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Culture and psychopathology: definitions, diagnoses and treatment across cultures

What this chapter will teach you

  • • What is the relationship between normality and culture?
  • • Does psychopathology differ across cultures?
  • • Is schizophrenia diagnosed consistently across cultures?
  • • Is there such a thing as a culture-bound syndrome?
  • • Are eating disorders culture-bound?
  • • Are all disorders culture-bound?
  • • Is psychotherapy universally effective?
  • • What therapies are used in Asia and Africa?

Culture, normality and psychopathology

In everyday discourse it is common (normal, even) to point out someone’s behaviour and declare it unusual, weird, abnormal. However, psychologists are rather more cautious about labelling behaviour ‘abnormal’. Traditionally they have struggled to establish workable criteria against which to judge behaviour as normal, abnormal or pathological (requiring medical treatment). Abnormality might however be equated with deviation from the statistical norm. This would mean defining abnormal behaviour as that which only a minority practise (being nocturnal is abnormal because hardly anyone does it). Another yardstick against which to assess normality might be the ability to function occupationally or socially (he’s abnormal because he is unable to form stable relationships). A third (and most relevant for our discussion here) criterion might be cultural. Thus, abnormal behaviour would be anything which transgresses the moral or behavioural codes of a particular social group (your behaviour may be normal in some places, but not others).



Psychological state without normal functioning, requiring treatment.

While all these criteria are useful, they don’t offer an altogether reliable guide for identifying psychopathology (a psychological state without normal functioning, requiring treatment). After all, it is perfectly feasible to behave in a way that is statistically unusual (being nocturnal, left-handed or vegetarian) or culturally inappropriate (dressing inappropriately in a particular cultural context) without requiring medical treatment. Nevertheless, it does seem reasonable to assume that any attempt to outline the characteristics of acceptable, ‘sane’ or normal behaviour requires an acknowledgement of the cultural context in which it takes place.

Evidently, what is deemed abnormal in one cultural or temporal context may be perfectly acceptable elsewhere. For example, while homosexuality ceased to be regarded as pathological in the US in 1973, several countries continue to punish sexual acts between people of the same sex with corporal or even capital punishment (ILGA, 2019). Elsewhere, the influence of cultural context allows such phenomena as auditory hallucinations, possession trance and glossolalia (speaking in tongues) to be considered pathological in one circumstance yet part of religious experience or therapeutic practice in another. The historical case of dra- petomania illustrates the historical relativity of psychopathology. This curious clinical phenomenon was described by the American physician Samuel Cartwright (1851), who argued that many slaves suffered from a form of mental illness that infected them with the uncontrollable urge to escape (Fernando, 2002). It seems that at certain points in history, diagnostic labels have served as convenient and temporary means of exerting control over vulnerable groups. Issues of power and control are also prevalent in the continued hegemony of Western medical and epistemological models in relation to diagnosing and treating psychopathology. We should remember, when exploring cultural issues in relation to psychopathology, that the majority of the world’s population live in the Global South, where western ideas about the mind as being separate entity from the body, and where spirituality held is being less central to what it is to be human, are not necessarily accepted (Fernando & Moodley, 2018). All of which reminds us of the variability and fluidity of many concepts which relate to culture, normality and psychopathology, many of which we will explore in this chapter.

The debate between universalists and relativists

While culture and psychopathology may be intertwined concepts, arguably there are certain patterns of behaviour - perhaps dangerous, threatening or deviant - that might be considered atypical across all times and places. Are there culturally universally agreed psychopathologies? Attempts to answer this question form the crux of the debate between universalists and relativists. Proponents of cultural relativism urge us to see all pathologies as inextricably linked to the cultural meanings prevailing in particular contexts. For them, there is no such thing as a universal psychopathology. There is an emerging context-driven, eco-social approach, which proposes that psychopathology owes much to exposure to adversity and risk (Kirmayer & Ryder, 2016). Thus, DSM-5 (APA, 2013) included input on mental disorder in relation to culture to a greater extent than hitherto, critiquing historical advocates of universalism who proposed the existence of underlying psychological mechanisms that are common to psychopathology across cultures (Murphy, 1976). Each of these viewpoints will be explored in turn in the light of disorders that have been explored in the global context.

Universalism, relativism and schizophrenia

The term schizophrenia refers to a syndrome involving severe and chronic mental disorder characterised by disturbances in thought, perception and behaviour (APA, 2013). Someone diagnosed with schizophrenia typically experiences delusions, hallucinations, low motivation, social isolation, impaired memory and emotional dysfunction (van Os & Kapur, 2009), with two of the following five being present for more than a month for diagnosis; delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour, diminished emotional expression (APA, 2013).

