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Chapter: Essentials of Psychiatry: The Cultural Context of Clinical Assessment

What Is Culture?

There is a famous saying to the effect that we do not know who discovered water but it was not the fish.

What Is Culture?


There is a famous saying to the effect that we do not know who discovered water but it was not the fish. So it is with culture: we are immersed in our own cultural worlds from birth, and consequently our culture is largely implicit and unexamined. Just as we are un-conscious of many of our own motivations and patterns of thought and behavior until they are reflected back to us by others, so too are we unconscious of our cultural background knowledge and assumptions. Bringing the cultural unconscious to light may be more difficult than facing the individual unconscious because in-stitutions and others around us may reinforce our assumptions and resist any attempt to question them. Our explicit appreciation of culture usually comes from intercultural encounters, which make us suddenly aware of culture through difference. More formally, anthropological research comparing different cultures allows us to see the tacit assumptions of our own worldviews. There is no sub-stitute for this sort of systematic reflection on cultural difference, which should extend to the critical analysis of the construction of psychiatric knowledge (Lock and Gordon, 1988; Young, 1995).


Older views of culture were based on ethnographic studies of relatively isolated small-scale societies. Many accounts tended to assume that cultures were finely balanced systems and that, as a result, everything was for a purpose and had an adaptive func-tion for the group (if not always for the individual). The outsider was thus cautioned not to pass judgment on cultural differences or to see pathology where there was simply difference. This is still wise advice. However, it is clear that cultures are not homeo-static systems in a steady state or equilibrium but are constantly shifting and evolving systems. They may be riven by conflict and create maladaptive circumstances not only for disadvantaged in-dividuals but for specific groups or even the society as a whole. Thus, while refraining from prejudging specific cultural values or practices, the clinician must nevertheless consider that every culture encompasses practices that may help or hinder patients, and aggravate or ameliorate any given type of psychopathology. Each society tends to cultivate blind spots around the specific forms of social suffering that it produces (Kleinman et al., 1997). Openness, respect and capacity for collective self-criticism are thus key elements of any transcultural clinical encounter.

At the same time, anthropologists have come to recognize the high level of individual variability within even small cultural groups and the active ways in which individuals and groups make use of a variety of forms of knowledge to fashion an identity and a viable way of living. In urban settings where many cultures meet, individuals have a wide range of options available and can position themselves both within and against any given ethnoc-ultural identity or way of living. This has led anthropologists to rethink the notion of culture or even to suggest that it has outlived its usefulness.


Indeed, the modern world includes forms of electronic com-munication and rapid transportation that have begun to weave the whole globe together in new ways. This results in the intermixing of cultural worlds and the creation of new ethnocultural groups and individuals with multiple or hybrid identities. Many people now see themselves as transnational, with networks of affiliation and support that span great distances. The mental health implications of these new forms of identity and community have been little ex-plored and will be an increasingly important issue for psychiatry in the years to come (Bibeau, 1997; Kirmayer and Minas, 2000).


As this brief discussion makes clear, the notion of culture covers a broad territory. It is useful precisely because of this breadth, but to apply it to clinical practice we need to make some further specifications and distinctions. In the North American context, it is useful to distinguish notions of race, ethnicity and social class from culture.


Race is a term used to mark off groups within and be-tween societies. Racial distinctions generally reflect a few superficial physical characteristics and hence have little correla-tion with clinically relevant genetic variation. The boundaries of any racial group are socially defined and have no biological reality (Graves, 2001). Race is usually ascribed by others and cannot readily be changed or discarded unless larger social criteria change. Race is significant as a social category that is employed in racist and discriminatory practices. Racism is clini-cally important because of its effects on mental and physical health and the challenge it presents to both individual and col-lective self-esteem.



Ethnicity refers to the collective identity of a group based on common heritage, which may include language, religion, geo-graphic origin and specific cultural practices. Ethnic identity is often constructed vis-à-vis others and a dominant society. Hence, it is sometimes assumed that “foreigners” or minorities have ethnicity while the dominant group (e.g., Americans of British or northern European extraction) does not. This obscures the fact that everyone may become aware of an ethnic identity in the right context (in China, an American clearly has a distinct ethnicity). Ethnicity may be chosen or ascribed by others. For ex-ample, the US census defined five ethnoracial blocs: White, Af-rican-American, Hispanic, Asian-American and Pacific Islander, and American Indian and Alaska Native. These are heterogene-ous categories variously based on race, language, geographic origin and ethnicity. Although the categories are fictive, they have acquired practical and political reality because they have been used to present epidemiological findings and define health service needs (Hollinger, 1995). Nevertheless, the clinician must recognize that to meet the patient on a common ground requires much more fine-grained notion of ethnocultural identity than afforded by these crude categories.


Finally, social class reflects the fact that most socie-ties are economically stratified and individuals’ opportunities, mobility, lifestyle and response to illness are heavily constrainedby their economic position. Issues of poverty, unemployment, powerlessness and marginalization may overshadow cultural factors as causes of illness and influences on identity and help-seeking behavior. Violence is a particularly striking example in North American society of the overlap of exclusion, poverty, dis-crimination and intergenerational transmission of trauma.


The notion of culture is sometimes extended to speak of various subcultures or the cultures of professions. In this sense, we can speak of the cultures of biomedicine and of psychiatry. Each of these systems of knowledge includes a wide range of behavioral norms and institutional practices that may be famil-iar to clinicians but novel and confusing to patients. However, familiar cultural notions of self and personhood underwrite these technical domains, which therefore serve to reinforce larger cul-tural ideologies (Lock and Gordon, 1988). This becomes clear when we consider alternative systems of medicine such as tra-ditional Chinese medicine or Indian Ayurveda, which are based on different notions of the person (ethnopsychology), the body (ethnophysiology), different roles for patient and healer, and, indeed, different epistemologies (Leslie and Young, 1992). Even the understanding and practice of biomedicine may differ across countries, so the clinician should not assume that familiar terms always refer to the same practice.

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