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Spring 2008 | Vol 11 No 3

Focus

Culture-specific syndromes

It’s all relative

By Sarah Hamid

I’m a living, breathing example of the ethnic diversity of B.C., indeed, Canada. Despite a mixed Parsi and Afghan ancestry, two mother tongues before English, and a non-Canadian birthplace, I have been immersed in Canadian society since the age of five – almost as far back as my memory begins.

I’m also a living, breathing example of a visibly ethnic individual with a mental illness. And like so many others in this increasingly multicultural North American continent of ours, I am in a unique position of having access to at least two ways of interpreting the root of my illness: the North American way, and an “Asian” way.

Lower Mainland [B.C.] clinicians have given me the label “major depressive disorder.” However, whenever I make progress with my medications, my Afghan aunt tells me she essentially wishes that no one should nazar me. That is, no one should give me the “evil eye,” long thought of in Latino, Mediterranean, and Islamic cultures as a main cause of sickness and misfortune. My aunt’s statement doesn’t have the same power in my Canadian home as it would have had in the Afghan one I could have grown up in, but it comforts me nonetheless. Her saying she doesn’t want nazar to take place is a statement of protection and luck, given almost in the same spirit that “break a leg” is to a stage actor.

“Of all the medical specialties ... psychiatry has the most pervasive relationship to culture. Psychiatry is, to begin with, a window on a culture’s sources of distress and on the human consequences of such distress” —Arthur Kleinman

Many people may think my aunt’s way of interpreting my emotional distress is “folksy” or even “cute.” But it’s not. In its own cultural context, it is not only just as viable an explanation as “major depressive disorder” is, but it is in fact more so because it has a meaning to middle-easterners that the Western diagnosis just can’t touch.

When I say “it’s all relative” in the title of this article, I mean exactly that: describing mental illness is relative to the culture that is interpreting that illness. I can’t even remove the Western bias that I’ve grown up with in writing this article. After all, calling mental illness an “illness” at all (or “disorder” or “disease” with “symptoms,” “diagnosis,” and “treatment”) places a psychological phenomenon firmly in the world of biology, medicine, and physical causes of human behaviour. But the medical model is not the only way to interpret a problem. Just like a native language is a shorthand by which people of a nation or culture can communicate with each other easily, so is a locally understood way of talking about psychological problems a kind of shorthand. It’s a point of entry for talking about feeling out of sorts within one’s self. It’s a metaphor a person in that culture knows he or she can use to express distress, initiate discussion, and negotiate help from the family or community. That metaphor carries a special power because it has instant meaning in the system of understanding the entire community shares.

My use of the word “metaphor” here is not accidental. Anthropologists have identified a culturally-sensitive way of talking about culturally different types of interpretations as “idioms of distress.” “Idiom” is another way of saying a culture-specific metaphor or symbol; “distress” covers the feelings of pain, negative changes, and general “not-feeling-myself”ness. So whether a psychological condition is attributed to the loss of one’s soul, the loss of the vital essence of semen, the interference of evil spirits or other supernatural forces, or problems with the heart, the point is that each culture has, in the course of its unique evolution, come up with an interpretive tool its citizens can accept and use with each other to describe what’s wrong in the head, heart, and body.

In the wake of all the cultural awareness messages in the ’90s, all of this may seem like common sense. But the fact of the matter is the study of psychiatry in the Western world still maintains a strong bias in favour of finding similarities rather than differences across cultures and of uncovering “universals” in mental disorder. Arthur Kleinman says, “This bias should not surprise us. Much cross-cultural research in psychiatry has been initiated with the desire to demonstrate that psychiatric disorder is like any other disorder and therefore occurs in all societies and can be detected if standardized diagnostic techniques are applied.” Although the biomedical model of North America and Western Europe has been certainly useful in managing a vast number of psychiatric symptoms, it may have been pushed so far as to obscure other models for interpreting similar complaints.

Kleinman and other cultural psychiatrists and medical anthropologists have gone on to argue that too much cross-cultural psychiatric research assumes that cultural differences are a superficial “mask” – a layer that must be peeled away to reveal the real, biological “fact” underlying the disorder. The danger of this bias though is illustrated by the old cliché “in the eyes of a hammer, everything looks like a nail.” In the cross-cultural psychiatry context, this saying warns that even if there are some universal mental disorders, that doesn’t mean there are only universal mental disorders with variations only in name. When dealing with human culture, it is much more complex than that. Biology and environment are too intertwined. A failure to understand this complexity can lead to misdiagnosis and inaccurate research.

For an example of easy misdiagnosis, taijin kyofusho is a Japanese phobic reaction associated with fear of others in social situations. A Western psychiatrist unfamiliar with this disorder in its native context might think it must be “just another name” for “social phobia.” However, there is an important difference in Japan that a treatment approach based on the diagnosis “social phobia” would not recognize. In our individual-centred rather than group-based society, the Western concept of social phobia typically sees a person’s fear and anxiety as being directed towards potential criticism by others. So, for instance, you obsessively worry about your zipper being down because you are worried about being laughed at. But in Japan’s taijin kyofusho, the focus is not on the self but rather on the embarrassment the individual does not want to inflict on others. It may be hard for us to understand that a person could worry about making someone else uncomfortable with virtually no thought of one’s own potential embarrassment, but it is just this kind of subtle yet significant nuance that Western psychiatrists need to understand if they hope to serve a multicultural clientele made of such differing worldviews.

In terms of research consequences, poor understanding of the cultural contexts of mental complaints does not bode well for being sensitive to translation in cross-cultural research. For example, “feeling blue” or “feeling down” is a common idiom of distress in the English language and can be useful in diagnosing depression when asked on written tests. However, a straight translation of this conversational phrase would have no meaning in non-Western languages. Only spending time living in other cultures could pinpoint the conversational phrases used to talk about various emotional states.

For another example, Kleinman relates the story of a test translated into Hopi, an American Indian language. The screening test had concepts of guilt, shame, and sinfulness in the same sentence, but the bilingual researchers realized each term had distinctive meaning and had to be separated out into three questions to get an accurate response. The findings would have had little meaning without this realization.

Kleinman notes that attention to culturally meaningful translation can yield amazing findings. For example, a Vietnamese-language depression scale for use with U.S. Vietnamese refugees found “shameful and dishonored” but not “guilt” to be important factors in discriminating depressed from non-depressed Viet-Americans.

Further studies of why guilt is less a symptom of depression among Vietnamese than it is for Westerners could yield valuable insights into stigma across cultures which could, in turn, spark further research into cultural conceptions of mental illness.

Culture and ethnicity are part of our personhood. Individuals who are living with a mental illness necessarily come up with their own ideas of what’s going on inside them even before they visit a clinician (if they do at all). And those ideas are often shaped by one’s cultural background and the ways of understanding the world with which one has grown up. Any successful client-centred approaches to therapy have to mesh with the individual’s own worldview.

Therefore, the only way to suggest the best courses of treatment action is to understand culture-specific “idioms of distress” as well as the person’s own unique take on those idioms. Only when modern psychiatry can embrace this kind of ethnocultural study for its own sake, not just as a means to proving the universality of mental disorder, do people stop becoming nails to the biased eye of the hammer and start becoming people again.

Excerpted with permission from Visions: BC’s Mental Health Journal.

Sarah Hamid-Balma is director of Public Education and Communications at the B.C. Division of the Canadian Mental Health Association and editor of Visions: BC’s Mental Health and Addictions Journal.