Editors’ Introduction

The evolution of cultural psychiatry over the last few decades has been an interesting phenomenon to observe. Psychiatry is perhaps one of the younger disciplines of medicine. The coming of age of psychiatry as a profession was clearly linked with the development of training and laying claim to a knowledge base which gradually has become more evidence based. The period between the two World Wars led to greater questioning of social factors in the aetiology and management of psychiatric disorders. In the UK at least, social psychiatry as a discipline became clearly established and produced impressive studies on life events and their impact on phenomenology, attachment and other social factors. In the last two decades, it would appear that social psychiatry has transmogrified into cultural psychiatry.

Kirmayer, in this chapter, maps out the history of cultural psychiatry as a discipline. In addition, he raises concerns related to this discipline, especially to universality of psychopathology and healing practices, development of diverse service needs of black and ethnic minority groups and analysis of psychiatric theory and practice as products of a particular cultural history. Culture has been defined as a civilizing process which, in European history, Kirmayer asserts, had to do with the transformations from migratory groups to agrarian societies to city states and, eventually, nation states. The definition of culture in this context was related to standards of refinement and sophistication. The second definition of culture has to do with collective identity, which is based on historical lineage, language, religion, genetics or ethnicity. Kirmayer suggests that these two definitions have become conflated. The historical development of comparative psychiatry in colonial times and until the 1960s, when research across cultures used dimensions of distress, ignored local cultural practices and interpretation of these experiences. The role of racism in diagnosis and management of individuals with psychiatric illnesses has not entirely gone away. Large-scale migrations from east to west and north to south across the globe have raised questions about ethnocultural diversity. An organized and relative newcomer within the larger discipline of psychiatry, cultural psychiatry is becoming mainstream and beginning to influence health-service delivery and research.

Introduction

Cultural psychiatry stands at the crossroads of disciplines concerned with the impact of culture on behaviour and experience. It emerges from a history of encounters between people of different backgrounds, struggling to understand and respond to human suffering in contexts that confound the alien qualities of psychopathology with the strangeness of the cultural ‘other’. The construct of culture offers one way to conceptualize such differences, allowing us to bring together race, ethnicity and ways of life under one broad rubric to examine the impact of social knowledge, institutions and practices on health, illness and healing. Cultural psychiatry differs from the social sciences of medicine, however, in being driven primarily not by theoretical problems but by clinical imperatives. The choice of research questions and methods, no less than the interpretation of findings and the framing of professional practice, is shaped by this clinical agenda, which emphasizes the quest for therapeutic efficacy.

Over the course of its history, cultural psychiatry has been driven by three major sets of concerns: questions about the universality or relativity of psychopathology and healing practices; the dilemmas of providing services to ethnically diverse populations; and, most recently, the analysis of psychiatric theory and practice as products of a particular cultural history and as vehicles of globalization. These concerns correspond to three successive waves of development of the field from colonialist and comparative psychiatry, to the mental health of ethnocultural communities and indigenous peoples in settler societies, and the post-colonial anthropology of psychiatry.

The emergence and development of each of these themes in cultural psychiatry can be tied to major historical events, especially to global patterns of migration and their associated social, political and economic consequences (Castles et al., Reference Castles, de Haas and Miller2013; Papastergiadis, Reference Papastergiadis2000). From the mid 1700s onwards, colonialist expansion of European powers led to observations relevant to psychiatry and to occasional efforts to provide healthcare in distant lands. Large-scale migrations of Europeans to North America, Australia and other regions in the nineteenth and twentieth centuries prompted attention to the impact of ethnicity on mental health and illness. Successive wars made psychological reactions to stress and trauma a salient concern for psychiatry. The Great Depression and the emergence of the welfare state highlighted the impact of social class and poverty as causes of illness. The promulgation of scientific racism forced researchers and clinicians to clarify their thinking about ethnocultural difference. The flight of refugees and displaced peoples following World War II and later conflicts, led to renewed work both on trauma-related disorders and the adaptation of migrants (Murphy, Reference Murphy1955). The UN Universal Declaration of Human Rights in 1948 and emerging anti-colonialist struggles around the world challenged the hegemony of Western versions of history and opened up the consideration of alternative systems of knowledge on both ethical and epistemological grounds.

Most recently, new waves of migration from east to west and south to north have challenged models of culture and ethnicity developed for earlier groups of immigrants from relatively similar European countries (Castles et al., Reference Castles, de Haas and Miller2013). At the same time, increasing recognition of the historical injustices suffered by indigenous peoples has made their cultures a focus of attention both in terms of the damaging effects of forced assimilation and the potential for resilience in indigenous identity, community and healing practices (Cohen, Reference Cohen1999; Kirmayer et al., Reference Kirmayer, Simpson and Cargo2003). The growth of the Hispanic, Asian and other non-European populations in the USA, and the corresponding increase in the numbers of mental health professionals from diverse ethnocultural backgrounds, pressed for change both from without and within the profession, and this has been reflected in the attention to culture in official psychiatric nosology, with inclusion of an Outline for Cultural Formulation in DSM-IV and the Cultural Formulation Interview in DSM-5 (Alarcon, Reference Alarcon2001; American Psychiatric Association, 2013; Mezzich et al., Reference Mezzich, Kleinman, Fabrega and Parron1996; Lewis-Fernández et al., Reference Lewis-Fernández, Aggarwal, Hinton, Hinton and Kirmayer2015). Similar demographic changes are affecting most societies, and will continue to make cultural issues a matter of central concern for psychiatry in the years to come. At the same time, backlash against globalization and the dynamics of migration, the Internet and social media will continue to give new meanings to cultural identity and community.

