MEDICAL HISTORIES – The third article in our short series discusses the long history of culture-based understandings of mental illnesses.
Culture has been taken more seriously by psychiatrists since the inclusion of the culture-bound syndromes as an appendix of the DSM-IV. But this is not a new fad – ideas about the effects of culture on mental health have been around since the beginnings of “modern” psychiatry.
A culture-bound syndrome, according to the DSM-IV (1994), is a group of symptoms recognised within a specific culture, with accepted treatments within these cultures. Such illnesses are not universal, and they are not caused by other neurological or psychiatric conditions.
Modern transcultural psychiatry insists that mental disorders are manifest in specific ways depending on the cultural idioms that can be drawn upon. Culture-bound syndromes can be somatic (koro) or behavioural (latah). Some culture-bound syndromes share features in several cultures, but with locally-specific traits, such as West African genital panics.
This interest in the effects of culture is not a late-twentieth-century development. The founders of psychiatry, Gorget (1820), Esquirol (1830), Morel (1859), all argued that modern life was responsible for an increase in insanity. Modern pressures, and the escapes provided by beer halls and gin palaces, combined with the stresses of living in close proximity with urban neighbours, were deemed to have a deleterious effect. In 1909, Emil Kraepelin called cities “directly pernicious breeding grounds of mental illness.”
These writings didn’t problematise culture as such because they assumed that Western cultures, although over-stimulating, were beyond further analysis. It was not until psychiatry started to engage with non-western cultures during the colonial period that culture itself became an intellectual problem for psychiatrists – and it happened in conjunction with the growing sophistication of anthropological theory.
The “madness” of other civilisations was increasingly pathologised in the twentieth century, as colonial psychiatry became a powerful tool for the control of aberrant populations. From the first encounters with indigenes, anthropologists and psychiatrists noted the local mental health.
Australian asylum director George Tucker’s “Lunacy In Many Lands” (1887) stated that mental disorder was rare in so-called “primitive peoples”. Psychiatrist German August Hirsch (1886), discussed hysterical symptoms in Africans, but rarely found psychotic symptoms, shared this view.
But such views were in contrast to H.M Shelley and W.H Watson working in colonial Nyassaland (Malawi), who in 1936 claimed that Africans had a definite propensity towards psychosis. They also argued that African mental illnesses were exacerbated by the huge cultural damage done by dispossession and associated trauma.
While common today in cases of trauma associated with dispossession and asylum-seeking, these views were an important development in the conceptualisation of culture in relation to psychiatry. The point is not that these men held ethnocentric views about culture — as reductionist and insensitive as these were — but that they were able to think of traumatic cultural change as generative of mental health problems.
This view continued a pattern of research that followed on from the nineteenth-century psychiatrists who argued that modern life was mentally deleterious. Cultural differences had started to explain mental health problems.
Dutch and British psychiatrists in Indonesia and the Malay Archipelago began focusing on locally-specific mental diseases in the 1890s. The main syndromes, latah, amok and koro remain the paradigm cases of the culture-bound syndromes.
In 1897, AH Vorstmann, a medical officer in Palembang in Borneo, linked koro specifically to the Chinese populations in East Asia. He concluded that alcohol abuse, a common habit with the Chinese of Borneo, was the background to this illness.
Visiting Singapore and Java in 1904, Emil Kraepelin noted, “If the characteristics of a people are manifested in its religion and its customs, in its intellectual and artistic achievements, in its political acts and its historical development, then they will also find expression in the frequency and clinical formation of its mental disorders, especially those that emerge from internal conditions.”
Mental illness explained something about the cultures of different peoples, just as explanations of the effects of urban environments could explain the “madness” of the modern European.
Postcolonialism and the continuation of psychiatry and culture
The psychiatric engagement with anthropology that typifies the postcolonial period shows an emphasis on local understanding of mental illnesses, and local treatment of these illnesses – within the local cultural setting.
The work of Margaret Field, originally a government ethnographer in the Gold Coast (Ghana) who re-trained as a psychiatrist, illustrates this engagement well. Field’s work is key for understanding how psychiatrists began to examine the cultural and religious contexts for mental illness—in particular the way that depressive conditions were related to conceptions of witchcraft.
The (1963) Nigerian Cornell-Aro Mental Health Research project saw the implementation of a “village system” of mental health care, in which cases that did not require full hospitalisation in the Aro Asylum were treated in a “traditional” village, where an interview method sensitive to Yoruban culture (especially gender, and witchcraft) was deployed, and where “traditional” support structures could be used (including the involvement of family members in treatment).
The study evaluated the effects of social disintegration on the Yoruba psyche, and an approach to trauma that’s still important in transcultural psychiatry today. These African examples, fitting with developments in transcultural psychiatry in other parts of the world, illustrate a major trend in psychiatric conceptions of culture.
Rethinking culture and psychiatry
The combined interest in psychiatry and anthropology have taken these older visions of culture as impacting mental health (especially of non-westerners) and shown that mental health issues cannot be reduced simply to neurological or psychopharmaceutical problems.
Rather, transcultural psychiatrists have insisted that mental health can only be made sense of with proper attention to the cultural context of the individual patient. This is especially important in multicultural societies, where people from other cultures are in need culturally-sensitive treatment.
It’s important to note that this is not a new, knee-jerk reaction to cosmopolitan societies – it has been a concern within psychiatry since the early nineteenth century. But the issue has recently become much more focused around contemporary problems, such as trauma and asylum seeking.
Rather than seeing modern psychiatry as a steady march towards biomedical understandings of the mind (as much of the historiography of twentieth-century psychiatry suggests), it’s important to see that cultural concerns have always been a central part of psychiatric thought. People do not suffer in a cultural vacuum.
This is part three of Medical Histories – click on the links below to read the other articles: