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The Role of Culture in a Theory of Psychiatric Illness

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The Role of Culture in a Theory of Psychiatric Illness Sm. Sci. Med. Vol. 35, No. I, pp. 91-103, 1992 0277-9536/92 $5.00 + 0.00 Printed in Great Britain. All rights reserved Copyright 0 1992 Pergamon Press Ltd THE ROLE OF CULTURE IN A THEORY OF PSYCHIATRIC ILLNESS HORACIO FABREGA JR Professor of Psychiatry and Anthropology, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, 381 I O’Hara Street, Pittsburgh, PA 15213, U.S.A. Abstract-A medical theory of phenomena thought of as psychiatric would rely on concepts and seek explanations that pertain to the concerns of biomedicine. A social theory of the psychiatric needs concepts and seeks explanations that pertain to concerns of the social and cultural sciences. Some of the requirements of such a social theory are reviewed with an emphasis on why and how the concept of culture is important. The Western medical bias of psychiatric illness needs to be faced as well as the problem of cultural relativism. The paper discusses the heuristic usefulness of a concept of human behavioral breakdowns. The many ways in which culture influences knowledge and practice of biomedical psychiatry are examined critically. The scope of a social theory of the psychiatric is also outlined. Key words-psychiatry, theory, ethnomedicine, relativism Psychiatry attempts to clarify etiologic and thera- this) are labelled and handled in different societies. peutic aspects of a number of ‘biological’ disorders This topic is elaborated in the paper with emphasis which differ from others in medicine only with respect given to both cultural and historical factors. I will to the organ affected and type of pathologic process also discuss that even in the contemporary setting, or ‘lesion’ [l-3]. In this light, a theory of schizo- where scientific objectivism characterizes psychiatric phrenia or bipolar manic disease (the classic ‘diseases’ knowledge and where rationalism dominates the of psychiatry) would address genetic factors, environ- thinking of mental health personnel and patient, mental precipitants, pathogenesis and natural history culture plays a no less critical role. For not only as well as response to pharmacology. These are have cultural factors conditioned basic meanings of factors whose conceptualization and empirical inves- psychiatric concepts, they also influence the interpret- tigation are analogous to those of diseases in general ation and application of clinical psychiatric knowl- medicine. Contemporary psychiatry is quintessen- edge. Finally, the whole enterprise of biomedical tially biomedical. The formulation and investigation psychiatry itself is rooted in distinctive cultural of a disease entity is grounded in the biological traditions and hence has a cultural character. sciences and in allied sociomedical sciences (e.g. The aim of this essay is to outline the issues epidemiology, demography), all of which share a pertinent to a social theory of psychiatric phenomena system of categories, explanatory frameworks, and concentrating on the conceptual problems posed underlying rationale with respect to what disease by the idea of culture and cultural relativism. By means and the purposes of treatment. ‘culture’ I mean a system of meanings that is learned, A social theory of psychiatric phenomena is differ- that provides people with a distinctive sense of reality ent insofar as it must be cross-culturally relevant. and which helps shape behavior and affective re- What the ‘psychiatric’ refers to in biomedical terms sponses [lo]. The cultural, historical and medical (e.g. schizophrenia, mania) may have no identity or factors that must be considered in formulating meaning in a local culture. Yet, one anticipates that the relation between psychiatric phenomena and behavioral disturbances (i.e. psychiatric phenomena) the functioning of societies will be discussed. are likely to be prevalent cross culturally. This, More specifically, I (1) argue for a broad synthetic in essence, is the problem of cultural relativism approach to theory construction in social science/ which entails the idea of emit and etic categories, all psychiatry; (2) review epistemological dilemmas of which have received a great deal of attention in linked to cultural relativism; (3) introduce and discuss anthropology and psychiatry [4-g]. A social theory of a concept of ‘human behavioral breakdowns’ as a the psychiatric thus encounters this problem directly. way of clarifying epistemological dilemmas; (4) elab- To attempt a social theory an analyst must first orate on why culture is so intertwined with the study define the psychiatric abstractly in order to embrace of human behavioral breakdowns and psychiatric phenomena that are comparable across societies but illness; and (5) offer some remarks about the kinds of which may be conceptualized differently. Then, a way issues in social science that a theory of psychiatric must be found of measuring in social terms how phenomena must confront. For now, I will use the instances of the psychiatric (as the analyst defines term ‘psychiatric illness’ in an abstract sense referring 91 SSM 35’1-0 92 HOKACIO FABREGA JR to conditions that disrupt the social life of persons knowledge is necessarily ‘culture bound’. The knowl- and their immediate co-members and that might be edge produced by a Western ‘science’ of biology equatable with biomedical categories (e.g. anxiety, would thus appear to dissolve as an explanatory schizophrenia, mania). foundation. Such a cultural relativistic perspective would place Western scientific knowledge and theory either external to a culturally sensitive theory and/or THE STUDY OF .MEDICINE IN A COMPARATIVE render its inclusion in such a theory highly problem- FRAMEWORK atic [l9]. All of this would seem to narrowly con- To deal theoretically with psychiatric illness in a fine or to render misguided a comprehensive social comparative, cross cultural framework is part of the theory of psychiatric illness as conceptualized here; enterprise of an ethnomedical science and involves namely, as importantly requiring the concept of making use of its basic concepts [1 11. Fundamental culture. to this field is a distinction between the concept A ‘radical’ form of cultural determinism which of disease as a biomedical condition and illness stops short of biology and does not allow using as a social behavioral response. In addition, ethno- concepts which have meaning across cultures (epis- medicine encompasses a range of concepts pertaining temological relativism) is eschewed here as being to properties and modes of functioning of systems pernicious to a scientific inquiry into illness, disease of medicine: for example, explanatory frameworks and related social behavior [l9]. Consequently. no pertaining to cause and treatment of illness, modes of inconsistency is presumed to arise when one connects production of medical knowledge. idioms of distress, the study of illness as a sociocultural enterprise to the practitioners and healers of different persuasion. study of disease as a biological one. institutions for training them and social practices The ubiquity of disease in human populations governing diagnosis, treatment and prevention means that illnesses are recurring eventualities in [12P15]. A fundamental axiom of ethnomedicine is social groups that constitute deviations and give rise that all societies are affected by disease. to corrective actions [20]. This means that how people Any theory of disease viewed in purely biological describe, show. recognize and respond to illness terms as affecting morbidity, mortality, reproductive varies in relation to cultural meanings. However, level and its range of social consequences. ultimately what can be labeled a medical event almost always rests on the theory of evolution [ 16, 171. Given (I ) involves a gross disturbance in adaptation, usually biological errors and genetic characteristics intrinsic with a bodily focus. Given that illness appears natu- to populations that operate as vulnerabilities and (2) rally anchored in the body, it is reasonable to assume environments that challenge and strain the organism. that there exist universal indicators of illness. This conditions are met for the endemicity of disease and would include such things as bleeding. visible the production of illnesses [l8]. In an ethnomedical anatomic lesions. varieties of pain, changes in bodily theory of illness, the endemicity of disease could be awareness and function, and impairments in sensory taken as a given fact; that is, as providing the ultimate and neuromuscular functioning all of which (to be conditions that create the social phenomena of illness sure) are registered in social behavior and adaptation which the theory was designed to explain; and hence. and can be directly observed as well as reported. In as outside the domain of the theory. On the other short. although the concept of illness is subject to hand, there are advantages to not excluding bio- cultural variation since it rests on sociopsychological logical factors from a theory of illnesses. if for no and/or behavioral conventions about behavior, it other reason than to increase the scope and power of refers to phenomena that also are somehow universal what the theory could explain. and ‘biological’. A biocultural unity operates at the However, to allow phenomena explained in terms level of manifestation of any illness episode as well as of biology to intrude into the domain of cultural at the level of causation, since reciprocal influences analysis raises the problem of universalism and cul-
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