The Uses of Culture

There are three broad but distinct uses of the term culture that are often conflated (Eagleton, Reference Eagleton2000; Kuper, Reference Kuper1999) and each has its reflection in the history of cultural psychiatry. Originally, ‘culture’ meant ‘cultivation’: the civilizing process which, in European history, had to do first with the move from migratory groups to agrarian societies (cultivating crops) and then to city states and larger political entities including nations and empires. Throughout this history, there was a progressive elaboration of codes of conduct and civility and the cultivation of specialized knowledge and power, initially the possession of elite social classes, but gradually accessible to others through formal education (Elias, Reference Elias1982; Gellner, Reference Gellner1988). Culture in this sense represents a standard of refinement or sophistication, measured against the cosmopolitan life of urban centres, the achievements of those with higher education, and the ‘high culture’ (with a capital ‘C’) of arts and letters. The view of culture as civilization has influenced thinking about psychopathology from Vico’s Renaissance views of culture as a civilizing force (Bergin and Fisch, Reference Bergin and Fisch1984). Early versions of this critiqued European society by contrasting it with the ‘natural’ qualities of the noble savage (Ellingson, Reference Ellingson2001); this took more dynamic form in Freud’s tragic view of the ego wrestling with conflicts of ‘instinctual’ desire and sociomoral constraint in Civilization and its Discontents (Freud, Reference Freud and Strachey1962). Western European civilization has tended to view itself myopically as the singular standard against which other traditions can be measured, and this hierarchical view of culture persists in characterizations of the contemporary world as a contest of great civilizations with incommensurable values and epistemologies (Huntington, Reference Huntington1996; Bettiza, Reference Bettiza2014).

A second meaning of culture has to do with collective identity, the setting apart of one group of people from another on the basis of historical lineage, language, religion, gender or ethnicity which may include membership in a community, regional group, nation or other historical people (Banks, Reference Banks1996). While the notion of culture as cultivation may be presented in terms of a universal system of values that can be attained by anyone allowed the opportunity to become ‘civilized’ (even if, in most instances, it depends on racialized or essentialized notions of identity that subvert this possibility), ethnocultural identity is local and particular, the property of groups that regulate its distribution along lines of historical descent, kinship, citizenship or other social markers of identity. Ethnicity is differently constructed in each society, and may merge with local notions of ‘race’, national identity or other invented traditions (Hobsbawm and Ranger, Reference Hobsbawm and Ranger1983). While ethnicity has been a source of positive identity, self-esteem and group cohesion, it has also fuelled discrimination, inter-group conflicts, social exclusion and genocidal violence.

The third notion of culture corresponds to its current use in anthropology as a way of life: the values, customs, beliefs, knowledge, institutions and practices that form a complex system (Kuper, Reference Kuper1999). As such, culture encompasses all of the humanly constructed and socially transmitted aspects of the environment. Cultural systems involve many levels of social organization including institutions, communities, families and local practices that cannot be reduced to the cultural models internalized by individuals. Much of culture resides in what might be called ‘affordances’, structured environments that provide opportunities for cooperative action (Kirmayer and Ramstead, Reference Kirmayer, Ramstead, Durt, Fuchs and Tewes2017). In the contemporary world, cultural affordances may be constituted both by local communities or ‘subcultures’ and transnational flows of knowledge and practice shared by groups of experts and professionals (Hannerz, Reference Hannerz1992, Reference Hannerz1996). Psychiatry itself is one such transnational cultural institution with national variants and subcultures (Ernst and Mueller, Reference Ernst and Mueller2010).

Comparative Psychiatry and the Legacy of Colonialism

The roots of cultural psychiatry can be traced to the very beginnings of modern psychiatry. Indeed, long before psychiatry emerged as a distinct medical specialty, examples of odd or deviant behaviour among distant peoples stimulated philosophical reflections on the uniqueness of humankind and the impact of the ‘civilizing process’ on human nature (Jahoda, Reference Jahoda1993). These early commentaries drew on travellers’ observations of foreign peoples who were culturally different, whether viewed as members of a different civilization or simply as undeveloped ‘barbarians’. This literature reveals an aesthetic fascination with the strangeness of the other that was often both morally and erotically charged (Segalen, Reference Segalen and Schlick2002). European explorers and colonizers generally took their own traditions to be the zenith of civilization, while others were seen as backward, primitive and uncivilized (Jahoda, Reference Jahoda1999; Gilman, Reference Gilman1985; Lucas and Barrett, Reference Lucas and Barrett1995; Todorov, Reference Todorov1993).

The taken-for-granted superiority of European civilization demanded that its institutions be established in the colonies, and asylum psychiatry was one of these exports. While attempting to care for suffering individuals, colonial psychiatry also served to justify and maintain the social order of colonial regimes (Bhugra and Littlewood, Reference Bhugra and Littlewood2001; Keller, Reference Keller2001, Reference Keller2005; McCulloch, Reference McCulloch1995; Sadowsky, Reference Sadowsky1999; Vaughan, Reference Vaughan1991). Colonial asylums became important sites for comparative studies of psychopathology. However, their status as colonizers and limited access to the everyday life of people outside hospitals and asylums made it difficult for the practitioners of colonial psychiatry to recognize the social and cultural context of patients’ afflictions. As local psychiatrists were trained and took over these institutions, possibilities emerged for innovative approaches to care based on local cultural values. The work of Thomas Adeoye Lambo at Aro village in Abeokuta, Nigeria was an important example of this ‘post-colonial’ turn, and his integration of traditional healers influenced international views of culture and community mental health through his tenure as Deputy Director General at the World Health Organization (Heaton, Reference Heaton2013).

In general, colonizers and alienists did not see large numbers of mentally ill persons and this prompted speculation about the protective effects of ‘primitive’ ways of life. The idea that insanity was rare among primitive or uncivilized peoples, as claimed by Jean-Jacques Rousseau, was popular among early writers in psychiatry including Esquirol, Moreau de Tours, Griesinger and Krafft-Ebing (Raimundo Oda et al., Reference Raimundo Oda, Banzato and Dalgalarrondo2005). Sometimes this notion of the ‘healthy savage’ was framed in terms of the protective effects of living a simple life with few demands, in contrast to the increasing expectations for productivity and consumption in the complex, urbanized, industrialized environment of Europe. An increase in nervousness was associated with the over-stimulation of modern civilization, especially for those required to do ‘brain work’, and hence the upper classes were seen as particularly prone to maladies like neurasthenia or nervous weakness – a diagnosis introduced by the American neurologist George Beard and taken up widely throughout Europe and East Asia (Beard, Reference Beard1869; Rabinbach, Reference Rabinbach1990). Over time, the living conditions of the poor in large cities, along with the impact of alcohol and a general erosion of traditional moral and religious values, were invoked to explain the apparent increase in mental disorders in urban settings.

