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This handbook of cultural (transcultural or comparative) psychiatry
deals with interesting and complex cultural aspects of clinical
practice and mental health of patients from various cultural, ethnic,
and social backgrounds. The handbook is the remarkable achievement
of 1 author who reviewed and quoted nearly 2000 works related to
cultural psychiatry, from both contemporary and historical perspectives.
He expresses gratitude to many of his eminent consultants, who expanded
his vision and insight in the field (p 11–13). W-S Tseng, professor
of psychiatry at the University of Hawaii School of Medicine, has
been well prepared for his task. He trained at Harvard Medical School
in Boston and has travelled as a World Health Organization (WHO)
consultant to many countries in Asia and the Pacific, developing
a wide network of colleagues while conducting research projects
related to culture and mental health. He has published numerous
articles and authored, edited, or coedited several books.
This comprehensive and clearly written volume enriches our knowledge
in many new ways. It has 9 sections and 50 chapters. The introduction
defines cultural psychiatry and medicine-related social and behavioural
sciences, as well as offering a chronology of interests in its investigation
of the changing scope of cultural aspects of psychiatry. Before
moving to clinical application, several chapters examine the cultural
aspects of human behaviour in relation to the human life cycle,
depth psychology, and ethnic identity. Themes that relate to the
latter part of life (aging and death) are elaborated in detail,
and controversial issues such as euthanasia and physician-assisted
suicide are not avoided.
Definitions of culture, race, and ethnicity and minority (Chapter
2) facilitate the understanding of societies, which can be studied
from the etic (rather universal) or emic (culture-specific) point
of view. The author examines cross-cultural studies of child development
and the cultural variations of family systems and structures, including
role division, communication, and parent–child and sibling
subsystems. Cross-cultural aspects of developmental theories are
discussed in terms of Freud’s psychosexual, Erikson’s
psychosocial, and Piaget’s cognitive development theory (Chapter
4).
The author reviews historical trends in the study of culture and
personality and selective studies of national characteristics, mainly
American, Japanese, Russian, and Chinese. He compares the universality
and cultural variations of emotional expression, shame and guilt,
verbal and nonverbal communication, rituals, etiquette and customs,
taboos, and superstitious beliefs.
Following a review of the cultural aspects of human behaviour in
general, the handbook focuses on clinical care from cultural perspectives.
It describes culturally inherent vulnerability and the ways culture
influences the perception of stress and coping patterns (Chapter
8). The author succeeds in the demanding task of presenting and
reviewing folk categories and groupings of mental illnesses in different
times, societies, and geographic locations. Clinical implications
concern the distinction between illness and disease and normality
vs pathology (p 161). Sensitivity toward illness and tolerance of
mental disease influence the sick role, help-seeking and service
use, as illustrated by examples from the US, Japan, Taiwan, and
Malaya.
Although the knowledge of the causes of psychiatric disorders has
increased, the author is well aware of our limitations, because
many explanations are still based on speculation and hypotheses.
Psychopathology can be attributed to multiple factors, and the author
attempts to expand their possible effects in terms of pathogenic,
pathoselective, pathoplastic, pathoelaborating, pathofacilitative,
and pathoreactive factors (Chapter 11). He describes the evolution
and methods of psychiatric epidemiology and the many problems inherent
in cross-cultural comparative epidemiology. He presents the results
of several important investigations, such as the WHO international
multicentre studies (since the 1970s) and the catchment-area studies
(in the 1980s in the US). Attempting to identify culture-shaped
variations of psychopathology, W-S Tseng proposes subgroupings of
the so-called culture-bound or culture-related specific syndromes
that are not easily categorized according to psychiatric classifications.
Selected case histories enhance our understanding of the clinical
pictures (Chapter 13).
The volume documents how cultural psychiatrists examine the multiple
levels of cultural impact in epidemic mental disorders, somatoform
disorders, and neurasthenia; or in states of altered consciousness,
including dissociation, possession, and hysteria. Mainly, however,
it documents the cultural aspects of depressive disorders, anxiety,
and schizophrenia. W-S Tseng discusses psychological factors associated
with alcohol and other substance-abuse problems that are documented
by epidemiological data from various societies. The handbook describes
the world trends in suicidal behaviour, its frequencies, types,
methods, and age distribution. It clarifies issues related to cross-cultural
studies of eating disorders by reviewing investigations from different
social and cultural settings in 14 countries on 4 continents. Excessive
concern with health and body weight seems common in our world and
may relate to modernization rather than Westernization.
There are debates among clinicians regarding the nature, diagnosis,
and categorization of personality disorders. Some propose the spectrum
view that considers the disorder as the extreme of normal personality
rather than a distinct category. Although a vast amount of work
has been done in the area of child development, W-S Tseng points
out that very little cross-cultural investigation has been carried
out in clinical areas. For example, it is not easy to obtain data
on sexual and other abuse in cross-cultural comparison.
The author dedicates a section in the handbook to culture and clinical
practice, focusing on culture-relevant assessment, diagnosis, and
treatment of patients from diversified ethnic and cultural backgrounds.
He examines therapist and patient relations and communication from
the point of view of various parameters, such as role division,
power structure, bond and commitment, and family involvement. The
author discusses psychiatric classification systems that are used
in different societies, with examples from the US, France, Russia,
Japan, China, and Latin America. Most psychodiagnostic tests were
developed for respondents of Euramerican backgrounds, raising questions
of reliability and usefulness when applied to respondents or patients
in other societies.
