Abstract
Rahul Bhattacharya, Sean Cross, & Dinesh Bhugra (Eds.), Clinical Topics in Cultural Psychiatry. London: Royal College of Psychiatrists Publications, 2010. 432 pp. £30.00 (pb), ISBN 9781904671824.
The past 30 years has seen major changes in the understanding of “culture” in relation to mental health and psychiatric practice. Prior to the 1960s, cultures as applied to individuals were seen as fairly static “patterns of belief, feeling and adaptation which people carry in their minds” (Leighton & Hughes, 1961, p. 447) – entities that were inherited and passed on within families. Today they are seen as dynamic systems of knowledge and practice, sustained by cognitive models, interpersonal interactions and social institutions, that give rise to values and world views that people live by, and through which they define identities and negotiate their lives (Eagleton, 2000; Kirmayer, 2006). Apart from the use of the term as a shorthand for explaining the way people live, discourse in the mental health field often refers to cultures of institutions, occupations or professions in referring (for example) to “police culture”, the culture of psychiatry, social work, and so on. We could call these organizational cultures as distinct from culture as the way people live. Finally, we tend to speak of the cultures of groups of people identifiable by particular characteristics such as age (e.g., youth culture), experience (culture of the oppressed), or some habit or predilection (e.g., drug culture, gun culture), all of which could fall into a category of experiential or situational cultures (Fernando, 2010).
When the terms “cultural psychiatry” and its extension “transcultural psychiatry” (to refer to the practice of psychiatry in non-western cultural locations or among people with non-western cultural backgrounds) began to be used in the 1950s (Murphy, 1986), they consisted of a body of knowledge about the prevalence of mental illness (diagnosed according to western bio-medical psychiatric models) and the differences these illnesses may show when diagnosed in other (i.e., non-western) cultures. Illnesses confined to people with non-western cultural backgrounds were often seen as “culture-bound”, while those identified in western countries were recognized as proper illnesses although sometimes affected by – even fashioned by – “culture”. This approach was represented in books such as Transcultural Psychiatry edited by De Rueck and Porter (1965) and Psychiatry Around the Globe by Leff (1981). But views critical of such an ethnocentric view came from social anthropology and new viewpoints were articulated in books such as The Great Universe of Kota by Carstairs and Kapur (1976), Cultural Conceptions of Mental Health and Therapy edited by Marsella and White (1982) and Ethnopsychiatry: The Cultural Construction of Professional and Folk Psychiatries edited by Gaines (1992), the turning point being epitomized by Arthur Kleinman’s seminal “Depression, somatization and the ‘new cross-cultural psychiatry’” (Kleinman, 1977) – a paper that criticized the search by psychiatry for disease entities that are culture free and coined the term “category fallacy” to name what is “perhaps the most basic and certainly the most crucial error one can make in cross-cultural research” (1977, p. 4, italics in original).
Critical accounts of the clinical practice of psychiatry in the British multicultural context of the late twentieth century appeared in the 1980s in several books written or edited by members of the Transcultural Psychiatry Society (UK): Race, Culture and Mental Disorder by Rack (1982), Aliens and Alienists by Littlewood and Lipsedge (1982), Transcultural Psychiatry edited by Cox (1986) and Race and Culture in Psychiatry by Fernando (1988). Today in Britain and many parts of the western world, cultural or transcultural psychiatry is mainly concerned with (a) addressing mental health and psychosocial problems of minority ethnic or cultural groups in Europe and North America, including discrimination, sometimes amounting to racism, that they may experience; and (b) diversity in the way health and illness are perceived across cultures, resulting in (among other matters) a critical approach to traditional psychiatric nosology. Thus, discussions within cultural psychiatry tend to focus on the training of psychiatrists to understand the nature of what illness means to people from various cultural backgrounds, the significance of racism in the practice of psychiatry, the place of cultural diversity in the construction of “illness” of the mind, issues around migration, “cultural competence” of people working in the field of mental health and so on.
