II. CULTURAL PERSPECTIVES

In the late 1970s and early 1980s anthropological researchers began to focus on the cross-cultural study of health and illness, both mental and physical, and systems of healthcare. In looking at Western views of mental illness, one finds the imprint of culture on the diseases distinguished and characterized, the symptoms associated with those diseases, and the etiological theories.

Anthropology and Medicine

The critical and reflexive view that leads to the the dissolution of traditional Western categories derives from anthropology's cross-cultural nature and tradition of long-term research on indigenous languages. That research demonstrates the created nature of those categories and highlights the culturally constructed nature of Western realities, whether popular, medical, or scientific (Carlson; Fausto-Sterling, 1992; Gaines, 1992a, 1992b; Geertz, 1973, 1983; Gould; Kleinman and Good).

Biological and social and cultural anthropologists study health, illness, and medical systems around the world. Biological anthropologists tend to use U.S. biomedical conceptualizations and research strategies in cross-cultural contexts. Although some medical anthropologists utilize biomedical definitions of illness in ethnomedical and ethnopsychiatric studies of specific cultural or ethnic forms of medicine and psychiatry, usually in non-Western cultures, many have abandoned that practice (Gaines, 1998c).

Those researchers have joined social scientists from all fields who utilize interpretive perspectives. In medical anthropology such scientists initially focused on folk medical traditions. However, since the late 1970s many have reflected on and analyzed the cultures of professional medical systems in the West and elsewhere (Kleinman, 1980; Leslie; Lock) and the sciences on which those systems draw (Gaines, 1979, Gaines, 1998c; Hahn and Gaines; Townsend; Young, 1995). Increasingly, anthropologically trained researchers come from the psychiatric profession (Kleinman, 1977, 1988; Littlewood and Lipsedge).

Interpretive social sciences have replaced Enlightenment science's ideas of cause and effect and use of universal laws to explain human behavior. Explanation has been supplanted by understanding and interpretation derived from idealist forms of social science theory and philosophy. Both popular and scientific realities now are seen as creations or constructions that are locally fabricated. In medical anthropology cultural constructivism is a major interpretive perspective that focuses on medical systems (Gaines, 1991, 1998c).

The interpretive constructivist perspectives allow one to see both professional and folk psychiatries equally as ethnopsychiatries, that is, cultural psychiatries. Constructivism suggests that psychiatry is a problematic but locally meaningful experience-near, ongoing historical construction that is constituted by various forms of embodied and disembodied discourse (Gaines, 1991, 1992a).

Constructivist perspectives have affinities to the history and philosophy of science (Foucault; Gilman, 1988; Gould; Hacking, 1983) and to gender studies (Fausto-Sterling, 1992, 2000; Gaines, 1992b). They have made it possible to penetrate the veneer of medical and other sciences to reveal their cultural assumptions and biases concerning madness, nature (human and otherwise), human development, human differences and biologies (gender, "race"), emotion, and identity (Duster; Fausto-Sterling, 1992, 2000; Gaines, 1987, 1992a, 1992b; Gaines and Farmer; Gilman; Kleinman and Good). Medical anthropology has added to these debates with ethnographic studies of healers, researchers, and patients in their cultural contexts (Gaines, 1979, 1992a; Hahn and Gaines; Kleinman, 1980, 1988; Lock; Marsella and White; Townsend; Young, 1995). Although each professional psychiatric tradition embodies culturally specific beliefs and values, they all represent their objects of concern (diseases) as real and universal. Depending on the culture or the cultural variations within a society, those realities are usually in the domain of nature but may have a more spiritual orientation (Gaines, 1998b).

Ethnopsychiatries represent distinct systems rather than versions of a unitary psychiatry. A review of mental illness in the cross-cultural record suggests that in other cultures illnesses often cannot be classified in accordance with Western nosologies such as the Diagnostic and Statistical Manuals (DSMs) of the American Psychiatric Association (APA). Novel disorders in traditional societies are not versions of homegrown disorders. Conversely, many disorders that are assumed to be natural entities in the West cannot be found in other cultures or lack key or even defining symptoms. This suggests that diagnostic criteria are altered to fit unruly entities into Western molds (Gaines, 1991; Gaines and Farmer; Kleinman, 1977, 1988; Kleinman and Good).

The Problem of Western Professional Psychiatry

A cultural focus on professional ethnopsychiatries, particularly that of the United States, shows that they differ in significant ways. This also shows a lack of a universally valid "gold standard" by which all forms of mental illness can be evaluated.

Although ethnopsychiatries can be expected to differ substantially, an advocate of biological causal realism would not expect that to be true of professional (ethno) psychiatries. The distinctiveness of ethnopsychiatries suggests their cultural construction; they are not the same psychiatry focused on natural illnesses as it is practiced in different countries.

Cross-Cultural Knowledge of Mental Illness

Research in ethnomedicine and ethnopsychiatry, in the philosophy of science and history, the history of medicine, and gender studies has converged to raise epistemological and ethical concerns for modern psychiatries in multicultural nation-states. Those concerns derive from the fact that popular and professional psychiatries have been revealed local cultural constructions. Hence, the key question of psychiatric systems—What is normal and what is abnormal?—may be posed in an ethical context: What are the ethical problems generated by one psychiatric theory or nosology applying its notions of normality and abnormality to members of distinct cultures in modern plural societies? A cultural assessment of U.S. professional ethnopsychiatry shows a diversity of opinions and the elusive nature of definitions and diagnoses of mental disorders, suggesting its inadequacy as a standard.

Are Mental Illnesses Natural and Universal? Deconstructing U.S. Ethnopsychiatry

The view that psychiatric illness is universal eschews culture as a formative influence and assumes that disorders have similar natures that are expressed everywhere. That is, each disorder is known by its symptoms, which by definition must be distinct, at least collectively, from those of other disorders. In this view, in studying mental illness crossculturally, one studies the same things in different cultural settings.

To make that argument one must posit that psychiatric disorders are biologically based (biochemical or genetic) and thus are beyond culture. One also must assume that there is a single human psychology that can be manifested in aberrant forms. If this view is correct, the same disorders should be identified and treated in all professional and popular psychiatries. It is assumed that a professional psychiatry discovers those entities and then names and classifies them (e.g., American Psychiatric Association, 1987, 1994); it does not invent them.

Labeled phenomena exist apart from their labels, it is thought. However, psychiatry mistakes its labels for realities rather than models (Geertz, 1973) or representations of reality (Hacking, 1983) that are used for particular purposes. This view expresses an implicit empiricist theory of language, holding that disease labels correspond to independently existing entities in the natural world. However, the empiricist theory is a cultural theory about, not a factual description of, the relationship of language to the world (Hacking, 1983).

When differences in disease entities or in systems of classification (nosologies) across cultures are found, psychiatrists assume that those differences indicate that universal diseases are overlooked, mislabeled, or differently labeled by less sophisticated others. When professional psychiatries disagree, they assert that one is more advanced than the others (Kleinman, 1988; Kleinman and Good).

Both views are evolutionist in form and have little scientific merit. It now is known that cultures change historically, not through evolution, because of contact with and borrowing from other cultures as well as innovation. Cultures are distinct because of their unique histories, that are constituted as local culture and passed on through socialization. Cultures do not differ because they represent developmental stages of a single human culture.

It is inappropriate to assume that the understandings of U.S. professional ethnopsychiatry are more advanced than those of other countries. For one thing, U.S. psychiatry has borrowed many of its fundamental ideas from other cultures and used them for its own purposes. Also, U.S. psychiatry has changed its views of mental illness radically over time.

The changes have not been in a specific direction, building on past knowledge. Rather, they represent a shift in paradigms. U.S. psychiatry has had dominant etiological paradigms that have been social, hereditarianist biological, psychoanalytic, psychosocial (interpersonal), and biological. The sciences seen as key to psychiatric formulations also have changed over the years. They have included psychology, eugenics, biology, physiology, genetics, and neurology (Dowbiggin; Gaines, 1992b; Hacking, 1995; Kleinman, 1988; Littlewood and Lipsedge; Lurhmann; Young, 1995).

ANOREXIA NERVOSA, CHRONIC FATIGUE SYNDROME, AND MULTIPLE PERSONALITY DISORDER. Anorexia nervosa. The potentially fatal disorder anorexia nervosa is found widely among middle- and upper-income Euro-American women. However, it is seen only rarely outside that narrow sociocultural context even in the United States.

In cross-cultural work key features of the disorder, such as fear of obesity and a distorted body image in the very thin, are not found (Mezzich et al.). Researchers have suggested dropping those symptoms, but in that case how could one find the same disorder with different symptoms when the disorder is defined by its symptoms?

Chronic fatigue syndrome. Chronic fatigue syndrome (CFS) is a disorder for which the search for a biological cause failed, yet it is referred to as if a somatic cause had been isolated as chronic Epstein-Barr virus infection or immune dysfunction syndrome. This disorder, which is fairly common in the United States but confined to specific ethnic and social class levels, is found in few other cultures. Currently, a century-old U.S. term, neurasthenia, is being resurrected and applied to CFS, moving it into the province of psychiatry from general medicine, although a somatic cause still is being sought (Kleinman, 1988).

Mutiple personality disorder. Multiple personality disorder is another condition that is found commonly in the United States. It is invoked in criminal trials as a legal defense and in popular culture. However, it is absent from the classifications and practice of other professional psychiatries (See Hancking, 1995).

PERSONALITY DISORDERS. Several new disorders appeared in an appendix in DSM-III-R (American Psychiatric Association, 1987), including dependent personality disorder and sadistic personality disorder. Those terms appear to be gendered: The former is said to be found among women who "allow" physical abuse over time, and the latter among the men who abuse them. There was considerable political opposition to the tentative formulation of those disorders, which blame female victims of abuse while giving their abusers a legal defense. In English psychiatry the adoption of a premenstrual syndrome made it possible to explain women's injuries: they did it to themselves.

The gender component of those personality disorders recalls the history of U.S. psychiatry, in which traditional notions of women's nature were upheld by psychiatric findings, as were racist notions about minorities (Fausto-Sterling, 1992; Thomas and Sillen). A more explicitly racist psychiatry was that of South Africa, in which a lower psychological and psychiatric evolutionary status was attributed to nonwhites (Gaines, 1992a).

Depression and Schizophrenia

Two disorders are considered in biological psychiatry to be models of biogenetic mental diseases: depression and schizophrenia. However, the cross-cultural literature and the most advanced epidemiological studies have challenged that assertion (Gaines, 1992a; Kleinman and Good; Kleinman, 1988; World Health Organization). The formulations of those disorders in the West have been shown to conceal powerful cultural and moral assumptions about emotion, autonomy, sex, and gender as well as human difference (ethnic and socalled racial) (Gaines, 1992a, 1992b; Kleinman and Good).

