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| PRESIDENTIAL ADDRESS |
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| Year : 2018 | Volume
: 34
| Issue : 1 | Page : 4-6 |
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Cultural diversity and mental health
Rajiv Gupta
Director Cum CEO, Institute of Mental Health, Pt. Bhagwat Dayal Sharma University of Health Sciences, Rohtak, Haryana, India
| Date of Web Publication | 29-Mar-2018 |
Correspondence Address:
Prof. Rajiv Gupta
Institute of Mental Health, Pt. Bhagwat Dayal Sharma University of Health Sciences, Rohtak - 124 001, Haryana
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijsp.ijsp_129_17
How to cite this article:
Gupta R. Cultural diversity and mental health. Indian J Soc Psychiatry 2018;34:4-6 |
| Cultural Diversity and Mental Health | |  |
I would like to organize this talk into three headings, namely, understanding cultural diversity, need of unity in diversity, and possible solutions.
| Understanding Cultural Diversity | | |
I would like to start with focus on a few important concepts and definitions. Three important terms are important: culture, race, and ethnicity. Culture is a social matrix of the whole human experience and a factor of neurobiological development. Race is a tenuous but pervasive catalog of identity including physical and physiognomic characteristics that nourish at times ideologically biased interpretations. Ethnicity is based on belongingness to a society, people, or community with common historical, geographic, linguistic, or religious roots. These terms are not mutually exclusive and apply to different aspects of bio-psycho-social model. Culture is mainly psycho (sociobiological), race predominantly bio (psychosocial), and ethnicity as socio (psychobiological), though it is not quite as simple, and the boundaries are mercurial with proportion of each component varying. Two more terms are often confused, i.e., cross-cultural and trans-cultural. Cross-cultural refers to comparisons made between two or more distinct social groups to clarify differences and similarities, whereas trans-cultural is the characteristics which are continuous or universally found in all human societies. The distinction between cultural specificity and universal human characteristics is important. In addition, two other terms used in anthropology to distinguish between different modes of communicating and interpreting human experiences are “emic” and “etic.” Emic is derived from linguistic expression phonemic. Emic denotes vocabulary, explanation of customs, and practices used by individuals within a particular culture. Emic features would represent the various ways in which people actually experience their illness, explain their symptoms, feel pain, etc., and how clinicians encounter patients (look, feel, and poke around for signs and symptoms). Etic, on the other hand, is derived from linguistic expression phonetic. Etic denotes scientific explanation and cultural practices employed in descriptions made by individuals outside of the particular culture. Etic features would be found in the body of accumulated technical data through which the diseases are understood, treated, and prevented, practitioners are trained, and health institutes are formed. These two different ways of looking at human experiences are fundamental, and understanding these terms has important bearing in the description of patterns of illness and management. We are trained “etically” but need “emic” approach for understanding and treating patients in a cultural context.
Importance of cultural formulation
Ethnographic research has highlighted that medicalizing often precludes our understanding of how individuals, families, and social groups actually respond to stress. Qualitative interviews are needed to elicit complex narratives of symptoms and illness experiences. Such interviews are required to elicit explanatory models and local idioms of distress as well as information related to health-seeking behaviors, treatment experiences, and the possible sources to be mobilized for healing. These considerations have been taken up by the Fifth Edition Diagnostic and Statistical Manual of Mental Disorders (DSM-5) through its “Cultural Formulation Interview” (CFI), which, instead of providing a “list” of idioms of distress or syndromes of suffering, provides a semi-structured qualitative interview to elicit these aspects. DSM-5 includes culturally based idioms of distress and cultural explanation of perceived illness.[1]
Let us examine a few important concepts in this context. First, cultural syndromes are entities that cluster co-occurring symptoms, may or may not be recognized as an illness within the culture, but occur, are relevant in the societies of origin, and may be noticed by an outside observer. Second, “cultural idioms of distress” is a relatively new name for an older concept. These “idioms” are linguistic terms, phrases, or even colloquial ways of talking about suffering, shared by people from the same culture; they are considered neither mental/emotional illnesses nor diagnostic or nosological categories, while their listing is useful and includes crying styles, body postures, and somatic manifestations. There is agreement on the need to approach them in a more systematic, empirical way. Finally, culturally based causal explanations are needed, which are reminiscent of Arthur Kleinman's rich “explanatory models” concept. These convey deeply ingrained views and beliefs about what the patient and his/her family consider the etiology of the reported symptoms, illness, or distress; they can be part of folk classifications of disease used by laypeople or healers, but beyond their formal presentation, they may also entail an anticipation of the patient's trust, faith, hopes, and expectations.
CFI, in its primary format, has a total of 16 questions operationalizing four main areas: cultural definitions of the clinical problem, perceptions of cause, context and support, and treatment factors (including self-coping and help-seeking patterns). Each section and most of the questions have additional probes to clarify or deepen the initial responses.
Research ignoring culture is not valid
We must understand that western psychiatry is not necessarily cross-culturally valid. Unfortunately, developing countries often lack culturally specific theories that can be applied to mental health problems and practices. In developing countries, mental health is on low priority (because of overwhelming problems of poverty, etc.) and research in mental health both toward prevention and service delivery lacks resources and funds.