Early studies in comparative psychiatry focused on the exotic in order to examine the universality of major psychiatric disorders. The psychiatric literature of the late 1800s and early 1900s was peppered with reports of ‘culture-bound syndromes’, e.g. pibloktoq, latah, amok, thought to be uniquely linked to cultural beliefs and practices (Simons and Hughes, Reference Simons and Hughes1985). These reports seemed to indicate the malleability of expression of psychopathology, captured in the distinction between pathoplasticity and pathogenesis (Yap, Reference Yap1952, Reference Yap1974). Major psychiatric textbooks usually devoted a chapter to exotic and culture-bound conditions. Unfortunately, early observers paid relatively little attention to the social context of the syndromes they were observing and describing.

For example, pibloktoq or ‘Arctic hysteria’, which was described in early accounts by explorers among the polar Inuit, became a stock example of a culture-bound syndrome. Anthropologists and psychiatrists have sought to link pibloktoq to specific features of Inuit child-rearing, social structure, religious practice, environment and nutrition (Brill, Reference Brill1913; Foulks, Reference Foulks1974; Gussow, Reference Gussow1960; Landy, Reference Landy1985; Wallace and Ackerman, Reference Wallace and Ackerman1960). Historian Lyle Dick (Reference Dick1995, Reference Dick2002) reviewed all available accounts of pibloktoq and found that the few detailed case descriptions came from Admiral Robert E. Peary’s visits to Greenland (c. 1982). There, on a few occasions, Inuit women were observed to become agitated and run out on the ice, stripping off their clothes, prompting others to restrain them until their agitation eventually subsided some hours later. This ‘hysterical’ behaviour seemed entirely inexplicable until Dick provided the missing context: Admiral Peary had sent these women’s menfolk out on exploratory missions at a time before solid ice, exposing them to great risk. The women presumably engaged in shamanistic prayer and magic to ensure the men’s safety. Peary also thought it important for the well-being of his crew that they have sexual companions and encouraged his men to take Inuit partners with little regard for existing relationships. Alcohol also played a role in these episodes. The women’s ‘erratic’ behaviour – watched with amusement by Peary’s men (as can be seen in a photograph reproduced as figure 6 in Dick Reference Dick1995: 21) – now seems less like evidence of a discrete culture-bound syndrome than a grimly familiar story of exploitation.

In another historical analysis, Marano (Reference Marano1983) showed how the culture-bound syndrome windigo, described among the Ojibway as the fear that one is possessed by a spirit that is turning one into a cannibal, probably never occurred as a behavioural syndrome, but was a part of a legend or mythological belief that could be used as an accusation to attack others. This accusation was effective not only in traditional society but served to mobilize the Royal Canadian Mounted Police as well, invoking a new form of social control available as a result of colonization. Once again, a phenomenon better understood in terms of power, conflict and social change was reified as a psychopathological entity located within individuals (Waldram, Reference Waldram2004). Similar historical accounts of behaviours like amok or latah suggest that adequate description of culture bound syndromes requires attention to the social context of power and the dynamics of protest and resistance (Kua, Reference Kua1991; Winzeler, Reference Winzeler and Karim1990, Reference Winzeler1995). Recognition of the importance of context, has led to a de-emphasis of culture bound syndromes in recent cultural psychiatry in favour of concepts (including idioms of distress and explanatory models) that focus on the pragmatic, social and communicative functions of local terminology (Lewis-Fernández, et al., Reference Lewis-Fernández, Aggarwal, Hinton, Hinton and Kirmayer2015).

This tendency to ignore social context also was characteristic of the comparative psychiatry (Vergleichende Psychiatrie) advanced by Emil Kraepelin (1856–1926), who visited Southeast Asia and Indonesia to study amok and examine the universality of major psychoses (Jilek, Reference Jilek1995). Kraepelin’s conclusion was that clinical phenomenology justified a qualified universalism. However, the differences he did find, he explained in terms of a developmental hierarchy:

Kraepelin viewed cultural differences as reflections of biological differences in races or peoples and effectively elided the social context of psychiatric illness (Roelcke, Reference Roelcke1997). His advocacy of theories of biological degeneration as a cause of mental disorder contributed to the rise of eugenic policies in Germany that culminated in the Nazi genocides.

While not adhering to Kraepelin’s biological essentialism, H. B. M. Murphy (1915–1987) at McGill University and Julian Leff at the Institute of Psychiatry in the UK identified themselves as heirs to the tradition of comparative psychiatry and used both clinical observations and epidemiological methods to make systematic cross-cultural comparisons. Although they eschewed the sort of colonialist thinking and social Darwinism that plagued earlier writing, both invoked developmental hierarchies in their explanations of certain cultural differences. Murphy (Reference Murphy1982) contrasted ‘traditional’ and ‘modern’ societies and Leff (Reference Leff1981) argued for a progressive differentiation of the emotion lexicon in Indo-European languages with contemporary British English as the most differentiated (for a critique, see Beeman, Reference Beeman, Kleinman and Good1985).

Much of the innovative work of Alexander Leighton and Jane Murphy (Leighton, Reference Leighton1981; Murphy and Leighton, Reference Murphy and Leighton1965) in Africa, Alaska and rural Nova Scotia also falls under the rubric of comparative psychiatry, although they employed dimensional measures of distress and, owing to their anthropological training, were interested in the impact of social and cultural context on mental health and illness. Despite this ethnographic orientation, Jane Murphy’s (Reference Murphy1976) influential paper arguing for the universal recognition of psychotic symptoms across diverse cultures did not consider the impact of colonial history on attitudes toward psychosis in the African and Alaskan communities she studied (Sadowsky, Reference Sadowsky1999).

The ‘neo-Kraepelinian’ revolution of DSM-III in 1980 introduced operationally defined discrete diagnostic categories in place of dimensional or narrative descriptions of psychiatric disorders (Wilson, Reference Wilson1993). With this new nosology and the accompanying technology of highly structured diagnostic interviews, comparative psychiatry followed the rest of the discipline, abandoning in-depth ethnographically informed studies in favour of research organized around discrete diagnostic categories. This line of research has culminated in a series of important cross-national studies of the prevalence, course and outcome of major psychiatric disorders including the International Pilot Study of Schizophrenia (IPSS; World Health Organization, 1973; Leff et al. Reference Leff, Sartorius, Jablensky, Korten and Ernberg1992), the Determinants of Outcome Study (Sartorius et al., Reference Sartorius, Jablensky and Korten1986), the WHO Collaborative Study on Standardized Assessment of Depressive Disorders (World Health Organization, 1983), and the International Consortium of Psychiatric Epidemiology (e.g. Andrade et al., Reference Andrade, Caraveo-Anduaga and Berglund2003). Successive generations of studies have used more refined measures, particularly standardized diagnostic interviews, most recently the Composite International Diagnostic Interview (Robins et al., Reference Robins, Wing and Wittchen1989). However, these instruments continue to have limitations when used across cultures and methodological artifacts have not been eliminated (Hicks, Reference Hicks2002; van Ommeren et al., Reference Van Ommeren, Sharma, Makaju, Thapa and de Jong2000). As well, most epidemiological studies have made little provision to identify culture-specific symptoms not included in the core definitions of disorders. In this way, the diagnostic categories of psychiatry bury the traces of their origins in European and American cultural history and become self-confirming ‘culture-free’ commodities ready for export.

Another important line of work in comparative psychiatry has centred on the effectiveness of traditional or indigenous healing practices (Kiev, Reference Kiev1969; Marsella and White, Reference Marsella and White1982; Rivers, Reference Rivers1924). Drawing from a rich ethnographic literature on healing rituals, Jerome Frank (Reference Frank1961), Raymond Prince (Reference Prince, Triandis and Draguns1980) and others argued that psychotherapy shares essential features with traditional healing and that both could be understood in terms of symbolic action at social, psychological and physiological levels. This work has become increasingly important as efforts are made to integrate or coordinate the activity of mental health practitioners and traditional or indigenous healers in many societies.

Cultural Essentialism and Racism in Psychiatry

A central feature of most colonial enterprises was the use of racist concepts and ideologies to justify the subordination and exploitation of colonized peoples (Fredrickson, Reference Fredrickson2002). Though they have no clear foundation in biology, notions of race serve to mark off particular groups as intrinsically different and less than other human beings (Lock, Reference Lock1993). Psychiatry itself has been used to buttress racist perspectives (Littlewood, Reference Littlewood1993). The notion that southern or non-Western peoples had underdeveloped frontal lobes and hence were prone to disinhibited behaviours was promoted by several generations of neuropsychiatrists, both to explain cross-national differences and to account for inequalities within colonized nations that actually reflected the legacy of racism, slavery and economic marginalization. For example, influenced by Lucien Lévy-Bruhl’s notion of primitive mentality, Antoine Porot, the head of the École d’Alger, argued that the native Algerian’s mind was structurally different from that of the civilized European (Lévy-Bruhl, Reference Lévy-Bruhl1923; Porot Reference Porot1918; Begue, Reference Begue1996). This biological essentialism was matched by a complete disregard of social, cultural and political context that served colonial interests. This sort of essentialism persisted into the 1950s in the work of J. C. Carothers on the African mind. For Carothers, the African was developmentally child-like owing to underdeveloped frontal lobes that result in an effective leucotomy (Carothers, Reference Carothers1953; McCulloch, Reference McCulloch1993, Reference McCulloch1995). A whole generation of African psychiatrists was educated with texts containing this tendentious account.

Of course, there were also essentializing accounts of cultural difference presented in psychological terms. In Prospero and Caliban (Reference Mannoni1990; originally published in French in 1948), French intellectual Octave Mannoni described the people of Madagascar as primitive, and uncivilized, with a fundamentally different mentality based on a ‘dependency complex’ that protected them from the neurotic conflicts that were the burden of Europeans. Although Mannoni later developed a more nuanced account of the psychology of colonization, with Lacan displacing Adler in his psychodynamic theorizing, his earlier portrait remained a provocation to others seeking to understand and escape from the colonization of the psyche that accompanied political domination (Lane, Reference Lane2002).

The migration of North African workers to France after 1945 stimulated French psychiatrists’ interest in cultural difference and gave rise to the field of ethnopsychiatry (Fassin and Rechtman, Reference Fassin and Rechtman2005). Thus, the study of ethnic diversity in colonizing societies was closely linked with the history of colonial comparative psychiatry. At the same time, there was the growing recognition that the colonial context itself was one of exploitation and stress that could account for some of the suffering and symptomatology seen in clinical contexts.

Frantz Fanon (1925–1961) was an important voice in this critique of the colonial origins of psychopathology (Gordon, Reference Gordon2015; Macey, Reference Macey1996; Razanajao et al., Reference Razanajao, Postel and Allen1996). Fanon denounced the theories of the École d’Alger, which he saw as based on a colonial perspective with racist devaluing of the values, traditions and autonomy of others. In Peau noire, masques blancs (1982; originally published in 1952), Fanon powerfully portrayed the self-alienating effects of racism and colonialism. Fanon’s account of the psychopathology of colonialism echoed the earlier account by the sociologist W. E. B. Du Bois (1868–1963) in The Souls of Black Folk on the ‘double consciousness’ of African Americans (Du Bois, Reference Du Bois1989). Fanon worked in the space between the political and the psychological – insisting on the primacy of politics and power, but showing how it was inscribed in the psychological and how change could come from within and without (Vergès, Reference Vergès, Gordon, Sharpley-Whiting and White1996). Ultimately, however, Fanon was less interested in the dynamics of culture and colonialism than in the struggle for political revolution and fell prey to the same tendency to essentialize cultural difference that plagued writers less aware than he was to the violence of racial stereotypes.

The process of unpacking the impact of racism and colonialism on the psychology of the colonizer and colonized is far from complete, the more so because the forms that oppression takes continue to mutate. This has been one focus of post-colonial theory, which offers a rich array of ideas about identity and alterity in the contemporary world that has as yet had little impact on cultural psychiatry (Bhabha, Reference Bhabha1994; Chakrabarty, Reference Chakrabarty2000; Gunew, Reference Gunew2003; Lazarus, Reference Lazarus2011; Said, Reference Said1994).

Ethnocultural Diversity: Settler Societies and Indigenous Peoples

The large migrations of Europeans to North America, Australia and other countries from the 1700s onwards created settler societies with high levels of ethnocultural diversity. This experience of people from many different national and regional backgrounds living side by side made ethnicity salient (Banks, Reference Banks1996). Epidemiological studies conducted from the 1930s onwards documented differential rates of psychiatric hospitalization for ethnocultural groups (Westermeyer, Reference Westermeyer1989). Of course, this difference reflected help-seeking and pathways to care more than population base rates. Subsequent waves of migration following World War II and other conflicts made the mental health needs of immigrants and refugees increasingly important in most psychiatric settings and led to a substantial literature on ethnic differences in illness behaviour.

The response to ethnic diversity has followed different trajectories in different countries owing to the history of colonization and migration but also following local ideologies of citizenship and dominant theories within psychiatry itself (Kirmayer and Minas, Reference Kirmayer and Minas2000; see for example, Bäärnhielm et al., Reference Bäärnhielm, Ekblad, Ekberg and Ginsburg2005; Beneduce and Martelli, Reference Beneduce and Martelli2005; Fassin and Rechtman, Reference Fassin and Rechtman2005; Fernando, Reference Fernando2005). Thus, the US and France share republican values of egalitarianism that imply that all citizens should be treated the same, with no regard to their cultural background (Todorov, Reference Todorov1993). Along with this came the assumption that, over time, ethnic groups would assimilate and acquire the cultural identity and practices of the dominant society. In fact, ethnicity has persisted in most settler societies despite pressure to assimilate. In the US, the egalitarian ideal has been complicated by the history of slavery and racial discrimination against African Americans and other groups. The current language of culture refers to ‘diversity’, defined in terms of ethnoracial blocs (Hollinger, Reference Hollinger1995), but this diversity is recognized mainly insofar as it is associated with health disparities (Smedley et al., Reference Smedley, Stith and Nelson2003). In Canada and Australia, the ideology of multiculturalism has encouraged explicit attention to ethnic difference as a positive social value that warrants direct support by the state (Kivisto, Reference Kivisto2002). At other moments, and in other societies, ethnicity has been profoundly divisive and, along with biologically essentialized notions of race, served as an incitement to violence and genocide (Fredrickson, Reference Fredrickson2002; wa Wamwere, Reference wa Wamwere2003).

In Britain, cultural psychiatry has focused more on issues of race than on culture or ethnicity because of the conviction that racism is a crucial determinant of mental health and of the adequacy of psychiatric services (Fernando, Reference Fernando1988; Littlewood and Lipsedge, Reference Littlewood and Lipsedge1982). African Caribbean immigrants have been observed to have high rates of schizophrenia. This phenomenon, which affects some other migrant groups in other countries as well, does not appear to be due to diagnostic biases but may result from the stresses of marginalization, discrimination and social exclusion (Hutchinson and Haasen, Reference Hutchinson and Haasen2004; Kelly, Reference Kelly2005; Veling, Reference Veling2013).

Recognition of the importance of culture, ethnicity and race has been prompted by demographic and political changes in settler countries, sometimes crystallized by specific confrontations or violent events that have commanded public attention. In the UK the death of Stephen Lawrence increased public awareness of issues of racism and social exclusion and prompted a government inquiry that led to changes in policy, with attention being directed to counter racism in institutions including health services (Fernando, Reference Fernando2003). In Canada, the Oka Crisis of 1990 (York and Pindera, Reference York and Pindera1991) led to the reports of the Royal Commission on Aboriginal Peoples and the establishment of the Aboriginal Healing Foundation to provide support for projects to address the legacy of the residential school system (Kirmayer, Simpson and Cargo, Reference Kirmayer, Simpson and Cargo2003). A Truth and Reconciliation Commission concluded that Canada had committed cultural genocide and called for wide ranging efforts to acknowledge and support indigenous peoples’ identity and communities.Footnote ¹ However, much of the response to cultural diversity has been at the grassroots level with minimal governmental support (Fernando, Reference Fernando2005). At the same time, subtler forms of racism and social exclusion continue to go unmarked and unchallenged (Gilroy, Reference Gilroy2005; Holt, Reference Holt2000).

