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.

     

Extraordinary Care for Extraordinary Conditions: Constructing Parental Care for Serious Mental Illness in Japan

This article presents an account of how Japanese parents in a family support group for mental illness constructed understandings of care for adult children with serious mental illness, primarily schizophrenia. I build from Janis H. Jenkins’s research on the “extraordinary condition” of schizophrenia to discuss “extraordinary care,” which parents practiced as a way to refute cultural and clinical beliefs about pathogenic families and degenerative diseases. Parents’ accounts of extraordinary care revealed a reliance on biomedical knowledge to treat the symptoms of mental illness coupled with an ongoing determination to improve children’s lives beyond what psychiatry could offer. Extraordinary care thus points to the therapeutic limits of biomedical psychiatry while also reinforcing the significance of social relations as families work toward recovery.     

Diagnosis,Power and Certainty: Response to Davis

Lennard Davis’s “Biocultural Critique” of the alleged certainty of diagnosis (Davis Journal of Bioethical Inquiry 7:227−235, 2010) makes errors of fact concerning psychiatric diagnostic categories, misunderstands the role of power in the therapeutic relationship, and provides an unsubstantiated and vague alternative to the management of psychological distress via a conceptually outdated model of the relationships between physical and psychological disease and illness. This response demonstrates that diagnostic knowledge vouchsafes legitimate power to physicians, and via them relief to patients who suffer from psychological distress. The history of medicine and psychiatry demonstrates that psychiatric diagnosis shares many features with physical diagnosis, while there is also reason to believe that the two types will continue to be distinct in some respects. Diagnostic categories in psychological medicine, like those in physical medicine, are provisional, probabilistic, and often uncertain. These features do not detract from the dependence on diagnosis of therapeutic efficacy in both domains.     

The interrelationship of tropical disease and mental disorder: conceptual framework and literature review (part I — malaria)

Substantial interactions between tropical diseases and psychiatric illness have long been recognized, but the impact of biological factors in the field of cross-cultural psychiatry has been less well studied than psychosocial factors. In reviewing the literature at the intersection of tropical medicine and psychiatry in order to summarize the existing data base in this field, a generalized interactive model informed by the theoretical contributions of George Engel, the WHO Scientific Working Group on Social and Economic Research, Arthur Kleinman, P. M. Yap, Edward Sapir and others has been developed to serve as a conceptual framework for this analysis of the literature and to guide further research. The clinical literature of tropical medicine and psychiatry which recognizes the significance of concurrent tropical disease and mental disorders is reviewed along with the more specific literature on malaria and concomitant psychiatric illness. Many authors have focused on the role of organic mental disorders, especially in connection with cerebral malaria, but several have also addressed psychosocial parameters through which the interrelationship between malaria and a full range of mental disorders is also mediated. The effects of malaria may serve as biological, psychological or social stressors operating in a cultural context which precipitate or shape features of psychiatric symptomatology. Psychiatric illness may likewise precipitate an episode of malaria with typical symptoms in a patient with a previously subclinical infection. Implications of the literature and this generalized interactive model are considered as they apply to clinical practice, public health and the application of social science theory in medicine.[/p]     

The revolution in psychiatric diagnosis: problems at the foundations

The third edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-III; 1974) not only revolutionized psychiatric diagnosis, it transformed and dominated American psychiatry. The nosology of psychiatry had been conceptually confusing, difficult to apply, and bound to widely questioned theories. Psychiatry and clinical psychology had been struggling with their scientific status. DSM attempted to solve psychiatry's problems by making psychiatry more like its authors' perception of general medicine. It tried to avoid theory, especially psychoanalytic theories, by discussing only observable manifestations of disorders. But DSM is actually highly theory-bound. It implicitly and powerfully includes an exclusively "medical" model of psychological disturbance, while excluding other psychiatric ideas. Its authors tried to meet what they saw as "scientific standards." To a surprising extent, DSM reflects its creators' personal distaste for psychoanalysis. The result is that DSM rests on a narrow philosophical perspective. The consequences of its adoption are widespread: it has profoundly affected drug development and other therapeutic studies, psychiatric education, attitudes toward patients, the public perception of psychiatry, and administrative and legal decisions. This article explores how DSM's most problematic features arise from its history in psychiatric controversies of the 1960s and its underlying positivistic philosophy.     