Culture is one of the many factors influencing psychiatric services,
and W-S Tseng argues that a clinician who is competent in cultural
issues is indeed a competent mental health practitioner. In addition,
the book describes mental disorder stigma, legal, ethical, and humanitarian
aspects, as well as various types and institutions of psychiatric
services. Culture in relation to genetic and other biological factors
and drug therapy, however, is only briefly presented, although these
expanding areas need examination and discussion of new perspectives.
The section on culture and psychological therapies is more detailed.
It reviews indigenous healing practices, shamanism, trance, religious
healing ceremonies, and divination, proceeding to culture-influenced
unique therapies, and then to “common” psychotherapies.
Examples of the unique therapies are Alcoholics Anonymous, Morita
therapy, and existential psychotherapy. The “common” psychotherapies
include individual psychotherapies, psychoanalysis, client-centred
psychotherapy, behavioural therapy, cognitive therapy, interpersonal
psychotherapy, family and marital therapy, and group therapies.
Methods and problems of psychotherapy practice are exemplified in
many societies and countries. Intercultural therapy is psychotherapy
that is delivered to patients with ethnic or cultural backgrounds
that differ considerably from that of the therapist. It requires
certain qualities, such as cultural sensitivity, knowledge, empathy,
and insight.
Culture-relevant or culture-responsive psychotherapy for minorities
and clients of cultural diversity is a challenge for modern mental
health workers. For example, because the use varies in societies
and cultures, there is still room for cross-cultural modification
of the theoretical structure of defence mechanisms. Psychotherapy
orientations are broad, and the author stresses the need to expand
psychotherapies from the medical and psychological to embrace the
supernatural, natural, and philosophical (p 595).
A section of the handbook contains chapters on culture and therapy
with special subpopulations: mainly with children and adolescents;
with couples, spouses and families; and with the aged. Family problems
and family pathology show wide cultural differences among generations.
The work with medically ill patients of various ethnic and cultural
backgrounds is a challenge in medical practice. Special medical
issues concern prescribing and receiving medication, performing
laboratory testing, donating organs and disclosing information on
terminal illness, stigmatized diseases such as AIDS, and controversial
medical practices such as abortion.
Final chapters of the handbook draw attention to social and cultural
changes that can occasionally reach a remarkable magnitude. Reaction
patterns differ to these changes, which encompass acculturation,
modernization, industrialization, urbanization, westernization,
and the disappearance of traditional cultures. Adjustment associated
with migration can cause psychological stress and other emotional
difficulties; these need attention and help from cultural psychiatrists
and experts in related fields. The handbook examines the impact
of migration on mental disorders—such as frequency, and time
span of onset and variables affecting the process of adjustment
(age and sex, language, occupation, family, and expectations). Interestingly,
upward economical migration is the most common form of migration
(p 700). The author examines different stages of adjustment, mainly
its longitudinal process. He describes the effects of migration
on the family and also the effects of unique refugee experiences,
particularly trauma. The handbook offers suggestions for therapeutic
approaches, support, and care.
The reader of the volume will find useful information concerning
minority status by ethnicity, sex, race, age, religion, and other
characteristics, as well as therapeutic implications and treatment
service utilization. Another area of detailed analysis focuses on
problems found in intercultural marriage. These problems include
different motivations, expectations, and commitments to marriage;
difficulties in communication and role division; differences in
values and customs; and the effects of prejudice and stereotypes.
Factors contributing to successful intermarriage include support
from family, friends, and environment. Therapy should reinforce
mutual respect and cultural empathy and allow time for gradual change
of culture-related emotions.
The author examines the relation of religion to psychopathology.
He describes major religions around the world, different patterns
of religious practice, and the experience of religious conversion.
While discussing religion and therapy, he stresses that religion
may have certain positive elements for mental health (p 756).
The last section of the handbook deals with issues of research,
theory, and training in cultural psychiatry, considering methods
of observation, surveys by testing or questionnaires, and experiments,
compared with use of existing ethnographic archives. The author
reviews issues concerning the examination of different psychiatric
disorder categories, the study of their prevalence related to migration,
and the process of adjustment. Further, he emphasizes the need for
studies related to psychotherapy. He examines the sociocultural
impact on theoretical views, stressing that revision and expansion
are needed, because most modern psychiatric knowledge and hypotheses
were historically derived from Europe and North America. Many theories
or conceptual issues await cross-cultural investigation to validate
their cross-cultural application (for example, the psychosexual
and psychosocial development theory and the theory of defence mechanisms).
The concluding outline of cultural psychiatry training contains
method and subject suggestions that would enhance cultural sensitivity,
empathy, and competence.
It is not easy to do justice to the overwhelming amount of detailed
information in this handbook—which is well structured, well
documented, and easy to read. The handbook offers a focused and
systematic view of cultural factors related to psychopathology interacting
on different levels of complexities. We are aware of the problems
of this relation: culture is a changing and abstract concept and
is not easy to assess or measure. Diagnostic concepts alternate
over time and place, implying different degrees of universality
and specificity. We need to consider biological and other factors
affecting psychopathology.
Readers will appreciate the author’s tolerant attitudes and
his empirical scientific method. They will find the appendix with
the book list relating to the subject of culture, psychiatry, and
mental health useful, as well as the index of authors and index
of subjects. To avoid theme repetition, the author has used cross-references
carefully and often. This contemporary and updated handbook will
enhance cultural sensitivity and facilitate work with people of
various cultural backgrounds, including those who are similar to
the practitioner. The handbook will interest psychiatrists, psychologists,
mental health workers, students, and practitioners in related medical
and social disciplines.
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