Global and Cultural Perspectives on Mental Healthcare (CULTURE AND…
Global and Cultural Perspectives on Mental Healthcare
Culture, Race, Ethnicity
Culture refers to the shared, and largely learned, attributes of a group of people. Anthropologists often describe culture as a system of shared meanings and practices.
Most people think of "race" as a biological category - as a way to divide and label different groups according to a set of common inborn biological traits (e.g., skin color, or shape of eyes, nose, and face). Despite this popular view, there are no biological criteria for dividing races into distinct categories
Ethnicity refers to a common heritage shared by a particular group. Heritage includes similar history, language, rituals, and preferences for music and foods. Historical experiences are so pivotal to understanding ethnic identity and current health status of diverse groups
Used in manuals to define grups
CULTURE MENTAL HEALTH
Symptoms (how symptoms are expressed can vary between groups)
Experience and understanding
POLITICAL USES OF PSYCHIATRY
Sluggish schizophrenia characterized by a slowly progressive course; it was diagnosed even in a patient who showed no symptoms of schizophrenia or other psychotic disorders, on the assumption that these symptoms would appear later
Sluggish schizophrenia was the most infamous of diagnoses used by Soviet psychiatrists, due to its usage against political dissidents.
CULTURE AND VOICES
Luhrmann, Padmavati, Tharoor, Osei (2014)
Differences in voice-hearing experiences of people with psychosis in the USA, India and Ghana: interview-based study
Participants in the USA were more likely to use diagnostic labels and to report violent commands than those in India and Ghana, who were more likely than the Americans to report rich relationships with their voices and less likely to describe the voices as the sign of a violated mind.
These observations suggest that the voice-hearing experiences of people with serious psychotic disorder are shaped by local culture. These differences may have clinical implications.
Stanford anthropologist Tanya Luhrmann found that voice-hearing experiences of people with serious psychotic disorders are shaped by local culture – in the United States, the voices are harsh and threatening; in Africa and India, they are more benign and playful. This may have clinical implications for how to treat people with schizophrenia, she suggests.
The research, Luhrmann observed, suggests that the "harsh, violent voices so common in the West may not be an inevitable feature of schizophrenia." Cultural shaping of schizophrenia behaviour may be even more profound than previously thought.
The findings may be clinically significant, according to the researchers. Prior research showed that specific therapies may alter what patients hear their voices say. One new approach claims it is possible to improve individuals' relationships with their voices by teaching them to name their voices and to build relationships with them, and that doing so diminishes their caustic qualities. "More benign voices may contribute to more benign course and outcome," they wrote.
This study compares 20 subjects, in each of three different settings, with serious psychotic disorder (they meet inclusion criteria for schizophrenia) who hear voices, and compares their voice-hearing experience. We find that while there is much that is similar, there are notable differences in the kinds of voices that people seem to experience.
In a California sample, people were more likely to describe their voices as intrusive unreal thoughts; in the South Indian sample, they were more likely to describe them as providing useful guidance; and in our West African sample, they were more likely to describe them as morally good and causally powerful. What we think we may be observing is that people who fall ill with serious psychotic disorder pay selective attention to a constant stream of many different auditory and quasi-auditory events because of different “cultural invitations”—variations in ways of thinking about minds, persons, spirits and so forth. Such a process is consistent with processes described in the cognitive psychology and psychiatric anthropology literature, but not yet described or understood with respect to cultural variations in auditory hallucinations. We call this process “social kindling.”
CULTURE AND HALLUCINATIONS
Laroi, Luhrmann and collegues, (2014)
A number of studies have explored hallucinations as complex experiences involving interactions between psychological, biological, and environmental factors and mechanisms. Nevertheless, relatively little attention has focused on the role of culture in shaping hallucinations. This article reviews the published research, drawing on the expertise of both anthropologists and psychologists. We argue that the extant body of work suggests that culture does indeed have a significant impact on the experience, understanding, and labeling of hallucinations and that there may be important theoretical and clinical consequences of that observation.
We find that culture can affect what is identified as a hallucination, that there are different patterns of hallucination among the clinical and nonclinical populations, that hallucinations are often culturally meaningful, that hallucinations occur at different rates in different settings; that culture affects the meaning and characteristics of hallucinations associated with psychosis, and that the cultural variations of psychotic hallucinations may have implications for the clinical outcome of those who struggle with psychosis. We conclude that a clinician should never assume that the mere report of what seems to be a hallucination is necessarily a symptom of pathology and that the patient’s cultural background needs to be taken into account when assessing and treating hallucinations
The richness of the ethnographic method captures meaning that experimental approaches will miss. For example, the Cashinahua, Siona, and Schuar peoples of the Upper Amazon all use the hallucinogenic brew ayahuasca as a spiritual guide. However, the Cashinahua consider the experiences as hallucinations that provide guidance,4 the Siona believe that ayahuasca provides access to an alternate reality,5 and the Schuar hold that all normal human experience is a hallucination and ayahuasca provides access to veridical reality.6 This is an important point because research on hallucinations usually involves asking people about experiences that are not explainable, have no obvious source or are not shared by others.7 Differing views of what constitutes veridical reality may affect how these experiences are reported
HALLUCINATIONS AS CULTURALLY
There is robust evidence that unusual sensory experiences have been given great importance as foundational spiritual experiences throughout the world—Moses and his burning bush, Paul on the road to Damascus, Arjuna’s vision of Krishna, Buddha beneath the Bo tree.
Bourguignon20examined data collected from the Human Relations Area File (HRAF) from 488 societies worldwide. In 62% of the cultures studied, hallucinations played a role in ordinary ritual practices. These hallucinations were positively valued, could be understood in the context of local beliefs and practices, and the presence of hallucinations was not usually associated with intake of psychoactive chemicals.
CONTACT WITH THE DIVINE
Typically, such sensory experiences of the immaterial are understood as contacts with gods, spirits, or the dead. While many such experiences never enter the historical record, others take on broad public meaning. Lourdes21 became a major healing shrine because a young girl, Bernadette Soubirous, reported that she saw the Virgin Mary there, and many people came to believe that indeed she had. The shrines of Fatima and Medjugore similarly draw millions of worshippers who believe that the Virgin appeared to specific individuals so that they saw her with their eyes and who come to worship and request favor from the Virgin at a place where her immaterial body was perceived with the physical human senses.
To become available as plausible experiences of the divine, such hallucinations must conform to local cultural expectations
VOICE OF GOD
Dein and Littlewood, 2007
Dein and Littlewood25 interviewed 25 members of a Pentecostal church in London who said that they had heard God speak audibly. In such churches, congregants talk of “discerning” whether such a voice comes from God by asking whether the voice is in accord with scripture, gives one peace, and so forth. The anthropologists described 1 man with bipolar disorder who distinguished between God’s voice and his own experience of psychosis this way: “God says something and doesn’t force you, so you can do what you like with it … [the psychotic voices] you can’t refuse to do something when you hear them. They are very pushy
Hallucinations are a vivid illustration of the way culture affects our most fundamental mental experience and the way that mind is shaped both by cultural invitation and by biological constraint. The anthropological evidence suggests that there are three patterns of hallucinations: experiences in which hallucinations are rare, brief, and not distressing; hallucinations that are frequent, extended, and distressing; and hallucinations that are frequent but not distressing. The ethnographic evidence also suggests that hallucinations are shaped by learning in at least two ways. People acquire specific representations about mind from their local social world, and people (particularly in spiritual pursuits) are encouraged to train their minds (or focus their attention) in specific ways. These two kinds of learning can affect even perception, this most basic domain of mental experience. This learning-centred approach may eventually have something to teach us about the pathways and trajectories of psychotic illness.
It is only in the 20th century, as Leudar and Thomas31 point out, that hallucinations have been described as exclusively the sign of an illness. As a result, the term “hallucination” can carry stigma. Nonetheless, events that appear technically to be hallucinations and that conform to popular expectations of the presence of God are still often reported as religious events in popular Western media.
