The Role of Culture in a Theory of Psychiatric Illness

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 biocultural 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- exist between phenomena labeled as biological or tural relativism [ 191. Biology implies universal mech- cultural. anisms and processes and points to sameness in the Because illnesses which we think of as physical and material production of illness and its manifestations. bodily are universal to human societies, manifest in Yet, culture implies differing conventions and con- relatively similar ways and are generally distressing, tents of meaning and, with respect to psychiatric concepts about them are widely encountered [ 14, 181. illness, cross cultural variation in appearance and They are easily found among the cultural objects of interpretation. How can sameness and differences be any comprehensive ethnography as are theories of reconciled? This problem is central to a social theory causation and medical treatment. What we ordinarily of psychiatric illness. mean by psychiatric illnesses, however, are more It is necessary to address the challenge of ‘radical’ difficult to locate in the medical vocabularies of cultural relativism. as well. The theory of evolution different people. Such illnesses prominently involve and biomedical science, which would serve to explain alterations in social and psychological behavior and the ubiquity of disease, are Western products. Ac- often are not identified locally. A concept that can cording to some (‘radical’) cultural relativists, such approximate the psychiatric is needed. The role of culture in a theory of psychiatric illness 93

HUMAN BEHAVIORAL BREAKDOWNS (HBB) in which such anomalies can be classified. One can use external and observer imposed (so-called ‘etic’) Our current understanding of psychiatric illness conventions or one can use those that are culturally is rooted in developments of Western European specific and local to the society (‘emit’ conventions). influenced societies. Three related developments can Anomalies of social behavior are sometimes judged be singled out. One is cultural or symbolic in nature positively by co-members, with affected individuals and includes, on the one hand, conceptions about valued and accorded power and status. Other personhood, social identity and social deviance; and anomalies are devalued and judged negatively. on other hand, conceptions of well being, illness and Whether the behaviors are judged as willful or not medical care. It is in the intersection of these con- is a further important consideration in the way ceptions that one finds the category of psychiatric behavioral anomalies are culturally defined. illness. The second set of developments are historical, Sustained anomalies of behavior that are judged as political and sociological in nature. They include the not willful and evaluated negatively by co-members demographic transition, growth of large urban cen- are here termed ‘human behavioral breakdowns’ ters, industrialization, the impoverishment and mar- (HBB). They incude all or some of the following: ginalization of population segments, centralization of disturbances in mentation and awareness that render governmental power, spread of liberal democratic work and relationships unproductive, impairments in ideas, the collectivization of social welfare activities emotional well being, irregularities of social identity under the auspices of the state and the growth of and conduct, and failure to meet standards of appear- health and welfare related professions. The third set ance, dress and cleanliness. An HBB encompasses of developments are biomedical in nature. These behaviors that could be the object of professional include the growth of scientific understanding of psychiatric diagnoses as well as lay labels of behav- brain function, psychiatric disease processes, and ioral derangements or dilapidation. However, it need medical therapeutics. This knowledge has had an not totally impair the individual’s functioning. The important effect on how the psychiatrically ill are idea that the behavioral change is locally devalued is viewed and handled in Western societies. the important feature. The term breakdown and/or Of course all three developments, though analyti- disturbance means that the behaviors in question are cally distinguishable, are in practice complementary defined as constituting an impairment and a disrup- and correlated. The cultural/symbolic, historical, so- tion in behavior; and a compromise of or threat to ciological and biomedical developments enumerated organized social life. The behaviors, in other words, here account for the way the category psychiatric cause trouble, or confuse, or interrupt the flow of illness is understood, used and applied today. In social life of the people connected to the individuals this sense, its meaning is quintessentially Western showing HBB. European. HBB related behaviors are (1) shaped by culture in In using a concept of psychiatric illness to explain some way; and (2) labeled by co-members using behavior, illness and well-being, one must thus guard categories drawn from a culturally constructed reper- against casting definitions and formulations in a toire of symbols. Each society possesses a system of Western European mould. If biological markers per- categories and explanatory frameworks in terms of taining to disease existed in psychiatry, they could which the self and the world, including HBB, are provide one basis for cross cultural measurement, but understood. In labeling a behavioral anomaly as an this would entail side-stepping the cultural context of HBB, a cultural co-member has classified the behav- illness and behavior. To deal effectively with the ior: he or she, in identifying it as a local variant of latter, one should try to understand different con- HBB, has ‘seen in it’ criteria that constitute the ventions about persons, behavior, deviance, illness, conceptual category HBB. medical practice and institutionalized forms of care. The label applied to HBB is by definition ‘negative’ Such an understanding might allow equating varieties because HBB involve changes that are devalued. It of behavioral syndromes cross-culturally as psychi- does not follow that HBB are handled as ‘medical’ atric illness and/or as forms of deviance or mere problems in a society although I will be giving eccentricities. However, what the analyst terms principal attention to material pertaining to this psychiatric illness will not necessarily be recognized eventuation. A fundamental issue in cultural studies as illness cross-culturally. To further clarify the socio- of psychiatry involves the question of what is medical cultural domain of behavior encompassing psychi- as opposed to something moral, political or religious, atric illness, the concepts of anomalies of human and on what bases these distinctions are made. This social behavior and ‘human behavior breakdowns’ problem will not be addressed directly in this essay, are introduced. although several considerations that bear on it are Anomalies in human social behavior that are not taken up later. In a loose sense, all societies are held merely transient and easily explained but instead to possess medical care ‘systems’ [2I]. It is in terms of sustained and socially marked and consequential are the knowledge and practice structures of these ‘sys- phenomena that human groups have always had to tems’ that people may diagnose and treat HBB as contend with and explain. There are many ways illness. The point here is that HBB and HBB which 94 HORACIO FABREGAJR

are culturally interpreted as illness are two ways of rendering them socially ineffectual, appears necessary developing a concept of ‘the psychiatric’ that might for an occurrence of HBB to be judged as illness. Yet be useful for an ethnomedical theory of psychiatric what constitutes a ‘psychiatric illness’ is very much a illness. socially and culturally negotiated condition [32, 331. Emphasis on HBB as illness is important because At root here is the question of ‘normal’ vs ‘abnormal’ labeling something an illness and hence worthy of behavior. medical care tends to bring into play special symbols, In 1956 George Devereux [34] wrote an influential qualifications and practices that have as their goal the article entitled ‘Normal and Abnormal: The Key restoration, melioration. and assimilation of HBB Problem of Psychiatric Anthropology’. He discussed [22]. Local conventions about what illness means the criteria that enabled one to define behavioral are thus incorporated theoretically, allowing richer phenomena in particular cultures as psychopatholog- analyses. The successful treatment of HBB illnesses is ical. Devereaux pushed a key problem of cultural not always possible. Some HBB that are labeled as psychiatry into the intrapsychic sphere, there to be illness may be recurring. persistent, debilitating and unraveled by careful assessments of how psycho- associated with increasing deterioration. This raises logical conflicts were culturally contextualized, the important question of how medically labeled shaped and interpreted. His analysis was centered HBB come to be viewed and handled in the society on the mode of adjustment of whole persons. He if local treatment practices prove unavailing. Conven- illustrated his perspective by concentrating on the tions about what constitutes a medical HBB and shaman, whose behavior could appear erratic, schizo- adequate treatment for it may or may not be shared phrenic and dissociated. Was the shaman normal across societies and cultures. HBB is likely to vary or was he instead ‘really schizophrenic’ but merely significantly across societies. within societies across labeled differently, being ‘protected’ by a role that time, and even within societies at one point in time sanctifies ‘pathological’ experience? Devereux’s logic but across social space. Nevertheless, the concept of was consistent with that of Silverman [35] who HBB (and the more general one of human behavioral showed how an acute schizophrenic syndrome, anomalies) may be put forward as an etic category for when played out in a local culture, could come to an ethnomedical theory of psychiatric illness. How transform the person’s mode of thinking and identity one can capture such a locally anchored concept (by the unfolding of schizophrenia in the light of (HBB) in a general and abstract frame of reference cultural meanings) so as to lead to the career of a (one that allows comparison across cultures) consti- shaman. tutes the central theoretical problem in ethnomedical In Devereux’s [34] formulation, psychopathology psychiatry [23]. consisted of the playing out of culturally specific conflicts that are common but ordinarily not problematic Such conflicts were said to be located in the HUMAN BEHAVIORAL BREAKDOWNS AND individual’s ethnic unconscious, The marginality of TRADITIONAL ANTHROPOLOGICAL ANALYSES the role selected by the shaman was said to constitute Illnesses that we qualify as psychiatric are recently one indicator of psychopathology, since it locates invented objects. They are inextricably linked to him/her in a position that is deviant and hence historical and cultural contingencies of Western discrediting. Moreover, because it requires the European societies [24-271. This point will be elabo- shaman to play out culturally specific conflicts, it rated in greater detail below. One can understand unduly burdens him/her and closes off opportunities ‘psychiatric illness’ to refer to types of human behav- for psychological growth, development and auton- ioral breakdowns (HBB) that can result from any omy. Another indicator of the shaman’s psycho- number of genetic and/or environmental factors. pathology was said to reside in the stability and HBB are realized in visceral, psychologial and social patterning of the psychological defenses that were behavioral changes and are recurring eventualities in relied on to resolve the conflicts of the ‘ethnic uncon- human groups. However, HBB carry differing mean- scious’. Such defenses were assumed to be weak or ings. Prophets, shamans, malcontents, eccentrics-to insufficient in protecting the shaman from behavioral name but a few-may be defined as manifesting difficulties. This (Devereux indicated) is especially forms of HBB [28]. Yet none may be negatively true at later stages in the life of the shaman. Normal labeled within their own societies. There also exist persons, who by definition harbor similar ethnic across societies behavioral syndromes (‘ethnic psy- unconscious