Transcultural Psychiatry: Cultural Difference,Universalism and Social Psychiatry in the Age of Decolonisation

In the mid-twentieth century, in the aftermath of WWII and the Nazi atrocities and in the midst of decolonisation, a new discipline of transcultural psychiatry was being established and institutionalised. This was part and parcel of a global political project in the course of which Western psychiatry attempted to leave behind its colonial legacies and entanglements, and lay the foundation for a more inclusive, egalitarian communication between Western and non-Western concepts of mental illness and healing. In this period, the infrastructure of post-colonial global and transcultural psychiatry was set up, and leading psychiatric figures across the world embarked on identifying, debating and sometimes critiquing the universal psychological characteristics and psychopathological mechanisms supposedly shared among all cultures and civilisations. The article will explore how this psychiatric, social and cultural search for a new definition of ‘common humanity’ was influenced and shaped by the concurrent global rise of social psychiatry. In the early phases of transcultural psychiatry, a large number of psychiatrists were very keen to determine how cultural and social environments shaped the basic traits of human psychology, and ‘psy’ practitioners and anthropologist from all over the world sought to re-define the relationship between culture, race and individual psyche. Most of them worked within the universalist framework, which posited that cultural differences merely formed a veneer of symptoms and expressions while the universal core of mental illness remained the same across all cultures. The article will argue that, even in this context, which explicitly challenged the hierarchical and racist paradigms of colonial psychiatry, the founding generations of transcultural psychiatrists from Western Europe and North America tended to conceive of broader environmental determinants of mental health and pathology in the decolonising world in fairly reductionist terms—focusing almost exclusively on ‘cultural difference’ and cultural, racial and ethnic ‘traditions’, essentialising and reifying them in the process, and failing to establish some common sociological or economic categories of analysis of Western and non-Western ‘mentalities’. On the other hand, it was African and Asian psychiatrists as well as Marxist psychiatrists from Eastern Europe who insisted on applying those broader social psychiatry concepts—such as social class, occupation, socio-economic change, political and group pressures and relations etc.—which were quickly becoming central to mental health research in the West but were largely missing from Western psychiatrists’ engagement with the decolonising world. In this way, some of the leading non-Western psychiatrists relied on social psychiatry to establish the limits of psychiatric universalism, and challenge some of its Eurocentric and essentialising tendencies. Even though they still subscribed to the predominant universalist framework, these practitioners invoked social psychiatry to draw attention to universalism’s internal incoherence, and sought to revise the lingering evolutionary thinking in transcultural psychiatry. They also contributed to re-imagining cross-cultural encounters and exchanges as potentially creative and progressive (whereas early Western transcultural psychiatry primarily viewed the cross-cultural through the prism of pathogenic and traumatic ‘cultural clash’). Therefore, the article will explore the complex politics of the shifting and overlapping definitions of ‘social’ and ‘cultural’ factors in mid-twentieth century transcultural psychiatry, and aims to recover the revolutionary voices of non-Western psychiatrists and their contributions to the global re-drawing of the boundaries of humanity in the second half of the twentieth century.

     

Psychiatry in General Practice

Psychiatrists should include the family doctor in their plans for future psychiatric services. The general practitioner now treats most of the patients who seek help for psychiatric disorder and he could not give up his psychiatric practice even if he wanted to. Furthermore, there are not now nor will there ever be enough psychiatrists to take over all patients with mental ills. Most emotionally disturbed patients can be better handled by their family physicians than by a specialist.To provide the best care for emotionally disturbed people the communication between family doctors and psychiatrists must be improved. The specialist must acknowledge the importance of the general practitioner''s role in psychiatric diagnosis and treatment and give him more help. Medical schools must provide better undergraduate and postgraduate psychiatric training for the students who will become family doctors. Health plans and other prepayment agencies should properly compensate the general practitioner for giving psychiatric treatment. The specialist in psychiatry should consult more readily with the general practitioner and help him carry out some of the therapy. General hospitals should permit family doctors to admit mental patients to psychiatric wards in a general hospital and to carry out psychiatric treatment with the help of the specialist in psychiatry.     

Is communication improving between general practitioners and psychiatrists?

