LONDON, ENGLAND - MARCH 27: Wellcome trust employee Zoe Middleton poses behind an artwork entitled 'My Soul' by Katharine Dowson, which consists of a laser etched lead chrystal glass formation in the shape of a brain, and was created using the artists own MRI Scan, at Wellcome Collection on March 27, 2012 in London, England. The exhibit makes up part of the Wellcome Collection's major new exhibition, 'Brains' which includes slices of Einstein's brain, 3000 year old trepanned skulls, ancient Egyptian mummified brains and brains in jars, and opens to the public from March 29 June 17, 2012. (Photo by Dan Kitwood/Getty Images)
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IDEAS

How culture shapes your mind — and your mental illness

THE PATIENT, A man in his early 20s, was clearly distressed, anxious. There were insects, he said, insects crawling around under his skin.

The graduate student doing the initial assessment was immediately concerned and went straight to her advisor, Dr. Brian Sharpless, a clinical psychologist and professor at Argosy University in Virginia. The patient sounded psychotic — possibly schizophrenic, she said, and she wanted to know what to do.

“Is he by any chance Nigerian?” Sharpless asked. “Yes!” she replied. “How did you know?”

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“He’s not psychotic — that’s Ode Ori,” Sharpless responded. “He’s having a panic attack.”

Ode Ori is, in Nigerian Yoruba culture, the manifestation of acute distress. It’s a crawling sensation in the head and under the skin, noises in the ears, heart palpitations, both an expression of and accompaniment to anxiety. And anxiety calls for a very different treatment protocol than schizophrenia. It was lucky, then, that Sharpless had just recently learned about Ode Ori.

“If the diagnostician wasn’t being careful, they could have diagnosed him with a psychotic disorder. Because in the West, having that sensation would be more associated with schizophrenia,” said Sharpless, the author of a 2017 book on rare psychological disorders. “But frankly, a few months before that, I wouldn’t have known that.”

Culture shapes who we are, so it follows that it would also shape our manifestations of stress, mental disorder, emotion. Yet, that also implies a kind of messiness that modern psychology and psychiatry, particularly the American kind, have spent the last 100 years struggling to tidy up.

Since their founding, psychology and psychiatry have striven to standardize the diagnosis and treatment of mental disorders — to bring some certainty to what can feel like a very uncertain field.

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But increasingly, clinicians are recognizing the downside of those strictures. Delivering the best care for patients will require something broader and more adaptable — mental health care models that can accommodate hundreds of individual cultures. And because no individual patient experiences a culture the same way, those models will ultimately have to do something even more radical: create the sort of super-personalized mental health care that the profession has aspired to — or, perhaps, should have aspired to — all along.

THERE HAS BEEN at least some recognition, from virtually the start of the field, that other cultures — other peoples — experience the world differently. In the late 1800s and early 1900s, explorers described afflictions that psychologists would soon label “culture-bound psychoses” or “culture-bound syndromes” — mental health disorders that seemed to beset only the people in a specific culture.

In 1894, Arctic explorer Josephine Peary described pibloktoq, an “Arctic hysteria” suffered by the Inuit women she and her husband employed on their expeditions. After a brief period of sullen reticence, the women would begin screaming and yelling insensibly, tear their clothes off, and rush out into the freezing dark. Spells could last hours, until the sufferers collapsed and fell into a deep sleep; when they woke, they’d have little recollection of what they’d done, and would recover quickly.

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Through the 20th century, psychologists and psychiatrists investigating pibloktoq came to various conclusions, some deeply rooted in racism and colonialism: That the women and, as they began to study it more intensely, the men who also experienced it, were mentally inferior, or that they were part of a culture that raised children as “savages.” This was a distinct mental illness that, for those reasons, did not affect Westerners (except when it did — there had been reports of European sailors hemmed in by ice exhibiting similar rages).

Later, researchers would hypothesize that the disorder didn’t exist prior to contact with Americans and Europeans — seeing it as a kind of psychosocial manifestation of cultural fears, stresses, and anxieties resulting from that clash. Still others suggested that it was an excess of vitamin A driving people raving into the snow, or a lack of calcium. Now, the Diagnostic and Statistical Manual, the mental health professionals’ Bible, says that pibloktoq is a dissociative trance disorder with a distinctive cultural expression, an involuntary state of disassociation that is found in several cultures around the world, different but sharing a similar mode.

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It’s part of the manual’s move away from a “simple list of culture-bound syndromes” to something called “cultural concepts of distress,” according to the American Psychiatric Association. This new wording reflects greater professional awareness of how different cultures might express distress — acknowledging, for instance, that one culture’s symptoms of depression may look very different from another’s. It also underscores efforts to stop exoticizing the expressions of emotional distress in other cultures, while at the same time asking psychologists and psychiatrists to be more fluent in the idioms of distress, whatever the language.

“I think psychology has gotten a lot better at recognizing the influence of culture, so I think that we’re far ahead of where we were even in the ’80s,” said Sharpless. “That being said, these things are very hard to measure and assess. We’re taking steps, but . . . there’s a lot we don’t understand.”

Culture and social environment can shape, even predict, common mental disorders, such as depression and anxiety. But, he said, we don’t know whether the “fundamental mechanisms” of mental health are the same across humanity and it’s the expressions of disorder that vary between cultures, or whether there are distinct, culturally mediated disorders.

These kinds of questions are complicated by who’s doing the asking. Dr. Yulia Chentsova-Dutton, a psychologist at Georgetown University studying the cultural manifestations of mental disorders, believes we don’t fully know the impact that culture may have on mental health. The vast majority of studies, she said, tend to use homogeneous groups of mostly white subjects and assume that “what we see here in the cultural environment or in Europe would apply anywhere.” The majority of studies that do include minorities or other cultures use diagnostic instruments that “assume everybody is the same.”

Even researchers who are aware of the cultural blind spots can make mistakes. Recently, she said, she went to Ghana on a research trip. She brought with her questionnaires asking respondents how they felt at various points in their day. She noticed that what would have taken American subjects a few minutes was taking the Ghanaians upwards of a half an hour. She asked why. “They say, ‘How are we supposed to know how we feel?,’” she said. “I’m just stunned.”

In Western culture, we are socially prepared to ask ourselves how we feel and give names to our emotional states from a very early age. But that is not the case everywhere, and it wasn’t in Ghana. “That ability is not a given. . . . Unless you start from scratch with expertise from the local context, unless you listen and carefully check what is happening, it’s so easy to make mistakes.” In the end, she significantly redesigned her study, with help from local researchers.

Even framing an apparent disorder as disorder could present problems: For one thing, what may look like mental illness in one culture might not in another. It might look like spirit possession or a voice from God. In a significant study published in 2015, Stanford anthropologist Tanya Luhrmann and her colleagues compared how people who met the criteria for schizophrenia in the United States, Ghana, and India considered their auditory hallucinations. The Americans largely perceived their voices as intrusions, violations of their individual mental sanctity, while Ghanaians and Indians had predominantly positive relationships with their voices — Ghanaians tended to hear the voice of God, while Indians described their voices as playful and friendly.

Researchers suggested the difference may be in how “American cultural emphasis on individual autonomy” shapes the response to auditory hallucinations as both a violation and a symptom of a disease, rather than as possibly more benign people or spirits; Ghanaians and Indians, on the other hand, were “more comfortable interpreting their voices as relationships.” Whatever the reason, they suggested, the evidence demonstrated that “everyday, socially-shaped expectations alter not only how what is heard is interpreted, but what is actually heard.” This has implications for how schizophrenia is treated, they suggested, citing evidence that schizophrenia treatments in developing nations tend to have better outcomes than in more developed nations. “More benign voices,” she says, “may contribute to more benign course and outcome.”

All of us live with the real consequences of underestimating the role of culture in mental health treatment. According to a 2017 fact sheet from the American Psychiatric Association, “Ethnic/racial minorities often bear a disproportionately high burden of disability resulting from mental disorders,” adding that, “People from racial/ethnic minority groups are less likely to receive mental health care.” Out of seven listed “barriers to mental health care,” four were related to culture: “Mental illness stigma, often greater among minority populations”; “lack of diversity among mental health care providers”; “lack of culturally competent providers”; and “language barriers.” All of these, the psychiatric association suggested, “may contribute to under-diagnosis and/or misdiagnosis of mental illness in people from racially/ethnically diverse populations.”

THERE IS AN obvious value in standardization — two different clinicians should be able to look at the same patient and come up with the same diagnosis. And there are biological mechanisms at work that cross cultures, ethnicities, and genders.

But the pursuit of the quantifiable also prompted a degree of standardization that may be overzealous. Dr. Roberto Lewis-Fernández, professor of clinical psychiatry at Columbia College of Physicians and past president of the World Association of Cultural Psychiatry, acknowledged that researchers and clinicians want to “get under the epiphenomenal elements and get to the ‘reality’ of the illness.” But this, he suggests, is problematic and obscures the fact that “no disease is standard all over the world, not even malaria or tuberculosis.” Lewis-Fernández, who led the culture and gender work group for the Diagnostic and Statistical Manual-5, continued, “Not even infectious diseases are standard, but diseases that are inherently involved in the apparatus of experience are especially prone to construction on the basis of these cultural understandings.”

Phenomenological subjectivity is the basis of human experience — what’s cold to me is not to you — and culture is an unavoidable layer on top of that variability. Trying to fit mental disorders into neat boxes leaves too little room for cultural, social, even individual wiggle. This tightness will only become more pronounced as cultures continue to meet, mingle, and morph; America now is more diverse than it has ever been and, according to the Pew Research Center, by 2065, there will be no one dominant racial or ethnic majority.

For psychiatrists and psychologists, culture and background must be a necessary part of the picture they form of a patient in assessment, diagnosis, and treatment. If not, the potential for misunderstanding is acute.

This is precisely the thinking behind initiatives like the Cultural Consultation Service at the Jewish General Hospital in Montreal, a partnership with McGill University’s Division of Social and Transcultural Psychiatry. Dr. Andrew Ryder, a cultural psychologist at Concordia University who works on the project, explained that clinicians can refer patients with unfamiliar cultural backgrounds to the service, which will then assess the patient’s situation in a thoroughly interdisciplinary fashion, with input from anthropologists, translators, and people they call “cultural brokers,” who can help explain cultural meanings and behaviors.

“We have these really fascinating meetings,” Ryder said, explaining that they then give that information back to the clinician to augment their treatment. “You’re arming the clinician with a lot of tools” — tools to not only deal with the patient in front of them, but also potential future patients from diverse backgrounds.

Though all of the researchers I spoke with agreed that psychology and psychiatry underestimate the role of culture in mental health, they all also agreed that clinicians are more and more aware of the impact that culture has on their patients and on themselves. Now, it’s a question of training. Chentsova-Dutton and Ryder, who are collaborating on a paper, said that though the American Psychiatric Association mandates cultural training for clinicians, it’s not particularly strong. “It has been for years dominated by the so-called ‘cookbook’ approach, where you get this book and it has a chapter on each group, like Jewish-Americans, this is what we know, Italian-Americans. . . it implies that everyone is the same in those groups,” said Chentsova-Dutton. “It’s more harmful than helpful. . . we cannot infer from the group to the individual.”

And perhaps the biggest blind spot we all have, not just psychologists and psychiatrists, is with people who we think are like us — just because we speak the same language, or share the same skin color, or are from the same region doesn’t mean that we share a culture.

“There’s a self-centeredness that I think is common, where you assume that everybody thinks like you do and everybody experiences the world like you do. And clearly from all we know about psychology, that is a spurious assumption,” said Sharpless. “But it’s very easy to do, because we use what we know to explain the world, we use what categories are available to us. But not everybody has the same categories.”

Since the 1990s, cultural psychologists and researchers have implemented a broader definition of what “culture” means, inspired in part by other disciplines, including anthropology. “Culture” isn’t any longer the strict ethnographic, religious, or nationalist background that we come from, but rather a subtle and complex landscape of all of those things, plus affiliations, gender, sexual orientation, age, profession, region, social class, and education — even technological immersion. Culture, explained Dr. Lewis-Fernández, is “the process by which a person makes sense of their experiences and the way that process is anchored or based in that person’s participation in particular social groups. . . anything that is in some way affecting, contributing to their understanding of the world.”

Cases like the Nigerian man suffering from Ode Ori are foreign to most Westerners, and if Sharpless hadn’t recently learned about the syndrome, then perhaps outcomes would have been different for the man. But with a broader definition of culture comes the recognition that it is subtle and it works on each of us uniquely. What is perhaps more necessary for modern psychiatrists and psychologists is not just a cultural awareness, but also an awareness that culture is everywhere, that each person has a unique context.

“The contextual approach is one that should be baked into clinical practice, not something we pull out of our pocket when we say, ‘Oh, this person is a minority or this person is an immigrant,’” said Ryder. In his classes, Ryder likes to use the phrase “informed curiosity” — “that’s the idea that you’re informed, in that you know what the different possibilities are. . . . But you have to be curious, rather than being closed and saying, ‘I read the book on Jewish-Americans, now I know what Jewish-Americans are like.’ I need to be curious about what’s going on for them.”