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Why Should Researchers Care About Culture?
Abandoning Egocentrism in Favour of Cosmopolitanism
Cross-cultural psychiatry began with a fascination for what is different. Previous generations of researchers looked for the “culture-bound syndromes,” such as koro and windigo, that make up the DSM-IV’s nod to the importance of culture, but which few practitioners can ever expect to see. Recent attempts to look for difference—for example, the search for cultural influence on the construction of symptoms—have been more subtle. Depression has been a favourite subject, with various theoreticians proposing that certain cultural groups do not experience emotion in the way that Europeans and North Americans do but, instead, suffer bodily rather than psychologically (5–7,41). The apothegm “Asians somatize, North Americans psychologize” sums up a great deal of this kind of thinking.
The proposition does not hold up to research scrutiny, however. West Africans, Southeast Asians, and First Nations children report depressive symptoms in psychological terms, and although there are subtle cross-cultural differences, the clustering of psychological and somatic symptoms among different cultural groups is more similar than different (11–13,17,20,23).
As in the case of symptoms, measures of well-being seem remarkably invariant across cultural groups (13). Cross-cultural invariance may apply not only to end states like symptoms and feelings of well-being but also to psychological processes that determine these end states. Consider, for example, “alexithymia,” the inability to recognize, describe, and express feelings. Kenneth Fung has provided important data about the cross-cultural applicability of this construct, which is seen as a major deterrent to psychotherapy. Fung’s research demonstrates that, contrary to widely held stereotypes, the concept of alexithymia is probably as relevant for the Chinese population as it is for other ethnocultural groups, and it is, moreover, equally subject to interindividual variation (42).
Although there is nothing inherently wrong in looking for differences, this approach must be balanced by an equal appreciation for what unites people and by investigations aimed at getting behind the veil of culture to glimpse the shared anxieties, aspirations, and hopes that transcend the gloss applied by culture.
The Canadian Dictionary of the English Language (43) defines “cosmopolitanism” as “having constituent elements from all over the world or from many different parts of the world.” Following from this definition, mutual respect and mutual learning are essential building blocks for true cosmopolitanism.
This dictionary also offers a second definition: “pertinent or common to the whole world.” This definition implies that researchers should abandon parochialism, substituting in its place appreciation, empathy, and a sense of responsibility for people beyond those in their immediate field of vision. Researchers who work with ethnocultural communities in their own countries, or with communities abroad, have to recognize that not only they but also the communities with whom they choose to work need to benefit from research.
What can communities gain from participating in research? For one thing, they can acquire a sense of mutual respect. For example, indigenous peoples and ethnocultural minority groups must be assured that ethical standards will be adhered to as rigorously as they are when research takes place among politically powerful communities. Although less dramatic than cloning or patenting genetically altered life forms, the ethical challenge of ensuring cross-cultural transferability of guidelines to protect human subjects is no less real.
In North America, informed consent has become a sine qua non for ethical research. Usually formulated in individual terms, the concept may not, however, be universally appropriate. In Senegal, in Nigeria, and in many other traditional societies, individuals have no meaning apart from the collective. Trying to secure an individual decision rather than a group consensus to take part in a study is worse than discourteous: it can violate the basic tenets of communal life. These considerations are not just pertinent to research in Africa and other exotic places: identifying the appropriate locus of decision making to ensure informed consent is a challenge for anyone working with cultural communities, whether in the developing world, or in North America, or in Europe (26).
Typically, communities that participate in research are offered vague promises about improved services. My research among the Serer was financed by the WHO, with the idea that the data obtained would provide a basis for planning mental health services in rural areas of Senegal. However, for the WHO, as for many international bodies, politics too often trumps humanitarianism (44). Before anything was ever done for the Serer, WHO priorities changed, and the project was abandoned (26).
It is important—but far from easy—to work with communities in need without raising unrealistic expectation that researchers can directly effect change. Researchers are seldom in a position to directly affect either policy or the distribution of resources. They can, however, offer knowledge, and communities increasingly recognize not only that knowledge is power but also that researchers have a responsibility to share information and expertise with them. This creates new challenges for research across cultures. How can researchers provide information in a form that communities find accessible and useful for their own community-building and lobbying efforts? How can researchers transfer not only knowledge but skills, so that communities can become more independent of imported know-how? How do researchers ensure that they do not cross the line between responsibility to provide useful information and advocacy—a position that compromises the research enterprise and damages credibility? How does one negotiate ownership of information? How do the parties to a research enterprise resolve potential disputes if the community prefers not to have data released, but researchers feel that the data have important implications for science?
A Final Word About Culture and Research
There are communities—ethnocultural communities, immigrant and refugee communities, and indigenous peoples’ communities—who deserve, and need to be the focus of, specific study. Although health and illness states may be more alike than different, needs for care in these communities differ from those in dominant and more powerful societies, as do the determinants of health and illness. Responding to these communities requires knowledge of the extent and types of those needs, of community expectations for care, and of community resources. This knowledge base is still emerging.
Culture—what societies learn and pass down over generations—should be considered in so-called “mainstream” research endeavours as well as in cross-cultural inquiries. Research samples inevitably represent a compromise between population representativeness, feasibility, and the need for certain constraints on heterogeneity. One result is that drug trials will almost always have limited generalizability—a limitation that must be acknowledged. Considerable research using family aggregation studies supports the conviction that genes play a major role in schizophrenia. However, the evidence is not consistent across ethnocultural groups. This means that either the basis for the genetic claim is not as strong as some would think or that there are different conditions subsumed under a common rubric awaiting better classificatory schemes. In the realm of standardized treatment studies, manualized psychotherapies seem to offer considerable therapeutic promise, but most reports fail to address important questions, such as for whom and under what circumstances they will be offered (45). Developments in medical ethics over the past decade have been breathtaking, but this domain of scholarship, like other parts of the research enterprise, requires constant vigilance and a strong dose of humility to guard against Western imperialism.
In a world still struggling with the fallout of social upheavals that began in the now mythical 1960s, the pursuit of cosmopolitanism in research must be defined as a moral imperative. Nevertheless, researchers must recognize—but not be deterred by—the fact that the loftiness of this ambition will be leavened by daunting challenges to its achievement.
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Author(s)
Manuscript received, revised, and accepted January 2003.
1. Professor of Psychiatry and Director, Toronto Joint Centre of Excellence for Research on Immigration and Settlement (CERIS), University of Toronto, Toronto, Ontario.
Address for correspondence: Dr M Beiser, Culture, Community, and Health Studies, University of Toronto Department of Psychiatry, Suite 625, 250 College St, Toronto, ON M5T 1R8
e-mail: morton_beiser@rogers.com
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