Culture and Psychopathology

Question 1

What is culture?

Victorian Times

Answer 1

• the biological basis of racial difference (Nazism)

- Higher and lower forms of civilisation (colonialism)

Question 2

What is culture?

1950s- 1970s

Answer 2

• shared values and beliefs
• stereotypes
• orientations as changeable conventions

Question 3

What is culture?

Psychiatry

Answer 3

• a demographic detail

- the dominance of bio-medical ideology

Question 4

What is culture?

Anthropology

Answer 4

• patterns of daily life activities
• experienced as an interpersonal flow of communication
• located not in the mind, but in groups (family, communities)

Question 5

The ‘discovery’ of culture: ethnopsychology

Answer 5

• the study of the psychology of races or peoples
• popularised by 19th century anthropologist-explorers who romanticised, mythologised and depicted culture as pure, unchanging and ‘other’
• the characterisation of black Africans as beast-like, childlike, unconscious and irrational

Question 6

The ‘discovery’ of culture: cross-cultural psychology

Answer 6

• research agenda “a search for the normative and universal”

- an ongoing concern with ‘cultural difference’

Question 7

The ‘discovery’ of culture: Apartheid era pscyhology

Answer 7

• cultural difference was a prominent theme, the investigation of which was encouraged in order to provide the ideological justification for apartheid rule

Question 8

Scientific racismin South African psychology: MacCrone 1930

Answer 8

“the strongly marked negroid features…and offensive bodily odour of the black reinforce the belief that he belongs to a lower human order”

Question 9

Scientific racismin South African psychology: Wilcocks (1932)

Answer 9

“Long continued economic equality of poor whites and the great mass of non-Europeans and propinquity of their dwellings tend to bring them to social equality. This impairs the tradition which counteracts miscegenation, and the social colour divisions are noticeably weakening.”

Question 10

Scientific racismin South African psychology: H. F. Verwoerd (1950s)

Answer 10

“The school must equip the Bantu to meet the demands which the economic life of South Africa will impose on him… There is no place for him in the European community above the level of certain forms of labour… What is the use of teaching a Bantu child mathematics when it cannot use it in practice? That is quite absurd. Education must train people in accordance with their opportunities in life, according to the sphere in which they live.”

Question 11

Scientific racismin South African psychology: Biesheuvel 1957 & 1958

Answer 11

“In the African population… the process of character development runs a more or less imperfect course.”

“By contrast the life of the mine labourer is completely secure. For the period of his contract he is looked after in every way; his accommodation and food are provided; the contract is equally binding on the employer. The majority wish to return to their tribal area, but they are encouraged to renew their contracts after a suitable period. This security, the absence of worry about everyday affairs, the safety of life in the compounds as compared to the hurly-burly and frequent lawlessness of the townships was in fact frequently commented upon.”

Question 12

Scientific racismin South African psychology: Morsbach (1973)

Answer 12

” with a high birth rate and numerical superiority, this group (Africans) poses the greatest threat to all long-range segregation plans.”

Question 13

Scientific racismin South African psychology—PsySSA national conference of 1994

Answer 13

public acknowledgement of the discipline’s complicity with apartheid ideology

Question 14

Everyday racist psychology: Howitt and Owusu-Bempah (1994)

Answer 14

note how:

• blacks are overrepresented in psychiatric institutions
• psychology text books refer to african cultures as ‘tribes’ and western ones as ‘societies’

Question 15

2 stereotypes about African culture

Answer 15

1. Traditional healers do not ask questions

2. dreams are significant events for black people

Question 16

Swartz (1991: 223)

Clinician: You have bad dreams.
Patient: I do not have dreams.
Clinician: You are troubled by your bad dreams.
Patient: I do not have bad dreams.
Clinician: You have bad dreams about your son.
Patient (quickly and apparently angrily): I do not have any dreams.

