To what extent are mental illnesses the product of human culture? Western practices have ensured that psychiatrists are now able to recognise disorders consistently worldwide. Nevertheless, this "culture-blind" approach, which denies the importance of ethnicity and culture in psychiatry often in favour of biological uniformity, is problematic. There is no doubt that culture dictates behavioural normality and deviance. It influences the self-perception of both the doctor and the patient, shaping their understanding of shared issues and defining how these issues are communicated. Dr Mario Hernandez and others have argued that culture directly influences what is defined as a problem and how it is understood. [1] Similarly, Michel Foucault critiqued psychiatry by portraying it as a form of social control. In his eyes, mental illnesses were constructed by society as labels that enabled the 'norm' to marginalise the 'deviant.' [2]
This essay examines two case studies of how culture shapes and influences perspectives on mental disorders, as well as one criticism of this approach. Firstly, the essay will investigate how Western superiority impacted the inaccurate outcomes of depression diagnoses in British colonial Nigeria and Kenya. Additionally, attention will be directed towards unravelling the roots of Chinese madness, intricately tied to its belief systems and social structure, as elucidated by Western psychiatry during the nineteenth and twentieth centuries. In essence, this essay explores the impact of culture on mental illnesses, highlighting its pivotal role in their production and conceptualization.
In discussing cultural influences on mental illness, it is crucial to recognize the broad scope of the term 'culture,' encompassing beliefs, norms, and values that give rise to shared meanings among diverse groups. [3] Their perceptions of reality and behaviours are profoundly shaped by these attributes. Furthermore, it is important to note that the cases examined in this essay and the conclusions drawn from them do not universally represent all of humanity. Variations may arise based on the specific location and period under consideration.
The emergence of psychiatry as a medical speciality in nineteenth-century Europe played a pivotal role in shaping its perspectives and establishing recognized norms. Psychiatry developed within a philosophical context that underscored the separation of mind and body, known as substance dualism, first introduced in the seventeenth century by Rene Descartes, and the importance of the scientific method. [4] While most cultures blended the “supernatural” and the “natural,” the Western approach diminished the validity of spirituality in medicine. Concurrently, racist ideologies became intertwined with psychiatry. Charles Darwin's theory of the continuous evolution of species, outlined in his 1859 work On the Origin of Species, and his concept of natural selection, fostered the belief in the supposed superiority of white races, particularly those of European descent.[5] Darwinism provided an excuse for racial hierarchies based on scientific reasoning, in keeping with Western society's preference at the time. [6] The expansion of European powers, asserting colonial dominance over Asia and Africa, further solidified and reinforced these ideologies.
Thus, through the Darwinian idea of evolution, the myth of white superiority became synonymous with the perceived superiority of the Western psyche, that is, the Western "mind". At the start of the twentieth century, Sigmund Freud introduced a new perspective on the human mind, conceptualising it as composed of three components within the human psyche. Freud distinguished the id, the ego, and the superego. The id oversaw basic and immediate desires, the ego was more strategic, securing satisfaction long-term, and lastly, the superego, the only one learned from society, was a repressive part that strived for perfection, internalising feelings and desires, becoming the source of shame or guilt. [7]Though these theories were not originally intended as a foundation for racial discourse, it is pertinent to revisit them for this essay.
