Cultural Assessment in Clinical Psychiatry: GAP Report 145

Culture counts! That’s what the Surgeon General’s 2001 report (1) said in bold letters. In the mid-1800s, American psychiatrists became interested in culture when mental hospitals filled with Irish and German immigrants. At the end of that century, unusual syndromes such as latah, amok, and koro were discovered by Western psychiatrists, and Emil Kraepelin traveled from Europe to Southeast Asia, described differences in symptoms among patients, and developed the field of comparative psychiatry. Freud, an armchair archeologist, turned to cultural studies as he matured. A small cadre of psychoanalysts kept the torch burning, but only Harry Stack Sullivan and Erik Erikson really made much of an impact.

McGill University was the birthplace of modern cultural psychiatry; in 1955 a division of transcultural psychiatry was established there along with an ongoing journal. Out of the social ferment of the 1960s and 1970s came the community mental health movement, which, although primarily based on sociological constructs, had a cultural subtext. In 1971 the World Psychiatric Association started a Transcultural Psychiatry Section. Arthur Kleinman cofounded the journal Culture, Medicine and Psychiatry in 1976. The American Journal of Psychiatry published an overview article on cultural psychiatry in 1978 (2). A year later the still vibrant Society for the Study of Psychiatry and Culture was founded.

Then came fluoxetine, followed by a cascade of efficacious medications that pushed culture to the bottom of the psychiatric chain. A new, primarily biological clinical paradigm emerged. But strange things were happening in the world. The decline of Communism and its class consciousness was followed by the eruption of ethnicity with its emphasis on geography and religion. Disaster upon disaster in Europe, Africa, the Middle East, and, most recently, Afghanistan has made the entire world aware that culture is a powerful force. In this environment it is little wonder that psychiatry has finally institutionalized cultural concerns in its diagnostic and statistical manual, and that residency training programs are now mandated to produce culturally competent psychiatrists.

I was delighted to receive Cultural Assessment in Clinical Psychiatry, a report by the Group for the Advancement of Psychiatry (GAP), to review, especially since I am working on a new cultural psychiatry chapter for the next edition of Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. I promised myself not to be too disappointed; a number of GAP reports over the years have been mediocre. I shouldn’t have worried. Ezra Griffith, Chairperson of the GAP Committee on Cultural Psychiatry, Renato Alarcón, the Project Coordinator, and colleagues such as Edward Foulks, Pedro Ruiz, and Ronald Wintrob have published a solid and useful book.

The report defines cultural psychiatry prosaically as

That’s quite a mouthful. On a grander scale, I believe that just as culture strives to organize a society into a logically integrated, functional, sense-making whole, so too does cultural psychiatry strive to make clinical psychiatry more logically integrated, functional, and sense-making. It has no unique predisposition to biological, psychological, or social approaches and reductionisms but, rather, is a synthetic discipline. Matter, mind, behavior, and society are meaningless until they are interpreted, explained, and accepted as reality through the cultural process.

The cultural variables discussed in the report include ethnic identity, race, gender and sexual orientation, age, religion, migration and country of origin, socioeconomic status, acculturation and the acculturative process, language, diet, and education. These are all neatly described (no mean feat). However, I was taken somewhat aback by the statement that drinking grapefruit juice can dramatically elevate the blood levels of several psychotropics, including benzodiazepines. If this were true in practice then all the alprazolam heads would be growing grapefruits in their garages.

The real value of the report rests in the application of a cultural formulation to six clinical cases. The cases include an Irish American who was alcoholic and a ritual masturbator, who, with the help of therapy and Alcoholics Anonymous, turned to a life of celibacy and sobriety by entering a Catholic seminary to become a priest. In another case, a cocaine-addled, depressed immigrant from Kenya was helped when he likened the recommendations of the American multidisciplinary inpatient team to those of a traditional council of elders. Other cases include a Pakistani immigrant family, a Filipino American medical student, an Irish American “good Catholic girl,” and an Ecuadorian immigrant who was a Baptist minister.

The formulations for each case are lively, detailed without being boring, and quite informative, covering multiple cultural variables. Several even contain brief nostalgic references to castration anxiety and demonized objects. The formulations are models that demonstrate clearly the importance of culture in assessment, diagnosis, and treatment. It is doubtful that most clinicians will be as comprehensive in making their formulations, but the report shows what can (and should) be done. I rank this among the best of the 145 GAP reports.