General practitioners and psychiatrists communicate mainly by letter. To ascertain the most important items of information that should be included in these letters ("key items") questionnaires were sent to 80 general practitioners and 80 psychiatrists. A total of 120 referral letters sent to psychiatric clinics in 1973 and 1983 were studied, together with the psychiatrists'' replies, and these were rated for the inclusion of "key items." General practitioners'' letters contain less information about the family but more about psychiatric history than they did a decade ago. Overall, psychiatrists'' letters have not changed. Registrars, however, now include noticeably more "key items" than they did 10 years ago, but their letters remain twice the length of those written by consultants. It is suggested that letter writing skills are vital to good patient management and should be taught to postgraduate trainees in general practice and psychiatry.     

Family Life and Social Medicine: Discourses and Discontents Surrounding Puebla’s Psychiatric Care

Drawing on clinical data from 15 months of on-site participant observation in the only public psychiatric hospital in the state of Puebla, Mexico, this article advances our understanding of globalization in relation to psychiatry. I challenge the construction of psychiatry as only treating the individual patient and provide grounded doctor-patient-family member interaction in a Mexican psychiatric clinic in order to review what happens when doctors cannot interact with patients as atomized individuals even though in theory they are trained to think of patients that way. Challenged by severe structural constraints and bolstered by lessons from other nations’ efforts at deinstitutionalization, psychiatrists in Puebla push to keep patients out of the inpatient wards and in their respective communities. To this end, psychiatrists call upon co-present kin who are identified both as the customer and part of the caretaking system outside the clinic. This modification to the visit structure changes the dynamic and content of clinical visits while doctors seamlessly respond to unspoken beliefs and values that are central to local life, ultimately showing that efforts to define a “global psychiatry” informed by global policy will fail because it cannot exist in a uniform way—interpersonal interaction and personal experience matters.     

Reducing the treatment gap for mental disorders: a WPA survey

The treatment gap for people with mental disorders exceeds 50% in all countries of the world, approaching astonishingly high rates of 90% in the least resourced countries. We report the findings of the first systematic survey of leaders of psychiatry in nearly 60 countries on the strategies for reducing the treatment gap. We sought to elicit the views of these representatives on the roles of different human resources and health care settings in delivering care and on the importance of a range of strategies to increase the coverage of evidence-based treatments for priority mental disorders for each demographic stage (childhood, adolescence, adulthood and old age). Our findings clearly indicate three strategies for reducing the treatment gap: increasing the numbers of psychiatrists and other mental health professionals; increasing the involvement of a range of appropriately trained non-specialist providers; and the active involvement of people affected by mental disorders. This is true for both high income and low/middle income countries, though relatively of more importance in the latter. We view this survey as a critically important first step in ascertaining the position of psychiatrists, one of the most influential stakeholder communities in global mental health, in addressing the global challenge of scaling up mental health services to reduce the treatment gap.     

A Contribution to the Comparative Epidemiology of Schizophrenia in Urban and Rural Places

In psychiatry, epidemiology rests upon statistical studies of mental illness in the population. Much attention was given to this as early as the work of Esquirol, (1) and I. F. Riul' (2) in our country. Zemstvo psychiatrists contributed much in the field of psychiatric morbidity. (3-8) However, as a result of the lack of outpatient psychoneurological institutions in prerevolutionary Russia, these studies, like the majority of those currently being conducted by psychiatrists abroad, resolved fundamentally to isolated unidimensional selective surveys of particular groups in the population. The existence in the Soviet Union of a broad network of outpatient psychiatric institutions permits Soviet psychiatrists to go beyond single-factor selective surveys, to make a systematic study of mental illness in accordance with the data of current dispensary records, and to provide timely therapeutic and social prophylactic assistance to the ill, i.e., to conduct epidemiological research on a higher level of scientific methodology. A number of such studies has been published. (8-23) Therefore the statement by Lin and Standley, (24) who allege — in a monograph, The Role of Epidemiology in Psychiatry, published by the World Health Organization — the absence of epidemiological psychiatric studies in the Soviet Union, must be rejected as unfounded.     

WPA guidance on how to combat stigmatization of psychiatry and psychiatrists

In 2009 the WPA President established a Task Force that was to examine available evidence about the stigmatization of psychiatry and psychiatrists and to make recommendations about action that national psychiatric societies and psychiatrists as professionals could do to reduce or prevent the stigmatization of their discipline as well as to prevent its nefarious consequences. This paper presents a summary of the Task Force’s findings and recommendations. The Task Force reviewed the literature concerning the image of psychiatry and psychiatrists in the media and the opinions about psychiatry and psychiatrists of the general public, of students of medicine, of health professionals other than psychiatrists and of persons with mental illness and their families. It also reviewed the evidence about the interventions that have been undertaken to combat stigma and consequent discrimination and made a series of recommendations to the national psychiatric societies and to individual psychiatrists. The Task Force laid emphasis on the formulation of best practices of psychiatry and their application in health services and on the revision of curricula for the training of health personnel. It also recommended that national psychiatric societies establish links with other professional associations, with organizations of patients and their relatives and with the media in order to approach the problems of stigma on a broad front. The Task Force also underlined the role that psychiatrists can play in the prevention of stigmatization of psychiatry, stressing the need to develop a respectful relationship with patients, to strictly observe ethical rules in the practice of psychiatry and to maintain professional competence.     

