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Debate: The concept of culture has outlived its usefulness for psychiatry

  • Mohammed A. Rashed (a1) (a2), Rachel Bingham (a3), Norman A. Poole (a2) (a4), Abdi Sanati (a5) and Werdie van Staden (a6)...
Abstract
Summary

This paper presents a debate in which the authors participated at the World Psychiatric Association conference in Cape Town, South Africa in November 2016. Professor van Staden acted as chair and here, as at the debate, provides a rationale for debating a topic that many of those involved in mental health believe to be decided. The discussion that ensued demonstrated, however, that while the arguments have moved on they have not ceased. Who won? Well that depends how you look at it. A few in the audience shifted position towards the motion but the majority remained opposed. What do you think?

Declaration of interest

None.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Correspondence to Norman A. Poole (norman.poole@gmail.com)
References
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1 American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders (5th edn). American Psychiatric Association, 2013.
2 Rashed, MA, Du Plessis, RR, Van Staden, CW. Culture and mental health. In Psychology: Themes & Variations (South African edn) (eds Weiten, W, Hassim, J): 486505. Cengage, 2016.
3 Jackson, M. Things As They Are: New Directions in Phenomenological Anthropology. Indiana University Press, 1996.
4 Rashed, MA. Culture, salience, and psychiatric diagnosis: exploring the concept of cultural congruence and its practical application. Philos Ethics Human Med 2013; 8(5): 112.
5 Rashed, MA. Talking past each other: conceptual confusion in culture and psychopathology. South Afr J Psychiatry 2013; 19(1): 1215.
6 Jenkins, J, Barrett, R. Introduction. In Schizophrenia, Culture and Subjectivity (eds Jenkins, J, Barrett, R): 128. Cambridge University Press, 2004.
7 Rashed, MA. Religious experience and psychiatry: analysis of the conflict and proposal for a way forward. Philos Psychiatry Psychol 2010; 17(3): 185204.
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Debate: The concept of culture has outlived its usefulness for psychiatry

  • Mohammed A. Rashed (a1) (a2), Rachel Bingham (a3), Norman A. Poole (a2) (a4), Abdi Sanati (a5) and Werdie van Staden (a6)...
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eLetters

Looking beyond culture in psychiatric formulations

Janaki Bansal, Consultant Child and Adolescent Psychiatrist, Tavistock and Portman NHS Foundation Trust
21 June 2018

I was very interested to read the recent debate on culture in psychiatry, as throughout my training and practice I had never thought to question the concepts of cultural variation and sensitivity that I had been taught. However having read the well presented arguments on both sides I now support the motion that the concept of culture has outlived its usefulness in psychiatry. Below I will attempt to set out my own argument as to why.

Firstly I would like to clarify that the promotion of cultural awareness was not misguided from the outset, but rather was a useful tool in challenging a ‘one size fits all’ approach to conceptualising mental illness in an increasingly diverse society. But perhaps this was a missed opportunity, as rather than widening our nosology and offering opportunities for diverse and individualised formulations of cases, it has arguably at times become a means of denoting otherness - attitudes that can be collectively grouped together against scientific conceptualisations. It is quite natural for medical professionals to believe that our attitudes to mental health are based is a fiction - knowledge is merely a web of belief, with ideas that have been more rigorously tested through experience or empiricism held more securely at the centre as “the truth”1. We find this empirical foundation reassuring, but the need for this reassurance can prevent us from looking back on the course of science and reflecting that firmly held models have repeatedly been swept away by new theories, in what Kuhn refers to as ‘paradigm shifts’2.

Furthermore, in all fields of medicine, not just psychiatry, empiricism can never be a sufficient basis for practice; to think that only that which is observable and measurable can encapsulate the human experience that is relevant to health is clearly short sighted. The upshot is that we all approach mental illness from the perspective of a belief system, whether that be a scientific or non scientific schema or a mixture of both.

The hegemony of scientific models of mental illness is likely much less powerful outside the scientific field, with conceptions of illness in all types of societies influenced significantly by folk psychology and individualised attempts to attribute meaning or identify cause. We implicitly acknowledge this in day to day practice. We would not assume in an appointment with a white, middle class family that we already know their experience of mental ill health, attitudes to symptoms and family dynamics just because we had explored this with the family seen before who were of the same ethnic and social background. These individualised attitudes and expectations held by the family will be very relevant in the success of any treatment strategy and are clearly important to elicit. My assertion is that it would be similarly unhelpful to approach any case with prior assumptions based purely on ethnic or geographical background. One reason for this is that rather than being bound by membership to one particular cultural group or another, we form our individual identities by picking features from the constellation of social groups we fall into such as nationality or ethnicity, gender, religion, socioeconomic status and education and profession, influenced also by the microcosm of our familial environment. A presumption of prior knowledge about someone on the basis of one or two of these categorisations would risk missing much of what is fascinating about that particular person and potentially relevant to their presenting difficulties.

Finally I would like to turn to the question of why we might feel inclined to refer to more rigid ideas of cultural identity. We are perhaps on the threshold of great societal shifts, with growing uncertainty about the future of the current global model of free trade and capitalism and questions about where the rapid developments in fields such as technology and artificial intelligence will lead us. In the face of such uncertainty it is more tempting to cling to notions of being able to codify or clearly categorise people and phenomena in the search for predictability. Attempts to broaden the range of recognised identities and groups, for example in the case of gender and sexuality, might on the surface look like an embracing of diversity and individuality. However it may also mask a need to label or stereotype, with the hope being that if we can find enough categories we can all eventually be neatly defined and understood. I feel that while it can be helpful to hold in mind the range of possible influences and identities that might be salient, it is best to approach our role as clinicians from a position of not knowing, and go forward with a spirit of curiosity about each patient and family that we find before us. As such I am in agreement with the motion that the concept of culture has outlived its usefulness for psychiatry.

References:

1. “Realism” Stanford Encyclopaedia of Philosophy https://plato.stanford.edu/entries/realism/ accessed on 21/06.2018

2. “Thomas Kuhn” Stanford Encyclopaedia of Philosophy https://plato.stanford.edu/entries/thomas-kuhn/ accessed on 21/06/2018
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Conflict of interest: None declared

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