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Textbook of Cultural Psychiatry

Richard  Balon, MD

Wayne State University, Detroit, MI, USA

Culture, cultural differences, acculturation, cultural aspects of mental illness, and cultural aspects of care for the mentally ill are an important and integral part of the modern era psychiatric practice. Actually, as the editors of this volume Drs. Bhugra and Bhui suggest in the Preface, “it appears that cultural psychiatry is gradually taking over the role of social psychiatry.”

Edited by Dinesh Bhugra and Kamaldeep Bhui; Cambridge University Press; New York, New York; 2007; ISBN: 978-0-521-85653-9; $145.00 (hardcover), pp 591.

Cultural psychiatry, as noted in an introductory note to this volume, “is concerned with understanding the impact of social and cultural differences and similarities on mental illness and its treatments.” Numerous articles, books, and several journals (eg, Transcultural Psychiatry or Culture Medicine and Psychiatry) address the issues of this growing “field.” This large volume is the latest addition to cultural psychiatry literature.

Drs. Dinesh Bhugra and Kamaldeep Bhui, both based in London, UK, gathered 60 contributors from 4 continents (Asia, Australia, Europe, and North America). The book consists of Foreword, Preface, 42 chapters divided into 6 parts, and After-word by the editors. As the editors point out, this volume is a bit different from the traditional cultural psychiatry books, as they “deliberately stepped away from one approach of cultural psychiatry (which relies on dealing with each individual cultural group as if it were isolated) to adopt one that emphasizes broad principles that can then be used to develop patient-based services rather than group or culture or ethnicity-based services.” From an editorial point, the book also is a bit different as each chapter starts with an Editors’ introduction.

Part I, “Cultural background”, contains 7 chapters addressing issues such as “Cultural psychiatry in historical perspective,” “Anthropology and psychiatry: the contemporary convergence,” “Suicide, violence and culture,” “Psychology and cultural psychiatry,” “Spirituality and cultural psychiatry,” “Culture, ethnicity and biological psychiatry,” and “Ethnic inequalities and cultural capability framework in mental healthcare.” Some chapters are fairly informative (eg, the chapter on history, explaining terms such as culture vs cultivation and comparative psychiatry vs cultural psychiatry), and interesting (eg, the chapter on suicide and violence—discussing suicide and violence in Canadian Aboriginals, Aboriginals of South Pacific, women in Asia, and adult males in Quebec). Other chapters have not much specific to say because there is not much to say (eg, the chapter on culture, ethnicity, and biological psychiatry). One has to realize that some areas of cultural psychiatry are characterized by a lot of opinion yet lack of data.

The second part, “Culture and mental health,” also consists of 7 chapters: “Culture and psychopathology: general view,” “Developmental aspects of cultural psychiatry,” “Explanatory models in psychiatry,” “Culture-bound syndromes: a reevaluation,” “Psychiatric epidemiology and its contributions to cultural psychiatry,” “Acculturation and identity,” and “Cultural consonance.” Again, only some chapters have something substantial to say, while others are theoretical and useful only for some. I found interesting the discussion of how culture contributes to psychopathology, including the pathogenic, pathoselective, pathoplastic, pathoelaborating, pathofacilitative, and pathoreactive effects. Less revealing is the mini-review of culture-bound syndromes—only dhat, koro, and latah are discussed for “illustration” (well, the culture bound syndromes seem to be mainly a fodder for tests of resident knowledge lately). I was most disappointed with the chapter on acculturation, probably because I expected more concrete, clinically relevant recommendations.

Part III, “Culture and mental disorders,” includes 11 chapters covering various groups of disorders, such as “Neurosis,” “Schizophrenia and related psychoses,” “Affective disorders,” “Substance misuse,” “Suicidal behavior” (again), “Personality disorders and culture,” “Obsessive-compulsive disorder,” “Eating disorders,” “Childhood and adolescent psychiatric disorders,” “Culture and schizophrenia” (again), and “Disorders of ageing across cultures.” The chapter on neurosis, which includes basically all anxiety disorders listed in the DSM-IV-TR—depressive neurosis, dissociative or conversion disorder, somatoform disorder, hypochondriasis, somatoform pain disorder, and neurasthenia—is probably the most informative. The rest of this part of the book is a fairly standard—at times disappointing—presentation. One would appreciate a more specific discussion of personality, eg, whether borderline personality disorder exists in all cultures and how antisocial personality disorder is defined in various cultures. Interestingly, the chapter on eating disorders says nothing about obesity as a possibly cultural phenomenon (if not disorder).

The fourth part, “Theoretical aspects of management,” includes 9 chapters reviewing various areas of management, such as “Traumascape: an ecological-cultural-historical model for extreme stress,” “Sexual dysfunction across cultures,” “Therapist-patient interactions and expectations,” “Developing mental-health services for multicultural societies,” “Psychopharmacology across cultures,” “Psychotherapy across cultures,” “Psychological interventions and assessments,” “Spiritual aspects of management,” and “Cultural aspects of suicide” (again). Though the chapter on suicide is the third one on this topic in this book, it is probably the most informative with an interesting table comparing suicide rates in various countries.

Part V, “Management with special groups” consists of 6 chapters covering variety of topics, including “Intellectual disabilities across cultures,” “Child psychiatry across cultures,” “Management of sexual dysfunction across cultures,” “Refugees and mental health,” “Working with elderly persons across cultures,” and “Working in liaison psychiatry.” Most chapters, like the rest of the book, are not too clinically useful. The most interesting chapter seems to be the one on intellectual disabilities.

The last part, in spite of its title, “Cultural research and training,” seems to cover very little research and education in 2 chapters: “Scope of cultural psychiatry” and “Coping with stressors: racism and migration.”

This book aspires to be a monumental and unique volume on cultural psychiatry and, in a way, it is a unique volume, different from the texts on cultural psychiatry published in the past. However, the question is its clinical usefulness and target audience. While those seriously interested in the field of cultural psychiatry will find it useful, busy clinicians probably will not. Some readers, such as psychiatry residents, may feel a bit drowned. A smaller, more tightly edited volume probably would be more useful for the general reader (there is a lot of overlap such as the mentioned 3 chapters on suicide and 2 on schizophrenia, with some other overlaps too).

I also started to feel that this entire field is living in its own world, a bit remote from the real word of practicing clinicians. I am not sure whether it is the field or the book that triggered it. An interesting question came to my mind while reading this book: how much is cultural psychiatry a Western cultural concept, possibly irrelevant to clinicians practicing psychiatry in non-Western countries without routine contacts with Western-style psychiatry? (by Western in this context, I mean Australia, New Zealand, Europe, and North America).

In summary, as a practicing clinician I found this book a bit disappointing. However, despite its flaws, it is a unique and authoritative text on cultural psychiatry that those seriously interested in this field will find interesting to read and to use as a major reference text.