Cultures in psychiatric nosology: The CCMD-2-R and International Classification of Mental Disorders

This essay reviews the Chinese Classification of Mental Disorders, Second Edition, Revised (CCMD-2-R, 1995), by assuming the theoretical stance that symptom recognition, disease construction, and taxonomic strategy in psychiatry reflect, and are constrained by, the cultural norms and values as well as the political and economic organizations of the society in which they are embedded. The CCMD-2-R is an ethnomedical classification grounded in both symptomatology and etiology, in which Chinese psychiatrists seek to conform with international classifications on the one hand, and to sustain a nosology with Chinese cultural characteristics on the other. Although broad similarities between the ICD-10 and CCMD-2-R are evident, their blending is legitimately incomplete. Thus, the particular additions (e.g., travelling psychosis, qigong induced mental disorders), deletions (e.g., somatoform disorders, pathological gambling, a number of personality and sexual disorders), retentions (e.g., unipolar mania, neurosis, hysteria, homosexuality), and variations (e.g., depressive neurosis, neurasthenia) reveal not only the changing notions of illness but also the shifting social realities in contemporary China. The CCMD-2-R will be widely used by Chinese psychiatrists and should standardize diagnostic practice and facilitate research, but its impact on everyday clinical work and psychiatric training remains to be evaluated. For Western researchers, it is one avenue for achieving an understanding of the Chinese social world, and should usefully be contrasted with the ICD-10 and DSM-IV as the move towards an international nosology continues.     

Psychiatry and Psychotherapy: Is a Divorce Imminent?

Despite the long tradition of psychiatrists practicing psychotherapy, many psychiatric and medical leaders are predicting and urging a reorientation of psychiatry toward the medical model. They would leave psychotherapy to psychologists, social workers and the like. Many social, governmental and institutional factors favor such a change. The marriage of psychiatry and psychotherapy has always been an uneasy one, and the push for divorce may be irresistible. The author cautions that a divorce could be detrimental to medicine by substituting, in the name of “science,” a dehumanized, technological psychiatry for the current “moral” treatment. One alternative to divorce is a broader approach to psychiatry, combining biological, neuromedical, socioenvironmental and psychodynamic factors. The divorce, though imminent, should be resisted.     

Psychiatrists' attitudes regarding genetic testing and patient safeguards: a preliminary study

AIMS: A probability sample of U.S. psychiatrists (n = 93) was invited to complete a mail survey regarding the likely impact of genetic testing on psychiatry; the clinical utility of pharmacogenetic, diagnostic, and susceptibility genetic testing; and 14 proposed ethical and legal safeguards for clinical genetic testing. RESULTS: Forty-five psychiatrists participated in the survey (response rate = 48%). The majority (80% and 60%, respectively) believed that genetic testing would benefit many psychiatric patients and would dramatically change the way psychiatry is practiced. Many psychiatrists (73-85%) also stated that pharmacogenetic, diagnostic, and susceptibility tests for common psychiatric disorders would be somewhat useful or extremely useful in the clinical setting. Nearly all (98-100%) believed that psychiatrists should obtain informed consent before genetic testing, should keep test results confidential, should provide pre- and posttest counseling, and should demonstrate competence in interpreting test results. Nearly all (96-100%) supported laws and regulations to prevent discrimination based on genetic test results and to protect consumers from misleading advertisements for testing. Ninety-one percent endorsed restrictions on the sale of genetic tests directly to consumers. CONCLUSIONS: This probability sample of U.S. psychiatrists expressed a strongly positive view of genetic testing in psychiatry, while voicing nearly unanimous support for seven ethical and legal safeguards.     