conflicts, have developed stronger and choses’) that appear strongly conditioned by local more flexible psychological defenses that are protec- cultural meanings and models of behavior [6,29]. tive and thus ameliorate the behavioral difficulties They also fall within the category HBB. that develop from these conflicts in the case of the Individuals showing HBB who are in deteriorated shaman. and dilapidated behavioral states are generally ident- In the Devereux formulation constituent symptoms ified as ill [6, 30, 3 11. Besides symptoms of behavioral of psychopathology as classically identified in disorganization, the lack of a capacity for some level biomedicine do not receive primary attention. Delu- of adaptive function and independent living, perhaps sions, hallucinations and other mental status changes The role of culture in a theory of psychiatric illness 95 are not addressed directly. Devereux tended to em- of course, society’s way of handling ‘chronic’ forms ploy generic diagnostic categories. Actual manifes- of HBB may contribute to their assimilation [40,41]. tations of illness are viewed in psychoanalytic terms Finally, less complex societies lack the central regu- and in relation to intracultural or idiosyncratic con- latory institutions and systems of surveillance and flicts. Yet, his formulation acknowledges cultural control that operate to closely regulate behavior and differences in the way behavioral anomalies and/or promote the categorization of deviance as well as its possible HBB might be labeled and played out. Thus, medicalization (see below). he addresses the question of cultural differences but Medical conceptualizations of HBB characteristic argues that psychiatric illness is universal and can be of pre-industrial societies are varied in nature. Some reliably measured and diagnosed cross culturally, are ascribed to either natural causes, supernatural using the universalistic language of psychoanalysis. intervention, or human malevolent doings [ 141.There Devereux, then, dealt with the question of cultural is no tendency for medicalized HBB to be equated relativism and argued for an underlying psycho- with distinctive causal explanations across societies analytic universahsm. nor is there a tendency for it to be explained differ- The idea that psychiatric illness had different mani- ently from other medical illnesses [42]. There is festations and was interpreted differently cross cuhur- perhaps a tendency for serious and/or chronic ill- ally was attacked by Murphy [30]. Her position I term nesses, regardless of their nature (psychiatric, medi- the weak or traditional relativist position insofar as cal), to be judged as more dangerous, ominous and it acknowledged surface or mere content differences threatening and to be explained in terms of supernat- cross culturally. Her study was actually meant to ural and/or malevolent factors. An essential feature challenge the labeling approach in sociology which of the way illness, including some HBB, is handled in can be thought of as a radical form of relativism. less complex societies is the social and public nature Murphy concentrated on schizophrenia and empha- of diagnosis and curing. Illness constitutes a social sized that underlying surface differences, one found and even political event in a group or village, and it universalistic aspects, arguing that schizophrenic be- brings into play moral and religious symbols [l1, 121. havior not only looked the same but also tended to Unique social happenings within the group are incor- be judged similarly in different cultures. Murphy’s porated into explanations of cause and the enactment paper actually supported a growing universalist per- of curing ceremonies and, together with details of the spective in contemporary psychiatry which, together personal life of the sick person, come to be part of the with the ascendancy of neurobiology, has achieved social drama of illness. The highly individuated dominance today. Qualifications of this position are nature of illness, an emphasis on its functional as- taken up below. Despite the contemporary criticisms pects and elaborations of its situational implications of the universalist position, recognition of and argue against the existence of an ontological view of conceptualizations about many of our ‘psychiatric illness. In other words, the notion that illness has a illnesses’ are found consistently across societies and unique existence with a predetermined, intrinsic their referents involve phenomena described above as course and outcome is not held, although illnesses do HBB and similar to what Murphy and others have ‘exist’ in the sense of constituting categories which are emphasized [4, 3 1, 361. identified and which command a measure of symbolic HBB are not transitory but possessed of some specificity. extension in time. The concept is not limited, however, to ‘chronic’, progressive or irreversible changes. HUMAN BEHAVIORAL BREAKDOWNS AND THE It is widely assumed that the reason why long lasting GREAT TRADITIONS OF MEDICINE forms of HBB are not frequently found in less complex societies is because of the differential sur- At least four ‘Great Traditions’ of medicine have vival of persons so affected. In subsistence economies, existed. The ancient and medieval societies of India, individuals functionally compromised with HBB can- China, Persia/Islam and Mediterranean Europe were not carry out expected responsibilities and are less each associated with literate, academic and scientific likely to survive and/or to be maintained and kept theories of illness [4348]. In all these traditions, alive [37-391. However, seemingly ‘chronic’ forms of medical illnesses were handled as somato-psychically HBB defined as illness have been described [30,31]. integrated objects and explained in terms of an Another reason for the seemingly lower prevalence elaborated ethnophysiology. The theory of illness was of HBB is said to be that the set of obligations/ predominantly functional. in that illness tended to be requirements inherent in less complex societies pose handled with emphasis given to its individualistic fewer and/or ‘simpler’ social psychological demands character. The symptoms and symptom complexes on persons; in this instance, it is claimed, HBB of persons, seen in terms of temperament, habits, phenomena are less likely to be created and/or to stage of life and the factors and processes delineated surface as management problems. Together with by the ethnophysiology, explained the illness and differing baselines and values regarding what consti- recommended the treatment. Although in some of tutes normal behavior as well as HBB, this would these traditions an emphasis was given to types of contribute to low levels of chronic HBB. In addition, illnesses and even specifically named conditions, an 96 HORACIO FABREGA JR