Whilst being a relatively low prevalence condition (less than 1% of the global population), it has been suggested that worldwide population growth and ageing is increasing diagnosis rates, especially in middle income countries (Charleson et al., 2018). But how globally applicable is this figure - or indeed this syndrome? Would presentation of similar symptoms in diverse cultures prompt different diagnoses? For example, from a Zulu and Xhosa speaking Southern African perspective, the condition of ‘ukuthwasa’, which is characterised by depression and manic episodes, might easily be diagnosed as schizophrenia by western medicine (Bojuwoye & Moletsane-Kekae, 2018).

Historically, doubts have been voiced about whether the label ‘schizophrenia’ is consistently applied across cultures. One large-scale, milestone cross-cultural study investigated the international reliability of diagnoses of schizophrenia (Leff, 1977a; WHO, 1979). The aim of the International Pilot Study of Schizophrenia (IPSS) was to test the culturally universal credentials of schizophrenia as a diagnostic label. The study was prompted by growing concerns about the objectivity and reliability (dependability, or relating to comparable sets of symptoms across different situations) of diagnoses, which some argued had historically been made on the basis of the first five minutes of clinical interviews (Kendell, 1973). Further doubts about the trustworthiness of diagnoses had been raised by evidence of the culturally variable use of the label ‘schizophrenic’ (Jablensky et al., 1992). In one study, case notes from

30 UK patients were distributed to psychiatrists in the US, Denmark, Norway and Sweden. European psychiatrists were less likely to apply the term ‘schizophrenia’, preferring ‘depression’ or ‘obsessional disorder’ (Rawnsley, 1968). Arguably, cultural variations in communication styles were among the factors preventing psychiatrists from arriving at reliable, culturally consistent diagnoses of psychological disorders (Leff, 1977a; Paniagua, 1998; Fernando & Moodley, 2018).

So how did the IPSS investigate the proposed cultural universality of schizophrenia? The design of the research followed that of Cooper et al. (1972), who compared diagnoses of schizophrenia in hospitals in London and New York. In this initial study between 300 and 400 patients (half recently admitted to nine hospitals in New York, half to nine in London) were randomly selected and interviewed by the research psychiatrists, using a standard interview method for assessing psychiatric symptoms. The use of this method, the Present State Examination (PSE; Wing et al., 1974), ensured that all the research psychiatrists were applying identical diagnostic criteria.

These research (PSE) diagnoses were compared with the hospitals’ own diagnoses for the same patients, which revealed that ‘schizophrenic’ labels were applied more commonly in New York than they were in London. So it appeared that US psychiatrists used a definition of schizophrenia that encompassed more symptoms. It also emerged that the subsequent use of a standardised diagnostic instrument reduced differences between US and UK practitioners. In other words, a more widely recognised model for the diagnosis of schizophrenia did seem to follow the use of more standardised procedures and guidelines.

In the light of these findings, the IPSS (WHO, 1974, 1979) broadened the scope of Cooper’s transatlantic comparison. Diagnoses of schizophrenia across nine countries (Colombia, Czechoslovakia [now Czech Republic], Denmark, England, India, Nigeria, Soviet Union [now predominantly Russia], Taiwan, US) were incorporated in order to find out whether international samples of psychiatrists applied the label ‘schizophrenia’ to patients with comparable groups of symptoms. The PSE was translated into the first languages of the nine countries. Psychiatrists from each country were trained to use the instrument, ensuring that symptoms were being assessed using standard criteria. In all, 1202 patients were interviewed in their respective countries and symptom profiles for the patients were compiled. These profiles were compared with standard diagnostic classifications (also based on PSE data) provided by WHO psychiatrists. To what extent would the diagnostic habits of psychiatrists in each country deviate from WHO diagnoses for schizophrenia? The overall finding was that there were close clinical similarities between patients being diagnosed as schizophrenic across the nine countries. In seven of the participating countries (excluding US and USSR) the overwhelming majority of patients diagnosed schizophrenic in situ were similarly diagnosed by the WHO procedure (there was an agreement level of 96% between WHO diagnoses and seven centres, excluding US and USSR). Notably, though, the incidence of US and USSR diagnoses for schizophrenia was marginally greater than elsewhere (the agreement level between US/ USSR and WHO on schizophrenia diagnoses was 71%).