Depression in 19/20th century colonial Africa
In 1835, James Prichard asserted that insanity in "savage" states, such as African and Native American tribes, was extremely rare, if not unknown. [8] In his view, the phenomenon of mental illness originated with civilization, a quality that, in his belief, these tribes did not possess. [9] Similarly, John C. Carothers in his Study of Mental Derangements in Africans […] (1947), offered cultural explanations for the apparent absence of depression in Africa. In Kenya, Carothers observed patients at the Mathari Mental Hospital and attributed their perceived absence of insanity to a relative lack of socio-economic pressures experienced by Kenyans and Africans compared to Europeans. [10] According to Carothers, “African culture” did not necessitate self-reliance, personal responsibility, or initiative. [11] Africans were said to be predisposed to attribute blame to external factors and place responsibility externally rather than internally. [12]
Carothers' assertions influenced his assessment of depression, which he considered non-existent or "genetically absent." Despite exhibiting similarities to typical depression, many people were diagnosed with manic-depressive psychosis instead of depression. [13] Carothers dismissed the concept of unnoticed depression and instead attributed the “unusual” behaviours to a lack of personal responsibility, and with it an absence of guilt, regret, and foresight. [14] In alignment with Freudian id, ego, and superego theory, the assertion arose that if Africans lacked experiences of guilt or shame and did not internalize their emotions, their superego, responsible for regulating emotions, was purportedly underdeveloped. Consequently, this reasoning suggested an inferiority in the psyches of Africans compared to Westerners. Concurrently, depression came to be perceived as a "civilized" illness, affecting only populations adhering to European principles.
Carothers' "absence" of depression in African communities has been discredited by the argument that he simply did not encounter depressed Nigerians. It is crucial to underscore that his studies were conducted on individuals who were admitted to Mathari Mental Hospital and certified as insane. Gaining admission to this institution was not easily attainable for all peoples exhibiting mental health issues. For a patient to be classified as "insane," the procedure involved a 14-day detainment period for comprehensive observation under the purview of a magistrate. After this period, medical officers determined the individual's mental state, discerning whether it fell within the spectrum of sanity or insanity. [15] Those who were placed in hospitals and asylums, facilities intended for the confinement of individuals considered dangerous or violent, were the ones who demonstrated overtly aggressive and disruptive behavioural patterns. Conversely, individuals experiencing depression would likely have undergone traditional healing practices within their homes and communities, a dimension overlooked by colonial psychiatry. [16] Moreover, the Western psychiatry of the twentieth century necessitated the internalization of aggression and self-deprecation for the diagnosis of depression. [17] By denying that Africans experienced those feelings in the first place, colonial psychiatrists found justification to question the existence of depression in Africa.
In contrast to colonial perceptions, depression was significantly more prevalent. The twentieth-century Nigerian psychiatrist Thomas Adeoye Lambo, attributed these misleading reports to widespread misclassifications and a failure to understand typical symptoms in African patients. This was primarily due to disparities between the reality of the situation and the criteria sought and accepted by colonial psychiatrists. In Lambo's research, in numerous instances, Nigerians outwardly appeared more agitated and anxious, and their external demeanour did not align with their true emotional states, which they chose not to disclose. [18] Therefore, Carothers's error lay in approaching Nigeria solely from a Western perspective. These conclusions align with the findings reported by researchers from the Cornell-Aro Mental Health research project in 1963. While investigating psychiatric disorders and their socio-cultural context among the Yoruba people of West Africa, they observed that many symptoms of depression, such as fatigue or sadness, were indeed present but largely went unreported. [19] They noted that depression, commonly understood by Western societies, was an unfamiliar concept to the Yoruba people and linguistic challenges arose when attempting to articulate the disorder in native terms.
This underscores the importance of considering cultural context in discussions about mental illness. Various cultures may manifest unfamiliar and previously unrecognized symptoms and encounter challenges in articulating them due to linguistic and cultural disparities with foreign medical terminology. The diagnosis of depression in Nigeria and Kenya during the nineteenth and twentieth centuries serves as a compelling example of how adopting a cultural perspective can result in misconceptions about mental disorders when applied within a different tradition. This case study illustrates how colonial psychiatrists applied racist doctrines to their examinations of patients and how their perspectives on what constituted normality and abnormality, as well as superiority and primitivity, clashed with the indigenous worldview. This analysis shows that mental health and culture are intricately connected, with the former influencing the latter.
