Chapter 12 (Lecture - Ch 11 in Textbook)

Question 1

what is culture?

Answer 1

Shared and learned beliefs and understanding

• plurality of cultures: cultural components related to race/ethnicity, but also class, profession, age, etc.
• all individuals participate in and have culture, but often obscured in relation to dominant social groups

Question 2

How we participate in culture

Answer 2

We all participate in “culture” - we are both products and producers of cultural knowledge and practices
- culture is fluid and ever-changing

Consider how we all shifted to online learning (and then transitioned back to in person learning): people had to learn new practices, and collectively figured out new modes of communicating and interacting

• disparities in power are important considerations in relation to culture (some groups and viewpoints have more dominance) and have larger impacts on how we understand mental illness (e.g., psychiatrists, the DSM)

Question 3

People’s experience of mental illness is influenced by culture

Answer 3

• culture itself is a social determinant of health
• our ways of communicating and expressing emotion are culturally mediated - but these also relate to components of diagnostic criteria for mental disorders, can influence the likelihood of receiving a diagnosis mental illness
• mental distress and psychological problems are expressed or “performed” in cultural ways (culturally appropriate and drawing on culture)

Question 4

Culture and Mental Illness

Answer 4

• when behaviour and personality do not fit well with cultural norms, a person is more likely to display “psychiatric symptoms” or be deemed to have a disorder (e.g., hyperactive kids and ADHD, or solitary behaviour)
• experiencing racism and discrimination due to cultural background may negatively impact mental health - may be risk factors for mental illness (they cause distress, may lead to marginalisation and barriers to care)
• as a risk factor: members of ethnic minority groups may be more likely to be diagnosed with a disorder (like schizophrenia) but may also experience more mental health problems than members of majority groups (likely partially due to racism and discrimination)
• culture can be a protective factor too: among some black women the tendency to avoid self-blame (which an individualise social problems, rather than consider structural drivers) may shield people from distress

Question 5

Our response to mental distress is influenced by our cultural perspectives

Answer 5

• we may or may not perceive that a feeling or thought is unusual or problematic depending on our cultural background (communicating with deceased ancestors, belief in possession)
• we may or may not believe that consulting a medical professional is the best option (we may seek help from a spiritual leader or advisor, a community leader or elder, or not seek help at all)
• our beliefs about the mental distress we experience (and how we understand it) are products of our cultural context (learned ideas and understandings)

Question 6

Emic vs Etic

Answer 6

Two terms used to describe two different perspectives for studying a culture or behaviour

Emic: insider perspective, or the perspective of the culture being studied
- emic research focuses on understanding a culture from the perspective of its members (subjective, grounded)

Etic: outsiders perspective, or the perspective of someone looking in at a culture
- Etic research studies cross-cultural differences and relies on pre-existing theories (objective, or applying external ideas or frameworks)

Is the DSM emic or etc in its orientation?
- Primarily etic

Question 7

Culture and Mental Illness - category fallacy

Answer 7

Coined by Arthur Kleinman (a anthropologist and psychiatrist)

Category fallacy: refers to the mistake of applying a diagnostic category or concept from one cultural context to another without recognizing the differences in meaning, relevance, or manifestation of that concept across cultures.

Question 8

culture and mental illness - transcultural psychiatry

Answer 8

Combines anthropology and psychiatry to examine how culture interacts with mental illness and the expression of mental illness

• mental disorders take different forms or look differently depending on socio-cultural context
• culture also defines how one experiences, expresses, manifests, and is treated for mental health problems - highly influential in numerous different ways

Important because:
- Reduces biases in diagnosis and treatment by recognizing cultural differences.
- Promotes culturally sensitive mental health care, improving outcomes for diverse populations.

