“He examined the chess problem and set out the pieces. ‘white to play and mate in two moves’. White always mates, he thought with a sort of cloudy mysticism. Always, without exception, it is so arranged. In no chess problem since the beginning of the world has black ever won.”
-George Orwell, Nineteen eighty-four

Introduction

All societies at all times have recognized something akin to madness, although the underlying reasons and meanings have been sought in different ways. Since ancient times, theories about mental illnesses have been constantly influenced by different social and political philosophies. The predominant paradigm in psychiatry today is that developed in Europe and North America over a past century or so. Though few people would agree with such a statement, there is evidence of biased, value-based and often racist undercurrents in psychiatry (Chakraborty, 1991).

What is “Transcultural Psychiatry”?

The definition of transcultural psychiatry is as elusive as the definition of culture. Very few people have attempted to define or specify what transcultural psychiatry is about. It is often argued that transcultural psychiatry will inform us of the pathoplastic effects of culture on mental illness, and that from such a basis we would even understand the etiological nature of such conditions. This approach is not at all dissimilar from other social or epidemiological enquiries in relation to health and ill-health; the delineation of transcultural psychiatry from social or epidemiological psychiatry or anthropology is often vague and imprecise (Sashidharan, 1986).

Murphy (1977) notes that much transcultural research is about “exotic” cultures and that one is left with the impression that all that merits the appellation “culture” is non-European. For e.g., while male-female difference in the clinical picture of psychosis in India is considered transcultural, the same differences are regarded as social in Ireland or France (Chakraborty, 1974). Again, when that particular topic appears in national journals, it is most likely to be dealt with under the heading of social psychiatry. Hence, with the development of psychiatry in the various underdeveloped countries, what is transcultural psychiatry today is likely to become social psychiatry tomorrow.

Ideology and Politics in Transcultural Psychiatry

A critical scrutiny of the historical antecedents of transcultural psychiatry will appraise us of the social and political context within which a need for this speciality was articulated, and of how economic and political considerations demanded that ‘scientific activity’ should include assiduous comparisons of Europeans with non-Europeans. It was an ideology that emerged in a historically specific context and as a product of capitalism in eastern Europe, and the advancement and appeal of transcultural psychiatry owed a great deal to colonialism and scientific racism (Sashidharan, 1986). The origins of cultural psychiatry are often located in Kraepelin’s voyage to Java to explore the universality of dementia praecox and manic depression. But his comparisons of disease frequency or its association with other factors became of secondary importance, and what Kraepelin offered as speculative explanations, the racial characteristics (lack of responsibility, the absence of deep self-reflection, etc.), became the sole concern of this new discipline. The subsequent evolution of transcultural psychiatry was heavily influenced by the emergence of psychoanalysis – the concepts of the unconscious and its mechanisms, the primitive, malevolent and destructive forces which were equated with the way ‘primitive people’ actually thought and behaved and how the minds of the child, the neurotic and that of the ‘primitive people’ were at parallel stages of development, were, in a limited sense, reiteration of common notions about non-European people that were embedded in the cultural history of nineteenth-century Europe. The advent of 20th century saw the colonization of black people in most of Africa and Asia by European nations, and the white man’s burden was not only to rule and ‘civilize’ but also to study and understand ‘the natives’.  And after the end of the Empire, the ideas and strategies fashioned abroad by the assiduous study of colonized people are being reformulated and applied by mental health professionals in the context of responding to ‘ethnic minority health problems in Europe’ (Sashidharan, 1986).

Kirmayer and Minas (2000) makes this point strikingly clear by the giving the example of pibloktoq, or arctic hysteria, among the Inuit. Most comprehensive psychiatric texts mention pibloktoq as a culture-bound syndrome characterized by sudden wild and erratic behavior. Recently, the historian Lyle Dick collected all the published accounts of pibloktoq, of which there are only about 25 (Dick, 1995). It seems that psychiatric case description transformed a situation of sexual exploitation of Inuit women by explorers into a discrete disorder worthy of a new diagnostic label.