Anthropology of Psychiatry

The revolution in philosophy of science provoked by the work of Thomas Kuhn made biomedicine and psychiatry appear not so much universal truths as culturally constructed bodies of knowledge. Post-colonial writing challenged the taken-for-grantedness of Euroamerican values. The antipsychiatry ‘movement’ of the 1960s (Boyers, Reference Boyers1974) and the labelling theory of mental illness (Rosenhan, Reference Rosenhan1973; Scheff, Reference Scheff1974) drew attention to the social and political dimensions of psychiatric diagnosis. Historical accounts showed the ways in which psychiatric notions of madness emerged from and helped to maintain core cultural values (Ellenberger, Reference Ellenberger1970; Foucault, Reference Foucault1965; Micale and Porter, Reference Micale and Porter1994; Porter, Reference Porter1988). Within mainstream psychiatry itself, the US–UK Diagnostic Project (Cooper et al., Reference Cooper, Kendell, Gurland, Sharpe, Copeland and Simon1972) revealed important differences in the practice of British and American psychiatrists, with overdiagnosis of schizophrenia and underdiagnosis of bipolar disorder in the US. Subsequent efforts to improve the reliability of diagnostic practice in the US contributed to the emergence of DSM-III (Wilson, Reference Wilson1993). These and other social changes encouraged a more self-reflective stance and led anthropologists to consider biomedicine and psychiatry as cultural institutions (Good, Reference Good1994; Kleinman, Reference Kleinman1988; Lock and Gordon, Reference Lock and Gordon1988). The anthropology of psychiatry developed a substantial body of literature showing how psychiatric practices draw from and contribute to cultural concepts of the person and experiences of the self (Gaines, Reference Gaines1992; Kleinman, Reference Kleinman1995; Young, Reference Young1995). The third phase in the history of cultural psychiatry is strongly influenced by this turn toward cultural analysis and critique of the institutions and practices of psychiatry itself.

The seminal figure in this body of work has been Arthur Kleinman (Reference Kleinman1977, Reference Kleinman1980, Reference Kleinman1986, Reference Kleinman1988, Reference Kleinman1995), who, through his incisive writing, vision and leadership, has stimulated a whole generation of scholars. The ‘new cross-cultural psychiatry’ introduced by Kleinman (Reference Kleinman1977) argued for a renewed emphasis on ethnographic research. Rather than assuming the universality of psychiatric categories and psychological modes of expressing distress, Kleinman insisted on paying close attention to the social and cultural context of suffering and healing. This approach could be applied equally well across cultures and within the institutional and community settings of Western psychiatry.

Kleinman introduced the notion of the category fallacy, the erroneous assumption that conceptual categories that work well in one cultural context will have the same meaning and utility in another. In cultural psychiatry this is most obvious in questions about the meaning of psychiatric diagnostic categories. A further epistemological complexity arises from what the philosopher Ian Hacking (Reference Hacking1999) has called ‘the looping effect of human kinds’ – that is, the tendency for the ways we categorize the world to become reified and institutionalized as cognitive and social facts.

The importance of these ideas for cultural psychiatry can be seen in the history of the emergence of diagnostic categories like post-traumatic stress disorder (Young, Reference Young1995) and dissociative disorders like multiple personality or fugue (Hacking, Reference Hacking1995, Reference Hacking1998). Psychiatric knowledge and practice reflect and reshape folk psychologies (Gaines, Reference Gaines1992; Littlewood, Reference Littlewood2002; Nuckolls, Reference Nuckolls1992). For example, the reception and evolution of psychoanalysis and other forms of psychotherapy in different countries provides a window onto cultural concepts of the person (Cushman, Reference Cushman1995; Ellenberger, Reference Ellenberger1970; Rose, Reference Rose1996; Shamdasani, Reference Shamdasani2003; Zaretsky, Reference Zaretsky2004). The broad shift away from psychoanalysis and toward biological accounts in the US in the 1980s reflects tensions within the discipline of psychiatry as well as larger political and economic forces (Luhrmann, Reference Luhrmann2000). Psychopharmacology has played a crucial role in the development of psychiatry, driving diagnostic nosology and clinical practice (Healy, Reference Healy2002). A growing body of research shows the role of the pharmaceutical industry in controlling the production of clinical ‘evidence’, establishing clinical guidelines, and influencing popular conceptions of mental illness, which now extends to marketing new disorders (Lakoff, Reference Lakoff2005; Metzl, Reference Metzl2003; Petryna et al., Reference Petryna, Lakoff and Kleinman2006; Cosgrove and Wheeler, Reference Cosgrove and Wheeler2013).

Psychiatric theory and practice are embedded in larger social and cultural systems. Understanding the impact of these systems on patients’ lives and psychiatric practice demands critical and social science perspectives. A growing body of work in critical neuroscience examines the social origins and implications of the increasing reliance on neurobiology in psychiatry (Choudhury and Slaby, Reference Choudhury and Slaby2011; Rose and Abi-Rached, Reference Rose and Abi-Rached2013). Of course, the attempt to apply social science perspectives to analysing psychiatric practice raises the problem of self-reflexivity, since social science theory itself is a product of the society it seeks to critique. Indeed, the notion of culture is also a cultural construction that changes with new configurations of society and geopolitical concerns.

The Contribution of Psychological Anthropology

Cultural psychiatry derived some of its early theoretical models from the various schools and approaches of psychological anthropology that link individual personality with broader social processes, particularly culturally shaped child-rearing practices (Bock, Reference Bock1999; Spindler, Reference Spindler1978). Franz Boas (1858–1942), often called the father of American anthropology, argued that culture could affect personality and behaviour by amplifying or suppressing certain traits, thus creating conflicts for different individuals. In the 1930s, ‘culture and personality’ researchers (notably Ruth Benedict and Margaret Mead) attempted to relate social structure, child-rearing and other cultural life-ways to modal national characters and specific patterns of psychopathology within groups (Spindler, Reference Spindler1978; Stocking, Reference Stocking1986). They used mainly ethnographic observations and borrowed psychodynamic theory or learning theory to explain the links between individual and culture.

For Benedict, Mead and later contributors to the field of culture and personality, psychopathology could be understood in part as an exaggeration of cultural traits or as a mismatch between individual personality and overarching cultural norms and values. This tradition enjoyed a period of prominence during and after World War II when studies of ‘nations at a distance’, based on interviews with small numbers of emigrés and analysis of media, were used as a form of military intelligence (e.g. Benedict, Reference Benedict1934).