Question 9

Our expression of mental distress is influenced by our culture

Answer 9

• illustrating how mental disorders may look very different (or be expressed differently) in different cultural contexts
• for example, somatisation (experiencing symptoms through/in the body) may be more common in cultures where the outward expression of emotionality and pain is discouraged
• it could be argued that mental illness is a way of “performing” mental distress in a way that is understandable to other members of our cultural group (culturally appropriate)

For example, North Americans and Europeans are thought to experience depression in largely psychological ways (less often through somatisation)

Question 10

More on culture and mental illness

Answer 10

• experiencing depression psychologically is perhaps culturally specific to European ancestry (consider implications of this view for the DSM, where description of “depression” is largely based on North American medical understanding of the condition)
• examination of cross-cultural and inter-ethnic manifestations of disorders (like OCD, ED, anxiety, and PTSD) leads to the conclusion that culture plays a key role in experience and expression of mental distress

Question 11

Culture and Mental Illness - are we looking at or experiencing the same illnesses or conditions?

Answer 11

• if the expression of mental distress is very different, how do we know if we see is the same disorder (depression, for example?)
• are there illnesses which are culturally specific, rather than universal
• has Western ethnocentrism fundamentally biased dominant diagnostic systems towards seeing European and North American norms as “universal”?

Question 12

Culture and Mental Illness - are disorders universal?

Answer 12

• assumption in psychiatry is that people around the world are experiencing the “same” disorder, but content of delusions (for instance) is culturally shaped
• argument is that disorders are universal diseases which have been discovered and documented as psychiatry and abnormal psychology have progressed (perhaps a positivist view)

Question 13

Other view (non-universal): argues there is little evidence for viewing them as “universal”

Answer 13

• diagnosis is a work in progress: not certain, or objective (no biomarkers, definitive lab tests)
• subjectively assessed through an interpersonal and cultural encounter (by definition, subjective)

Suman Fernando: clinical assessment/diagnosis is a meeting between two people, in which both human actors (not robots) bring their own language, feelings, tensions, and underlying beliefs (cultural influences) to the clinical encounter
- somatized depression (stomach and chest pain) vs psychological (low mood, hopelessness) depression: 2 expressions of same condition or different/separate conditions?

Question 14

Critiques of Psychiatry and its view of culture

Answer 14

• psychiatry has tended towards broad (and perhaps overly simplified or stereotyped) generalisations of non-Euro/American cultural groups
• (until recently) has not meaningfully considered culture in relation to conceptualisations of mental health and illness, and views itself as neutral and objective - treats culture as an “afterthought” rather than recognising the influential and deterministic role it has
• “culture” is something patents (rather than practitioners) possess
• people outside of majority cultural groups are more likely to be mistreated and misdiagnosed in healthcare settings
• culturally appropriate behaviours (belief in possession, communication with ancestors) may be deemed a behaviour indicating a psychiatric condition (disorder)
• real psychological stress may be discounted as just “cultural difference”, as it may not be recognised as a symptom in the DSM

Question 15

critiques of psychiatry

Answer 15

• it may be helpful to consider that psychiatry itself is a set of cultural beliefs (a shared system of knowledge, evolving, and transmitting among individuals and between groups)

Viewing psychiatry as a cultural system may help illustrate some of these key issues:
What can be done? How to incorporate these ideas and their implications into practice?
- culture is not contained within individuals, it is shaped by social context and social interactions
- psychiatry as system of knowledge represents “cultural beliefs” not an universally applicable (truly) objective “science”
- avoid racial and ethnic stereotypes, and take a nuanced view (like transcultural psychiatry suggests) recognising diversity within non-majority groups

Question 16

Culture and the DSM

Answer 16

• DSM is North American in origin and is used globally now and influences our systems like ICD
• DSM has previously ignored culture or treated it too simply
• DSM-5 acknowledges (or tries to) the importance of cultural context in understanding and responding to mental distress
• it now describes concepts such as “cultural symptoms”, “cultural idioms of distress”, and “culturally explanations or perceived causes”, and “culture-related diagnostic issues”

Question 17

The DSM-5 states (making an effort to acknowledge culture):