It needs to be recognized that a clinician is also part of a culture and that the factors that affect the clinician’s interpretation of hallucinatory experiences need to be understood in making clinical judgments
Schizophrenia and Culture
Meanwhile, Barrett found that his attempt to translate the Present State Examination from English into the Iban language failed when it came to rendering thought insertion and withdrawal. In the Iban culture, thinking arises from the heart-liver region. It is not contained in the mind, which is somehow contained in the brain—a more Western conception. Fabrega44 had already made this criticism of the Schneiderian first-rank symptoms: “These symptoms imply to a large extent persons are independent beings whose bodies and minds as separated from each other and function autonomously.” Barrett found that the process of making thought insertion/withdrawal questions intelligible to the Iban meant that they lost their core Schneiderian meaning.
INTERNATIONAL PILOT STUDY
Sponsored by World Health Organization
Interviewed first-contact patients in Columbia,
Czechoslovakia, Denmark, India, Nigeria, Taiwan, United Kingdom, former Soviet Union, and United States
Found no noticeable differences in incidence and prevalence of schizophrenia between developed and developing countries.
However, follow-up studies 2 and 5 years later showed:
– Course of illness significantly better in developing countries than in technologically advanced countries. Good outcomes:
58% in Nigeria, 51% in India
7% in Moscow, 6% in Denmark
Possibly due to blame, and social support, expressed emotions...
Pinto, Ashworth and Jones, 2008
The incidence of schizophrenia in black Caribbeans living in the UK is substantially higher than in the white British population. When first reported, these findings were assumed to be a first-generation migrant effect or merely the result of methodological artefacts associated with inconsistencies in the diagnosis of schizophrenia in black Caribbeans and doubts about population denominators. More recently, it has become clear that the incidence of schizophrenia, based on standardised diagnosis and sophisticated census methods, is higher still in second-generation black Caribbeans
Genetic predisposition (no biological basis for cultural differences)
Health service factors (who used them)
Psychological factors (also higher non clinically sig. hallucinations in black people in the UK)
Elevated incidence rates of schizophrenia in UK black Caribbeans have been consistently reported. The UK-based Aetiology and Ethnicity in Schizophrenia and Other Psychoses (ÆSOP) multisite (Bristol, south-east London, and Nottingham) study is one of the largest studies to examine ethnic variations in schizophrenia incidence.7 In 2006, ÆSOP reported a ninefold increase in the risk of developing schizophrenia in black Caribbeans when compared with the white British population: the increased risk was 5.8 in black Africans and 1.4 in South Asians
The high level of schizophrenia in black Caribbeans living in the UK probably reflects the interaction of multiple risk factors, many of which cluster in the black Caribbean community in the UK. Particularly significant factors appear to be the combination of isolation and exclusion, both within society (living in areas of low ethnic density and reduced participation in society) and within the family (family break-up and paternal separation). These factors seem to be more powerful than socioeconomic disadvantage, which is more likely to be a consequence than causal. Racism itself may contribute to social exclusion, increasing the vulnerability to schizophrenia. Biological or genetic susceptibility do not appear to explain high rates of schizophrenia in black Caribbeans. More research is needed about the role of cannabis, particularly in its more potent forms, and whether this contributes to the excess of schizophrenia in black Caribbeans.
OUTCOMES OF SCHIZOPHRENIA
Patel, Cohen, Thara, Gureje (2006)
In developing countries:
Higher social support
Cultural belief systems that externalize causality
Greater opportunities for social reintegration and normalized work roles in rural areas
Extended kinship networks
Fewer problems accepting interdependence
That schizophrenia has a better prognosis in non-industrialized societies has become an axiom in international psychiatry; the evidence most often cited comes from three World Health Organization (WHO) cross-national studies. Although a host of socio-cultural factors have been considered as contributing to variation in the course of schizophrenia in different settings, we have little evidence from low-income countries that clearly demonstrates the beneficial influence of these variables.
