DSM and the problem with culture

The contemporary model of the cultural formulation in the DSM-5 and DSM-IV dates from the criticism of the insensitivity to cultural issues in the DSM-III. ^{Reference Kleinman6} The institutional culture of medicine was characterised as a ‘culture of no culture’, with limited interest in cultural issues. ^{Reference Taylor7} The OCF was first published in the DSM-IV in 1984, with a glossary of culture-bound syndromes, culturally relevant diagnostic categories and cultural considerations in the narratives introducing each chapter. ^{Reference Lim8} The National Institute of Mental Health in the USA supported the creation of a culture and diagnosis group in 1991, whose main goal was to advise the DSM-IV task force on how to make culture more central to the manual. ^{Reference Lewis-Fernandez and Diàz9} However, although the culture and diagnosis group succeeded in emphasising the relevance of cultural issues in psychiatry, there has been criticism of the cultural formulation from leading medical anthropologists over the years. This criticism can be summed up in the following four points.

1. 1 There is a lack of evidence that culturally informed therapeutic practices work. ^{Reference Kirmayer10,Reference Kleinman and Benson11} Kleinman & Benson suggest that the major claims about the value of cultural competence for professional caregiving are not supported by evaluation research showing that systematic attention to culture really improves clinical services. ^{Reference Kleinman and Benson11} This lack of evidence is a failure of outcome research to take culture seriously enough to asses the cost-effectiveness of culturally informed therapeutic practices. ^{Reference Kleinman and Benson11} Moreover, evidence-based practice should include a broader view of evidence that takes into account how different cultures recognise different ways of knowing. ^{Reference Kirmayer10}

2. 2 In striking contrast to its current use in anthropology, the concept of culture tends to be defined in medicine as something possessed by the patient and not the doctor.

3. 3 Culture is conceived as a confounding variable that White practitioners must deal with when they interact with people from ethnic minority groups. ^{Reference Littlewood1} The locus of normality is white. Taking whiteness for granted represents a specific view of culture that is shared by many White practitioners. ^{Reference Littlewood and Cross13} The Black and minority ethnic patient is construed as the object of specialised knowledge, while the professional and their cultural context are left unquestioned. ^{Reference Littlewood and Cross13} Historically, this view is reflected in the ways of linking psychiatric knowledge production and implementation to a strictly Western agency, while non-Westerners are often posited as passive receivers of this knowledge. ^{Reference Heaton14}

4. 4 Clinicians are criticised for lacking a cultural self-reflexive attitude towards their own professional practice. ^{Reference Kleinman15}

The cultural formulation of the DSM-5 aims to address these criticisms. The OCF is converted into the Cultural Formulation Interview (CFI), including 16 questions focusing on the patient's presenting concerns and definition of their problem and idiom of distress. ^{16(p.749–760)} Culture is defined as the systems of knowledge, concepts, rules and practices that are learned and transmitted across generations, yet are open, dynamic and undergo continuous changes over time.

The formulation emphasises that cultural information must not be overgeneralised or stereotype groups of fixed cultural traits. ^16(p.749) The OCF calls for a systematic assessment of the following four categories when conducting the CFI:

1. • cultural identity of the individual

2. • cultural conceptualisation of distress

3. • psychosocial stressors and cultural features of vulnerability and resilience

4. • cultural features of the relationship between the individual and the clinician. ^16(p.750)

A persistent challenge faced by clinicians in implementing the cultural formulation in the DSM-5 is how to translate insights from the social sciences in intelligible, practical and sustainable ways. ^{Reference Aggarwal, Nicasion, DeSilva, Boiler and Lewsi-Fernàndez17}

I aim to delve deeper into the fourth category: the clinical relationship. I aim to translate insights from anthropological fieldwork into practical methods for clinicians. Cultural difference can affect the clinical encounter, and part of the role of culturally informed psychiatry is to address this difference. Using ethnographic material from my anthropological fieldwork in Tanzania, I explore the cultural experience evoked in the encounter. This knowledge is transferred into the context of medical practice.

White person, where are you going?

