Historically, cultural psychiatry did not get off to a particularly good start in the United States. Take the case of drapetomania (Szasz, 1971). In times of slavery, this medical diagnosis could be applied to slaves who tried to run away. Such slaves were thought to be "mad" or "crazy" for trying to escape. The medical therapy recommended was whipping, and the "cure" was submission to the slave owner. Although drapetomania has not been in any of our recent diagnostic manuals, the need remains to consider the influence of culture on psychiatry.
Definition of Cultural Psychiatry
In considering terminology of this topic, cultural psychiatry is the term that has the broadest references. Cross-cultural is often used, but only refers to interactions where the culture of the patient is markedly different from that of the clinician, as in drapetomania. Psychologically speaking, major perceived cultural differences between people can cause initial uncertainty, misunderstanding and fear. Culture is relevant, however, even in matches of very similar cultures, as in situations where there is a good therapeutic fit or where the clinician overidentifies with the patient and makes unwarranted cultural assumptions (Moffic et al., 1988).
The term transcultural usually implies interactions across cultures. Culture itself has problems in definition. Does it apply to the fine arts or, more generally, to the identification of groups of people by their collective historical values and behaviors (Moffic, 1983)? From a different perspective, cultural psychiatry can be defined by what it is not. It is not a psychiatric subspecialty, a psychiatry of ethnic minorities, a psychiatry of exotic lands, an antibiological psychiatry or a ploy of political correctness (Alarcon, 1998).
In this broad sense then, all clinicians and patients have a cultural identification or, in many cases, multiple cultural identifications. One's culture can refer to ethnicity, religion, sex, gender, sexual preference, age, socioeconomic status, language, geography, occupation and certain disabilities. Representative examples of each of these categories are those who identify with, respectively, Native Americans, Jewish-Americans, women, transsexuals, homosexuals, teen-agers, VIPs, Spanish-speaking people, Southerners, firefighters and the deaf. It can also be fluid and experiential, changing over time. Old simplistic labels may at times no longer fit, such as a child with an ethnic heritage of Nigerian, Irish, African-American, Russian, Jewish and Polish being simply called "black."
Importance of Cultural Psychiatry
Given that cultural psychiatry involves values, it should not be surprising that it influences psychiatric services (Kleinman, 1977). Even the field of psychiatry in the United States can be said to have a culture all its own, emphasizing the treatment of individuals--akin to the value of individuality in the United States. It also cannot help but be influenced by the health care systems that exist in the United States. The United States is the only developed country without universal health care coverage. Insurance often does not cover mental health care as well as it provides for general health care. No other country currently has such a well-developed and extensive managed care system that is designed to control costs and review utilization. This fits our capitalistic economy.
How culture interacts with this unique and fragmented system of psychiatric care is complex. It can influence the development and recognition of mental disorders, access to care, appropriate diagnosis, and the provision of treatment (U.S. Department of Health and Human Services, 1999). Even research findings can be influenced, depending in part on what patient culture(s) are included and identified in the research (Rogler, 1999).
History of Cultural Psychiatry
Reviewing the history of how culture has interacted with psychiatric services can help illustrate its effects. After drapetomania and slavery, and after psychiatry became a recognized specialty, there was a gradual improvement in addressing cultural factors in clinical services. Usually these changes shadowed cultural events and changes in the larger society (Moffic and Kinzie, 1996). The same cultural groups that have been often discriminated against in general society have been plagued by disparities in availability and access to appropriate mental health care (Lehmann, 2003).
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