Cultural Psychiatry and Medical Anthropology: An Introduction and Reader

This book is a collection of influential papers on culture and psychopathology published from 1880 to 1971. Most are written by magisterial figures in the field such as George Beard, W.H.R. Rivers, Ernest Jones, Emil Kraepelin, Irving Hallowell, Claude Levi-Strauss, P.-M. Yap, George Devereux, and Henry B.M. Murphy. The contents explore comparative psychiatry, concepts of normal and abnormal, oedipal conflict and family structure, magic and religion, death, suicide, intoxicants, the social uses of anxiety, effectiveness of symbols, and the so-called culture-bound syndromes (diseases reputed to be peculiar to specific cultures), including their function and development. Most papers describe unusual manifestations of pathology (both individual and collective) related to a particular cultural setting, with social-constructionist explanatory models heavily influenced by psychoanalytic thinking. Each paper is prefaced by the editors with a brief contextual note and questions evoked by the content.

The senior editor is Roland Littlewood, a professor of anthropology and psychiatry at University College, London, a prominent name in cultural psychiatry. The introduction offers a masterful historical summary of the evolution of anthropological thinking on psychopathology. The editors note the influence of Zeitgeist on theory, the implicit assumptions of cultural psychiatry regarding the cognitive-affective processes of “primitive” human groups during eras of colonialism, imperialist expansion, and forced assimilation of indigenous peoples. Initially developed as readings for postgraduate students in anthropology and psychiatry, the contents will appeal to clinicians and social scientists interested in intellectual history. For this audience, the selections provide fascinating insights into the evolution of thought regarding the very nature of disease. For psychiatrists seeking practical help to understand and treat patients from different cultures, the book will be a disappointment.

I also found it disappointing that the editors stopped their ethnographic clock 30 years ago, largely ignoring current research. Following their own rationale, both theory and observation are inevitably reshaped by the currents of evolving knowledge. The fascinating case histories here are rich in theory but burdened by all the limitations of antiquated ethnographic research techniques, their contemporary meaning and relevance confounded by the irresistible force of culture change. If the intent was to stimulate thought based on earlier paradigms, their historical effects on current thinking should be more clearly delineated.

Cultural psychiatry has been concerned with the most critical questions in psychiatric theory, diagnosis, and practice, essentially related to the degree and type of variance in our species. Granted that human groups may differ in their conceptions of normal and deviant behavior, are specific behaviors universally recognized as mental disorders? Are theories of etiology valid across cultures? Can psychiatric nosology be universally applied? Are symptoms manifested uniformly? Are diagnostic distributions the same across racial/ethnic groups, both within and across national boundaries? Do disorders manifest the same natural history? Are treatment modalities developed in the West appropriate for non-Western cultures?

Research has provided tentative answers to some of these questions, particularly with respect to schizophrenia. According to World Health Organization reports (1) and current thinking on culture and psychiatric diagnosis (2), schizophrenia is found in stable tribal groups as well as stressful industrial cultures. Distributions seem pretty much universal. Symptoms may be manifested differently, but the differences are largely in the content and salience of diagnostic indicators rather than in their essential form. With a proliferation of international research, child-rearing theories have yielded to biogenetic etiology. Increasingly, the term “environment” refers not to nurture but to external conditions that affect maternal health and generate intrauterine insults to fetal development.

On the other hand, universal prevalence and diagnosis for affective disorders is still problematic (3), and most other ICD diagnostic categories are still to be explored. We have yet fully to understand why prognosis for schizophrenia is significantly better in the developing world than in industrialized nations, or the meaning of rate differences in subcategories. With respect to ethnic/racial variation in dose levels of psychotropic medications, we must learn more about the ratio of biological to cultural substrates. And we still have an unclear picture of the relationship of individual psychopathology to social stress and culture change. These are some of the issues that fascinate us today and that have a tangible impact on psychiatric practice and mental health planning.

Despite the excellent historical introduction, this book suffers from the lack of a common thread. The medical anthropology in its title reflects the non-Cartesian focus of its contents but will be misleading to readers expecting discussion of nonpsychiatric conditions. The readings are rather disparate, and their termination in 1971 is strange. Although Murphy’s work on the evolution of syndromes such as amok and latah is indeed canonical, his more recent thoughts on comparative psychiatry and interpretation of epidemiological and quality-of-life indicators (4) may be more germane to contemporary discourse. Readings from Good (5) on phenomenological approaches and especially Kleinman (6) on the new cross-cultural psychiatry would have been welcome.

This book will not be useful for readers expecting tips on treating culturally diverse patients. Carefully absorbed, however, the anthropological viewpoint may be enormously useful in changing the way clinicians perceive their patients and, perhaps, the subsequent effects of the clinical interaction on patients’ progress. As the editors note, our adaptation to the illness experience, whether as observer or observed, is always socially prescribed.