ontological view of illness did not gain dominance. and explanatory models in the Great Traditions that Thus, the idea that an illness had a unique identity that pertain to HBB illnesses point to similar behavioral encompassed cause, mechanism, manifestation and characteristics. In large part, these descriptions of natural history and that the illness, as it were, invaded behavior conform to what in Western medical history or lodged itself in the person, was not characteristic is termed insanity, psychosis and/or madness. It of the Great Traditions of medicine. Of course schol- would seem that the conditions referred to can be ars have pointed to ideas that implied an ontological viewed as comprising a more or less universal medical perspective in Greek medicine [49, 501. For example, category. In summary, the following generalizations in the Hellenistic corpus, a nosology of sorts existed, seem warranted: (1) HBB phenomena are universal to which implies entification of illness (the elements of human societies; (2) many varieties of these tend to this ontology are still with us today), and Galen is be viewed as comprising illness; (3) when they ‘enter’ said to have used the idea of ‘seeds of disease’, which the system of medicine in which a ‘great’ theoretical implies the same. However, an ontological view as tradition holds sway, HBB illnesses are scientifically such is held to be a feature that became recognizable ‘naturalized’, and thereby socially neutralized; and only after the ideas of Paracelsus, Van Helmont and (4) the prevalence of a set of more or less common Harvey in the early modern period [51-541. genera1 sociopsychological behavioral manifestations All of the Great Traditions of medicine have of HBB illnesses supports the idea of human univer- encompassed certain varieties of what I have termed sals and the psychic unity of man. These generaliz- HBB as illness conditions. The degree of specific ations do not contradict the points of view emphasis given to HBB illnesses in the corpus of encompassed by what one can term the weak and medicine differed. For example, the organs and/or strong forms of cultural relativism, but they appear mechanisms that explained HBB phenomena as ill- to be disallowed by the radical form which, as I ness varied, as did the extent to which these illnesses have applied, seems to preclude a consideration of received elaborate analysis. However, all appear to biological factors and scientific explanation more have singled out rather general sociopsychological generally [6, 19, 551. behavioral problems that reflected adaptive failures, conditions of psychosis and social breakdowns [55]. HUMAN BEHAVIORAL BREAKDOWNS AND An emphasis on elaborated aspects of human psy- EUROPEAN SOCIETIES chology (rationality, emotion) and their explanaton in these terms, as in modern Western psychiatry, was Since the Greek period, the topic of HBB illness not central. Yet, it has been possible for scholars to (i.e. melancholia, mania, the irrational) has become equate some forms of illness entities with our modern an important cultural category in Western societies. disorders [55-581. All of the theories tended to handle Conceptualizations of HBB illnesses were used as a HBB illnesses as naturalistic objects, which is to say vehicle for the clarification and celebration of basic that no stigma was attached to the ill person. An values and beliefs, such as those associated with exception seems to have been the Western Mediter- reason, individuality and civic responsibility-hall- ranean tradition during the Christian era [59]. More- marks of the classical heritage [59-631. Such at- over, in all the theories, what can be termed tributes of personhood are not only contrastive with supernatural and/or demonic factors were sometimes states of HBB illnesses, but in being raised to markers represented and/or actively vitiated, which implies of the healthy and virtuous, they also help set apart that competing or alternative conceptualizations as devalued the conditions which negate them. HBB (outside the Great Tradition) have attached to HBB illnesses could also be equated with the mysterious, illnesses. However, such factors were not uniquely the inexplicable, the fateful and with the dangerous associated with HBB illnesses. but with all types of and violent. They were explained as resulting from illnesses. Finally, it would appear that in many of the the punishment of the gods for impious actions and societies where the Great Traditions prevailed (i.e. sacrilegious behavior and also equated with religious outside the dominant academic/scientific ‘system’ of pollution requiring purification. Finally, from the medicine), a social stigma of sorts was found, picture of HBB illnesses created by the tragedians, it although there were differences of degree [42, 591. can be argued that such illnesses were seen as some- There appears to be wide differences in the way such how rooted in sociocultural circumstances; influenced HBB illnesses were labeled and handled based on the if not brought on by the play of social forces stem- economic standing and family connectedness of the ming from cultural traditions and conflicts. person ill, with affluent persons more likely to be These themes that are found in the classical period treated by academic physicians, confined when raise the question of psychiatric stigma; that is, they necessary to their homes and less subject to ridicule associate the shadowy, harmful, and bad with HBB and punishment. illnesses and suggest some social condemnation and Cultural factors no doubt affect the labeling of disapprobation. If not quintessential ingredients, normal versus abnormal behavior, a social process these at least