Dressed in training tights, a t-shirt and running shoes, I stood in an outside gathering hall in a squatter area of Dar es Salaam, Tanzania, in January 1989. I was preparing to exercise young Tanzanian women in aerobic. As a new teacher in physical education from Norway, I was engaged for 1 month in the Norwegian sports development project, Sports for All, with the aim of giving working class women the opportunity to exercise. Twenty women arrived; none of them was wearing training gear or running shoes, but they had colourful dresses or blouses and skirts and were barefoot. I started to count one, two, three, and then pressed the play button on the music player. The Tanzanian women questioned every move I made. They wondered if they would get paid for exercising. They wanted to touch my white, pale skin and glanced at my freckles. They laughed in a friendly way at jumping up and down, commenting that the moves were a bit childish. Every day, when I left the daily training, people glanced at me and called out: ‘White person, where are you going?’ This question persecuted me in the years to come during several field visits to Tanzania and filled me with uneasiness, curiosity and amazement. ^{Reference Leseth18}

The amazement was first and foremost a ‘culture shock’ that caused me to question my whiteness, my way of practice and instruction. The Danish anthropologist Kirsten Hastrup used the term ‘amazement’ as a cultural pivotal point and a way of understanding that brings a person through emotional and embodied states. ^{Reference Hastrup19} When our habitual practices are questioned we become amazed. When the Tanzanian women questioned the way I moved my arms up and down, they questioned body practices that were part of my professional education and that I had taken for granted. When they commented on my moves or skin colour, I was amazed, as I never thought about these in terms other than ‘normal ways’. The amazement is embodied and cultured. ^{Reference Desjarlais and Throop20}

It was in the encounter with the Tanzanian women that I became aware of my habitual practices and cultural ways. It was by being amazed that I became conscious that, like the Tanzanians, I too possessed systems of knowledge, concepts, rules and practices that are learned and transmitted across generations, yet are open, dynamic and undergo continuous changes over time.

Next, I will discuss how this experience can be relevant to a Western clinician by elaborating on some characteristics of the encounter between the doctor and patient, as discussed by Roland Littlewood, among others. ^{Reference Littlewood and Lipsedge21}

The clinical encounter

The encounter between the psychiatrist and the patient involves two people who have their own expectations. If the doctor–patient situation is familiar to both, they will each probably make an effort to live up to the other's expectations. For example, the expectation that the patient is seeking advice to solve a specific problem and that the doctor is an expert who will provide this advice. However, the psychiatrist and the patient face challenges if their cultural backgrounds differ considerably. The psychiatrist might have a less clear expectation of how the patient is likely to behave and what the limits of normality and abnormality are. In this sense, the encounter between the psychiatrist and the patient shares several similarities with the encounter between the researcher and informants from different cultural contexts. The psychiatrist's attitude towards a patient from a minority ethnic background will be informed by the clinician's own experiences, stereotypes and conscious and unconscious racial assumptions. For example, the clinician might have certain race-related assumptions and the patient might be assumed to have a core set of beliefs. ^{Reference Johansen, Olwig and Pærregaard22} Stereotypes of how other groups of people (such as Danish-Somalis, Native Americans and British Pakistanis) tend to behave influence the treatment options. Patients have their own expectations and the extent to which they see themselves as mentally ill varies with cultural background. What might be tolerated in Tanzania, such as spirit possession, witchcraft and healing ritual, are regarded as forms of abnormality (if not mental illness), in Britain. ^{Reference Littlewood23} Patients with a migrant background seeking help in psychiatric out-patient clinics in European counties might have experiences of mental illness that differ from the doctor's experiences. For example, they might experience their illness as a physical disability or have felt lost in a fragmented health system. ^{Reference Rosso and Bärnhielm5} How the psychiatrist copes with their own amazement is therefore of importance. ^{Reference Bäarnhielm and Ekblad24} I present two cases based on my own experience to demonstrate two ways clinicians might respond to amazement.

Amazement: cultural understanding or withdrawal?

Culturally informed psychiatry is required in domestic contexts familiar to the clinician. Clinicians' experiences of differences, such as language barriers, patients' expressions of distress and orientations of belief can trigger fear, anxiety and amazement. To be aware of one's own amazement might uncover issues taken for granted that the clinician assumes to be inevitable and universal. These often unnoticed assumptions may refer to all sorts of beliefs, habits, practices and values, from body comportment to being accustomed to urban infrastructure. I suggest two responses to this amazement: cultural understanding and withdrawal.