IMMIGRANTS

STEREOTYPE, RACE PREJUDICE DIAGNOSTIC CATEGORIES

CULTURAL SYMBOLIC HEALING

• SYMBOLIC HEALING HEALING THAT RELY ON LANGUAGE, RITUAL AND

MANIPULATION OF POWERFUL CULTURAL SYMBOLS STEPS : 1. THE HEALER MUST HAVE A COHERENT SYSTEM OF EXPLANATION OR FRAME OF REFERENCE FOR THE ORIGIN AND NATURE OF THE PROBLEM AND HOW IT CAN BE DEALT WITH THE MYTHIC WORLD 2. THE SUFFERING INDIVIDUALS MUST BE ABLE TO UNDERSTAND THEIR SITUATION AND ITS RESOLUTION IN TERMS OF ITS IMAGERY AND SYMBOLS SYMBOLIC BRIDGE 3. THE HEALER CONVINCE THE PATIENT TO ACCEPT AN EXPLANATION OF HIS PROBLEM BASED ON THE MYTHIC WORLD

4. PATIENT, EITHER EMOTIONALLY OR INTELECTUALLY

ATTACHED TO THE SYMBOLS OF THE MYTHIC WORLD

5. THERAPEUTIC CHANGE BY MANIPULATING THE

SYMBOLS OF THE MYTHIC WORLD EXORCISM

6. THE HEALED PATIENT ACQUIRED A NEW WAY OF

CONCEPTUALIZING THEIR EXPERIENCE IN SYMBOLIC

TERMS AND A NEW WAY OF FUNCTIONING, CONFIRMED

BY THE HEALER LIVED A NEW LIFE

• IN MANY NON-WESTERN SOCIETIES, ESP. RURAL, SMALL SCALE COMMUNITIES MENTAL ILLNESS IS OFTEN CONSIDERED AS A SOCIAL EVENTS INVOLVES THE PATIENT’S FAMILY, FRIENDS & COMMUNITY

MENTAL AND PHYSICAL ILL-HEALTH INDICATED CONFLICTS, PROBLEMS IN THE SOCIAL FABRIC KLEINMAN , CULTURAL HEALING : HEALING RITUALS ATTEMPT TO REPAIR THE SOCIAL TEARS AND REASSERT THREATENED VALUES AND ARBITRATE SOCIAL TENSIONS RESOLVE THE CONFLICTS CAUSING THE PATIENT’S ILLNESS, RESTORE GROUP COHESION AND INTEGRATE THE PATIENT BACK INTO NORMAL SOCIETY THE PATIENT AND THE COMMUNITY ALL RESTORED TO HEALTH MENTAL ILLNESS SEEMS MORE EASILY CURED AND SHORT-LIVED• MENTAL ILLNESS SOMETIMES USEFUL TO THE COMMUNITY INCURS OBLIGATIONS AMONG THE FAMILIES AND MEMBERS OF THE COMMUNITY ESP DURING THE HEALING RITUALS AND PROCESS STRENGTHENING THE TIES WITHIN AND BETWEEN GROUPS INTEGRATIVE FUNCTION

• THE CULTURAL HEALING MAY CAUSE SUFFERINGS TO THE MENTAL PATIENT IMPRISONING, KILLING, EXCILATION

• SYMBOLIC HEALING

HEAL THE ILLNESS > CURE THE DISEASE

• THE WAY TRADITIONAL HEALERS WORKS :

WORKING WITHIN THE SHARED BLIEFS OF THE GROUP

REINFORCING IT

INVOLVE THE PATIENT AND HIS COMMUNITY IN THE HEALING RITUALS

PATIENT SURROUND BY HIS FAMILIES AND FRIENDS

BY BECOMING “CONTROLLED POSSESSED” SHOWS HIS MASTERY OVER THE ACCUSED-CAUSAL SPIRITS

THE FAMILY

• FAMILY CULTURE FAMILY IS THE PRIMARY SOCIAL GROUP OF A PATIENT

SMALL SCALE SOCIETY, SMALL TRIBE WITH ITS OWN DISTINCTIVE ORGANIZATION AND CULTURE, WHICH CAN BE EITHER PROTECTIVE OR PATHOGENIC

• INTERCONNECTEDNESS VS SEPARATENESS• EXTENDED OR JOINT FAMILY VS NUCLEAR FAMILY

REFERENCES1. HELMAN CG, CULTURE, HEALTH & ILLNESS, 4TH ED, OXFORD,

BUTTERWORTH HEINEMANN, p170-201,20002. KAPLAN & SADOCK’S SYNOPSIS OF PSYCHIATRY, BEHAVIORAL

SCIENCES/CLINICAL PSYCHIATRY 9TH ED, LIPPINCOT WILLIAMS & WILKINS, 2003