Overall, the IPSS showed that, especially with the use of standardised training with a single diagnostic instrument, there existed a common core of schizoid symptoms in most countries. Social and emotional withdrawal, delusions and emotional flatness were commonplace in those diagnosed as schizophrenic virtually across the board. However, there were local variations in symptoms. For example, Nigerian and Danish schizophrenics scored higher on auditory hallucinations than did US patients.

Since this landmark study, other cultural discrepancies have emerged. Recovery from schizoid conditions showed up as better in the Global South, than in more affluent nations (Hopper et al., 2007), perhaps owing to extended kin networks or supportive communities in some of those countries (Matsumoto & Juang, 2017). Discrepant recovery rates by nation showed that; 36% of Nigerians showed full remission after an initial one-month period of schizoid illness, compared with India (27%), Denmark (2%) and Moscow (1%). Perhaps these differences were due to stronger community and extended family support networks in some regions (Matsumoto & Juang, 2017). Elsewhere, it has also been suggested that tolerance of symptoms associated with schizophrenia varies across cultures. For example, auditory hallucinations are reportedly more tolerated (less pathologised) in Nigeria than they are elsewhere (Hopper et al., 2007). Likelihood of relapse following recovery has also been reported as varying across cultures as a function of communication patterns within families and communities (Myers, 2010).

Debates about the universality or otherwise of schizophrenia are of course related to theories of its origins or precursors. Poverty, overcrowding, parental separation and neglect are amongst environmental factors to have been associated with schizophrenia, as van Os explains here:

Although heritability is often emphasized, onset is associated with environmental factors such as early life adversity, growing up in an urban environment, minority group position and cannabis use, suggesting that exposure may have an impact on the developing ‘social’ brain during sensitive periods.

(van Os et al., 2010, p. 3)

However, genetic precursors to schizophrenia have also been identified. Walder et al. (2014) suggest that genetic and biological predispositions to the condition can increase the likelihood of being diagnosed in the presence of important environmental triggers. This so-called diathesis- stress model (Matsumoto & Juang, 2017) reflects the presence of both inherited (culturally universal) and ecological (culturally relative) precursors to the incidence of schizophrenia. Overall, whilst there are reported local variations in patterns of incidence, diagnosis and recovery from schizophrenia, there remains tentative support for schizophrenia as a culturally widespread syndrome with a common core of symptoms.

Limitations of schizophrenia research

  • 1 Cultural insensitivity of standardised instruments. The historical IPSS research used the PSE to standardise criteria for diagnosing schizophrenia. This helped to ensure that all the psychiatrists involved followed similar guidelines. However, the use of the PSE, an instrument developed in the UK, in diverse cultural settings meant that these projects were unable to take account of local meanings attached to this psychosis. Patients from Nigeria, Colombia and India were being diagnosed according to a procedure that was insensitive to local notions of illness and health. Such a procedure carries the assumption that schizophrenia is a universal concept, defined and diagnosed in the west and then applied cross-culturally (Fernando & Moodley, 2018). This approach arguably undervalues the view that psychological abnormality can be understood according to diverse systems of meaning.
  • 2 Further evidence of differential application of the ‘schizoid’ label. Arguments about the cultural universality of schizophrenia as a syndrome are somewhat undermined by research showing that practitioners in some regions are more likely to diagnose people from certain racial groups as schizophrenic. Loring and Powell (1988) showed that psychiatrists sometimes apply diagnostic labels differently when treating different racial groups. They presented 290 US psychiatrists with identical case notes for black and white patients, only to find that blacks were over-diagnosed schizophrenic. Interestingly, the effect showed up for black and white psychiatrists. There are other examples of over-diagnosis of schizophrenia in a racialised context (Steinberg et al., 1977; Mukherjee et al., 1983; Harrison et al., 1997; Bhugra et al., 1997; Metzl, 2010). Evidently, the term ‘schizophrenia’ can be applied differently by clinicians from different cultures and to patients from different groups.

It remains debatable whether disorders such as schizophrenia can be understood as global phenomena that are defined and diagnosed against comparable criteria in different places. Those who doubt the cultural universality of psychopathology point to the incidence of conditions that seemingly are observable only in particular cultural contexts. It is to these that we now turn.