The Relevance of Transcultural Psychiatry: A Critique

Whereas Western societies are considered ‘multi-cultural’ so that studies need to be conducted for different ethnic groups to ensure findings are ‘culturally correct’, non-industrialized societies are not offered the same privilege. It is common to see studies from vast, and hugely diverse, countries such as India or China being used to suggest that the findings are representative of the culture of the entire nation. Such naive assumptions have greatly limited the value of cross-cultural studies where the choice of country settings is used as a means of ensuring representativeness of cultural diversity (Patel and Sumathipala, 2001).

Transcultural psychiatry fails to recognize that cultures are dynamic, complex social constructs which defy easy definition or measurement. Globalization has been phenomenal in its impact on culture; cultures are integrating, with values and beliefs from one culture finding new homes in other cultures. The homogenization of cultures in the non-industrialized world in the past decade is a marker of the vulnerability of cultures to the onslaught of modern marketing and global media networks. In the face of this reality, one of the key rationales behind transcultural psychiatry is becoming rapidly redundant (Patel, 2001).

The assumption that there is an interdependence between psychiatric and sociocultural processes that is in some measure distinct from the relationship between psychiatric processes and organic experiences or heredity as the major reason for existence of transcultural psychiatry merits more than an axiomatic acceptance. Culture is often a blanket term to cover and obscure economic, political, social, biological and physical environmental factors (Jablensky, 1975). To note an occurrence of a disease in a certain “culture” should, in fact, be a signal to elucidate the presence or absence of other factors. An e.g. is Gajdusek’s work on Kuru in New Guinea that demonstrated that the ingestion of diseased brain transmitted a slow virus. This work has been an important source of our understanding the pathogenesis Jakob- Creudzfeldt syndrome. Whereas the common psychoses such as schizophrenia are ubiquitous in distribution, the exotic psychiatric syndromes that have been described in different regions of the globe may well be reclassified as universal syndromes with similar pathological processes (Wallace, 1975).

Culture and Classification: Some Facts

If one considers the composition of the team that finalized ICD 10, it hardly appears to fairly represent different cultures. Of the 47 eminent psychiatrists who contributed the initial draft, only 2 are from Africa, and none of the 14 field trial centers have been in sub-Saharan Africa. The results are not surprising; categories such as nymphomania and multiple personality disorder are classified under individual codes, while conditions such as brain fag syndrome, which has been described for over 30 years in Africa, are not classified at all (Patel and Winston, 1994).

The ethnographic database strongly suggests that, apart from brain tumors and infections, Alzheimer’s disease, metabolic encephalopathy, substance abuse and other well documented brain-based disorders such as certain sleep disorders, only five psychiatric syndromes of the adults can be found cross-culturally. The conditions are schizophrenia, brief reactive psychoses, major depression, bipolar disorder, and a range of anxiety disorders from panic states through phobias to obsessive-compulsive disorder. Most of the other hundreds of conditions described in DSM IV, for example, are culture bound to Euro-America (Kleinman, 2000).

Category fallacy: This is a concept given by Kleinman, and refers to the reification of a nosological category developed for a particular cultural group that is then applied to members of another culture for whom it lacks coherence and its validity has not been established. Dysthymia a possible example. It may hold coherence in the more affluent west, but it represents the medicalisation of social problems in much of the rest of the world where severe economic, political and health constraints create endemic feelings of hopelessness and helplessness, where demoralization and despair are responses to real conditions of chronic deprivation and persistent loss, where powerlessness is not a cognitive distortion but an accurate mapping of one’s place in an oppressive social system. This state of chronic demoralization, furthermore, is not infrequently associated with anemia and other physiological effects of malnutrition and other tropical disorders (Kleinman, 1987).

Some observers have noted that significant portions of what was recommended by the Culture and Diagnosis Task Force were left out by the final arbiters of DSM-IV. For e.g., the Task Force had recommended that DSM-IV disorders such as anorexia nervosa and chronic fatigue syndrome be included in the "Glossary of Culture Bound Syndromes" because they represent North American disorders strongly shaped by culture (Lopez and Guernaccia, 2000).