To examine the epistomology of the formulations of depression and schizophrenia, one first must consider certain key underlying psychological dimensions. Those culturally defined dimensions are constructions of self, will, emotion, and cognition (Gaines, 1992b).

SELF. There are differences in cultural conceptions of self and person with respect to mental illness, its diagnosis, and its treatment. Conceptions of the self vary widely and may include spiritual elements. For example, it is common for people to have spirit siblings in Bali (Marsella and White), but this would be seen as pathological in the United States.

Formulations of the self in India, the Mediterranean countries, and Japan would be seen as incomplete, dependent, and/or unindividuated by U.S. psychiatric standards despite the fact that those familistic, interactionally altering indexical selves that maintain interactional harmony and family reputation exist in cultural environments that foster, support, and reward their sociocentrism (Marsella and White). Conversely, the egocentric, referential Northern European Protestant self (Gaines, 1992b; Marsella and White) with its asocial nature would be seen as antisocial, naïve, and alienated in other contexts. It is the locally conceived self in which psychological disorders occur. Logically, different selves must have different disorders and therefore require different healing strategies. To complicate matters further, many cultures do not exhibit a purely psychological self. Instead, they exhibit social selves (the self is a social psychological, not a psychological, phenomenon), and this is found even in Europe (Gaines, 1992b, 1998b; Marsella and White).

EMOTION AND COGNITION. The distinction between cognition and affect (thinking and feeling) in the West, which is central to the differentiation of psychiatric disease entities, does not exist universally in human nature or biology. The cross-cultural record indicates that these are cultural constructions (Kleinman and Good). Those findings challenge the validity of the construction of depression and schizophrenia as universal diseases grounded in biology, for the psychological domains in which disturbance is said to occur (cognition and affect) are not innate; they are Western cultural constructions.

DEPRESSION. Assessment methods for depression are often ethnocentric even when the approach is said to be entirely descriptive, as in DSM-III (1980), DSM-III-R (1987), and DSM-IV (1994). An example is dysphoric affect (an unpleasant, sad feeling), that is a central element of the Western depressive experience.

Dysphoric affect, although disvalued in some Western traditions, is highly valued in others, such as the Mediterranean world with its Latin Catholic, Orthodox, and Islamic traditions (Gaines, 1992a; Kleinman and Good), where suffering is seen as ennobling and indicative of divine interest in the sufferer (Gaines and Farmer). It serves as the basis for interaction in which the self is presented through the rhetoric of complaint as beset with problems and as a fellow sufferer (Gaines and Farmer).

In the Buddhist tradition recognition of the worthlessness of the world and the self and the futility of human activity is part of enlightened understanding (Kleinman and Good). Such thoughts therefore have positive personal value rather than being pathognomic: They are eudysphoric (Gaines, 1987).

The complexity of the dysphoric experience can be understood by reference to the interrelation of the cultural context and history, cultural psychology, symbols, and family, status, and gender roles and power relations that collectively contribute to its construction (Kleinman and Good; Gaines and Farmer). Only then is it possible to assess the need for assistance. The intricate patterning of social and cultural forces is complex and requires detailed contextual analysis (Good, 1994).

The patterning of symptoms can vary widely across cultures so that key features of Western-defined disorders such as depression are absent from the experience of members of other cultures even when they are diagnosed as depressed with U.S. psychiatric instruments. For example, there is no psychomotor retardation among depressives in France or Morocco, only short periods of dysphoric experience among the Hopi, and feelings of insight and satisfaction in Sri Lanka and India (Gaines and Farmer; Kleinman and Good).

No consistent definitive statement about the prevalence, the incidence, or even the forms of depressive manifestation across cultures can be made, although a variety of assessment techniques have been employed for that purpose (Kleinman and Good). One problem is that false positives appear in the West just as they do in epidemiological studies done in Mediterranean and other countries where there are social and personal values of suffering and social support for its expression.

In attempting to focus on a single disease entity known as depression one is confronted with a semantic problem. The term depression is used inconsistently in psychiatric literature. At various times and often in the same study it is used to refer to a mood, a disorder, and/or a symptom of a disorder. Some researchers stress a cognitive explanation of depression, and there are cognitive therapies that may equal or surpass biological/pharmacological interventions in speed and efficacy.

SCHIZOPHRENIA. Research on schizophrenia is hampered by a lack of consistent clarity of definition, particularly in regard to the boundaries of the disorder. Epidemiological, familial, twin, and adoption studies have been interpreted to suggest that a genetic factors is involved in schizophrenia. Although some work has shown a genetic or familial link in a few cases, no genetic link or common abnormality has been demonstrated or implicated in the vast majority of cases. Results involving genetic interpretations often are overstated, and important social/cultural information or explanations are ignored (Duster). Claims implicating various genes as causative of schizophrenia have been withdrawn.

Many findings of central nervous system (CNS) dysfunction appear in the literature, but none is specific or shared by all people who have the diagnosis of schizophrenia. Also, no symptom of schizophrenia is unique to that disorder; all the symptoms associated with or diagnostic of it appear in other disorders described by U.S. psychiatry

The World Health Organization's (WHO) study of schizophrenia (1979) found that schizophrenic patients with similar symptoms on initial evaluation whose disorders met strict diagnostic criteria showed marked variability in the two-year to five-year course and outcome within and across research centers. Patients in developing countries had a much more favorable course and outcome than did those in developed countries.