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.     

Biomarkers and clinical staging in psychiatry

Personalized medicine is rapidly becoming a reality in today's physical medicine. However, as yet this is largely an aspirational goal in psychiatry, despite significant advances in our understanding of the biochemical, genetic and neurobiological processes underlying major mental disorders. Preventive medicine relies on the availability of predictive tools; in psychiatry we still largely lack these. Furthermore, our current diagnostic systems, with their focus on well‐established, largely chronic illness, do not support a pre‐emptive, let alone a preventive, approach, since it is during the early stages of a disorder that interventions have the potential to offer the greatest benefit. Here, we present a clinical staging model for severe mental disorders and discuss examples of biological markers that have already undergone some systematic evaluation and that could be integrated into such a framework. The advantage of this model is that it explicitly considers the evolution of psychopathology during the development of a mental illness and emphasizes that progression of illness is by no means inevitable, but can be altered by providing appropriate interventions that target individual modifiable risk and protective factors. The specific goals of therapeutic intervention are therefore broadened to include the prevention of illness onset or progression, and to minimize the risk of harm associated with more complex treatment regimens. The staging model also facilitates the integration of new data on the biological, social and environmental factors that influence mental illness into our clinical and diagnostic infrastructure, which will provide a major step forward in the development of a truly pre‐emptive psychiatry.     

Y-Chromosome Diversity in Modern Bulgarians: New Clues about Their Ancestry

To better define the structure and origin of the Bulgarian paternal gene pool, we have examined the Y-chromosome variation in 808 Bulgarian males. The analysis was performed by high-resolution genotyping of biallelic markers and by analyzing the STR variation within the most informative haplogroups. We found that the Y-chromosome gene pool in modern Bulgarians is primarily represented by Western Eurasian haplogroups with ∼ 40% belonging to haplogroups E-V13 and I-M423, and 20% to R-M17. Haplogroups common in the Middle East (J and G) and in South Western Asia (R-L23*) occur at frequencies of 19% and 5%, respectively. Haplogroups C, N and Q, distinctive for Altaic and Central Asian Turkic-speaking populations, occur at the negligible frequency of only 1.5%. Principal Component analyses group Bulgarians with European populations, apart from Central Asian Turkic-speaking groups and South Western Asia populations. Within the country, the genetic variation is structured in Western, Central and Eastern Bulgaria indicating that the Balkan Mountains have been permeable to human movements. The lineage analysis provided the following interesting results: (i) R-L23* is present in Eastern Bulgaria since the post glacial period; (ii) haplogroup E-V13 has a Mesolithic age in Bulgaria from where it expanded after the arrival of farming; (iii) haplogroup J-M241 probably reflects the Neolithic westward expansion of farmers from the earliest sites along the Black Sea. On the whole, in light of the most recent historical studies, which indicate a substantial proto-Bulgarian input to the contemporary Bulgarian people, our data suggest that a common paternal ancestry between the proto-Bulgarians and the Altaic and Central Asian Turkic-speaking populations either did not exist or was negligible.     

Society as Cause and Cure: The Norms of Transgender Social Medicine

This article analyzes how trans health was negotiated on the margins of psychiatry from the late 1970s and early 1980s. In this period, a new model of medical transition was established for trans people in Norway. Psychiatrists and other medical doctors as well as psychologists and social workers with a special interest and training in social medicine created a new diagnostic and therapeutic regime in which the social aspects of transitioning took center stage. The article situates this regime in a long Norwegian tradition of social medicine, including the important political role of social medicine in the creation of the postwar welfare state and its scope of addressing and changing the societal structures involved in disease. By using archival material, medical records and oral history interviews with former patients and health professionals, I demonstrate how social aspects not only underpinned diagnostic evaluations but were an integral component of the entire therapeutic regime. Sex reassignment became an integrative way of imagining and practicing psychiatry as social medicine. The article specifically unpacks the social element of these diagnostic and therapeutic approaches in trans medicine. Because the locus of intervention and treatment remained the individual, an approach with subversive potential ended up reproducing the norms that caused illness in the first place: “the social” became a conformist tool to help the patient integrate, adjust to and transform the pathology-producing forces of society.