constitute preconditions or require- that always precedes the recognition of HBB as ments for stigma. There is evidence that these intellec- illness [32]. Yet, the descriptions of manifestations tually rooted cultural interpretations of HBB illnesses The role of culture in a theory of psychiatric illness 97 were broadly held and extended in time into Hellenis- all problems that psychiatrists dealt with came to tic and subsequent periods of European history. partake of this amalgam of cultural meanings. Moreover, there exists ample evidence that socially, Psychiatric stigma has traditionally been associated persons showing HBB illnesses could be forcefully with certain varieties of HBB phenomena (e.g. mad- confined and/or restricted [28, 59,61-63]. ness and insanity) but in the modern and contempo- Recent histories of modern psychiatry have empha- rary period this stigma has broadened and spread to sized categories such as madness and insanity. I have encompass such problems as somatization, neuroses, suggested that these categories cover phenomena that and personality disorders because they are dealt with in this paper are termed HBB and handled culturally by psychiatrists. Whether all of these ‘conditions’ can and socially in medical terms. Historical writings be handled conceptually as HBB phenomena is prob- have also emphasized the sociological correlates of lematic. They certainly are defined as ‘psychiatric’ psychiatric phenomena [26, 64,651. The latter studies and thought of as forms of (somatic, psychological have as their focus the reform movements associated and/or interpersonal) ‘behavioral breakdowns’ by with the development of the asylum in European and many psychiatrists. This topic is taken up in greater Anglo-American societies and the growth of the detail elsewhere [6,27,74] and is touched upon below discipline of psychiatry. Influenced by and/or react- also. ing to the writings of Foucault [65], they have emphasized segregation and incarceration which, in leading PSYCHIATRIC DISEASE AS A CULTURAL AND to a loss of civil liberties and dependence, promoted HISTORICAL PRODUCT OF WESTERN BIOMEDICINE marginalization. This has accentuated the problem of psychiatric stigma [66]. The overlap between behavior The social and intellectual history of medicine, labeled as HBB illness and behavior labeled anti- psychiatry and mental illness is a field of study that social, which raises the question of criminal responsi- has expanded in the last two decades. The notion bility, is part of this story [67]. This connection goes that the modern concept of disease is particularly far back into European history and, of course, is not rooted in Western medicine has, of course, long unique to European societies. The medicalizaton and been appreciated [47-521. In the West, disease entities consequent exculpation of persons with insanity/ are described as possessing individuated histories, madness, and the social/legal dilemmas raised by this, mechanisms, and, eventually, genes/chemistries/ were found in classical societies and in other systems physiologies. Diseases have taken on the character of of medicine [28,42,68, 691. Scholars have pointed to objects amenable to special technologies for their the stigma linked to insanity in China, but this stigma explanation, diagnosis and treatment. Such a modern attaches mainly to the family and seems rooted in concept has been instrumental in mediating the moral traditions and outside the system of medicine growth and development of distinctive disciplines itself [70]. Psychiatric stigma appears less apparent in within medicine. Recent studies involving psychiatry Islam [63, 711, it is clearly reflected in ancient Indian and mental illness have been based on and elaborated texts [69], yet seems muted in some societies where upon these ‘modern’ developments. Ayurvedic Medicine is practiced [40, 72, 731. An important line of theoretical work has focused In summary. several things have contributed to on the history of psychiatry as a scientific medical the special cultural meanings of HBB phenomena, discipline [75-801. The conceptual categories used including HBB illnesses, in European societies to describe varieties of insanity/madness have been [42, 59, 661. To the special meanings of the classical elucidated, emphasizing largely intellectual and period were added during the medieval era, aspects of rational functions, as in melancholia and mania. An demonology and deviant sexuality. These cultural expansion in the meaning of concepts took place in associations were endorsed by clerical physicians and the early modern period, conditions being named in for a period got a foothold in the system of medicine which intellectual/rational functions were relatively [59]. In the early modern period, the handling of HBB preserved, as in moral insanity, partial insanity and phenomena in jails and poorhouses, with persons monomania. More recently, the concepts have in- showing it assembled with the destitute and marginal, cluded psychoses (dementia praecox, schizophrenia) is important for it heightened condemnation and disturbances of mood (mania and depression) and the associated mortification. The state came to control, neuroses. The line of development leading to a system isolate and deprive of basic liberties persons showing of descriptive psychopathology has also been out- HBB. Incarceration in asylums and brutal treatments lined and along with this the underlying conceptual are part of the story also. Later during the modern framework, all of which leads up to the contemporary period, the profession of psychiatry itself contributed picture of psychiatric disease as depicted in bio- special cultural meanings involving the brain, heredi- medical psychiatry [80]. tary mental degeneration and social behavior itself Although rooted in Western history and hence (the moral insanities). However, as agents of the state intrinsically a part of developments in Western psy- empowered to control and regulate ‘the mad and chology [8l], these developments must be seen as insane’, psychiatrists also came to be seen as ‘mad culture bound. The Western cultural concept of the doctors’ and (mental) ‘alienists’ [26]. Eventually, person is integral to the biomedical picture of the 98 HORACIOFABKEGA JR