A case of madness in 20th-Century China
To understand mental health perspectives in China, particularly pre-1930s and post, it's crucial to highlight key aspects of Confucian philosophy - a deeply influential religious philosophy in Chinese history. This philosophy, emphasizing balance, plays a significant role in shaping approaches to mental illness, incorporating both professional and popular perspectives. The Chinese believed that preserving a healthy balance between yin and yang, positive and negative forces, was essential for maintaining a healthy body. [20] Thus, mental disorders stemmed from disruptions in this delicate harmony rather than any defects in the brain. The brain seldom played a significant role, as thought was perceived to originate in the heart. [21] Instead, various other causes were proposed, starting with a weakening of qi (the vital energy), an excess of emotion, or even demonic possession.
Importantly, as Charlotte Ikels noted, Confucianism underscores the profound internalization of emotions. Followers believed that suppressing issues until reaching the point of ignorance is required to foster self-control and self-resolution. [22] Consequently, individuals deemed 'morally disturbed' often faced social rejection, leading to confinement within their homes, away from public view. [23] The deep-seated shame and fear of exclusion had a profound impact, particularly on East Asian cultures and their family dynamics. Traditional beliefs indicated that mental illness was perceived as a punishment for ancestral sins, and the resulting shame extended to the entire family, not just the individual who suffered. [24] Even in modern times, Asian American patients exhibit selective reporting of symptoms, showing a preference for physical symptoms over emotional ones and expressing themselves in culturally acceptable ways. [25]
Until the second half of the nineteenth century, legal responsibility for the care of the mentally ill primarily rested within the family and kin. [26] Madness posed a potential threat to public safety, and it became the family's responsibility to manage the mentally ill as a private liability. Domestic confinement was a commonly employed practice. In 1853, Dr John Kerr, an American medical missionary representing the American Presbyterian Board of Foreign Missions, arrived in Canton. Having received medical education in America, his perspectives diverged from Chinese customs. Unlike the prevalent notion of families being competent to take care of the "insane," he viewed them as potential sources of insanity. Dr Kerr aimed to establish a "proper" psychiatric practice. In 1891, he inaugurated the first Chinese asylum, named the John G. Kerr Refuge for the Insane. This marked the introduction of a significantly unfamiliar medical and cultural practice. [27]
Kerr also highlighted the correlation between mental illnesses and Chinese cultural stresses, focusing particularly on women within the Chinese marriage and concubinage systems. In "A Daughter of Han [...]," set in 1870s P’engali, the narrator recounts a poignant tale in which her sister was routinely mistreated by her husband and his family. As per Chinese tradition, married women frequently stood in gateways during the evenings to observe the streets. Nevertheless, on one fateful day, distressed following a quarrel, the sister is said to have left her residence and started wandering through the city. The narrator notes that many people gathered to see the sister rather than help her. The sister's behaviour deviated from the established traditions of her society and that eventually earned her the moniker of ‘the crazy woman.’[28]
Her actions, openly contradicting societal expectations, led to her being perceived as disruptive and labelled as insane by the public, not because she visibly suffered from any mental illness. Contrarily, no correlation was suggested between the sister's mistreatment and the potential stress from conforming to traditional expectations impacting her mental state. To observers, the "outlandish" behaviour was synonymous with descending into madness. This underscores why psychiatrists like John Kerr, beyond advocating for changes in practices, recognized the imperative need for social reform that would contribute to the enhancement of society's mental health. While in Chinese society, a deviation from the norm was perceived as madness, Western psychiatrists attributed it to the traditional Chinese family model and patriarchal oppression. Nevertheless, it cannot be denied that Chinese culture, its philosophies, and beliefs in the late nineteenth and early twentieth centuries not only influenced what was perceived as a mental illness but also played a role in its conceptualization and creation.
The modern universalist approach to mental illness
The theory that cultures determine mental illnesses has faced scrutiny. Following Nigeria's independence in the 1960s, Nigerian psychiatrists advocated for a universalist approach to mental illnesses. By demonstrating that Nigerians experience depression on a scale similar to Europeans, Thomas A. Lambo argued that these similarities transcend race and culture. He asserted that all humans are psychologically equal worldwide. [29] It is evident that cultural contexts still exerted a strong influence on those claims. Such conclusions held huge significance for the global decolonization movement and Nigeria's integration into the "modern" medical scene. It was this principle of equality that resulted in the de-pathologization of individuals previously deemed inferior based on their ethnicity. [30] Universality was as much of a political statement as a scientific one.