This multi-author book of well over 400 pages is published by the Royal College of Psychiatrists of the UK and is clearly aimed at a British readership. According to the short preface by the editors, the book contains updated versions of papers originally published in the journal Advances in Psychiatric Treatment (also published by the same organization), together with “several new chapters”. The editors go on to state that it was decided to put the articles together in a single volume because the Royal College of Psychiatrists developed a “new curriculum” (presumably for the examination for membership of the College). The book contains 29 chapters grouped into three parts – theoretical and general issues; specific mental health conditions across cultures; and management issues in the cultural context. The topics covered include globalization, migration, effects of racism on mental health, expressed emotion, schizophrenia in African-Caribbeans, addiction in ethnic minorities, cultural factors in psychopharmacology, eating disorders and forensic psychiatry. The chapters are in the form of reviews rather than presentations of new ideas or new work.
Multi-author books – even when they are supposed to address topics covering a limited field – are difficult to review because the individual chapters are so often very diverse in approach and quality. This is especially so in the case of this book. There appears to be very little consistency of approach across the chapters and little apparent agreement among the authors on how the main themes (which I reckon are “race” and “culture” as applied to the clinical practice of psychiatry) are understood. The way “culture” is interpreted varies a great deal throughout the book. Nearly every chapter provides its own definition, some authors taking a very old fashioned view, seeing “culture” as a static set of values and beliefs that affect the way mental illness is expressed; but others are more up-to-date, but still do not really address the issue of how culture affects the process of mental health assessment and diagnosis in a practical sense.
The definition of what “race” means too is inconsistent across the book. For example, in the chapter “Mental health of the ageing immigrant population”, “race” is seen as a genetic entity while in other chapters (for example in “Racism, racial events and mental ill health”) “race” is interpreted in the more modern sense as a socially constructed entity (see Omi & Winant, 1994). What is striking though is that, except in the case of the chapter on the mental health of refugees and asylum seekers (see below), the concept of psychiatric “illness” is taken throughout the book as something “given” – a rarefied “thing” that is applicable irrespective of cultural background or context. In other words the knowledge within ethno-psychiatry and the critiques of the narrow (western) medical model of illness so often voiced in the transcultural psychiatry world – and indeed by users (“consumers”) of mental health services who come from non-western cultural backgrounds – are not taken on board to any extent in any of the chapters.
Having outlined the limitations of this book as a whole, it must be said that there are some chapters that may be useful for practising mental health professionals. Training in “cultural competence” and the more popular (in UK) “diversity training” is discussed in several chapters. The chapter “Diversity training for psychiatrists” by two child and adolescent psychiatrists, Nisha Dogra and Khalid Karim, covers the topic fairly comprehensively and trainees in psychiatry could gain from studying this. The most useful and well written chapter that all mental health professionals should read is “Intellectual disability and ethnicity; achieving cultural competence” by Jean O’Hara, a consultant in psychiatry of intellectual disability. Another chapter that is easy to read and informative is “Mental health of refugees and asylum seekers” by Rachel Tribe, professor of psychology at University of East London (UK). Racism features in several chapters; although it is never dealt with very adequately vis-a-vis its effect via institutional racism on the practice of psychiatry itself, something written about quite a lot in the UK recently (e.g., by Bhui, 2002; Fernando, 2010) and often raised by people who use mental health services. Unfortunately, chapters that should have dealt with racism in the clinical encounter and with institutional racism in the practice of psychiatry fail to address the major – although contentious – clinical issues around diagnosis, recently explored so well in the book The Protest Psychosis: How Schizophrenia Became a Black Disease by Jonathan Metzl (2009).
In conclusion, this is a book for psychiatric libraries in the UK to hold – libraries that do not subscribe to the journal Advances in Psychiatric Treatment – so that it may be accessed by psychiatric trainees in the UK studying for the examinations set by the Royal College of Psychiatrists, assuming (as implied by the editors of the book) that it represents the sort of answers required at these examinations. A few chapters noted above may be useful for other professional groups in the mental health field, but not many. It is noteworthy that no less than 30 of the 34 authors are psychiatrists, including four trainees. There are no contributors who speak for users (consumers) of mental health services or for carers of people with mental health problems; in fact their roles and viewpoints are hardly ever mentioned except for a brief reference to carers of people with dementia and a good account of the roles of carers in minority ethnic communities in the chapter on intellectual disability and ethnicity. Finally, there are no contributions from any of the several non-governmental organizations that have developed mental health services for British minority ethnic communities (Fernando, 2005; Fernando & Keating, 2009) – a very serious deficiency indeed because they have been in the forefront of providing mental health services that are considered to be sensitive to the needs of black and minority ethnic people in the UK.