No more ignoring culture: deep re-thinking of mental health frameworks needed

TW: Mention of mental illness

On Boxing Day 2004, a tsunami struck Sri Lanka. A 9.1-magnitude earthquake, deep in the Indian Ocean, led to the loss of over 30,000 Sri Lankan lives. Across Asia, the event devastated coastal communities. A wave of Western trauma counselors followed, eager to diagnose survivors with a certain illness: post-traumatic stress disorder.

In the fifth and most recent edition of their Diagnostic and Statistical Manual of Mental Disorders, the American Psychological Association provides a strict and prescriptive checklist for PTSD. Once a diagnosis is made, the floodgates for pharmaceutical treatment open. Psychiatrists prescribe Zoloft, Prozac, SSRIs galore, all in the name of curing the consequences of trauma.

However, when psychologist Greg Miller visited Sri Lanka after the tsunami, he observed spirited, resilient survivors. He wrote that people seemed to be “coping better than expected, aided by the Asian emphasis on strong family and community ties.” Instead, patients consistently reported physical symptoms: “aches, pains, and discomforts that have no apparent physical cause.” Verbal admissions of all the above criteria were rare, yet trauma counselors showered survivors with PTSD diagnoses. They ‘exported’ a Western checklist, formulated by Western practitioners and tested in Western laboratories, to a completely different culture. 

Mental health differs immensely across the world, and Western institutions fail to recognise this. As the people of Sri Lanka illustrated, experiences of mental illness can be somatic, where an emotional condition manifests itself physically — sadness, for example, may be exhibited in an ear ache. Somatic symptoms are reported worldwide, yet tend to be more common in Asian populations. In Korea, patients suffering from Hwa-Byung, an anger syndrome characterised by depression and resentment, report heavy chest and back pains. When depression is diagnosed in Japan, physicians assess psychological symptoms as well as futeishuso: physical complaints such as shoulder pains, stomach distress and palpitations. In the DSM, these symptoms are lazily relegated to another specific somatic symptom disorder. For anxiety and depression, the manual ignores somatic symptoms. 

In its fourth edition, the DSM did provide an Outline for Cultural Formulation (OCF), helping clinicians organise culturally-specific information. However, studies on its use demonstrate inconsistency and confusion as to how to apply a universal framework to individual culture-specific disorders — for this reason, the DSM remains wanting in wisdom for clinicians seeking cultural competency.

There are fundamental differences in mental health frameworks that exist worldwide. In a study, researchers sourced 100 sufferers of neurasthenia, a Chinese-specific diagnosis equivalent to depression. However, when evaluated against the Western DSM, 18 patients did not fulfill criteria. This has serious implications for the treatment of immigrants and different cultural groups in a host country; without culturally competent tools, symptoms are misinterpreted and misdiagnosed.

Somatic symptoms are generally more common in Asia, since the collectivistic mindset that governs many Asian cultures draws attention away from individual psychological conditions. The Western concept of the personal ‘psyche’ is unfamiliar, and since people cope with trauma through group resilience and community support, the outlet for distress is physical. An additional stigma also surrounds mental illness, where reporting psychological symptoms can alienate people from communities that are either apprehensive or unaware of an increasingly medicalised Western therapy culture. 

Further, benchmarks of normality differ between cultures. Anthropologist Tanya Luhrmann found that, in Africa and India, some people report positive experiences with hearing hallucinatory voices, perceiving them as more gentle and benign, or like hearing from God. In the United States, however, attitudes towards voice-hearing were consistently negative, explaining the experience as an “assault on the senses.” The reality is that what the West perceives as ‘mental illness’ may not even be reported — physical symptoms might only be more prevalent because treatment is more commonly sought. 

Alongside the somatisation of symptoms, different ethnic groups employ varying cultural idioms to express their distress. As physician William Osler notoriously claimed, “It is much more important to know what sort of patient has a disease, than what sort of disease a patient has”. Indeed, culture permeates the ways in which a patient expresses their emotions. It is then the task of the psychologist to decipher meaning, couched in what appear to be cryptic phrases — for example, a “sinking heart” or a “wrong way relationship.” 

Like other cultures, Aboriginal conceptions of mental health differ greatly from their non-Indigenous counterparts. However, this is largely misunderstood by ignorant healthcare providers. Where Western conceptions center on neurobiological explanations for mental illness, such as abnormalities in neurotransmitter levels, Native Americans focus on notions of mind, body, emotion and spirit, and interconnectedness with family, land and community. Aboriginal scholars in the North formulated a ‘Medicine Wheel’ to present a holistic nature of mental health that incorporated these numerous factors. Treatment, then, is markedly different for Indigenous individuals in North America, where it aims to bridge an individual’s “disconnection from their culture,” the culprit of their disease. In Aboriginal healing ceremonies, Elders and traditional healers take the central role and use the structure of the circle and outdoor physical setting, traditional teachings and storytelling. Most importantly, Native American healers report an awareness that an eclectic and flexible approach is needed, considering Aboriginal spirituality varies across individuals and communities. This is a far cry from the unhelpful standardised frameworks that Western nations blanket over all people. 

In Australia, at least seven culture-bound syndromes exist across Indigenous communities. However, there is a notable absence of empirical research into these illnesses, which must be urgently rectified to improve the nation’s provision of effective healthcare. Recent research firstly draws attention to a difference in Indigenous clinical presentation due to cultural factors: Indigenous patients report feeling “shame” in the presence of non-Aboriginal authority figures, and in communicating emotions to them. Additionally, research shows that Indigenous individuals are frequently and readily misdiagnosed due to stereotypes for expressing symptoms that fall under the umbrella of normality in their culture. These include ‘sorry cutting’ during grieving time, and spiritual visits from those who have passed on. Overdiagnosis of Indigenous individuals with psychosis disorders reflects a lack of consultation with Elders and ignorance of culturally normal processes; this leads to coercive institutionalisation which further drives harmful narratives. 

Research also illuminates that psychological treatments are often geared towards the Western patient, bolstered by the paucity of experiments on cultural minorities. Antidepressants are formulated for a Western patient’s body, and thus African-American and Asian-Americans often report less success with medication alone. Treatment developed for Western patients also notably does not target the aforementioned somatic symptoms suffered by many ethnic groups. When considering treatment, one must also consider the severe stigma surrounding seeking psychological treatment for different cultures. 
For diagnoses and treatment to be accurate and synergetic, clinicians must strive for genuine cultural understanding. Frameworks are only helpful to a certain degree — any universal skeleton fails to account for diversity. In that case, psychologists need to step in and actually listen to their patients, not hear echoes of DSM criteria.