Culture-bound syndromes

In his book The English Malady (1733), George Cheyne suggested that a specific combination of nervous symptoms (hypochondriasis, low spirits, vapours) constituted a peculiarly English disease. Justified or not, Cheyne was one of the first to suggest that particular illnesses might be associated with particular cultural groups. As time went by this idea became contagious. In 1893, Gilmore Ellis, a British colonial official in Malaya (now part of Malaysia), identified two nervous conditions - latah


Figure 9.1 Latah


Figure 9.2 Amok

and amok (Figures 9.1 and 9.2) - as being present among Malays but unknown elsewhere. Later still, in 1969, Pow Meng Yap, a Chinese psychiatrist working in Hong Kong, coined the term culture-bound syndrome (CBS) to denote a culture-specific disorder that tends to be undiagnosed or misunderstood elsewhere.

Historically, much of the CBS literature focused on what have been rather dismissively referred to as ‘exotic’ diseases, meaning syndromes that are exclusively observed in regions outside North America and Europe (Fernando, 2002). Yap (1969) coined the term culture-bound syndrome to refer to rare, exotic, unpredictable or chaotic behaviours from specific cultural contexts (Ventriglio et al., 2015) to account for behavioural patterns that were deemed difficult to classify. At this time these categories reflected a lack of understanding of the cultural context or psychopathology (Bhugra & Jacob, 1997).

Some writers have also identified disorders from within western settings that might also qualify for CBS status on the grounds that they are associated with affluent lifestyles. For example, the widely recognised Type A behaviour pattern (incorporating competitiveness, work-related stress, pressurised deadline-chasing) has been linked with consumerist lifestyles prevalent in capitalist economies (Littlewood, 1996). Another example of a ‘western malady’ is the eating disorder anorexia nervosa (Figure 9.3), though the worldwide dissemination of affluence and

Anorexia nervosa

Figure 9.3 Anorexia nervosa

consumerism may be implicated in its increasing incidence in China, Hong Kong and Korea (Gordon, 2001). However, understanding CBS in the context of a western versus non-western dichotomy has perhaps become outmoded, with these traditional cross-cultural boundaries now porous and fluid in an era of rapid globalisation (Ventriglio et al., 2015).

DSM-5 and CBS

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (APA, 2013) sought to reflect greater cultural sensitivity, yet eschewed a simple list of culture-bound syndromes, as well as the term CBS (Ventriglio et al., 2015). In this edition of DSM, the American Psychiatric Association (APA) reflect the view that symptoms are explained differently across cultures, and thus that it is important for clinicians to have access to contextual factors relating to culture, ethnicity, religion or region, when making diagnoses. Cultural diversity was taken into account when devising categories in the DSM-5. For example, the criteria for social anxiety disorder were modified to include a fear of offending others in order to reflect Japanese social conventions and concerns. The culturally diverse concept of distress is also acknowledged, with explicit reference to how different cultures describe symptoms.

Another innovation in DSM-5 is a culturally sensitive interview protocol for helping to take into account cultural factors during the diagnostic process. This includes questions about patients’ culture, ethnicity, religion or region. Crucially, this protocol facilitates the description of distress in the clients’ words, derived from their cultural context, offering clinicians an opportunity to make a more culturally sensitive diagnosis and care plan.

CBS, universaiism and relativism

Psychology has tended to approach the culture-bound syndromes from two theoretical directions. The universalist approach regards these syndromes through the eyes of North American and European based

(western) psychiatry, often reserving the term ‘exotic’ to refer to them. Symptoms are compared with those of disorders that are traditionally diagnosed by western clinicians. One might therefore look at latah and ask - how similar is this syndrome to schizophrenia? Strictly speaking, since universalists try to assimilate exotic syndromes into established diagnostic frameworks, they only marginally recognise the notion of culture-bound syndromes. Consequently, these tend to figure only peripherally in the appendices of mainstream western classifications of psychiatric disorders.

A second, relativist approach, emphasises indigenous categories of pathology, occupying a space beyond the stronghold of western psychiatry. Here, syndromes are examined within the meaning systems of their host cultures, prompting questions such as - what do Malaysians understand by the term ‘latah’? Ritenbaugh (1982) exemplified this view, suggesting that according to certain criteria all disorders might be considered culture-bound. Since all the world’s illnesses can only genuinely be understood from within their local contexts and their own indigenous meaning systems, every disease is actually a unique product of its specific culture. Correspondingly, the evolution of culturally specific diagnostic systems such as the Chinese Classification of Mental Disorders (Chen, 2002) indicate a shift in some cultures from a universal classification of mental disorders to a more culture-specific classification (Ventriglio et al., 2016). This relativist approach to mental health assumes that all syndromes (not just ‘exotic’ ones) can be best comprehended using detailed knowledge about the cultures from which they emerge (Fernando, 2002).