psychiatrically diseased person [82]. Yet, because this universalism, his formation is similar to the form picture is generated by the science of biomedical versus content principle. However, in contrast to the psychiatry it tends to be handled by academic psychi- emphasis given to local interpretations and meanings atrists as not only panhuman or universal but also as of symptoms by Devereux, in the form vs content culture free. The neuroanatomic, neurophysiologic approach of Western contemporary psychiatry little and neurochemical substrates of psychiatric dis- importance is given to the question of whether a orders, core entities making up the contemporary putatively psychiatrically ill person is judged locally HBB illness category, appear securely placed in the as normal or abnormal. It is the universal, panhuman universalistic idiom of Western science. Thus, human form of the behavioral syndrome that constitutes the populations may differ in genetic and neurobiological important fact, not whether and if so how situational structures, not to say cultural and social conventions, factors and local meanings blend in to the disorder yet the mechanisms and processes that account for coloring its essential nature. contemporary varieties of HBB illness are held to Implicit in the form vs content principle is the conform to a common human form. As implied notion that there exists a universal mode of psycho- earlier, this biological universalism obviously clashes logical experience and that as a consequence any with the problem of cultural relativism. clinically relevant syndrome of behavior must reflect a common underlying pattern, architecture or taxa of behavior. All of the forms of behavioral syndromes EXPLAINING THE MANIFESTATIONS OF PSYCHIATRIC ILLNESS: EMPHASIS ON FORM VERSUS CONTENT or illnesses of mankind, it is assumed, can be reduced to or conform to a finite set of taxa such as schizo- Several disciplines, including psychiatry. psychol- phrenia, bipolar disease, anxiety, startle reactions, ogy, and portions of anthropology and sociology and acute/agitated panic attacks [29]. Superficial (as in psychiatric epidemiology) share a scientific differences in these behavioral syndromes cross- perspective about psychiatric illness. The kinds of culturally are to be expected insofar as persons hold psychiatric illnesses that are said to exist are held to different beliefs about self and reality, different ways be finite and distributed throughout the species, of conceptualizing and displaying mental experiences though prevalence levels may differ across societies, and different ways of behaving in relation to a More importantly, the social, psychological and be- behavioral environment that differs as a function of havioral properties of these illnesses are in an import- culture. However, differences in the content of experi- ant sense described as universal and hence beyond the ence or behavior are held to be trivial. It is the reach of cultural influences. This is stipulated in terms underlying form that is salient. of the principle of ‘form vs content’ in explanations The principle involving form vs content extends to of behavior. the following assumptions: (1) the discoveries of the The form vs content principle can be applied to nineteenth century involving the phenomenology of components of illness (e.g. elements of cognition. experience make clear that self awareness in rational affect) or to whole illness syndromes (e.g. the nature man consists of distinctive categories, such as beliefs, of schizophrenia. depression). In a typical formu- judgments, perceptions, volitions;‘intentions, feelings,’ lation, a disorder is said to be universally character- emotions. etc.: (2) such categories constitute basic ized by elements such as mood disturbances, panhuman modes of awareness and experience; (3) delusions and hallucinations, while what these consist such categories account for, indeed constrain and of and/or how they are interpreted and reacted to structure, the experience of self and of reality and (their ‘content’) may differ. For example. anxiety underlie or regulate ongoing behavior: (4) disruptions disorder is said to consist of universal behaviors of these categories of experience via disease/organic reflecting fearfulness, traceable to the autonomic factors are registered in disorders of a person’s nervous system and due to midbrain neurochemical awareness. sense of self and behavior: (5) such disrup- changes. However, the realization of this disorder tions are the essence of psychopathology; and (6) the may involve morbid preoccupations about and health categories, structures or forms of psychopathology care actions directed at sensations involving the are universal since they reflect disturbances in the thoracic cavity and/or heart (‘cardiac neurosis’) or universal normal pattern in which human experience the lower abdomen and penis (Koro), two cultural is cast, In this schema, then, contemporary HBB variations based on distinctive content interpret- illnesses are quintessentially mental. a far cry from ations The same is held to be the case for illness the more socio-psychological grounded behavioral syndromes such as schizophrenia and depression and descriptions of HBB illnesses found in other tra- even the so-called ethnic psychoses. In other words, ditions of medicine. these also are said to reflect in their organization The form vs content approach assumes that behav- basic forms or taxa of behavior [29]. ior can be culturally decontextualized. The meanings It will be recalled that Devereux’s [34] formulation of the content of behavior are ignored and the acknowledged differences in content manifestations structure or form is all important. From this perspec- and local interpretations but argued for psychoana- tive the claim that a cultural variety of HBB or lytic commonahties. Because of its (psychoanalytic) ‘schizophrenia’ actually involves a difference in the The role of culture in a theory of psychiatric illness 99