The disorder is chronic in the West, but this is not the case in the Third World, where the majority people with schizophrenia return to normal functioning (World Health Organization). It has been argued that schizophrenia is a culture-bound, Western ethnic psychosis, one specific to a single culture or ethnic group (Devereux). Cultural expectations may play a central role in chronicity; cultures that expect chronicity produce it, and those which expect recovery foster it. WHO data on the prevalence and incidence of schizophrenia in different cultures have been interpreted as establishing broad similarities across cultures (World Health Organization), suggesting similar processes, but similarities appear only when contextual evidence is excluded (Kleinman, 1988).

The assertion of the biological nature of psychiatric disorders in certain psychiatries appears to be a result of a patterned misinterpretation of cultural or social phenomena as biological. Those misinterpretations appear to be expressions of a professional thought model, a patterned way of thinking (Devereux). This model is a reflection of a folk form of biological essentialism borrowed from German psychiatry as well as a result of narrow biological training (Devereux; Kleinman, 1988).

Challenges to that theory include a resurgent psychoanalytic theory, feminist analytic theories, new psychologies, and cultural psychiatric studies. The biological model has dominated the field in the United States (Luhrman), but some movement away from it can be seen in the inclusion of a "Glossary of Culture-Bound Syndromes and Idioms of Distress" (Mezzich et al.) in DSM-IV (1994). However, cultural thinking has not been centrally present in the text of any edition of the DSM since 1980, when the classifications were intentionally fashioned to promote biological definitions of illness.

The Biological Perspective: Science or Folk Theory?

Researchers believe that the biological emphasis is a result of a long process of scientific advances. Studies of the development of psychiatries in anthropology, philosophy, and the history of medicine and psychiatry suggest otherwise. The biological view in psychiatry has its origins not in science but in the traditional folk culture of Germany and is at least a thousand years old (Gaines, 1992b). That view is an expression of a cultural theory that is a form of biological essentialism. That essentialism holds that the essence of self and other in terms of identity (ethnicity and kinship) and moral worth is determined by biology. Blut ("blood") is thought to be inherited and determines a person's identity, character, and moral worth.

The modern versions of this theory are the constructions of genetic and other somatic differences that are alleged to exist among people with specific disorders. In this view people who have mental illnesses are different kinds of people (Gaines, 1992a).

Some psychiatries, especially U.S., Scandinavian, and Russian, tended to follow in the footsteps of the nineteenth-century dean of German psychiatry, Wilhelm Griesinger, and his follower Emile Kraepelin, the founder of comparative psychiatry. Griesinger and Kraepelin after him in the early twentieth century asserted a biological basis for mental disorders. Kraepelin maintained Griesinger's dictum that "mental diseases are brain diseases," a notion borrowed from German (idealist) philosophy and French racial biology of the late 1700s (Gilman).

In first third of the twentieth century Carl Schneider, in the German materialist (and the Nazi racialist) tradition, advanced the notion of the "first rank symptoms" of schizophrenia. Those symptoms were pathognomic, or definitively diagnostic, of the disorder. Although many were influenced by that formulation in the United States and elsewhere, there was no analysis of the veracity of Schneider's theory until the 1980s when it was discerned that these symptoms were not unique to schizophrenia.

That biological model is dominant in contemporary U.S. psychiatry, although it competed with psychoanalytic and psychosocial perspectives before winning out in 1980 with the publication of DSM-III (Luhrman). Although the biological interpretation of mental illness is said to be based on empirical scientific evidence, its source in a foreign popular culture is apparent.

Social categories from the wider, lay culture—races—are construed in science as distinct biological groups, just as they were in German psychiatry and in South Africa. However, U.S. and German notions of race appear in different contexts and are applied to different experiences and thus are not the same folk biological theories. In the United States both the biological psychiatric perspective and the social categories are borrowed and reworked historical cultural constructions, rather than modern advances in psychiatric science.

CULTURE AND THE CLASSIFICATION OF MADNESS. Professional psychiatric classifications of diseases (nosologies), along with the diseases that are classified, change over time. Those changes are seen in psychiatric traditions as improvements and progress that may be viewed in evolutionary terms; that is, Western classifications are different from others because they are more evolved.

Changes in classification often represent shifts in assumptions about mental disorders that are products of ideological conflicts, competing explanations for which no data or ambiguous data exist. Rather than pointing in any direction, those changes simply show shifts in dominant theoretical models or political ideologies. They also may represent the imposition of foreign formulations and institutions (Gaines, 1992a).

Terms are deleted or reintroduced, but such actions do not indicate advances. Neurosis appeared in the disease classifications of U.S. psychiatry from 1952 to 1980 but was deleted from the 1980 and later classifications. These classifications are biological in orientation and thus exclude clearly psychogenic illness terms such as neurosis despite ample clinical evidence of their existence. French and other psychiatries continue to use the term and diagnose the illness. There are also "reconstructions" (old terms used for new disorders) in professional psychiatry, such as neurasthenia applied to chronic fatigue syndrome in the United States.

Interpretive analyses of U.S. psychiatric classifications reveal the underlying culture-, gender-, and age-specific viewpoint (Germanic Protestant, male, adult) from which U.S. nosologies are created. Behavioral or ideational differences perceived in others who vary in age, culture, or gender from the ideal are interpreted as a lack of (self-) control expressed as pathology such as depressive illness or psychotic conditions and personality disorders. That deficit is perceived as being caused by differences in group (age, "racial," gender) biology (Gaines, 1992b) i.e., local biology, culturally constituted biologies (Gaines, 1998c). This suggests that classifications are largely a cultural psychological discursive formations, not a classification of naturally appearing diseases (Gaines, 1992b).