The long and diverse history of the culture-bound syndrome serves as an illustration of the inextricable link between culture and psychopathology. Aboud (1998) articulates this link eloquently, arguing that all cultures apparently distinguish between normal and abnormal behaviour and that furthermore common cross-cultural elements appear to exist between behaviours that are deemed to be abnormal. Inevitably, these symptoms manifest themselves differently according to the culturally unique influences of local values and meaning systems. In other words, there is arguably a culture-bound element to all abnormal syndromes. Going forward, it is likely that culturally diverse syndromes be deemed not so much ‘culture-bound’ as culturally influenced (Ventriglio et al., 2016). Within the context of cultural exchange and globalisation, what is required is greater understanding of health and illness across cultures, as well as more culturally sensitive approaches to diagnostic categories and treatment.

Limitations of culture-bound syndrome research

  • 1 Universalists and relativists both have their weaknesses. The debate between universalists (who see the value of classifying culturally diverse syndromes according to their diagnostic similarities) and relativists (who regard all diseases as uniquely bound to their own cultures) reflects broader disputes between distinct approaches to global psychology (Kleinman, 1987b). Universalists are allied to cross- cultural psychology, wherein the search is on for aspects of behaviour and experience that are common across cultures. Relativists take a more ethnographic viewpoint, similar to that of cultural psychology. Here the emphasis is on examining all behaviour, including aspects of psychological illness, in relation to its unique cultural context.
  • 2 What use is the CBS concept? The very worth of the concept of the CBS is questioned from various perspectives. Western psychiatry highlights similarities between so-called ‘exotic’ syndromes and established conditions, thus casting doubt on the need for a distinct class of unique or exotic illnesses (Yap, 1969). Latah, for example, may be likened to a ‘primary fear reaction’ in western parlance. Amok may be seen as an example of a ‘rage reaction’. On the other hand, those who argue that all psychopathologies are only fully comprehensible within their own contexts might assert that there is little need for a discrete category of culture-bound syndromes. After all, if culture is recognised as influencing all disorders then maybe all of them are effectively culture-bound (Sumathipala & Siribaddana, 2004). We have learned so far that psychopathology cannot be understood without some sensitivity to cultural contexts. As we are about to find out, the treatment of atypical behaviour also reflects diverse cultural traditions.

Culture, psychotherapy and healing

Ought we to expect a therapy that aids psychological wellbeing in one location to be similarly effective across cultures? Questions regarding the universal effectiveness of psychotherapy understandably tax practitioners and researchers who concern themselves with the relationship between culture and therapy. Arguably, one positive argument for the global applicability of psychotherapy is its historical rate of export, primarily from Europe. Freudian psychoanalysis, for example, originally developed in twentieth-century Europe, is now used in China and Southeast Asia (Zhang et al., 2002). The hegemonic place of psychoanalysis in Argentinian psychotherapeutic practice is a well-known and oft cited examples of its global reach (Dagfal, 2018). Yet we should note that such therapies have not been exported in unadulterated form. The success of imported therapies, for example of counselling techniques that have been introduced into China, really depends on how well these techniques gel with local norms and beliefs. In effect, there is a requirement for them to be localised (Zhang, 2014). Nor, as we will learn later in this section, is the direction of export always from Europe and North America.

Does therapy work equally well for everyone, irrespective of culture? One American study suggested not, showing that psychotherapy was relatively unsuccessful in African American groups in the US in comparison with success rates among the white population (Sue et al., 1994). Another study revealed Latinos in Los Angeles to respond more effectively than their counterparts from other ethnic groups (Sue et al., 1994). Elsewhere, a research project conducted longitudinally in India among participants who had been diagnosed with schizophrenia recorded rates of recovery among clients from Madras that were ‘much better’ than those in other nations (Thara, 2004). However, rather than seeking to compare the effectiveness of particular therapies in different cultures, it may be more salient to estimate the effectiveness of culturally adapted, or localised (Zhang, 2014) therapies, as compared with those which have not undergone cultural adaptation. In a meta-analysis, it was found that in the treatment of depressive disorders, therapies that had been adapted (for example, by using local colloquial language, integrating local remedies, idioms and symbolism) fared better than did non-adapted therapies (Chowdhary et al., 2014).