In the present era, universalists stress the role of biology in unifying mental illnesses globally. Eric R. Kandel suggests that while differences in manifestations may arise cross-culturally, the underlying biological issue of mental illness remains consistent. [31] Mark Winton and Vikram Patel explained that, from a medical standpoint, mental illnesses, akin to infectious diseases, are part of a "universal human experience." If corresponding manifestations are found across cultures, then the reason must lie in genetic factors. [32] Nevertheless, this argument is not entirely persuasive and necessitates further conclusions that have not yet been universally agreed upon. An overemphasis on biology neglects environmental and cultural factors and implies that the human mind is purely physical. Accepting this approach would necessitate reducing other mental experiences, such as memories, wishes, etc., to nothing more than physical processes in the brain.
Conclusion
The "culture-blind" belief that mental illnesses affect everyone identically, regardless of ethnicity or background, does not hold. Preconceptions about mental disorders did not arise in isolation; thus, psychiatry needs to explore the impact of cultural influences on mental health. Society and politics consistently shape the individual by defining the concept of "normality" and identifying deviations from it. Examples from Nigeria, Kenya, and China in the nineteenth and twentieth centuries align with Foucauldian theories, viewing madness as a product of societal constructs. Western psychiatry became inextricably influenced by prevalent racist doctrines at the time of its emergence, incorporating them into the treatment of minds in colonial contexts. The traditional Chinese expectations of behaviour, coupled with Confucian suppression, had an impact on the mental well-being of members of Chinese society. Recognizing the intricate tapestry of mental health requires acknowledging the nuanced interplay between biological and socio-cultural dimensions. Each thread contributes to the rich fabric of human experience, and oversimplifying by neglecting either aspect undermines our ability to embrace the complexity of mental well-being. As we unravel these intricacies, we pave the way for a more holistic and compassionate approach to mental health.
Sandra Liwanowska is currently undertaking an MPhil in the History and Philosophy of Science and Medicine at the University of Cambridge.
Notes:
[1] Mario Hernandez and others, ‘Cultural Competence: A Literature Review and Conceptual Model for Mental Health Services’, Psychiatric Services (Washington, D.C.), Vol. 60, No. 8 (2009), p. 1047.
[2] Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason (London; Sydney: Tavistock Publications, 1967), pp. 44-78, particularly: pp. 48-49, p. 55, p. 73.
[3] 'Culture', in Oxford Dictionary of English, 2nd ed. (Oxford: Oxford University Press, 2005)
[4] Rene Descartes and Michael Moriarty (trans.), Meditations on First Philosophy with Selections from the Objections and Replies (Oxford: Oxford University Press, 2008), pp. 1-62.
[5] Charles Darwin, On the Origin of Species By Means of Natural Selection Or, the Preservation of Favoured Races in the Struggle for Life (Project Gutenberg, 1998).
[6] Steven Rose, ‘Darwin, Race and Gender’, EMBO Reports, Vol. 10, No. 4 (2009), p. 297.
[7] Sigmund Freud, ‘The Ego and the ld’, ‘The Ego and the Super-Ego (Ego Ideal)’, in James Strachey (ed.) and Joan Riviere (trans.), The Ego and the Id. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 24 (W. W. Norton & Company: London, 1960), pp. 11-21, 22-36.
[8] The term “African” here and forward categorises a population based on common continental origin. It is a broad term, which bears almost no value as Africa is a continent populated by an enormous number of diverse cultures. However, it will be employed to illustrate the overgeneralization of colonial beliefs.
[9] “Among nations existing in a savage state, in which the human mind is uncultivated, and its higher faculties remain undeveloped, it appears that mental diseases are comparatively rare phenomena.” - John C. Prichard, A treatise on insanity and other disorders affecting the mind (1835), p. 198.