Biological essentialism may be seen to act as a psychological defense because it allows one to claim that the afflicted are biogenetically different from normals. That is, members of the psychiatric profession, it is presumed, are normal and thus could not have the same biological defects as does a mental patient (Devereux).

PHARMACOLOGY AND "ETHNIC BIOLOGY." Biological essentialism can be seen in research in U.S. psychiatry that focuses on the study of ethnicity and psychopharmacology (called ethnic psychobiology, an oxymoron). Regarded as cutting-edge research, those studies recognize ethnic differences in biochemistry. Findings suggest that different doses of particular agents are appropriate for members of different ethnic groups with the same psychiatric disorder. This research takes as its units of research members of ethnic or racial groups. Biomedicine assumes that these terms are synonymous and refer to genetically distinct groups. The allegedly distinct biological ("racial") groups that appear commonly in such research are Hispanics (a language group), Asians (a geographical designation), blacks (a color), Native Americans (a geographical designation), and whites or Caucasians (a color or geographical designation, respectively). Those groups are in reality social categories that were created by a particular culture in the last two centuries and adopted by health research. The racial designations and the biological theory underlying them are neither universal nor biological.

Research that assumes that members in each category are biologically defined assumes that the members of each category are identical, or nearly so, in genetic composition; what is true of one person belonging to a race is generalizable to all members of the putative group. This perspective has several flaws.

The notion of race varies from culture to culture and is absent from most cultures in the present time; it was absent from all cultures in the past. Other modern sciences have different notions of the number and membership of human races. Japanese science considers the Japanese, Koreans, Chinese, and Indians to be members of different races, and the Germanic theory separates Germans from all other white groups on genetic bases. One may ask with reference to U.S. research, Why is one racial theory accepted whereas others are rejected?

This research ignores the substantial variations in doses seen and clinically "proved" to be effective within so-called races, including Europeans, in the practice of different national psychiatries. For example, much larger doses of antipsychotics are needed for white U.S. patients than for French, English, and German patients. If those patients all belonged to the same race, that variation would not occur in doses that are predicated on racial affiliation.

Biology is assumed to be the basis of physical and genetic distinctiveness and to be stable over time. However, physical anthropology and evolutionary biology have demonstrated that human biology has a common source (Africa) and is extremely plastic. That plasticity is responsible for the great morphological diversification of humankind that has occurred in the last 100,000 years (Gould).

These findings contradict the ideas of biological distinctiveness and constancy over time that the notion of race requires. In contrast, pharmacological work framed in racial/biological terms reflects the biological essentialism noted above. It serves to maintain the cultural construction of race and biological explanations of social and cultural differences. Racial biology is thus a form of what has been called local biology (Gaines, 1992a, 1998c).

Professional Ethnopsychiatry around the World

CHINESE PSYCHIATRY. Chinese psychiatry originally was borrowed from the West but also drew from classical Chinese medicine (Kleinman, 1988; Leslie). This suggests that psychiatry can be borrowed and adopted by a culture.

Because it represents China's understandings of Western notions of mental disorders, a number of Chinese disorders are unknown elsewhere. Qi-gong reaction is an acute episode that follows overly intense involvement in the Qi-gong exercises and breathing practices that are used to promote health and long life. Neither the condition nor the related health practice is known to U.S. psychiatry.

Shenjing shuairuo ("neurasthenia") is the most common psychiatric diagnosis in Chinese psychiatry (Kleinman, 1988; Mezzich et al.) and in areas within the sphere of Chinese influence. The label was borrowed from the United States, where the term was developed over a century ago but fell into disuse, as did the conception of disease it labeled (Kleinman, 1988).

Koro is an acute episodic event characterized by intense concern and anxiety about the withdrawal of the external genitalia into the body; it is related to the Chinese cultural belief that the genitals of the dead recede into the body. Koro is found in China and Southeast Asia, where there have been large epidemics. Western psychiatrists, ignorant about Chinese folk beliefs, might see koro as a psychosis or panic disorder.

In Chinese psychiatry psychological explanations are not regarded as sensible explanations of suffering (Kleinman, 1980, 1988; Kleinman and Good; Leslie). Patients present somatic (bodily) symptoms such as koro almost exclusively. Optimal intervention is somatic as well, often involving herbal medicines to enhance or unblock the passage of vital energies throughout the body. The physiological conception of mental phenomena is related to notions in India, where in the traditional Ayurvedic psychiatric theory mental phenomena are held to be expressions of bodily states, not psychological dynamics in the Western sense. Indian professional psychiatry is entirely somatopsychic (Leslie; Leslie and Young).

JAPANESE PSYCHIATRY. In Japanese psychiatry two important disorders are widely known in practice and in society: shinkeishitsu and taijin kyofusho. Both are considered social phobias in the West.