It seems, then, that while data on the relative effects of therapy among different cultural groups are relatively scarce (Matsumoto & Juang, 2017), they do suggest a discernible level of cultural variation in response rates. This indicates that culture may be a factor in the efficacy of treatments. We would be naive to regard psychotherapy as a culture-free phenomenon, serving all humans equally well. Rather, the effectiveness of psychotherapy as a global tool may depend not just on clients’ values or place of residence, but on how well the therapy adapts to those values and to diverse belief systems, perhaps for example by incorporating spiritual or religious elements that are meaningful in diverse contexts. Before we ask how therapies might make such adaptations, let us first consider more closely the nature of culture’s influence on the effectiveness of psychotherapy.

Factors influencing the effectiveness of psychotherapy across cultures

Several factors are likely to influence how well clients from different ethnic or cultural groups are served by psychotherapy. These factors illustrate that psychotherapy’s effectiveness depends partly on the values held by the clients and practitioners who take part in the therapeutic process.

Conceptual factors: ideas about health and illness

When client and a therapist hold similar views about what constitutes psychological health and illness, treatment is likely to be more effective. This is more likely to be the case where therapist and client share similar cultural backgrounds. Yet besides the influence of their cultural background, a therapist’s views on pathology and health will also be influenced by values instilled in them during training, perhaps due to their adherence to a particular therapeutic tradition. For example, where a Freudian psychoanalyst (following a European-based paradigm that interprets neurosis in terms of repressed sexual energy) treats a client from a cultural group whose belief system regards illness as arising from spiritual concerns, there may be a lack of understanding and empathy between the two parties. After all, it is culturally sanctioned in many regions to conceptualise illness within a spiritual belief system, rather than within the medical paradigm favoured by western psychiatry. For example, a Taoist interpretation of anxiety might seek solutions in unselfish conduct, in line with Taoist religious teachings (Zhang et al., 2002), wherein the road to health involves the elimination of spiritual contamination (Fernando & Moodley, 2018). Similarly, Ayurvedic yogic healing, based on Indian Vedic scriptures dating back to 5000 вс, represents a religious or spiritual approach to illness and health (Fernando & Moodley, 2018). For clients whose value system is informed by spirituality, the most appropriate therapy might seek to incorporate religious or spiritual features, perhaps in combination with a medical, scientific approach.

There is a growing acceptance of the local effectiveness of religion- based healing systems (Jilek, 1993; Rodrigues, 2018). Practitioners in Europe and North America are now increasingly likely to incorporate, say, acupuncture, Buddhist or yogic remedies when seeking to promote health and balance. A notable historical example of a religion- based psychotherapy is possession trance (Bourguignon, 1984; Oyarce, 2018). Interestingly, some critics have debated whether this practice is a therapy, pathological state, or merely a culturally meaningful practice of communication (see Figure 9.4).

Possession trance

Figure 9.4 Possession trance

Interpersonal factors: at the client-therapist interface

With or without a shared belief system, diverse codes of interpersonal conduct and communication can also have a profound effect on the success of therapy. Like the values we hold about illness and health, these codes can differ from one cultural group to another. Where a client consults a therapist from another cultural group, there may be a lack of appreciation of these differing codes. For example, Arabic clients have reportedly found direct eye-contact disrespectful during consultations, and this has adversely affected the success of diagnosis and treatment (Al-Krenawi & Graham, 2000). Additionally, a lack of knowledge of the dominant language of the health provider is also a factor that deters members of some communities from seeking consultation (Snowden et al., 2011).

Cultural differences also emerge in perceptions of status and power relations between clients and therapists. In some regions a therapist is more likely to be regarded as a ‘fixer’, an authority figure blessed with powers to lead the therapeutic process. While Arab American groups have been found to favour such proactivity from therapists (Al-Krenawi & Graham, 2000), more democratic, client-centred expectations may be held by Puerto Rican and First Nations American clients (Atkinson et al., 1984). It has been suggested that a preference for more directive therapy may appeal to groups who are traditionally accustomed to seeking healing within their own families or communities, so that where these measures fall short the recruitment of a professional outsider represents a search for a last-resort solution (Lin et al., 1992). Whether we are dealing with diverse communication styles or differing interpretations of status, it seems clear that the most effective therapists will be those who are prepared to engage with their clients on their own interpersonal terms. This said, there remains a stigma attached to seeking therapy for some cultural groups, and this too can influence the effectiveness of treatments. For example, it has been shown that a loss of face associated with mental illness can result in an under-utilisation of services for some Asian-American cultural groups (Jimenez et al., 2013).

