In my second year of medical school, I had the opportunity to choose my student-selected component of the course. There were several interesting options, ranging from short language courses to exploring case studies in medical law. However, one option stood out: ‘Cultural psychiatry.’
As a woman of colour, I'd always been fascinated with how culture shapes our understanding of mental health. In my Nigerian community, for instance, mental illness is often shrouded in stigma, with many attributing it to evil spirits' possession or drug use.
The course promised to explore the role of cultural and transcultural factors in the world of psychiatry. This meant exploring how a patient's background could influence everything from how they experience symptoms to their ultimate prognosis.
We'd also be looking at fascinating concepts like ‘culturally bound psychiatric syndromes.’ Culturally bound psychiatric syndromes are experiences which are recognisable as illnesses and thought to only exist within a specific culture.
An example of a culturally bound psychiatric syndrome is susto, a term used in Latino cultures. 'Susto' can occur when someone experiences a frightening event and feels their soul has left their body, causing symptoms like listlessness and poor appetite. Another example is brain fag syndrome found in West Africa, which is associated with mental strain, and manifests as confusion and tiredness.
The interaction between different cultures poses unique challenges in the field of psychiatry, which has led to the development of cultural psychiatry. The General Medical Council acknowledges the importance of doctors endeavouring to understand the impact of culture and personal experiences on the care that they provide to patients. Indeed, it is not enough for clinicians to just be accepting of other cultures; everyone should endeavour to learn about other cultures beyond the stereotypes.
I am British. I am Black British. I am Nigerian.
When thinking about culture, the first thought is often about a person’s ethnicity, nationality, or race. For example, I am black. That is a cultural identity for me, but even within that seemingly defined group, there are several different cultural groups that I belong to.
There is, for example, a different cultural experience for Black British people and African Americans. Even within the Black British label, there are different cultural experiences. Whilst a small example, there is an ongoing discussion between people of African and Caribbean descent about pronouncing the food plantain - those of African descent commonly pronounce it plantAYNE, whilst those of Caribbean descent commonly pronounce it planTIN.
Even within the seemingly specific label of Black-British-African, there are several ethnic divisions. We can look to the frequent discussion amongst West African nations regarding ownership and execution of the best jollof rice.
What is culture?
“Culture” was adapted from "cultura animi" (cultivation of the soul), a term coined by the Roman speaker Cicero. At this time, it referred to how humans moved towards developing an understanding of philosophy. Edward Taylor proposed an anthropological definition of culture which “includes knowledge, belief, art, morals, law, custom, and any other capabilities and habits acquired by man as a member of society”, this showed culture to be a collaboration.
The current Cambridge dictionary definition of culture is “the way of life, especially the general customs and beliefs, of a particular group of people at a particular time.”
Looking at these three definitions, we can see that culture is more than race or ethnicity. Culture is created, learned and shared. Culture is dynamic and open to interpretation. It is important to stress that culture can change, especially with evolving technology and cross-cultural interaction.
Beyond race, nationality, and ethnicity, cultural identity is a vast spectrum. It is important to understand that different cultural identities can intersect. For example, I am Black British, but I am also a woman and a medical student. All of which are important aspects of how I experience and navigate the world.
Cultural concepts of distress
The concept of culturally bound syndromes has now been replaced with ‘cultural concepts of distress’ in the DSM-5, a book used to classify mental health disorders. This has been a positive change, as the term now acknowledges that all mental disorders can be culturally shaped.
Understanding cultural concepts of distress is crucial for dismantling barriers to mental health care. An individual's cultural background shapes their perception of mental illness, coping mechanisms, and even help-seeking behaviour.
Cultural concepts of distress encompass three key areas: cultural syndromes, cultural idioms of distress, and cultural explanations.
Cultural syndromes are unique clusters of symptoms specific to certain cultures. They include many of the same conditions as the former ‘culturally-bound psychiatric syndromes’ in the DSM-5. However, whilst these cultural syndromes may be more common in certain cultures, they may not be solely unique to that culture.
For example, hikikomori is a cultural syndrome characterized by extreme social withdrawal and originated in Japan. However, recent international studies have found the phenomena of hikikomori has been observed outside of Japan.
Secondly, we have cultural idioms of distress. Cultural idioms are ways of expressing emotional suffering, often through culturally specific terms that may not directly translate to Western diagnoses. For example, the Punjabi term, “sinking heart”, might be used instead of "depression" or "anxiety." Mental health professionals should be aware of these idioms to assess a patient's condition accurately.
When a patient expresses distress through an unfamiliar phrase, like "feeling a sinking heart", asking "What does that mean to you?" can encourage the patient to share context, ultimately facilitating a better understanding of culturally specific idioms of distress, and informing a more accurate assessment.
Lastly, cultural explanations view mental distress through the values, beliefs, and norms of a person's culture. The cause of distress for that person may be explained as the result of spiritual imbalances or social disharmony within that person's culture.
Therefore, by recognizing these cultural concepts, one can acknowledge the vast variation in how people experience and express mental health concerns.
Where to go from here?
Intrigued by the world of culture in psychiatry? Here are some places to learn more:
The Royal College of Psychiatrists offers a dedicated course on cultural psychiatry. Check out their website. The Royal College of Psychiatrists also has a Transcultural Psychiatry Special Interest Group. Consider joining to network with and learn more from like-minded individuals.
The most important thing is to keep cultivating genuine curiosity about other cultures. Remember that culture is dynamic, and cultural nuances are constantly evolving. Try to continuously engage with other cultures through books, documentaries, or even conversations with people from diverse backgrounds.
Try to avoid making assumptions regarding a person’s cultural identity based on appearance. Instead, ask open-ended questions to understand their unique experience within their cultural context. Everyone, but clinicians in particular, should strive to pay attention not just to the words, but also to the emotions and body language of the others.