Taijin kyofusho presents as extreme concern over actions or personal hygiene that could be disturbing or disrespectful to others. Shinkeishitu is characterized by shyness, tension in social relations, feelings of inferiority, and fear of failure in maintaining appropriate interactions. It is treated successfully by Morita psychotherapy, a blend of Buddhism, German psychiatry, and understandings of Japanese life that is administered on an outpatient basis or in hospitals dedicated to the treatment of shinkeishitu. Inpatient treatments for this and most other disorders serious enough to warrant hospitalization are much longer than they are in the United States. This is expected by patients, who see the hospital as a second home and the psychiatrist as a teacher (Lock; Gaines, 1992a). There are a number of psychotherapies in Japan for which there are equivalents of neither the disorders nor the therapies in the West (Reynolds).

Several new disorders in Japanese psychiatry have been recognized by the medical anthropologist Margaret Lock(1980), including housewife syndrome and school refusal syndrome. Both relate to pressures for achievement and success and the relationship of the individual to the group in Japanese society and culture. In the Chinese and Japanese cases the importance of harmony, right role performance, and the social nature of the person is clear.

GERMAN PSYCHIATRY. In Germany research has demonstrated a striking parallel between lay beliefs about mental illness and those of mental health professionals (Townsend). In that country lay and professional segments believe that there are two basic types of mental illness: Gemütskrankheit (emotional sickness), which is transient and caused by outside events, and Geisteskrankheit (mental sickness), which is said to be inherited, chronic, and not amenable to treatment.

Since the twentieth century German psychiatry has attempted to formulate biological notions of serious mental illness and has influenced many other psychiatric systems, especially that of the United States. Psychiatry makes a sharp distinction between the ill and the well that strongly affects diagnosis and treatment. Mental patients are different kinds of people; they are biologically defective. Many family studies focusing on the inheritance of mental disorders have been done in Germany and Scandinavia (Duster; Townsend).

This biological notion was developed in the nineteenth century and was central to the mental hygiene movement of the Third Reich. Because those people were biologically defective, they could not be helped and were a burden to the normal, and their lives thus were not worth living. That ideology led to the killing of tens of thousands of mentally ill and retarded patients in a process that was the forerunner of the Holocaust.

That ideology also asserted that certain groups of people—so-called races (e.g., Jews, Slavs, Arabs, Gypsies, Celts, Latins, Africans, and people from the East)—although not insane, were nonetheless defective and represented a potential threat. In the German ideology defective and dangerous meant non-German.

SOVIET PSYCHIATRY. Before the dissolution of the Soviet Union Russian psychiatric practice was strongly influenced by German psychiatry and its biological approach. Also influenced by Pavlov, Soviet psychiatry banned psychological and psychoanalytic approaches. Marxist ideology attributed madness and other problems to the evils of nonsocialist economic systems. Because individuals manifested mental disturbances long after the revolution, the causes had to be personal and internal, not social or economic. Hence, dissent was seen as pathology.

Soviet psychiatry described a unique form of schizophrenia—creeping schizophrenia—whose symptoms were usually nonconformity and dislike of expected work duties. Diagnosis could lead to hospitalization and the administration of powerful drugs. The opening of the Soviet Union to the West included a new acceptance of psychoanalytic theory (Mitchell and Black).

FRENCH PSYCHIATRY. French psychiatry identifies and treats several disorders that are not known in the United States or elsewhere. The practice of psychiatry, like the society around it, is hierarchical and authoritarian (Gaines, 1992a). It developed a nonphysical notion of mental disorders in the late 1790s and therefore did not adopt German biological theorizing entirely despite the neurologist Jean-Martin Charcot's organic approach and the rise of hereditarianism. The latter helped the French psychiatric profession gain prominence and authority over the treatment of mental illness (Dowbiggin). French psychiatry historically has been much more intimately connected with the state than have other psychiatric establishments in the West (Dowbiggin; Foucault).

A number of conditions exist in France that have no equivalents in other countries, including spasmophilie (literally "prone to spasms" but referring to a variety of vague, nonspecific complaints that include tiredness, loss of appetite, and various somatic complaints) and triste (or fatigué) tout le temps (chronic sadness or tiredness as a result of a great loss or disappointment). In those formulations French ethnopsychiatry expresses its culture's notions of the burden and exquisite sadness of life (Gaines and Farmer; Marsella and White; Gaines, 1991). French psychotherapies aim not at change in but at recognition and acceptance of a historicized self.

French psychiatry has unique historical concerns, such as passion and obsession expressed as monomania (fixed ideas). It was in France that the notion of the toxic nature of the asylum developed.

Culture and Context: Beyond Biological Thinking

Sociologists have long considered social contexts in Western industrial societies as affecting people's psychological status. Classic studies suggested that there is a relationship between social class position, urban dwelling, and an increased incidence of certain forms of mental illness. Although the lower classes have a higher frequency of some illnesses, it was found that the upper classes have a higher frequency of others.

Researchers with anthropological expertise implicated high levels of social disorganization as contributing to increases in the incidence of mental illness. People subject to extreme pressures, such as discrimination and other forms of oppression, that limited their life chances would have less stable environments and therefore would be more vulnerable to psychological afflictions. It also is known that U.S. psychiatry commonly misdiagnoses members of minority groups, attributing serious mental illness to individuals largely on the basis of ethnic group and gender group membership rather than on the basis of symptoms. Thus, the same symptoms in members of different ethnic groups or genders produce different diagnoses and prognoses (Gaines, 1992a, 1992b; Kleinman, 1988; Littlewood and Lipsedge).