Answer 17

• mental disorders are defined in relation to cultural, social, and familial norms and values
• the boundaries between normality and pathology vary across cultures for specific types of behaviours
• diagnostic assessment must therefore consider whether an individuals experiences, symptoms, and behaviours differ from sociocultural norms before diagnosing a persons as pathological

This appears to acknowledge that mental illness is a culturally-specific phenomena (not universal, but relative)
- was previously more limited: culture bound syndromes - described abnormal, patterns of behaviour recognised only within specific cultural contexts
But these were viewed as potentially pathologizing and exoticizing non-Western forms and expressions of mental distress, while cementing the DSM as independent of culture (and thus unbiased/correct)

Question 18

DSM still treats culture somewhat paradoxically

Answer 18

• acknowledges culture as central to defining and responding to mental disorders, encouraging practitioners to consider whether behaviours/symptoms/experiences differ from sociocultural norms before diagnosing
• despite acknowledging that mental disorders are cultural formations, it still conceptualises Eurocentric formulations of “core” disorder as UNIVERSAL

Question 19

what does “cultural syndromes” mean in the DSM

Answer 19

• describe presentations of abnormal behaviour found only within a specific (non-Western) culture - somewhat similar to the previous “culture-bound syndrome”
• these are then linked to related (Western-defined) conditions

Question 20

what does “cultural idioms of distress” mean in the DSM

Answer 20

How distress is understood and described (linguistic practices)
- ways of talking about suffering within a given cultural group without involving specific symptoms or syndromes –> describe general patterns of describing an individuals personal or social problems “kufungisisa” (Shona people of Zimbabwe) = “thinking too much” - an idiom of distress, but DSM then links it to conventional symptoms (like panic attacks)
- also non-specific, may be applied in varied ways –> i.e., the way we colloquially use “depression”

Question 21

what is “cultural explanations or perceived causes” in the DSM?

Answer 21

• describe causal reasons for a persons psychological distress and abnormal behaviour that are culturally-specific
• Haitian term “maladi moun”, which posits that a mental disorder may be caused by the bad intentions of other people

Question 22

what does “culture-related diagnostic issues” mean in the DSM

Answer 22

• lists cultural factors that might affect how clinicians form a diagnosis
• includes flexibility for regional variation in both symptom expression and attitudes/interpretations of varying behaviour
• e.g.: form that OCD takes may differ based on sociocultural location; differences in ADHD rates may be due to whether or not hyperactivity is thought of as problematic

Question 23

DSM - Cultural Formulation Interview

Answer 23

Designed to assist practitioners in working out how a individual’s culture might impact their understanding and experience of their illness
- and whether culture may be significant in terms of accessing care or choosing treatment

Intended to avoid stereotyping individuals and patients, streamline decision-making in diagnosis, and take culture into consideration - and acknowledge influence of culture in illness experience and help-seeking
- consists of semi-structured questions that clinicians can discuss with patient to understand cultural issues and influences
Adoption and impact of the CFI remains unknown and is yet to be seen

Question 24

Despite the attempts in DSM-5 to improve the manuals approach to culture, some important critiques persist

Answer 24

1. continues to treat both “disorder” and “culture” as binary, presence/absence, no/little overlap between expression of culture and expression of a disorder
2. the core disorders, which are a product of Euro-American research, are still presented as universal
3. expressions of mental distress associated with non Euro-American populations are presented as cultural
4. the section on “culture-related diagnostic issues” relies on overly-broad stereotypes, ignoring the heterogeneity of most ethnic groups and diversity within group

Question 25

3 key approaches have characterised the debate about whether mental illnesses are universal or culturally specific

Answer 25

1. The absolutist school: mental disorder are globally shared (form & content of mental disorders are “universal” phenomena)
2. The universalist school: illnesses are globally consistent, but content and expression is shaped by culture
3. The relativist school: perceptions of distress are unique to each culture and diagnosis is culturally-bound (mental disorders cannot be universal, they inherently involve violations of “normality” which are by definition culturally dependent)

