Handbook of Cultural Psychiatry

A labor of love is not only a sentimental commentary on goals accomplished in the name of tenacity and sacrifice, driven by superior causes or principle-laden exhortations. In the writing of a book, a labor of love is, essentially, a tribute to generations of teachers, to thousands of real and potential students, to knowledge that is needed because it is there and we may not know it. And it is—it must be—a solid piece of work in order to catch the attention of readers and become a truly credible source of information. The Handbook of Cultural Psychiatry is, in this sense, a labor of love. Nowadays a sole-author book is a rarity (although Dr. Tseng is listed as editor, he is the only author named in the book). As he points out, it took a profound vocation and the right mentors along the way, several decades of work, the review of thousands of bibliographic materials, the advice of dozens of consultants, and the continuous support of many individuals. The results are rewarding: this is a gem of a book, a rich source of data, a catalog of needs and problems to solve, and a call for more work. Like many volumes of this magnitude (nine sections, 50 chapters, almost 100 illustrations and tables), it is not perfect. But perfection is not even another rarity; it simply does not exist.

Figure 1 of chapter 1 in section 1 illustrates the complexity of the subject known as cultural psychiatry. One of many “subfields” (a term that can be questionable) within our discipline, it has a close connection with the social sciences, but it should not be construed as antagonistic to or totally independent from such areas as neurobiology or other neurosciences. Its history is as fascinating as it is multidimensional because human behavior is shaped as much by genetic endowments as by environmental factors. The definition of cultural psychiatry and the many ways to interpret its component variables occupy a whole chapter dealing with the concrete entities such as family (and all its “intra” relationships) that shape human development, from early family enculturation processes to the myriad encounters and struggles constituting the life cycle. The cultural scaffolding of each phase of this cycle is carefully examined, as is personality, which acquires its own features to become the beacon of resilience or the bundle of vulnerabilities that clinicians learn to appreciate. The book reviews (but does not subscribe to) the “national characters” that five decades ago provided “scientific” sanction to the centuries-old undercurrents of racism and stereotyping.

It is clear in the section on culture, stress, and illness that the contribution of culture to both stress and coping patterns is undeniable and includes the crucial but still polemical distinctions between disease and illness. It would have been appropriate to include here the thinking of authors such as Pedro Lain-Entralgo (1) or Honorio Delgado (2) to broaden the discussion on this topic. The topic of illness behavior is very well discussed.

The section on culture and psychopathology contains 14 chapters. The impact of culture, which the book calls “effects,” is multidimensional and inherently complex (3). An epidemiology review uncovers the use of cultural factors “by default” in the assessment of psychopathology but still offers a sound summary of current knowledge. The inclusion of a chapter titled “Culture-Related Specific Syndromes” here may be premature, but it still is a thorough review of the subject and includes illustrative cases (predominantly of Asian patients). This section also deals with most of the conventional diagnostic labels, including anxiety disorders, eating disorders, depression, dissociative disorders, and personality disorders. Issues such as the relationships between axis I and axis II disorders from a cultural perspective are only one example of the complexity of the effects of culture on psychopathology. One observation in this section is the pervasiveness of “culture-bound syndromes” in different facets or clinical variants of all these disorders. Whether this speaks to the subtleties of culture as a pathogenic agent or the insufficiency of current clinical elaborations or neurobiological substrates remains a matter for future research.

The therapist-patient relationship is a heavily culturally charged item. Figure 26.1 of the book shows elegantly the complicated thread of situations that make this the unique encounter that it is. Format, communication, expectations, or actual interactions with patient and relatives are all areas of concern. That the chapter on clinical assessment and diagnosis (concepts that are neatly differentiated in the text) comes after (not before) the previous topic does not affect its relevance. The whole issue of diagnosis and classification, about which a lot has been written but not much from the cultural perspective—prospects for a better DSM are much better now (4)—is discussed, as are psychological testing and measurement.

The section dealing with culture and psychiatric services deals with many of the topics these two concepts include. Some omissions are related to a specific discussion of the fashionable “cultural competence” issue, even though the message from the book is obvious. The same applies to ethnopsychopharmacology. On the other hand, the chapter on culture-embedded indigenous healing practices is one of the most elaborated of the volume, and the chapter titled “Culture-Influenced Unique Psychotherapy” is a true original, dealing with somatopsychotherapy, Alcoholics Anonymous, Morita therapy, existential psychotherapy, and others. The “intercultural” aspects of psychotherapy are well explored; the author recognizes context and meaning as essential features of this vantage point. Another well-conceived series of chapters has to do with “special populations” (children, the elderly, refugees, the medically ill), even though specific sections on women or gay and lesbian issues are missing.

The book’s last chapters are devoted to social change and related topics, including migration, intercultural marriages, religious realities, gender, war, and the impact of politics on culture and mental health. The closing chapter, quite appropriately, deals with cross-cultural research. The inherent difficulties of such research in terms of methodology, measurements, statistical treatment, adequate inclusion of the cultural nuances of the patient’s “social world,” tension between social and biological sciences, and help-seeking patterns make the final section of the book a real challenge for researchers and clinicians alike.

As already noted, this book is one of encyclopedic proportions. At times a big, solid catalog of topics, at times a rich source of an unusually unique knowledge, it is always imbued with a genuinely compassionate sense for the suffering of many. If only for its wealth of data from so many countries and cultures, it is an exceptional contribution to the literature. It is a shame it was published before the U.S. Surgeon General’s Report on culture and mental health (5) and the World Health Organization’s most recent documents about the realities of mental health in the world (6); these publications could have given even more authority to its main message. The fact that the Handbook of Cultural Psychiatry is with us (and will be for years to come, with desirable new editions) is reason enough for the enjoyment of learning so much from it.