     

Public attitudes towards psychiatry and psychiatric treatment at the beginning of the 21st century: a systematic review and meta‐analysis of population surveys

Public attitudes towards psychiatry are crucial determinants of help‐seeking for mental illness. It has been argued that psychiatry as a discipline enjoys low esteem among the public, and a “crisis” of psychiatry has been noted. We conducted a systematic review and meta‐analysis of population studies examining public attitudes towards various aspects of psychiatric care. Our search in PubMed, Web of Science, PsychINFO and bibliographies yielded 162 papers based on population surveys conducted since 2000 and published no later than 2015. We found that professional help for mental disorders generally enjoys high esteem. While general practitioners are the preferred source of help for depression, mental health professionals are the most trusted helpers for schizophrenia. If respondents have to rank sources of help, they tend to favor mental health professionals, while open questions yield results more favorable to general practitioners. Psychiatrists and psychologists/psychotherapists are equally recommended for the treatment of schizophrenia, while for depression psychologists/psychotherapists are more recommended, at least in Europe and America. Psychotherapy is consistently preferred over medication. Attitudes towards seeking help from psychiatrists or psychologists/psychotherapists as well as towards medication and psychotherapy have markedly improved over the last twenty‐five years. Biological concepts of mental illness are associated with stronger approval of psychiatric help, particularly medication. Self‐stigma and negative attitudes towards persons with mental illness decrease the likelihood of personally considering psychiatric help. In conclusion, the public readily recommends psychiatric help for the treatment of mental disorders. Psychotherapy is the most popular method of psychiatric treatment. A useful strategy to further improve the public image of psychiatry could be to stress that listening and understanding are at the core of psychiatric care.     

A phenomenological account of users' experiences of assertive community treatment

Assertive community treatment (ACT) is a widely propagated team approach to community mental health care that 'assertively' engages a subgroup of individuals with severe mental illness who continuously disengage from mental health services. It involves a number of interested parties – including clients, carers, clinicians and managers. Each operates according to perceived ethical principles related to their values, mores and principles. ACT condenses a dilemma that is common in psychiatry. ACT proffers social control whilst simultaneously holding therapeutic aspiration. The clients' perspective of this dilemma was studied in interviews with 12 clients using the 'grounded theory' approach. Results suggest that clients' disengagement is as much a historical and cultural phenomenon as a result of lack of insight. Many clients had experienced rejection of early help–seeking behaviour and all had been subject to coercive interventions. These coercive interventions were experienced as an attack on identity. All felt that their voice had not been listened to in previous interactions with psychiatric services. Consequentially the clients had an increased level of arousal around issues of power, which needs to be incorporated when examining the ethics of community psychiatry. Traditional notions of the difference between persuasion and coercion – for example – may need to be adapted for this client group. Results are compared with the provider perspective. We conclude that the perspectives differ on two key dimensions. Such an empirical approach to examining psychiatric ethics may ensure that we incorporate the subjectivities of various interested parties in the clinical decision–making process.     

Beyond Critique: Rethinking Roles for the Anthropology of Mental Health

The current supremacy of the ‘bio-bio-bio’ model within the discipline of psychiatry has progressively marginalized social science approaches to mental health. This situation begs the question, what role is there for the anthropology of mental health? In this essay, I contend that there are three essential roles for the anthropology of mental health in an era of biological psychiatry. These roles are to (i) provide a meaningful critique of practices, beliefs, and movements within current psychiatry; (ii) illuminate the socio-cultural, clinical, and familial context of suffering and healing regarding emotional distress/mental illness; and (iii) act as a catalyst for positive change regarding healing, services and provisions for people with emotional distress/mental illness. My argument is unified by my contention that a credible anthropology of mental health intending to make a societal contribution should offer no opposition without proposition. In other words, any critique must be counter-balanced by the detailing of solutions and proposals for change. This will ensure that the anthropology of mental health continues to contribute critical knowledge to the understanding of mental suffering, distress, and healing. Such social and cultural approaches are becoming especially important given the widespread disenchantment with an increasingly dominant biological psychiatry.     

De la « théorie sexuelle » à l’anthropopsychiatrie

The creation of scientific psychiatry, which was modelled after the medical classification of diseases, was brought into question by the tenets of Sigmund Freud’s theory of psychoanalysis. We draw on Leopold Szondi’s method of developing an analytically inspired psychiatry in our effort to interpret Freud’s work from an anthropological perspective, removing psychiatry from the naturalistic medical model and giving it a genuinely human bearing. Szondi’s drive system ranges from the analysis of constitution (as in the animal biomedical model) to the analysis of destiny (as in Schicksalsanalyse). Within this system, the human is considered a driven being, existing in a psychological dimension from the outset, outside animal, sexual instincts. This distinction between mankind and animals accounts for the specificities of mental disorders and illnesses and paves the way to a purely anthropological psychiatry we can call cultural psychiatry. In this kind of psychiatry, any pathology is considered inherent in the destiny of a human being, a part of a person’s development. Its analysis, called pathoanalysis, deals with the human suffering at the heart of mankind’s place in the world.     

Darwinian psychiatry and the concept of mental disorder

In this paper, we discuss the concept of mental disorder from the perspective of Darwinian psychiatry. Using this perspective does not resolve all of the quandaries which philosophers of medicine face when trying to provide a general definition of disease. However, it does take an important step toward clarifying why current methods of psychiatric diagnosis are criticizable and how clinicians can improve the identification of true mental disorders. According to Darwinian psychiatry, the validity of the conventional criteria of psychiatric morbidity is dependent on their association with functional impairment. Suffering, statistical deviance, and physical lesion are frequent correlates of mental disorders but, in absence of dysfunctional consequences, none of these criteria is sufficient for considering a psychological or behavioral condition as a psychiatric disorder. The Darwinian concept of mental disorder builds from two basic ideas: (1) the capacity to achieve biological goals is the best single attribute that characterizes mental health; and (2), the assessment of functional capacities cannot be properly made without consideration of the environment in which the individual lives. These two ideas reflect a concept of mental disorder that is both functional and ecological. A correct application of evolutionary knowledge should not necessarily lead to the conclusion that therapeutic intervention should be limited to conditions that jeopardize biological adaptation. Because one of the basic aims of medicine is to alleviate human suffering, an understanding of the evolutionary foundations of the concept of mental disorder should translate into more effective ways for promoting individual and social well-being, not into the search for natural laws determining what is therapeutically right or wrong.     

Reshaping chronicity: neuroleptics and changing meanings of therapy in French psychiatry, 1950-1975

This article explores the transformations in the regime of practice and discourse concerning chronic mental illness in French psychiatry in the post-war period and the role played by chemotherapy in these transformations. From the 1950s and 60s on, chronicity was reconstructed as a new experience, involving a new set of expectations, of dilemmas and negotiations, and involving new types of actors giving a new meaning to what they were doing with patients. While some psychiatrists thought that neuroleptics could open the way to active treatment of these pathologies, in effect this project faced a series of obstacles: some came from psychiatric ideologies, others from the conditions of psychiatric work. As a result chronicity acquired a new uncertain and elusive shape. Based on an examination of the interplay of meaning and action in psychiatrists’ recourse to neuroleptics in the treatment of their chronic patients, this article seeks to highlight the difficult construction of the idea of chemotherapy in post-war French psychiatry and, more generally, the transformations in its notion of therapy.     

