Culture is far from having outlived its usefulness for psychiatry.
The quote cited above was the provocative title of a symposium presented at the International Congress of the World Psychiatric Association (WPA) held last November in Cape Town, South Africa. Organized by the WPA Section on Religion, Spirituality, and Psychiatry, the discussion for and against the implied para-legislative “resolution of the House” (House of what, not specified) was conducted by 1 moderator and had 4 speakers, all from the UK. It attracted an eager audience and generated an active flow of ideas and thoughts on the subject. Also worth mentioning is the fact that the exclusionary-sounding pronouncement of the symposium title was made in a Congress whose main theme was “Psychiatry: Integrative Care for the Community.” This only added fire to the ontological oven.
To be sure, the debate kept an expected scholarly level. The moderator opened it up by invoking the philosophical saying that to improve knowledge and thinking “it is better to argue against your own inclinations.” He enumerated the “varied and profound” connections between culture and mental health, but also outlined “misleading” cultural concepts such as ethnicity, geographic locality, international links, social sciences’ definitions, symbols, and languages that become “trees inside the forest” and create neglectful reifications and ambiguous homogeneities. The first advocate of the notion that culture has “outlived” its usefulness alluded to the changing nature of the concept and its content, to discrepancies regarding cultural explanations, interpretations, and the “social acquisition” process of meanings and clinical responses. One of the most interesting arguments of this position was that people’s beliefs are useful to identify views about mental health problems, but such views emerge mostly out of “political” considerations in such a way that any psychiatric intervention along those lines may be “detrimental.”
The second advocate of this way of thinking emphasized the view that a cultural approach prioritizes differences, exoticizes clinical descriptions, and forces a mutual alienation of patients and professionals; folkloric psychiatry, adduced, is as parasitic as intuitive psychology, and the mechanisms of belief acquisition (cognitive processes?) undermine the need and the value of resorting to culture as the main source of explanatory models. Culture “misconceives multidimensionality,” “provides an incomplete definition of concepts,” “does not make a sound argument for values,” becomes a “banner” and, ultimately, leads to its own kind of reductionism.
The panelists that objected to the leading affirmation focused on the notion of values and beliefs as cultural factors of paramount relevance in the framing, actual occurrence, and understanding of mental disorders. Clinical facts alone, they argued, “don’t tell us what is normal or abnormal, functional or dysfunctional,” as environmental, culturally determined factors “shape clinical events” in a process made out of “inseparable components.” The relationship between language and the complex communicational processes that it nourishes in a given society configures an unequivocal association that produces clinical manifestations. In such context, the abandonment of stereotypes, of fallacious equivocations, and a joint work with native healers can be useful resources in the efforts to establish the genuine role of culture in mental health and psychiatric work.
In my opinion and despite the arguments that would give yes as an answer to the “House resolution,” an overwhelming evidence to the contrary has materialized in recent years. In fact, the inclusion of socio-cultural concepts and factors in diagnostic, treatment, prevention, and policy-making fields can only be compared today to the neuroscientific and technological advances in research and clinical practice: both areas constitute hallmarks of 21st century psychiatry. And a bridging conceptualization of bio-cultural correlates emerges as one of the richest and most promising sources of knowledge for future generations.
In fact, research on cultural psychiatry is a growing field. Academic centers, professional organizations, clinical settings, community groups, and government institutions witness nowadays the advances of projects that incorporate cultural issues as a substantial component. Clinical conditions such as depression, PTSD, anxiety, or personality disorders now possess more evidence of cultural ingredients than a few decades ago. A variety of technical tools increase measurement precision and enhance options of correlating highly subjective, culturally induced variables with actual structural or neuro-physiological changes. Instruments such as the Cultural Formulation Interview included in DSM-5 objectively foster comprehensiveness in diagnosis and management. And epidemiological research renews itself with the focused exploration of cultural issues and factors in the course of mental illnesses.
There is more. Have the concepts of identity, context, meaning, and cultural dynamics lost relevance in contemporary clinical work? Has the humanistic basis of a cultural approach to psychiatric conditions been abandoned by today’s practitioners? Have they missed the interpretive-explanatory, pathogenic-pathoplastic, diagnostic-nosological, and treatment-management roles of culture in current psychiatric endeavors? Can phenomena like global migrations, globalization, massive historical changes (including violence of all kinds), and their mental/emotional consequences be ignored by governments and professional societies around the world? Are stigma, prejudice, and discrimination toward the mentally ill to be set aside as minor curiosities or useless distractions? Is the concept of integrated care going to be deprived of its essential cultural elements?
These questions are suggested by the deficiencies of supposedly post-modern conceptions regarding the broad and crucial relations of psychiatry and culture. Culture entails a genuine universalism of humanity and its features among ethnic, geographic, historical, linguistic, or religious terrains: broad and all-inclusive, not an absolutist yes-no alternative, or a robotic mathematical or biochemical formula-both, essential indices of any reductionism. Culture is recognition and respectful acceptance of differences, those that make diversity the cradle of understanding and compassion. And culture is not, should not be a rhetoric or demagogic resource of immature or frustrated politicians and bureaucrats.
The symposium in Cape Town undoubtedly brought up a number of inciting reflections. I reiterate my own conclusion: culture is far from having outlived its usefulness for psychiatry. The World Health Organization recognized recently that “there is no health without mental health.” Other voices within our profession claimed, in turn, that “there is no mental health without psychiatry.” I would modestly but firmly add that “there is no psychiatry without culture.”
Dr. AlarcÃ³n is Emeritus Professor and Consultant in the Department of Psychiatry and Psychology at the Mayo Clinic College of Medicine in Rochester, MN.