Western Medicine as a Cultural Construction

Western medicine is itself a cultural construction and needs to be seen as one of different ways of dealing with the experience of illness and distress (Kakar, 1995).  Each culture has developed its own methods for dealing with disorders of the mind. Trivedi and Sethi (1980) observed that 33.2 % of their patients have had treatment from faith healers prior to consulting them. Traditional healers have the advantage of sharing the same belief system about illness with their clients. Skilled healers are adept at understanding the relationship problems that underlie the client’s bodily problems, and their prescription of rituals is aimed at involving the client’s social network and regularizing relationships. The healers are able to manage neurotic states, hysterical psychoses and dissociative states (Rao, 1986). It is a sobering thought that rauwolfia, an effective herbal antipsychotic, was used by Indian traditional healers for hundreds of years before chlorpromazine was introduced.

Psychiatric Research and the Developing Countries

The production and export of psychiatric knowledge is tied to political-economic issues and to the cultural framing of problems. The call for evidence-based-medicine promises a more rational approach to psychiatric practice. However, evidence-based-medicine is circumscribed by the research literature. Research funding often comes from parties interested in accruing certain types of evidence (and ignoring others), so that we may end up with scientific evidence for those practices that serve powerful economic and political interests (Kirmayer and Minas, 2000). Indeed, 90% of the world’s research funding is directed at problems that affect 10% of the world’s population (Global Forum for Health Research, 1999). Opportunities for training and supervision in research are very limited in many developing countries (Okasha and Karam, 1998). Furthermore, research from Western cultures is considered to be of international significance whereas research from non-industrialized countries is of interest for its demonstration of culture on psychiatric disorders (Patel, 2001). The psychiatric problems of the world’s poor, and research aimed at the resolution of those problems, do not feature significantly in the psychiatric journals with the highest impact factors. Patel and Sumathipala (2001) reviewed articles published in six leading psychiatric journals over a 3 year period to compare the contribution of Euro-American countries and the rest of the world, and found that out of a total of 2902 articles, number of articles from the rest of the world was 173 (6%). This imbalance potentially restricts the growth of psychiatry as a truly international medical discipline.

Future Directions (The Way Out)

There are considerable variations in cultural models, pharmacodynamic factors, health service variations and drug availability in different regions of the world. Moreover, health policy-makers and planners in developing countries are unlikely to be impressed solely by data from the West. Thus a major research priority in developing countries should be the evaluation of the efficacy and cost-effectiveness of health service interventions and treatments for various psychiatric disorders.

In the absence of validating pathological criteria, the process of determining the nature and prevalence of mental disorders in different cultures need to begin with the identification of particular illness categories as described by communities in those different cultures. Once such regional classification is developed, categories could then be compared with those identified elsewhere. While generating such culturally valid diagnostic categories may seem a daunting task, such research has been accomplished successfully (Beiser et al, 1972), and it is likely to be less complex and costly than multinational studies.

The opportunities and resources for research in developing countries could be improved in a number of ways, including establishing research-oriented training programmes linked with ongoing project collaborations, facilitating research training in the form of short courses and distance education, and providing a resource for advising on research design, methodology and analysis. Multilateral agencies like WHO and international research institutions can play an especially influential role in this process. Established research institutions in developing countries should be encouraged to play a leading role in raising capacity for mental health research skills (Patel and Sumathipala, 2001).

Conclusion

Although ethnic and cultural pluralism is a common feature of developing countries, the most pressing cultural issue is the wholesale importation of forms of psychiatric thinking and practice that may not be appropriate to local circumstances. Fortunately, as is evident from the literature reviewed in this discussion, the world is changing. Increasingly, people who were once the object of ethnographic study are having their own say in how their worlds are to be interpreted and understood by others, and indeed, they are offering their own mordant readings of Euramerican cultures and colonialist projects. And it is high time for those in the West to give an ear to these voices, if Psychiatry is to be a relevant international public health discipline.

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