Mental illness from the perspective of theoretical neuroscience

Theoretical neuroscience, which characterizes neural mechanisms using mathematical and computational models, is highly relevant to central problems in the philosophy of psychiatry. These models can help to solve the explanation problem of causally connecting neural processes with the behaviors and experiences found in mental illnesses. Such explanations will also be useful for generating better classifications and treatments of psychiatric disorders. The result should help to eliminate concerns that mental illnesses such as depression and schizophrenia are not objectively real. A philosophical approach to mental illness based on neuroscience need not neglect the inherently social and historical nature of mental phenomena.     

The rise of counselling and the return of alienism.

Current services for those with mental disorders show two trends. Psychiatric services are becoming concentrated on the care of those with "severe mental illness," largely (but unjustifiably) synonymous with chronic psychosis. The retreat of psychiatry from the care of those with non-psychotic mental disorders has helped the growth of counselling services for these patients. However, there is no evidence that non-directive counselling is effective for such disorders, in contrast to the evidence for the effectiveness of other treatments that are usually delivered by psychologists or community psychiatric nurses. By retreating from the concerns of general practice and general medicine, psychiatry is returning to the days of alienism: in Victorian terms, the care of "the mad." Possible consequences include increasing expectations of psychiatric services that cannot be met, a loss of skills within psychiatry, and increased demoralisation in the mental health services.     

La crise de la psychiatrie contemporaine 2ème partie: la reconquête du singulier

The first part of this article (PSN vol. 1, No 3 : 19–24) sets out to reveal the theoretical weakness and the practical constraints which burden present-day psychiatry, which is dominated by an excessive medicalization process in the absence of conceptions of normality and disease. In this second part, the authors reply to scientific reductionism purposing the development of a philosophical anthropology. A global approach to the human reality, which takes into account the biological, psychological, social and cultural dimensions, would enable a better understanding of the individual’s experience as well as of his dependence or autonomy on the environment. The individual’s different ways to experience social rules and values form the basis of “existential types” which will play different part in social and historical processes. Owing to biological and environmental factors, individuals prone to psychiatric disorders are unbendingly dominated by a single type of relationship to values: over-identification in manic-depressive disorders (“hypernomia”); weakness in schizophrenia (“hétéronomia”); under-identification in some personality disorders (“hyponomia”); and conflict in obsessive disorders (“idionomia”).     

Lamessende individualpsychologie: sur le rôle de l’expérimentation psychologique dans la psychiatrie d’Emil Kraepelin (seconde partie)

Contemporary historical investigations on Emil Kraepelin’s experimental work have argued variously that the psychological experiment had either no influence on his nosology, or that it was the very precondition of the nosology, or that it skewed the nosology in favor of organic disorders. The first part of this article considered Kraepelin’s experimental research in Wilhelm Wundt’s laboratory in Leipzig during the 1880s. This second part deals with Kraepelin’s work in Heidelberg in the 1890s. It emphasizes the role of the psychological experiment in stabilizing the professional and scientific legitimacy of psychiatry vis-à-vis general medicine and jurisprudence. Above all, it argues that Kraepelin’s experimental research agenda had not just nosological aims, but also clinico-diagnostic aims. Kraepelin believed that his research would help to develop a battery of diagnostic tools that could reveal prodromal symptoms, speed up diagnostic procedures, alleviate institutional overcrowding, and both generate and stabilize psychiatric norms.     

Cord blood stem cell transplantation. Why it is necessary to establish a Bulgarian cord blood bank?

The allogenic transplantation of hemopoietic stem cell from bone marrow and peripheral blood is limited due to the necessity to identify HLA matched donor within the family or in bone marrow donor registries. Although, more than 10 million donors are available worldwide, completely HLA matched donors could be found only for 75% of the patients. It is well known that transplantations of hematopoietic stem cell from cord blood are characterized with a lower risk of GvHD and therefore do not require so strict criteria for HLA matching, and less time for search of matched donor is needed. The necessity to establish a National cord blood bank in Bulgaria is emphasized further by the heterogeneity of HLA allele and haplotype distribution in the Bulgarian population. That could be explained by the ethnic diversity of the population. As a result some alleles are more frequent in Bulgarians compared to other populations. The organization, accreditation, and development of a strategy for a National cord blood bank will be discussed.