Benedict (Reference Benedict1934) saw culture as personality writ large. Anthropologist Edward Sapir rejected this view, arguing that culture had no reality beyond the actions and representations of individuals, each of whom responds differently to social exigencies. Sapir was a close colleague of psychiatrist Harry Stack Sullivan and looked to psychiatry to provide a way of understanding culture through the vicissitudes of individual biographies (Sapir, Reference Sapir1938; Kirmayer, Reference Kirmayer2001). This approach led to more theoretically sophisticated accounts of the interplay of culture, social structure and character, notably in the work of A. I. Hallowell (Reference Hallowell1955), but the field of culture and personality waned in the late 1950s owing to the failure to develop more rigorous methodology and a tendency to caricature whole societies with broad strokes (Levine, Reference Levine2001).

A parallel tradition in psychological anthropology has used clinical psychoanalytic methods and perspectives to study individuals cross-culturally (Devereux, Reference Devereux1961, Reference Devereux1979; Kardiner and Linton, Reference Kardiner and Linton1939; Delille, Reference Davies2016). In these various forms of ‘ethnopsychoanalysis’, the emphasis has been on examining the universality of psychodynamics and considering the ways in which these psychological mechanisms might resolve dynamic tensions created by particular social systems. In-depth interviews, prolonged relationships with subjects and attention to ‘clinical material’ including psychopathological symptoms, dreams, fantasies and ‘transference’ distortions, all contributed to the effort to characterize the psychic interior cross-culturally. A nuanced attempt to integrate cultural identity and psychoanalytic ideas was developed in the work of the Department of Psychiatry at the Fann Hospital of the University of Dakar in Senegal in the 1960s. Under the direction of Dr Henri Collomb (who remained chief until 1978), a group of clinicians and researchers undertook careful empirical studies on the interface of Senegalese culture and Western psychiatry (Bullard, Reference Bullard2005; Collignon, Reference Collignon1978). There is a rich literature based on clinical experiences with psychoanalytic theory and methods that offers insights into the cultural logic of diverse traditions, increasingly conducted by clinicians who can integrate psychodynamic perspectives with their own intimate cultural knowledge (e.g. Crapanzano, Reference Crapanzano1973; Doi, Reference Doi1973; Kakar, Reference Kakar1978; Levy, Reference Levy1978; Obeyesekere, Reference Obeyesekere1981, Reference Obeyesekere1991).

In contrast to the case study approach of ethnopsychoanalysis, the field of cross-cultural psychology has employed quantitative statistical methods to compare personality and psychopathology in different cultural or national groups. Despite its origins in German social psychology (Hogan and Tartaglini, Reference Hogan, Tartaglini, Adler and Gielen1994; Jahoda, Reference Jahoda1993), cross-cultural psychology has been dominated methodologically by Anglo-American empiricism and conceptually by an individualistic cultural concept of the person (Kim and Berry, Reference Kim and Berry1993; Marsella et al., Reference Marsella, DeVos and Hsu1985). This cultural concept is taken over from American folk psychology and supports a large body of research that is generally presented as universal truths about the human psyche. The recent movement for indigenous psychologies attempts to reformulate basic models of personality from alternative perspectives, emphasizing, for example, the centrality of relationships with others in the dynamics of the self (Ho et al., Reference Ho, Peng, Lai and Chan2001).

Another strand in the development of psychological anthropology relevant to cultural psychiatry has its roots in the early ethnographic work of W. H. R. Rivers (1864–1922), who emphasized the rationality and potential efficacy of healing practices in the Melanesian and other societies he studied (Rivers, Reference Rivers1924). As a leading figure in both anthropology and psychiatry, Rivers used a variety of models to understand psychopathology and healing, but was most invested in psychological explanations that could be connected to an evolutionary biology (Young, Reference Young1993; Reference Young1999). Gregory Bateson (1904–1980) followed the direction of Rivers’ work, incorporating psychological notions from Benedict and Mead, but approaching mind with biological metaphors (Bateson, Reference Bateson1972). Bateson challenged the static view of culture in early British social anthropology by developing a ‘cybernetic’ approach to culture as a dynamical system (Stagoll, Reference Stagoll2005; Wardle, Reference Wardle1999). In the 1950s and 1960s, Bateson’s ideas about communication, interaction and the ‘ecology of mind’ had tremendous influence on the emerging field of family therapy.

Psychological anthropology has had a renaissance in recent decades with an increasingly eclectic range of theories brought to bear on understanding personality, identity, and psychopathology (Good, Reference Good, Schwartz, White and Lutz1992). Most recently, contemporary versions of cognitive, social and developmental psychology, and social neuroscience have provided models for the interplay of culture and psychology (Casey and Edgerton, Reference Casey and Edgerton2005; Hinton, Reference Hinton1999; Shore, Reference Shore1996; Shweder, Reference Shweder1991; Sperber, Reference Sperber1996; Stigler et al., Reference Stigler, Shweder and Herdt1990; Strauss and Quinn, Reference Strauss and Quinn1997). This work is concerned with understanding culture in terms of discourse, interpersonal interaction and socially distributed knowledge, and makes links with cognitive science and discursive psychology (Kirmayer, Reference Kirmayer2006; Kirmayer and Ramstead, Reference Kirmayer, Ramstead, Durt, Fuchs and Tewes2017).

A Fourth Wave? Cultural Psychiatry in the Anthropocene

Recent events suggest we are on the cusp of a fourth wave in the history of cultural psychiatry. In part, this reflects the changing meanings of culture brought on by globalization and the pervasive impact of the Internet and social media. Information and telecommunication media made new forms of community possible by linking distant individuals in real time. This can give rise to new forms of pathology (like ‘Internet addiction’), forms of social support and networks that may help or exacerbate particular mental health problems as well as pointing toward new strategies for prevention and intervention (Kirmayer et al., Reference Kirmayer, Raikhel and Rahimi2013).