Question 26

International Trauma interventions - groups involved, and services provided

Answer 26

• Since the 1990s a number of international organisations have mobilised to provide emergency mental health interventions in responses to emergencies such as famine, war, and natural disasters
• These groups include the Red Cross, Medecins sans Frontiers, and WHO
• services include counselling, and training and support of local workers

Question 27

International Trauma Interventions - what they do, and how it helps

Answer 27

• these programs attract support because they are considered to be effective long-term investments, and appear benevolent
• another rationale is the usefulness of early intervention in order to prevent PTSD and reduce subsequent burden
• also, responding to trauma in a population can help prevent future violence and conflict (as potential sequelae of war or armed conflict)
• finally, these initiatives are a way of maintaining connections between the global community and the traumatised population (not ignoring these problems and communities)

Question 28

International Trauma Interventions - Critiques

Answer 28

• are these programs culturally relevant/appropriate? (may sideline or displace indigenous/local responses and forms of care and healing)
• is there actually a universal response to trauma, and does it always look like PTSD, or is this a Western construct?
• is it possible that Western-style interventions, like individual counselling, could actually be harmful in other cultural contexts? (perhaps collective, group, or communal approaches would be more appropriate and effective)

Question 29

Critiques of Western Psychiatry by people experienced in the mental health system who self identify by

Answer 29

• psychiatric survivors
• ex patients
• psychiatric prisoners, psychiatrically incarcerated
• consumer-survivors
• service users
• “mad people”, those experiencing madness

These represent a rejection of system-imposed diagnostic labels (i.e. schizophrenic), which are often homogenous and essentializing

Question 30

People w/in the mental healthcare system have experienced a range of harmful treatments

Answer 30

Which are seemingly “justified” by the classification of people into diagnostic categories (which can be seen as labelling and pathologizing)
- these include: coercion, restraint, forced confinement, criminalisation, forced medication, and other inhuman treatments
- critiques by people who have experienced the mental healthcare system are an important counterpoint to prevailing assumptions about the rationality and justness of the system

Question 31

During 19th Century there was a lot of scientific advances which supported medical diagnosis

Answer 31

• Anatomical method in medicine linked clinical signs (symptoms) with biological changes not evident in “healthy” bodies/organs
• pathology emerged as a science and allowed physicians to connect these physical changes with illness- autopsies identified pathological lesions in organs and tissues
• however madness or mental illness is rarely associated with visible structural abnormalities (2 exceptions: dementia paralytic featuring cognitive impairment, Alzheimers disease as a neurodegenerative condition)
• while it is assumed that madness is a disease of the brain, there are many uncertainties but the biological model remains dominant: belief is that advances in science will allow us to observe the causal mechanisms in time (i.e. chemical imbalances, differences in brain function)

Question 32

Ontology, Epistemology, and Experience: What is mental illness?

Answer 32

• the biomedical model (mental illness is a brain disease) can be considered a model of “reality” and for “reality”
• it is a worldview used to explain phenomena and to justify treatments which provides an “aura of factuality” - but it is still not fully proven
• there are a number of important critiques of this explanatory model of mental illness

Question 33

The biomedical model has been critiques in a number of ways:

Answer 33

• some argue that it is best seen as “a myth”
• others point to the diagnostic process as a means of social control and surveillance
• some argue that inequities in power and control are mediators of mental illness
• colonialism has been identified as causing mental distress and illness

Question 34

Anti-psychiatry

Answer 34

Emerged in the mid-20th century as a critique of mainstream psychiatry, questioning its practices, beliefs, and the medical model of mental illness.

R.D. Laing: advocated for the understanding of psychiatric disorders as meaningful experiences within a social context rather than as diseases to be treated.

Thomas Szasz: A psychiatrist who argued that “mental illness” is a myth and that psychiatric diagnoses are a form of social control.

Robert Whitaker: Focused on the overuse of psychiatric medications.