[10] John C. Carothers, ‘A Study of Mental Derangement in Africans, and an Attempt to Explain Its Peculiarities, More Especially in Relation to the African Attitude to Life’, Journal of Mental Science, Vol. 93, No. 392 (1947), p. 587.
[11] Ibid., p. 592.
[12] Ibid., p. 581.
[13] Ibid., p. 575, 590-591.
[14] Ibid., p. 556, 570.
[15] Ibid., p. 555.
[16] Matthew M. Heaton, Black Skin, White Coats: Nigerian Psychiatrists, Decolonization, and the Globalization of Psychiatry (Athens, OH: Ohio University Press, 2013), p. 102.
[17] Ibid., p. 102.
[18] Adeoye T. Lambo, ‘Further Neuropsychiatric Observations in Nigeria’, British Medical Journal, Vol. 2, No. 5214 (1960), pp. 1698–1699.
[19] The Yoruba people are an ethnic sub-Saharan ethnic group, prevalent in West Africa, including Nigeria; Alexander H. Leighton, T. Adeoye Lambo, Charles C. Hughes, Dorothea C. Leighton, Jane M. Murphy and David B. Macklin, Psychiatric Disorder among the Yoruba: A Report from the Cornell-Aro Mental Health Research Project in the Western Region, Nigeria (Ithaca, NY: Cornell University Press, 1963), p. 112.
[20] Emily Baum, ‘Choosing Cures for Mental Ills: Psychiatry and Chinese Medicine in Early Twentieth-Century China’, The Asian Review of World Histories, Vol. 6, No. 1 (2018), p. 16.
[21] Ning Yu, The Chinese HEART in a Cognitive Perspective, The Chinese HEART in a Cognitive Perspective (Berlin/Boston: Mouton de Gruyter, 2009), p. 1-3.
[22] Charlotte Ikels, ‘The Experience of Dementia in China’, Culture, Medicine and Psychiatry, Vol. 22, No. 3 (1998), p. 275.
[23] Lawrence H. Yang., ‘Application of mental illness stigma theory to Chinese societies: Synthesis and new directions’, Singapore Medical Journal, Vol. 48, No. 11 (2007), p. 980.
[24] Veronica Pearson, ‘Families in China: An Undervalued Resource for Mental Health?’, Journal of Family Therapy, Vol. 15, No. 2 (1993), p. 166.
[25] Keh-Ming Lin, and Freda Cheung, ‘Mental Health Issues for Asian Americans’, Psychiatric Services (Washington, D.C.), Vol. 50, No. 6 (1999), pp. 774–80.
[26] Zhiying Ma, ‘An Iron Cage of Civilization? Missionary Psychiatry, The Chinese Family and A Colonial Dialectic of Enlightenment’, in Howard Chiang (ed.), Psychiatry and Chinese History (London; New York: Routledge, 2014), p. 99.
[27] Howard Chiang, ‘Introduction: Historicizing Chinese Psychiatry’, in Chiang, Psychiatry, p. 6.
[28] Ida I. Pruitt, and Ning Lao T'ai-T'ai, ‘Book One: On the Family’, in A Daughter of Han: The Autobiography of a Chinese Working Woman (Potomac, Maryland: Pickle Partners Publishing, 2015), pp. 31-32.
[29] Heaton, ‘Introduction’, p. 13, 20.
[30] Ibid., p. 21.
[31] Glorisa Canino and Margarita Alegría, ‘Psychiatric Diagnosis - Is It Universal or Relative to Culture?’, Journal of Child Psychology and Psychiatry, Vol. 49, No. 3 (2008), p. 238.
[32] Vikram Patel, and Mark Winston, ‘Universality of Mental Illness’ Revisited: Assumptions, Artefacts and New Directions’, British Journal of Psychiatry, Vol. 165, No. 4 (1994), p. 437.
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