Globalization has reduced some economic inequalities but amplified others – and we now face a world in which inequalities within and between countries are likely to accelerate (Milanovic, Reference Milanovic2016). Recognition of the enormous disparities in mental health across the globe has given new impetus to efforts to make mental health a higher priority in global development, as advocated by the Movement for Global Mental Health (Patel, 2014). Efforts to provide mental health services for the majority of the world population acknowledges the importance of cultural and contextual adaptation but usually assume that current diagnostic and treatment methods of psychiatry are adequate to the task. The history of cultural psychiatry provides some reasons for caution and urges on us a more serious engagement with diversity and with the power structures that privilege the interests of wealthy countries and corporations (Kirmayer and Pedersen, Reference Kirmayer and Pedersen2014).

Finally, theories of globalization have emphasized the role of economic systems but a broader perspective would approach health in terms of our planetary ecosystems (Whitmee et al., Reference Whitmee, Haines and Beyrer2015). Geologists have proposed that we have entered the Anthropocene, a new epoch characterized by the human reshaping of our planet on a large scale (Davies, Reference Davies2016). In the years to come, urbanization, climate change, and forced migration will challenge our concepts of culture, community and mental health in ways that will demand rethinking the concepts of cultural psychiatry (Kirmayer et al., Reference Kirmayer, Lemelson and Cummings2015).

Conclusion: a World in Flux

As an organized field within the larger discipline, cultural psychiatry has a relatively short institutional history. A section of transcultural psychiatry was established in 1955 at McGill University by Eric Wittkower and Jacob Fried (Reference Wittkower and Fried1959). At the Second International Psychiatric Congress in Zurich in 1957, Wittkower organized a meeting attended by psychiatrists from 20 countries, including many who became major contributors to the field: Tsung-Yi Lin (Taiwan), Thomas A. Lambo (Nigeria), Morris Carstairs (Britain), Carlos Alberto Seguin (Peru) and Pow-Meng Yap (Hong Kong) (Prince, Reference Prince2000). The American Psychiatric Association established a Committee on Transcultural Psychiatry in 1964, as did the Canadian Psychiatric Association in 1967. H. B. M. Murphy of McGill founded the World Psychiatric Association Section on Transcultural Psychiatry in 1970. By the mid 1970s transcultural psychiatry societies were set up in England, France, Italy and Cuba (Cox, Reference Cox1986). The World Association for Cultural Psychiatry was founded in 2005. The major journals in the field, Transcultural Psychiatry (formerly Transcultural Psychiatric Research Review), Psychopathologie Africaine, Culture Medicine and Psychiatry and Curare, began in 1956, 1965, 1977 and 1978, respectively.

Over the last 60 years, the discipline has grown from a marginal field, concerned mainly with folklore, exotica and the distant cultural ‘other’, to a dynamic research and clinical enterprise of crucial importance in the light of increasing migration, globalization, cultural intermixing and new insights from social and cultural neuroscience (Seligman et al., Reference Seligman, Choudhury, Kirmayer, Chiao, Turner, Li and Seligman2015). Over this same period of time, both the meanings of culture and the dominant theory and modes of practice of psychiatry have changed substantially in ways that have reshaped the field of cultural psychiatry.

Despite this progress, there is a persistent legacy of colonialism in contemporary cultural psychiatry that can be seen in the continuing romance with exoticism, the de-contextualized view of mental health problems and focus on culture-bound syndromes, efforts to reify and essentialize culture as individual traits, and the tendency to employ developmental hierarchies contrasting traditional and modern societies. The corrective to these biases requires thinking about culture as a dynamic process of creativity and contestation among individuals participating in different ways of life, with issues of power and agency always at stake.

Wittkower adopted the term ‘transcultural’ to imply moving through and beyond cultural barriers (Wittkower and Rin, Reference Wittkower and Rin1965). Others have preferred to call the field ‘cultural psychiatry’ to indicate that all human experience is culturally constituted and that we can examine cultural meanings in a single society as well as comparatively (Prince, Reference Prince1997). In the context of globalization, ‘transcultural’ takes on new meaning based on the recognition that cultures are always mixed or creolized, giving rise to new forms (Glissant, Reference Glissant and Wing1997; Kraidy, Reference Kraidy2005). Many urban settings now present a sort of ‘hyperdiversity’ in which many different groups co-exist and hybrid forms of identity abound. Transcultural psychiatry must explore the significance for mental health and illness of various forms of cultural hybridity at both social and individual levels (Bibeau, Reference Bibeau1997).

Among the central questions for contemporary cultural psychiatry are the nature of the interaction of psychopathological processes and cultural idioms of distress in the genesis and course of disorders; the specific mechanisms of action of socio-cultural factors on the course of schizophrenia and other disorders; the range of cross-cultural applicability of psychopharmacological, psychotherapeutic and psychosocial interventions – both those derived from biomedicine and those of indigenous origin; and the impact of emerging practice models and healthcare systems that aim to provide culturally sensitive or responsive care across cultures and within culturally diverse settings. To do this, cultural psychiatry must consider how local clinical and research practices reproduce larger gender, class and other social differences of the dominant society.

In addition to these enduring concerns, new issues are emerging. Psychiatry has been enjoined to play a role in conflict resolution and rebuilding communities torn apart by ethnic violence (Kirmayer, Reference Kirmayer2010). Cultural psychiatry itself has been co-opted by pharmaceutical companies seeking strategies to open up new markets for their products (Kirmayer, Reference Kirmayer2006). Clinical trials for new drugs are now taking place in the developing economies of Eastern Europe and South Asia, raising important questions about the role of culture in psychopharmacology. At the same time, the changing configurations of the world system – through migration, ethnic nationalism, ethnogenesis, globalization, telecommunications and the growing web of the Internet with its communities and identities forged in cyberspace – require us to rethink the nature of culture. These social changes directly impact on health and raise fundamental questions, not only of a scientific nature but also with an ethical or sociomoral dimension that concerns the value of diversity versus integration, of sameness and difference, and the implications for mental health and illness of cultural pluralism and the dramatically enlarged scale of community and malleability of identity made possible by new technologies. The creative potential of cultural pluralism will be an essential resource in the years to come as we face the challenges of the growth of political extremism and the crisis of climate change.