• these critics viewed diagnostic process and labelling with disorders as a form of social and political control
• social, political, and philosophical context and dynamics shape our understandings and responses to mental health and illness
• anti-psychiatry considered by mainstream psychiatry as a “fad”, but a rather dangerous one
• Martin Roth, deemed the ideas of anti-psychiatry as “anti-medical, anti-therapeutic, anti-scientific” in 1973

Question 35

Anti-psychiatry - general 2 points

Answer 35

• essentially a challenge to mainstream (orthodox) psychiatry
• seen as a passing phase: an aberration or discontinuity - but there is value in these critiques

Question 36

Critical Psychiatry

Answer 36

Critical psychiatry is a perspective that questions the traditional biomedical model and the ways in which psychiatric diagnoses and treatments are conceptualized and implemented

• contests the notion that mental illness is reducible to a disease of the brain - argues that the mind is a more holistic construct than just the brain
• Conventional psychiatry assumes is that causes of brain pathology or faulty psychological processes will eventually be discovered, but in the interim this provides a justification for (objectifying) psychiatric treatment
• in the view of Critical Psychiatry, conventional psychiatry is part of the problem rather than the cure

Question 37

what does critical psychiatry critique?

Answer 37

• critiques the “technological paradigm” applied to understanding mental illness and suggests that this provides insufficient rationale for specific treatments
• Critiques “mechanistic understandings”: mental illness is due to faulty cognitive or emotional processing
• argues that the biomedical model, which views mental disorders primarily as brain diseases or chemical imbalances, is overly reductionist.

Question 38

Critical psychiatry - Robert Whitaker “Anatomy of an epidemic (2010)

Answer 38

Documented that disability payments and compensation (and diagnoses) had tripled in the US over prior 2 decades
- suggested psycho-pharmaceutical medications may be a key cause in this trend
- persistent use of psycho-pharmaceutical medications (think maintenance therapy) may worsen long-term mental health outcomes
- again, brought a defensive reaction, some labelled Whitaker as an anti-psychiatry activist

Question 39

Critical psychiatry - biomedical propaganda

Answer 39

These opposing views are illustrated in the debates about the effectiveness of ADMs:
- biomedical view asserts they “work”, proven beyond a doubt
- “Critical” perspective emphasises questions related to placebo effect, relapse, non-response and inflated perceptions of effectiveness - highlighting that the “chemical imbalance” theory is still just a theory

Question 40

________ previously described “abnormal” patterns of behaviour that were recognized only within specific cultural contexts.
1. Culture-bound syndromes
2. Culture-informed mental illness
3. Culture-centered psychopathology
4. Culturally-specific disorders

Answer 40

1. Culture-bound syndromes

Question 41

In the most recent edition of the DSM, the term “cultural-bound syndrome” has been replaced with three new terms. Which of the below is NOT one such term?
1. Cultural pathology
2. Cultural syndromes
3. Cultural idioms of distress
4. Cultural explanations or perceived causes

Answer 41

1. Cultural pathology

Question 42

Who would not be a representative of the “anti-psychiatry” movement?
1. R.D. Laing
2. Thomas Szasz
3. Martin Roth
4. Robert Whitaker

Answer 42

3. Martin Roth

Question 43

________ refer to a cluster or group of co-occurring, relatively invariant symptoms found in a specific cultural group, community or context.
1. Cultural bound syndromes
2. Cultural syndromes
3. Cultural idioms
4. Cultural perceived causes

Answer 43

2. Cultural syndromes

Question 44

Transcultural psychiatry is a field of study that ________.
1. combines culture and psychiatry to explore the consequences of mental health
2. uses sociocultural methodologies to study the antecedents and consequences of mental health
3. draws on anthropological methodologies to understand mental health outcomes
4. combines anthropology and psychiatry to examine how culture interacts with mental illness

Answer 44

4. combines anthropology and psychiatry to examine how culture interacts with mental illness