form of schizophrenia is false because by definition What needs emphasis now is that even within Euro- schizophrenia structures do not vary as a function of pean societies the application of the form vs content culture. In contrast, Devereux’s approach requires principle poses problems. the analyst to look at behavior in cultural terms. The The doctrine of universal form includes such things litmus test in Devereux’s approach is also, however, as hallucinations and delusions. These are often easy the architecture of the behavior viewed in relation to to spot. However, many times it can be extraordi- the way the culture programs individuals. Culture is narily difficult to determine if a person’s beliefs not only responsible for the ‘surface’ content of constitute true distortions of his or her sense of behavior but also for part of its structure; that is, the reality. Delusions about religion and delusions about nature of the conflicts, stresses, and the patterning discrimination and persecution are particularly of psychological defenses brought to bear on the difficult since they spring from general orientations of conflicts all influence content as well as form. When a group. Sometimes, delusions have the elusive prop- behavior is shown to reflect a faulty architecture it is erty of being present only when the assumptive world diagnosed as abnormal or psychotic. However, of the mental health clinician differs from that of the although the analyst is here required to take culture client or patient. Distinguishing between belief and and content seriously, it is still in terms of normative delusion is notoriously problematic. Very often, it is intraphysical structures as stipulated in an external not the presence of a cognition per se that prompts theoretical schema (psychoanalytic theory). Accord- diagnosis of delusion (i.e. an alleged feature of form) ing to Devereux, then, there exist culturally but rather the overall adjustment pattern and context distinctive psychopathological structures (looked for evaluation that underscores a behavioral dilapida- at psychoanalytically) whereas in the form versus tion or adjustment failure. In other words, the person content paradigm there exists only one common form is non-functional, hospitalized and hence his/her that reflects psychosis panculturally. strangeness ‘must’ entail delusions. The difficulty of saying what is a hallucination has raised disturbing questions, including the public versus private nature LIMITATION OF THE FORM VERSUS of perception [85] and exactly where altered percep- CONTENT PRINCIPLE tions or hallucinations are located (arising in or Descriptive psychopathology and its sibling, clini- outside the head) and the degree of associated insight cal phenomenology, are the psychiatric offspring of [86, 871. the nineteeth century intellectual movement in the Consider that the meanings of delusion and hallu- semiology of disease [80]. This ‘science’ of clinical cination are blurred in German and French psychi- medicine involved the study of the signs of disease, atry: in the former case they refer to false beliefs and which were handled not as symbolic aspects but altered perceptions, respectively, but in the latter case rather as (‘real’) external manifestations of the dis- hallucinations are really delusions about perception. ease. Public and physical data amenable to the Here, then, the cultural factors tied to national senses-sound, color, consistency, temperature and traditions influence what passes as a ‘form of psycho- odor-onstituted the proper means of describing the pathology’ [79,81, 88, 891. Ambiguities about the signs of general disease. The neurological exam can nature of form elements of psychopathology have led be considered an analogous approach to the mapping analysts to suggest that they are best handled not as of the signs of neurological disease, seminal to the categories but rather as regions on a continua [go]. growth of this discipline. This, of course, might blunt some of the power of the The language of descriptive psychopathology universalists’ claims which reflect categorical thinking claims to deal with signs of psychiatric disease. and emphasize invariance. Related phenomenologic Cultural ‘content’ is held to constitute the external or aspects of psychosis, such as the first rank symptoms surface manifestation of psychiatric disorders. Since mentioned by Schneider [77,91] or the disorders of the alleged link is between cerebral disease processes willed intention mentioned by Frith [92], are also and changes in the form/structure of psychological postulated as though they constituted universal el- experience, biomedical psychiatry creates the illusion ements of form. But they could more likely implicate that an analyst can cross the brain/behavior or content issues related to our notion of self, autonomy body/mind ‘barrier’; and provided linguistic semantic of self, and personal control. Finally, there is the problems are ‘solved’ through translation, he or she problem of ethnic differences in psychopathology can do so panculturally. Thus, the signs of organic [93-951. psychiatric diseases are realized in disorders in the Even in contemporary societies, an analysis of form of mental (psycho) pathology stipulated by some of the symptoms and signs of psychiatric illness means of the form vs content principle. This position clashes with the notion of invariance in the form simplifies a complex, philosophical problem [82-841. of psychopathology. Manifestations of psychiatric I have already indicated that intellectual insights illness implicate content issues or meanings that are about experience and behavior developed in Western cultural, blending in with alleged features of form. culture are generalized and applied to all societies Dilemmas raised by an analysis of the principle of where different conventions of personhood prevail. form vs content do not, of course, negate a nosology, 100 HORACIO FABREGA JR classification or diagnostic criteria. They merely larity [98,99]. It could also clarify differences regard- reinforce the view that (1) general sociopsycho- ing the course of psychiatric illness which are logical and behavioral factors (as opposed to purely currently imperfectly understood [IOO]. psychological ones narrowly conceived) are the essential hallmarks of HBB illnesses or psychiatric THE ROLE OF CULTURE IN CONTEMPORARY phenomena; (2) the purely intellectualistic and PSYCHIATRIC THEORY AND PRACTICE emotional manifestations of psychiatric illness appear rooted in rather fluid semantic structures; and The differences