Answer 16

• breaking the rules of ‘blackness’
• lack of insight
• fusion of blackness and madness (irrationality/ powerlessness)

Question 17

using culture as a weapon: the importance of culture

Answer 17

• asserted by white staff, rejected by black staff
• a white institution making recommendations on the basis of black African culture
• impractical recommendations
• relinquishment of clinical responsibility
• cultural relativism
• cultural racism

Question 18

Cultural and mental illness: Absolutism

Answer 18

• culture is irrelevant to the meaning or expression of mental illness

Question 19

Cultural and mental illness: Universalism

Answer 19

• mental illnesses are universal, but culture shapes their expression
• cross-cultural diagnostic decision- making depends on clinical judgment

Question 20

Cultural and mental illness: Relativism

Answer 20

• psychiatric categories are culturally relative

- cultural concepts of distress (DSM 5)

Question 21

Cultural and mental illness: Multiculturalism

Answer 21

• universalist-relativist
• voluntary/involuntary worldwide migration
• adjustment/ acculturation
• adaption of assessment instruments

Question 22

Cultural commitments of the DSM

Answer 22

• mental illness exists in the natural world
• mental illness is verifiable through objective observation
• overemphasis on diagnostic reliability (verification of observations)
• underemphasis on diagnostic validity (verification of concepts underlying those observations)
• mental illnesses are pre-programmed diatheses with naturally unfolding courses
• the mind-body dichotomy (eg. somatic symptom and related disorders)
• single, stable personalities are socially and personally normative (eg. dissociative and personality disorder
• The pathogenetic-pathoplastic division in major mental disorders

90% of DSM categories are culturally bound to North America and western Europe

Question 23

pathogenetic

Answer 23

the aspect of a disorder that is given, fixed, genetically determined

Question 24

pathoplastic

Answer 24

the aspect of a disorder that is mutable, changeable, environmentally determined

Question 25

Universal disorders

Answer 25

• schizophrenia (international differences in delusional contents and subtypes, better outcomes in poorer countries)
• bipolar mood disorder
• major depression
• anxiety diorders (panic, phobic, ocd)
• in the minority

Question 26

cultural concepts of distress

Answer 26

Refers to “ways that cultural groups experience, understand, and communicate suffering, behavioral problems, or troubling thoughts and emotions”

• cultural syndromes
• cultural explanations
• cultural idioms

Question 27

Cultural syndromes definition

Answer 27

• a combination of psychiatric and somatic symptoms that are considered to be a recognizable disease only within a specific society or culture
• DSM-IV: an atheoretical cataloguing of symptoms referring to a syndrome that is:
  1. Locality-specific
  2. A pattern of aberrant behaviour
  3. Experienced as distressing

Question 28

Cultural syndromes: a meaning-centred approach

Answer 28

• cultural syndromes communicate personal and social meaning/distress
• are designed to “readjust personal relationships”
• are designed to “readjust personal relationships”
• undermines the authority of DSM empiricism
• implies the cultural constitution of all psychiatric patterns (eating d/o, drug overdose etc)
• The notion of ‘cultural syndromes’ may end up becoming obsolete in an increasingly globalized and therefore homogeneous world culture

Question 29

Cultural syndromes in South Africa: Amafufunyana

Answer 29

• sorcery-induced spirit possession
• a mixture of soil and ants taken from a graveyard, placed in the path of the desired victim

She becomes hysterical and weeps aloud uncontrollably, throws herself on the ground, tears off her clothes, runs in a frenzy, and usually attempts to commit suicide. She reacts violently and aggressively to those who try to calm her. She is said to be possessed by a horde of spirits of different racial groups. Usually there may be thousands of Indians or Whites, some hundreds of Sotho or Zulu spirits.

Question 30

Amafufunyana: meaning centred approac

Answer 30

• occurs usually in disempowered people (women)
• the person perceives separation from her usual social role
• she demonstrates this separation via signs of illness
• This demonstration is recognized by significant others, who identify it as an illness beyond the control of the person
• She is then restored to her usual social position
• In sum, a wide variety of symptoms, with a wide variety of outcomes, the combination of which confounds the possibility of diagnostic coherence

Question 31

Cultural syndromes in South Africa: Ukuthwasa

Answer 31

• generally a positive phenomenon
• “the state of emotional turmoil a person goes through on the path to becoming an indigenous healer”
• Not all will become healers
• The definition therefore “lies partly in the experiences of the person undergoing it and partly in the way these are handled by existing healers”
• Also used to explain a variety of problems (e.g. TB)
• Sometimes includes antisocial features
• One example of a meaning-centred interpretation: an expression of “gender relationships in the context of migrant labour”
• It is less a diagnostic category than it is an explanatory model
• As with amafufunyana, it has no single meaning, describing “a variety of conditions and negotiations of social and personal conflict”