Related to social disorganization are the consequences of personal and group traumas such as accidents and criminal victimization (assault, rape, abuse) as well as war, statesponsored violence and terror, racism, genocide and ethnocide, forced migration, epidemics, poverty, and starvation. Native Americans and African Americans have been the subjects of pogroms, genocide, and terrorism as well as abuse, discrimination, and neglect. It is difficult to deny that those experiences have had a considerable psychological impact.

Stress, a notion derived from World War II and modeled on combat experiences, is relevant in the United States for dispossessed ethnic groups and for veterans, as can be seen in the recent formulation of posttraumatic stress disorder (PTSD) (Young, 1995), which combines trauma and stress with ideas of the unconscious mind that are not found in most other cultures.

The notion of universal biological mental diseases limits the understanding of the known variety of detrimental as well as beneficial sociocultural conditions. It leads observers to see defective persons instead of social inequalities and to seek biological vulnerabilities instead of hopelessness born of despair or the horrors of war. It ignores conditions that are responses to noxious circumstances. As an example, there has been a move to redefine PTSD as a biological defect rather than a reaction to war in veterans and to persecution and torture among Latin American immigrants to the United States.

Biological reductionism cannot explain the appearance of mental disorders across cultures. Although all people are human, they do not have the same ways of living, feeling, thinking, and behaving. To argue that pathology is purely biological is to contradict the fact that normal behavior, although supported by biology, is not determined by it.

Standards of normality vary from culture to culture; what is sane in one culture is insane in another. There is no evidence of a biological basis for the heterogeneity of conceptions of normality and abnormality. The advances offered by biological psychiatry are considerably less than advertised: Modern views of the genetics and biology of madness recapitulate theories of eugenics and hereditarianism from the nineteenth century (Carlson; Dowbiggin; Foucault; Gaines, 1992b; Gould) and earlier.

Professional Psychiatries: Ethical Implications

Historical and cross-cultural studies of professional psychiatries suggest that each one is a cultural construction, not a system of dispassionate discernment of natural psychopathologies; there are psychiatries, not one psychiatry. The application of a single theory or practice in a culturally diverse world leads to an ethical question: Are there negative consequences of the application of one culture's psychological medicine as a standard of normality in the evaluation and treatment of cultural others, including immigrants (Gaines, 1998a)?

Bioethics in the United States has grown out of concerns involving personal autonomy (a cultural value), experimentation (including that in the Third Reich), technological change, and informed consent but also out of a cultural context that gives meaning to those concerns. Bioethicists sometimes excludes social, political, and cultural issues such as "race" and gender, asserting that those things lie outside its domain or that cultural others are "really" the same (Midgley). Such assertions ignore more than a century of cross-cultural research demonstrating the contrary. In much the same way biological psychiatry excludes cross-cultural and historical research that contradicts the current version of psychiatric reality. Thus, it is able to operate in a closed domain that ignores complex historical and cultural realities.

A universalistic bioethics that is beyond culture is illogical. What is ethical in one context is unethical in another. Telling a patient the diagnosis in Japan is unethical, not telling in the United States is (now) unethical; leaving a patient uninformed about a disorder or the rationale for treatment is normal and ethical in Japanese and Italian psychiatry but not in U.S. psychiatry.

Biological distinctions that are reified as natural, such as the concept of race in the United States, have negative consequences. Those distinctions produce unequal treatment, disproportionate institutionalization, and higher morbidity and mortality. Adherents of those social views do not address social justice.

Nearly a thousand years ago in Islamic medical ethics physicians were enjoined to be social activists and advocate better living conditions for their community members. That ideology potentially opens the door to change and adaptation as well as social justice. The need to integrate the importance of cultural and social differences into theory and practice while maintaining appropriate levels of care in the face of increasing cultural diversity is the moral dilemma of modern Western and Eastern professional psychiatries in a multicultural, postmodern world.

atwood d. gaines (1995)

revised by author

SEE ALSO: Medicine, Anthropology of; Mental Institutions, Commitment to; Homosexuality; Mental Health, Meaning of Mental Health; Mental Health Services; Mentally Disabled and Mentally Ill Persons; Psychiatry, Abuses of; Psychopharmacology; Psychosurgery, Medical and Historical Aspects of; Race and Racism; Sexism; Women, Historical

BIBLIOGRAPHY

American Psychiatric Association. 1987. Diagnostic and Statistical Manual, Third Edition, Revised (DSM III-R). Washington, D.C.: American Psychiatric Association.

American Psychiatric Association. 1994. Diagnostic and Statistical Manual, Fourth Edition, Revised (DSM-IV). Washington, D.C.: American Psychiatric Association.

Carlson, Elof Axel. 2001. The Unfit: A History of a Bad Idea. Cold Spring Harbor, NY: Cold Spring Harbor Laboratory Press.

Devereux, George. 1980. Basic Problems of Ethnopsychiatry, tr. Basia Miller Gulati and George Devereux. Chicago: University of Chicago Press.

Dowbiggin, Ian. 1991. Inheriting Madness: Professionalization and Psychiatric Knowledge in Nineteenth-Century France. Berkeley: University of California Press.

Duster, Troy. 1990. Backdoor to Eugenics. London: Routledge.

Fausto-Sterling, Anne. 1992. Myths of Gender: Biological Theories about Women and Men. New York: Basic Books.

Fausto-Sterling, Anne. 2000. Sexing the Body: Gender Politics and the Construction of Sexuality. New York: Basic Books.

Foucault, Michel. 1973. Madness and Civilization: A History of Insanity In the Age of Reason. New York: Vintage.