Material factors: access to treatment

We should acknowledge the key influence of material and economic factors. Wherever you are when you read this, ask yourself how long it would take you to walk to the nearest provider of psychotherapy. Answers to this question will vary wildly (Bedi, 2018). Monaco (41), Norway (29.7), Belgium (20.3), Netherlands (20.1) and UK (14.6) lead the list of nations with greatest number of psychiatrists per 1000 of the population, with India (0.3) and Turkey (1.5) at the foot of the table (WHO, 2015). A caveat here is that these figures do not include providers of indigenous healing. It is estimated that in Ethiopia the client-psychotherapist ratio is approximately 1 to 8 million, while in the US the comparable figure stands at 1 to 10,000 - a figure becoming still more favourable for city dwellers (Hopper et al., 2007).

Clearly, economic prosperity and place of residence have an influence on access to psychotherapy. We should remember, though, that figures reflecting access to professional therapeutic services do not tell the whole story. As already hinted, in many regions, largely in the developing world, healing is the province of the extended family or community. Consequently, even though one may live miles from the nearest qualified provider, healing remains available ‘on the doorstep’. It is to these varieties of indigenous healing that we now turn.

Indigenous therapies

It has already been suggested that the successful export of psychotherapy from the west depends to some extent on how well these practices incorporate values that are prevalent in the regions where they are introduced. Likewise, there is an increasing reciprocal tendency for therapies that are indigenous to the Global South to be applied more globally.

Some examples of non-western, indigenous healing techniques are outlined in Table 9.1 (see also Figure 9.4). Lin et al. (1992) characterised nonwestern indigenous therapies as those which: utilise expertise from family or community networks, rather than from professionally trained experts; focus on the reintegration of individuals into the community, rather than on improving individual wellbeing; incorporate religious or spiritual elements as well as or instead of scientific, medical principles; and take place in community settings such as churches, homes or other non-medical communal spaces. It has been noted that increasingly, clients who consult spiritual healers across Asia and Africa are likely to seek medical consultations simultaneously (Fernando, 2002) where these are available. Interestingly, then, in many regions indigenous therapies are not regarded as alternatives to western treatments, but as their complements.


Indigenous therapies



Therapeutic approach

Sri Lankan spiritual healing

Aimed at exorcising malevolent spirits or counteracting sorcery, this approach addresses spiritual aspects of human existence at times of anxiety. While analogous to western psychotherapy, the spiritual tradition is based on deepening self-knowledge by meditation (Kakar, 1984). The therapy itself may also include astrology or exorcism rituals to relieve possession, during which masked actors may perform dances depicting demons and agents who are charged with their expulsion. These practices are likely to take place at temples or shrines (Kapferer, 1997).

Tibetan psychiatry

A system of addressing psychological distress which is based on Tibetan Buddhism, fusing religion and psychology, Tibetan psychiatry is often combined with herbal and dietary treatments. The aim is to tackle mind-body imbalances in which may arise from a lack of self-awareness or unhealthy cravings (analogous to addictions). By adhering to Buddha's teachings in everyday life (the dharma), the individual attempts to retain holistic balance. Treatments are tailored to feelings of imbalance and may involve yogic practice, breath control, dietary restrictions. The ultimate aim is to lead a life that is not counter to one’s inherent disposition, or to Buddhist teachings which reject the notion of the individual self in favour of notions of cognition and consciousness that transcend individual identity (Fernando & Moodley, 2018).

Yoruba incantations in West Africa

West African Yoruba healing practices have been widely exported and have exerted an influence in the Caribbean and Latin America (Fernando & Moodley, 2018). Based on attempting to capture an individual's ‘vital force’ or inner self, perhaps by use of incantations (spells), which are spoken by a specialist spiritual healer or medicine man (Ayoade, 1979). Incantations help to dispel fear and drive out spirits that are in possession of the client's soul. Healing involves a combined treatment of the body and soul, by herbal medication as well as spiritual methods, in order to restore the balance of the body and soul.

Mapuche healing, Chile

Originating in one of South America’s largest indigenous populations, the Mapuche, this indigenous model of wellbeing centres on living a ‘good life'

(ките mongen), or being in a state of balance with oneself and one’s family or community and one's environment and ancestors (Oyarce, 2018). This is a holistic concept of wellbeing. Ill-health is equated with a lack of balance between the person and the forces around him. Tasked with restoring this balance is the intermediary between the person and the spiritual world; the Shaman (Machi). Machi attempts to restore equilibrium by suggesting behavioural changes to the individual, and to community representatives. Using trance to consult with the deities, Machi traverses paths to the spirit world that are not commonly available.