In this article, we suggest that the finding of better outcomes in developing countries needs re-examination for five reasons: methodological limitations of the World Health Organization studies; the lack of evidence on the specific socio-cultural factors which apparently contribute to the better outcomes; increasing anecdotal evidence describing the abuse of basic human rights of people with schizophrenia in developing countries; new evidence from cohorts in developing countries depicting a much gloomier picture than originally believed; and, rapid social and economic changes are undermining family care systems for people with schizophrenia in developing countries. We argue that the study of the long-term course of this mental disorder in developing countries is a major research question and believe it is time to thoroughly and systematically explore cross-cultural variation in the course and outcome of schizophrenia
EMOTIONS AND AFFECTIVE DISRDERS
Research on the relationship between culture and emotions dates back to 1872 when Darwin argued that emotions and the expression of emotions are universal. Since that time, the universality of the six basic emotions (i.e., happiness, sadness, anger, fear, disgust, and surprise) has ignited a discussion amongst psychologists, anthropologists, and sociologists.
It seems to me that the interesting questions begin with the assumption that nearly all emotional experiences, everywhere, reflect both human nature and cultural context
Having a biological predisposition.. but being culturally determined (e.g. how emotions are expressed)
WESTERN BASED DIAGNOSTIC
The literature pertaining to culture and depression is still dominated by studies based upon ‘Western’-based diagnostic criteria and focus upon the incidence and prevalence rates and / or levels of specific symptoms in various countries
There is a tension between anthropological and epidemiological methods. Whereas epidemiology focuses on the prevalence of affective disorder, deploys the definitions of the DSM –V, and assumes that western based diagnostic criteria for diagnosing depressive disorder reflect a culturally universal pathology of the disorder
While anthropologists trend to view depression as an affect, psychiatrists view it as an affective disorder. Keyes(1985) asserts that biomedicine is unique in that it deals with illness by interpreting experience without reference to the problem of suffering.
Basing western criteria on all groups
Western psychiatric practice is predicated on a mind- body dualism (Miresco and kirmayer, 2006). Models of mental illness typically place causality either in the mind (e.g. as in cognitive models of depression) or in the body/brain (e.g. psychiatric explanations of depression resulting from low levels of serotonin, dopamine or noradrenaline).
Those models that initially appear to transcend this dualism (e.g. the biopsychosocial model, psychodynamic models) fail in this respect. In contrast mind and body are viewed as integrated in other cultures. In China for instance illness of the mind cannot be separated from illness of the body.
Cross cultural studies indicate a high prevalence of somatic symptoms in depressed and anxious patients in non-western cultures. Symptom attribution, a key element in the concept of somatization - is an interpretive process which is strongly shaped by cultural factors
INDIVIDUALISM VS COLLECTIVISM
INDIVIDUALISM AND COLLECTIVISM
In countries with more individualistic views such as America, happiness is viewed as infinite, attainable, and internally experienced. In collectivistic cultures such as Japan, emotions such as happiness are very relational, include a myriad of social and external factors, and reside in shared experiences with other people
Those from more collectivist cultures value social harmony above individualism and support behaviours that enhance group cohesion and interdependence. More collectivist cultures may provide individuals who are genetically susceptible to depression an implied or expressed social support which protects them from depressive episodes.
Specifically, it is argued that most people worldwide now develop a bicultural identity that combines their local identity with an identity linked to the global culture; that identity confusion may be increasing among young people in non-Western cultures as a result of globalization; that some people join self-selected cultures to maintain an identity that is separate from the global culture; and that a period of emerging adulthood increasingly extends identity explorations beyond adolescence, through the mid- to late twenties.
Growth of individualism and breakdown of traditional values
Higher rates of depression
Some evidence suggests that traditional healers can provide an effective psychosocial intervention. Their interventions might help to relieve distress and improve mild symptoms in common mental disorders such as depression and anxiety..
However, little evidence exists to suggest that they change the course of severe mental illnesses such as bipolar and psychotic disorders. Nevertheless, qualitative changes that are captured poorly by conventional rating scales might be as important as the quantitative changes reviewed here. We conclude by outlining the challenges involved in assessing the effectiveness of traditional healers