between psychiatry and general (3) the targets of any classification schema are medicine need emphasis. All systems of diagnosis in objects that are best seen as prototypical and not general medicine are complex, difficult to apply and categorical, that is, as objects that can at best only be ultimately based on statistical conventions of normal- approximated and can never be fully and discretely ity. Different ‘schools’ or groups of scientific clini- itemized [96]. cians, often endorse different interpretations with I want to challenge, here, the form vs content respect to cut-off points, significance, and the logical principle which stipulates a biomedical universalism. necessity of specific biological indicators. However, Part of my argument is that, although the principle inferences about disease are anchored in processes provides a way of coping with the problem of cultural and functions pertaining to lower order systems. In relativism (essentially by negating it), it nonetheless not connecting directly with the self, as beliefs, falls short because it seems based on implicit cultural emotions, and hallucinations do, they stop short of conventions. Other models of human nature (based qualifying the social person. The diagnosis and treat- on differing sorts of structures) may be equally ment of psychiatric illness, however, require direct relevant to the study of HBB, illness HBB. or psychi- involvement with the self, which creates special social atric illness. Third world psychiatrists and social problems and broaches cultural questions [IOI]. scientists, for example, may develop alternative Psychiatry’s reliance on the concept of culture is schemes in order to better understand ‘psychiatric most vividly realized in the complex web of social illness’. Could, for example, an Indian or Chinese psychological phenomena implicated in personal psychiatry prove important as a way of understand- problems. It is among these ‘disorders’. described ing the manifestations and course of psychiatric nosologically using ‘clinical‘ terms (such as obsessive- illness? Could other cultural conceptions of order, compulsive neurosis, anxiety, adjustment disorder, the self, the external world and behavior prove dissociation or somatization) or descriptively (as in- instructive for a description and theory of HBB volving eating, drinking, sexuality, stress, marriage or illnesses and/or psychopathology‘? What inheres in personality), that cultural standards about normality, the construction of psychiatric illness that reflects the meaning of behavior, and general norms of neurobiology and not ethnopsychologic conventions? function become integral to the psychiatric enterprise. Questions such as these touch on central theoretical In some of these ‘disorders’ one finds the concept of issues in cultural anthropology and cultural psychi- psychiatric illness coalescing with that of culture. atry and are basic to an ethnomedical theory of Decisions about diagnosis and treatment literally psychiatric phenomena as conceptualized here [97]. require the clinician to use his or her cultural under- Stated succinctly, the appropriate categories for standings (and biases) about persons and behavior. the study of HBB, HBB illnesses and psychiatric Thus. culture as it informs contemporary psychiatric phenomena more generally are those that are diagnosis and practice is not a ‘visible’ or ‘exotic’ grounded not in models derived from Western difference in symbolic orientation, but rather a subtle psychology but in symbolic, culturally relevant all pervasive frame of reference that the psychiatrist parameters of social behavior [23]. may or may not share with his/her patient. and that A rigid adherence to the form vs content doctrine involves the construction of persons, the assessment of biomedical psychiatry can close off opportunities of behavior, the choice of a therapeutic rationale and for understanding how culture shapes the experience a suitable ‘end stage’ of adaptive function that is and organization of the self and social behavior and targeted as and/or signals a cure. An important by extension, HBB and HBB illness [6. 23.41, 821. task in cultural psychiatry involves clarifying the Psychiatric phenomena need to be conceptualized as relationship between psychiatric illness and psychi- involving disruptions in how the self is organized and atric practice as culturally grounded. how it meaningfully connects to social and inter- The cultural basis of psychiatric practice encom- personal networks. Psychiatric phenomena thus arc passes not only the content of manifestations of equivalent to disturbances of the self and its adjust- disorders, conventions about the form of disorders, ment, a topic that requires considering symbolic conventions about the way the self is supposed to factors and sociality consequential behaviors. A behave and conventions about the meanings and social theory of psychiatric phenomena using new implications of behavioral breakdowns. The culture approaches from cultural anthropology. could of modernity and of capitalism also influence broaden understandings about manifestations and strongly psychiatric practice. The system of biomedi- address questions about their universality vs particu- cal psychiatry is promulgated by support from a state The role of culture in a theory of psychiatric illness 101

institutional apparatus that uses its nosology to con- ings associated with HBB illnesses in Western so- trol and regulate behavior in other institutional sec- cieties were given emphasis. The alleged universalism tors. The criminal justice system, the welfare system of key tenets of biomedical psychiatry as stipulated and the educational system all interact with the in the form vs content principle was challenged mental health (psychiatric practice) system. Symbolic by drawing attention to how the tenets are shaped by conventions about how people are to behave in Western culture. The practice of psychiatry is seen as various civic areas permeate the practice of psychia- particularly dependent on cultural conventions about trists; and its tenets, in turn, are integral to delibera- normality and appropriate behavior all of which are tions in these other institutional sectors. 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