Question 32

benefits of cultural concepts

Answer 32

• prevent incorrect diagnoses
• gather useful clinical info
• enhance rapport
• improve therapeutic efficiency
• guide clinical research
• determine epidemiology of cultural concepts

Question 33

Society vs culture

Answer 33

• developed vs developing nations
• is western (industrialised) society a ‘culture’?
• Culture as ‘otherness’, society as “the standard by which others are judged
• Cultural syndromes as ‘atypical’ or ‘exotic’ psychoses
• Poor evidence for the discrete existence of some cultural syndromes

Question 34

The Cultural Formulation Interview

Answer 34

• used to assess the impact of culture on key aspects of the patient’s clinical presentation and care
• it is person-centred => avoid stereotyping
• no right or wrong answers

Question 35

Culture according to the CFI

Answer 35

1. the patient’s values, knowledge and practices associated with membership in diverse social groups
2. aspects of the patient’s backgroung/ current context that can affect perspective on illness (geographical location, migration, language, religion etc)
   - influence of the social network on the patient’s experience of illness (family, friends, wider community)

Question 36

The CFI’s assessment categories

Answer 36

1. cultural identity of the individual
2. cultural conceptualisations of distress
3. psychosocial stressors and cultural features of vulnerability and resilience
4. cultural features of the relationship between the individual and the clinician
5. overall cultural assessment

Question 37

Indications for the use of the CFI

Answer 37

especially useful when:

• There are diagnostic difficulties related to cultural, religious or socioeconomic differences between clinician and the patient;
• There is uncertainty about the relationship between culturally distinctive symptoms and diagnostic criteria;
• It is difficult to assess the severity / impairment of the illness;
• The patient and clinician disagree on the treatment plan; and
• The patient neither engages with nor adheres to the treatment plan

Question 38

The goals of the CFI

Answer 38

1. enhance cultural validity of diagnosis
2. facilitate treatment planning
3. promote patient engagement and satisfaction

Question 39

4 domains of the CFI assessment

Answer 39

• 16 questions in total
  1. cultural definition of the problem (1-3)
  2. cultural perceptions of the cause, context and support (4-10)
  3. cultural factors affecting self-coping and past help seeking (11-13)
  4. cultural factors affecting current help seeking (14-16)

Question 40

The place of ‘culture’ in DSM 5

Answer 40

• cultural data is included in-text for some disorders

- glossary of cultural concepts of distress

Question 41

the trouble with African philosophy..

Answer 41

It “diverts attention from the fundamental political problems of the Bantu peoples by fixing it on the level of fantasy, remote from the burning reality of colonial exploitation”

third person narratives

Question 42

the problem with third person narratives

Answer 42

• encourages a habit of talking ‘about africa’ rather than ‘among africans’
• speaking in the name of whole people although they have never asked to do so and are usually unaware that such a dialogue is taking place

Question 43

Defining African psychology

Answer 43

It “consists of the past and present peoples and cultures and experiences of life in Africa, with priority given to their individual and collective experiences; joys and losses; hopes and impediments; frustrations and challenges; needs and preferences; and attitudes to place, life, and land, death and the after-life, marriage and family, war and peace, spirituality and the supernatural order, morality and ethics, and African cultural institutions and practices”

Question 44

Explaining the ongoing malaise within African psychology

Answer 44

• white guily/ white alienation
• an obsession with ‘the African’
• a glaring omission is the issue with class inequality (psychology thrives in modern societies)

Question 45

A viable African psychology…

Answer 45

… should not restrict itself to the heady but ultimately empty rhetoric of ‘Africanization,’ but must also examine the material conditions of oppression.

Question 46

what is true mental health?

Answer 46

• it is political (mental illness does not reside within the individual, it exists between the individual and society, it is embedded within socio-historical contingencies)
• suffering is a response to political domination
• mental illness= suffering = expropriation of being = alienation

Question 47

Being African…

Answer 47

… is less about cultural uniqueness than material exploitation.

African psychology has to engage with the question of economic violence.