Research in developing countries is over influenced by western research and even the instruments used are western using translation-back translation method which provides poor equivalence. Validity in all the following five criteria is compromised using such translated version of instruments:
- Criterion – not measuring the same responses
- Technical – applicability to nonliterate culture
- Conceptual – response to relate to theoretical construct within the culture
- Semantic – words must have the same meaning
- Content – should have relevance for culture.
That is the main reason that there is scant attention to findings from research conducted in nonwestern societies which often remain unpublished or published in nonindexed journals.
[TAG:2]Need of Unity in Diversity: Are We Moving in the Right Direction?[/TAG:2]
False assumptions in contemporary psychiatry
Three false assumptions which should not be viewed as an antipsychiatry perspective but rather need serious introspection are as follows:
- Genes are most important in causing mental disorder
- Most patients have single disorder that respond to specific evidence-based treatment
- Best treatment for mental disorder is drugs (pharmacotherapy).
We must reiterate the fact that psychosocial and environmental factors are common in causation of mental disorder and comorbidity: This is the rule and not an exception. The psychosocial treatments in conjunction with medication are the effective ways of managing many difficult problems. The price that we have to pay for these false assumptions is treatment resistance and loss of psychotherapy and psychosocial treatments as part of training and practice of psychiatry.
Biological reductionist paradigm
The increasing focus and tilt toward medical model as a dominant paradigm for understanding and treating patients and moving away from biopsychosocial model is quite evident, and the powerful influence of the financial power of the pharmaceutical industry behind this cannot be denied.
Main factors shaping contemporary psychiatry are as follows:
- Discovery of neurobiological correlates of mental disorders
- The medical model coming as a dominant paradigm
- Effectiveness of contemporary psychotropic drugs
- Hope that research will reveal genes that underlie major mental disorders
- Influence and financial power of the pharmaceutical industry
- Insurance and reimbursement policies.
Despite evidence of effectiveness of psychotherapy at psychosocial treatments, their training and practice is endangered.[2],[3] The future of these treatments depends on the survival of the biopsychosocial model which is threatened to be reduced to only medical model. Should psychiatrist's future direction continue to focus on such reductionist “bio-bio-bio” model as the former APA President Steven Sharfstein provocatively called it; then, the practice of psychotherapy and psychosocial treatment may be forfeited to other professional disciplines.[4] There has been increasing evidence of protests and intolerance among various professionals seen doing the conferences. Recent 2017 WPA Conference at Berlin witnessed major antipsychiatry campaign and protests at the venue of the conference, leading to unpleasant scenes and violent interactions. We need integration and respect for each other and need to join hands with all the possible streams of mental health care.
Stigma across cultures
Stigma is perhaps the greatest challenge facing our profession and patient population across cultures. We must be a leader in actively combating society's notions about the mentally ill and the treatments we have at our disposal. Growing intolerance among mental health providers and indulging in false propaganda adds onto the stigma.
| Possible Solutions | | |
No single sector or discipline has all the answers. World views make little distinction between mind and body and divisions between mental health and physical health are becoming less and less tenable. Comorbidities are the rule rather than the exception. Health promotion that does not take account of mental health is flawed. Mental health promotion that does not take “health” into account is equally flawed.
Defragmentation
Our postgraduate training program will need to be enhanced in a number of key areas pertaining to the biological and socio-cultural/economic dimensions of psychiatry. We must expand our community affiliations as well as our connections to other health organizations. Broadly speaking, psychiatry is creeping closer to a future where it will not be practiced by solo practitioners, rather by teams. We must educate our residents in interprofessional models of collaboration so that they may work with other services and agencies.
Cultural formulation needs priority
CFI needs to be actively incorporated in evaluation and not left as an inactive appendix of DSM 5.
Diverse populations understand well-being in different ways. Culturally based systems of knowledge are not identical to scientific systems of knowledge. Cultural knowledge may be based on religious beliefs, ethnic customs, or indigenous world views.
Fight stigma
Mental health promotion is about empowering people to take control of their own lives in ways that are adaptive, responsible, satisfying, and rewarding.
| Moving Forward: Action Plan 2017–2018 | | |
Prevention of mental disorders, promotion of mental health, and evolving multidisciplinary culture of work are going to be the main concerns in the days to come. Underserved populations such as elderly and those with intellectual disability and fighting stigma will be our priority.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Washington D.C.: American Psychiatric Publication; 2013.  |
| 2. | Plakun EM. Psychotherapy and psychosocial treatment: Recent advances and future directions. Psychiatr Clin North Am 2015;38:405-18. [ PUBMED] |
| 3. | Lazar SG, editor. Psychotherapy is Worth It: A Comprehensive Review of its Cost-Effectiveness. Washington D.C.: American Psychiatric Publication; 2010. |
| 4. | Sharfstein SS. Big pharma and American psychiatry: The good, the bad, and the ugly. Psychiatr News 2005;40:3. |
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