Gaines, Atwood D. 1979. "Definitions and Diagnoses." Culture, Medicine and Psychiatry 3(4): 381–418.

Gaines, Atwood D. 1987. "Cultures, Biologies and Dysphorias." Transcultural Psychiatric Research Review 24(1): 31–57.

Gaines, Atwood D. 1991. "Cultural Constructivism." In Anthropologies of Medicine, ed. Beatrix Pfleiderer and Gilles Bibeau. Wiesbaden, Germany: Vieweg und Sohn Verlag.

Gaines, Atwood D. 1998a. "Mental Illness and Immigration." In Handbook of Immigrant Health, ed. Sana Loue. New York: Plenum.

Gaines, Atwood D. 1998b. "Religion and Culture in Psychiatry: Christian and Secular Psychiatric Theory and Practice in the United States." In Handbook of Religion and Mental Health, ed. Harold G. Koenig. New York: Academic Press.

Gaines, Atwood D. 1998c. "From Margin to Center: From Medical Anthropology to Cultural Studies of Science." American Anthropologist 100(1): 191–194.

Gaines, Atwood D., ed. 1992a. Ethnopsychiatry: The Cultural Construction of Professional and Folk Psychiatries. Albany: State University of New York Press.

Gaines, Atwood D., ed. 1992b. "From DSM-I to III-R: Voices of Self, Mastery and the Other: A Cultural Constructivist Reading of U. S. Psychiatric Classification." Social Science and Medicine 33(1): 3–24.

Gaines, Atwood D., and Farmer, Paul E. 1986. "Visible Saints: Social Cynosures and Dysphoria in the Mediterranean Tradition." Culture, Medicine and Psychiatry 10(3): 295–330.

Geertz, Clifford. 1973. The Interpretation of Cultures. New York: Basic Books.

Geertz, Clifford. 1983. Local Knowledge: Further Essays in Interpretive Anthropology. New York: Basic Books.

Gilman, Sander. 1988. Illness and Representation. Ithaca, NY: Cornell University Press.

Good, Byron J. 1994. Medicine, Rationality and Experience: An Anthropological Perspective. Cambridge, Eng., and New York: Cambridge University Press.

Gould, Stephen Jay. 1996. The Mismeasure of Man, 15th anniversary edition. New York: W.W. Norton.

Hacking, Ian. 1983. Representing and Intervening. Cambridge, Eng., and New York: Cambridge University Press.

Hacking, Ian. 1995. Rewriting the Soul: Multiple Personality and the Sciences of Memory. Princeton, NJ: Princeton University Press.

Hahn, Robert A., and Gaines, Atwood D., eds. 1985. Physicians of Western Medicine: Anthropological Approaches to Theory and Practice. Dordrecht, Netherlands: D. Reidel.

Kleinman, Arthur. 1977. "Rethinking the Social and Cultural Context of Psychopathology and Psychiatric Care." In Renewal in Psychiatry, ed. Theo Manschreck and Arthur Kleinman. Washington, D.C.: Hemisphere.

Kleinman, Arthur. 1980. Patients and Healers in the Context of Culture. Berkeley: University of California Press.

Kleinman, Arthur. 1988. Rethinking Psychiatry. New York: Free Press.

Kleinman, Arthur. 1995. Writing at the Margins: Discourse between Anthropology and Medicine. Berkeley: University of California Press.

Kleinman, Arthur, and Good, Byron, eds. 1985. Culture and Depression. Berkeley: University of California Press.

Leslie, Charles. 1977. Asian Medical Systems. Berkeley: University of California Press.

Leslie, Charles, and Young, Allan, eds. 1992. "Paths to Asian Medical Knowledge." Berkeley: University of California Press.

Littlewood, Roland, and Lipsedge, M. 1982. Aliens and Alienists: Ethnic Minorities and Psychiatry. Harmondsworth, Eng.: Penguin Books.

Lock, Margaret. 1980. East Asian Medicine in Urban Japan. Berkeley: University of California Press.

Luhrmann, Tanya. 2000. Of Two Minds. New York: Knopf.

Marsella, Anthony, and White, Geoffrey, eds. 1982. Cultural Conceptions of Mental Health and Therapy. Dordrecht, Netherlands: D. Reidel.

Mezzich, Juan; Hughes, Charles; Good, Bryon; et al. 1994. "Outline for Cultural Formulation and Glossary of Culture Bound Syndromes." In Diagnostic and Statistical Manual, 4th edition. Washington, D.C. American Psychiatric Association.

Midgely, Mary. 1991. Can't We Make Moral Judgements? New York: St. Martin's Press.

Mitchell, Stephen, and Black, Margaret, eds. 1995. Freud and Beyond: A History of Modern Psychoanalytic Thought. New York: Basic Books.

Reynolds, David K. 1980. The Quiet Therapies: Japanese Pathways to Personal Growth. Honolulu: University Press of Hawaii.

Thomas, Alexander, and Sillen, Samuel. 1976 (1972). Racism and Psychiatry. Secaucus, NJ: Citadel.

Townsend, J. Marshall. 1978. Cultural Conceptions and Mental Illness. Chicago: University of Chicago Press.

World Health Organization. 1979. Schizophrenia: An International Follow-up Study. Chichester, Eng.: Wiley.

Young, Allan. 1981. "The Creation of Medical Knowledge: Some Problems of Interpretation." Social Science and Medicine 15B(3): 379–386.

Young, Allan. 1995. The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. Princeton, NJ: Princeton University Press.