Limitations of research on therapy and culture

  • 1 Limited samples. While it is informative to learn about the therapeutic choices of clients that recognise varying philosophical traditions, it has been noted that the vastly greater part of research on the topic overall comes from Europe and North America (Fernando, 2002). We await more research on therapeutic choices made by participants from the developing world.
  • 2 The hidden therapies. Traditional indigenous therapies from outside Europe and North America, often being religion-based, are by their very nature less formal than their western counterparts. They do not require formal training and take place within the home in many cases. They are not documented by professional bodies or medical councils. Consequently, their prevalence remains difficult to document effectively, other than with the use of small-scale or ethnographic and qualitative research. We therefore lack a reliable quantitative appreciation of the breadth of indigenous healing, thus limiting our own appreciation of its global uptake. This limitation appears to be inherent in the use of informal (what are often termed ‘folk’) remedies.

Culture and psychotherapy: multiculturalism, globalisation and healing

Recent history reveals an increasing global movement of medical and therapeutic knowledge along a two-way street. This of course reflects a more general trend towards globalisation (defined as the global integration and sharing of culturally, socially and internationally diverse ideas). For example, treatments originating in Asia are increasingly exported, with Chinese acupuncture and Indian Ayurvedic treatments becoming ever more popular in Europe and North America.



The global integration and sharing of culturally, socially and internationally diverse ideas.

Such treatments provide patients in many countries with alternatives to those that are conventionally available. They offer ideas about diagnosis and treatment (of physical and psychological problems) that are distinct from those historically favoured by western psychiatrists (Lin et al., 1992). Recent research suggests that the cross-trafficking of treatments between cultures yields a global scenario wherein western and non-western treatments happily coexist within societies. This illustrates a general trend towards multiculturalism (wherein people from diverse ethnic and cultural groups coexist in society) in both therapeutic practice and wider society. For example, in many nations local healers and western-trained medics are often consulted simultaneously. Flealy and Aslam (1990) found Asian patients living England regularly consulting GPs as well as hakims (Ayurvedic healers trained in India or Pakistan). Similarly, Dein and Sembhi (2001) asked whether (and how) traditional South Asian treatments for psychological ills were being used by psychiatric patients in England. They uncovered a tendency to consult traditional South Asian healers during their psychiatric illness, while simultaneously consulting psychiatrists (where affordable). The simultaneous use of healthcare from multiple traditions shows that clients have few reservations about using psychiatrists and other healers in tandem. Indeed, there is a strong belief among some clients that Ayurvedic treatments address the underlying causes of illness, with western treatments often not seen as treating the root causes (Dein & Sembhi, 2001).

The idea that clients favour the simultaneous use of therapies from different traditions is well supported. Frank and Stollberg (2004) looked at the growing popularity of acupuncture and Ayurvedic treatments in Germany. They suggest that their introduction illustrates a process of hybridisation. In other words, as treatments enter a European setting from outside they undergo an adaptation process, with European and South Asian elements combining to produce therapy which has roots in several cultural tradition.

These developments give the lie to the image of western medicine as a dominant worldwide movement. Traditional healing, it seems, can thrive both indigenously and as an export to Europe. Arguably, these treatments, and the diverse belief systems that underpin them, have a key role to play in preserving the cultural identity of communities who themselves have undergone movements across continents. Indeed, the movement of healing between cultures reflects the simultaneous movement of people in today’s world. It also shows that successful therapies in a globalised world are those that can adapt to a populace that values both the scientific and the spiritual.


Chapter 9 puts definitions, classifications and treatments of abnormality in a cultural context. Not surprisingly, how we define normal behaviour is not standard worldwide. Correspondingly, behaviours that are deemed pathological and requiring treatment vary from place to place too. Our discussion assesses some examples of culturally relative definitions and diagnoses. Yet extensive research has been carried out which suggests that some disorders, for example schizophrenia, have common core symptoms cross-culturally. This case for schizophrenia as a universal syndrome is discussed here. However, the influence of culture on the diagnosis of psychopathology is widely recognised, especially in the case of the so-called culture-bound syndromes (disorders that are recognised and diagnosed only in specific cultural contexts). The implications of these syndromes, along with several examples, are examined.

Finally, examples of culturally diverse psychotherapies are reviewed, especially in relation to their nature and relative effectiveness across cultures. This discussion covers both western psychotherapies and indigenous treatments. In this context there is also an assessment of the increasing crossmigration of treatments, illustrating the globalised nature of healing.


Match up the definitions on the right with the terms on the left (see p. 211 for answers)


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