Modeling the Pre-Industrial Roots of Modern Super-Exponential Population Growth

To Malthus, rapid human population growth—so evident in 18th Century Europe—was obviously unsustainable. In his Essay on the Principle of Population, Malthus cogently argued that environmental and socioeconomic constraints on population rise were inevitable. Yet, he penned his essay on the eve of the global census size reaching one billion, as nearly two centuries of super-exponential increase were taking off. Introducing a novel extension of J. E. Cohen''s hallmark coupled difference equation model of human population dynamics and carrying capacity, this article examines just how elastic population growth limits may be in response to demographic change. The revised model involves a simple formalization of how consumption costs influence carrying capacity elasticity over time. Recognizing that complex social resource-extraction networks support ongoing consumption-based investment in family formation and intergenerational resource transfers, it is important to consider how consumption has impacted the human environment and demography—especially as global population has become very large. Sensitivity analysis of the consumption-cost model''s fit to historical population estimates, modern census data, and 21^st Century demographic projections supports a critical conclusion. The recent population explosion was systemically determined by long-term, distinctly pre-industrial cultural evolution. It is suggested that modern globalizing transitions in technology, susceptibility to infectious disease, information flows and accumulation, and economic complexity were endogenous products of much earlier biocultural evolution of family formation''s embeddedness in larger, hierarchically self-organizing cultural systems, which could potentially support high population elasticity of carrying capacity. Modern super-exponential population growth cannot be considered separately from long-term change in the multi-scalar political economy that connects family formation and intergenerational resource transfers to wider institutions and social networks.     

Association between the Density of Physicians and Suicide Rates in Japan: Nationwide Ecological Study Using a Spatial Bayesian Model

Background

Regional disparity in suicide rates is a serious problem worldwide. One possible cause is unequal distribution of the health workforce, especially psychiatrists. Research about the association between regional physician numbers and suicide rates is therefore important but studies are rare. The objective of this study was to evaluate the association between physician numbers and suicide rates in Japan, by municipality.

Methods

The study included all the municipalities in Japan (n = 1,896). We estimated smoothed standardized mortality ratios of suicide rates for each municipality and evaluated the association between health workforce and suicide rates using a hierarchical Bayesian model accounting for spatially correlated random effects, a conditional autoregressive model. We assumed a Poisson distribution for the observed number of suicides and set the expected number of suicides as the offset variable. The explanatory variables were numbers of physicians, a binary variable for the presence of psychiatrists, and social covariates.

Results

After adjustment for socioeconomic factors, suicide rates in municipalities that had at least one psychiatrist were lower than those in the other municipalities. There was, however, a positive and statistically significant association between the number of physicians and suicide rates.

Conclusions

Suicide rates in municipalities that had at least one psychiatrist were lower than those in other municipalities, but the number of physicians was positively and significantly related with suicide rates. To improve the regional disparity in suicide rates, the government should encourage psychiatrists to participate in community-based suicide prevention programs and to settle in municipalities that currently have no psychiatrists. The government and other stakeholders should also construct better networks between psychiatrists and non-psychiatrists to support sharing of information for suicide prevention.     

Psychological and social evaluation in cases of deliberate self-poisoning admitted to a general hospital.

In a prospective clinical trial 312 cases of self-poisoning (276 patients) consecutively admitted to hospital were randomly allocated to medical teams or to psychiatrists for an initial psychiatric assessment and a decision as to "disposal." Junior doctors and nurses received some instruction in this work. Both groups of assessors asked for help from social workers when necessary. Once the medical teams had completed their assessments, psychiatrists provided most of the hospital treatment. Follow-up at one year showed no significant difference between the two groups of patients in the numbers who repeated their self-poisoning or self-injury (or both), or committed suicide. Provided junior doctors and nurses are taught to assess self-poisoned patients, we think medical teams can evaluate the suicidal risk and identify patients requiring psychiatric treatment or help from social workers, or both. Contrary to the Department of Health''s recommendation that all cases of deliberate self-poisoning should be seen by psychiatrists, we have reached the conclusion that physicians should decide for each of their patients if specialist psychiatric advice is necessary.     

Understanding self and others: from origins to disorders

In order to interpret and engage with the social world, individuals must understand how they relate to others. Self–other understanding forms the backbone of social cognition and is a central concept explored by research into basic processes such as action perception and empathy, as well as research on more sophisticated social behaviours such as cooperation and intergroup interaction. This theme issue integrates the latest research into self–other understanding from evolutionary biology, anthropology, psychology, neuroscience and psychiatry. By gathering perspectives from a diverse range of disciplines, the contributions showcase ways in which research in these areas both informs and is informed by approaches spanning the biological and social sciences, thus deepening our understanding of how we relate to others in a social world.     

Relative costs of specialist services in a family practice population

The frequency and cost of referrals to specialists in March 1984 for 8980 rostered patients attending a family practice clinic located in a teaching hospital were analysed. The patients made 1891 visits to specialists. In all age groups and for all specialties female patients were more likely to be seen. The total direct provider costs were higher for female patients than for male patients. However, costs per patient seen were higher for male patients, except for psychiatry and medicine. Visits to surgeons had the highest total cost, while visits to psychiatrists had the highest cost per patient seen. Of the direct provider costs 61% was for specialist services. The family physician, in the “gatekeeper” role, has an opportunity to control some of the costs of the health care system by ensuring that the best and most efficient use is made of the referral network.     

New Data on the Problem of Social Perception (A Person's Perception and Conception of Another Person)

Throughout the world at the present time more and more scientists are working on the problem of social perception. Though they are interested in different aspects of this problem, all are helping to elucidate the more or less complex features that characterize the process of how a human being forms images of other people and how he develops conceptions of their personalities. It was no slip of the pen when we included as a part of "social perception" the evolution of one's conception of another human being as a personality, for today the term "social perception" has been extended by most psychologists working on this problem to include the whole range of phenomena involved in one person's knowledge of another on the level of feeling as well as on the rational plane.     

Host–parasitoid spatial models: the interplay of demographic stochasticity and dynamics

Host–parasitoid metapopulation models have typically been deterministic models formulated with population numbers as a continuous variable. Spatial heterogeneity in local population abundance is a typical (and often essential) feature of these models and means that, even when average population density is high, some patches have small population sizes. In addition, large temporal population fluctuations are characteristic of many of these models, and this also results in periodically small local population sizes. Whenever population abundances are small, demographic stochasticity can become important in several ways. To investigate this problem, we have reformulated a deterministic, host–parasitoid metapopulation as an integer-based model in which encounters between hosts and parasitoids, and the fecundity of individuals are modelled as stochastic processes. This has a number of important consequences: (1) stochastic fluctuations at small population sizes tend to be amplified by the dynamics to cause massive population variability, i.e. the demographic stochasticity has a destabilizing effect; (2) the spatial patterns of local abundance observed in the deterministic counterpart are largely maintained (although the area of ''spatial chaos'' is extended); (3) at small population sizes, dispersal by discrete individuals leads to a smaller fraction of new patches being colonized, so that parasitoids with small dispersal rates have a greater tendency for extinction and higher dispersal rates have a larger competitive advantage; and (4) competing parasitoids that could coexist in the deterministic model due to spatial segregation cannot now coexist for any combination of parameters.     

Attitudes to Psychiatry in the General Hospital

A survey of consultant attitudes to psychiatry in six general hospitals is presented and compared with reported findings in general practitioners and medical students.Psychological factors were accepted as important in a variety of medical conditions. Different specialties differed little in their attitudes to neurotic patients and to psychiatrists, younger consultants tending to be more critical. Consultants had a lower level of neuroticism than the general population and medical students, and physicians were less extraverted than surgeons; these personality factors were not related to expressed attitudes.The results suggest that other specialties accept the role of psychiatry, and its integration into the general hospital is not likely to meet with antagonism.     

WHAT PSYCHIATRISTS THINK ABOUT ALCOHOLISM

The one approach most favored for alcoholism by psychiatrists in Southern California who answered a questionnaire is membership in Alcoholics Anonymous. Ninety-nine per cent of them approved Alcoholics Anonymous, and 80 per cent had referred patients to the organization. Yet they believed only 10 per cent of the persons who join A.A. remain sober for over two years. This against the claim of A.A. that 60 per cent or more of their fellowship are recovered emphasized the pessimism of the psychiatrists questioned.Ninety per cent of the psychiatrists who replied said they do not treat alcoholics or that they limit the number or the type they will accept for treatment. They obtain recovery, they said, of 10 per cent of patients, improvement of 50 per cent, and the rest are unchanged.The emphasis in psychiatry is on elimination of the anxieties leading to alcoholism; in Alcoholics Anonymous the emphasis is on the strength to bear these anxieties. Ninety per cent of the replies received were in favor of clinics for alcoholics, and the respondents felt that governmental agencies should support these clinics. Under such circumstances psychiatrists would combine their abilities with psychologists, social workers and Alcoholics Anonymous. Thirty-five per cent of psychiatrists said they are willing to work in a clinic, the majority without recompense.