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Cultural Influences in Psychiatry
Abstract
To the Editor In a Viewpoint, Dr Guinart et al¹ highlighted the need for fuller consideration of transcultural psychiatry to better explain cultural variation in clinical trials of psychotropic medicines. As the article suggested, such research is bedeviled by questions of interrater reliability, variations in the expression of stigmatizing emotional experience, and capacity for measuring treatment response. Neglecting cultural contexts distorts the results of clinical trials. Such concerns about cultural validity for effective clinical practice, in fact, motivated formulation of the “new cross-cultural psychiatry” as an upgrade for transcultural psychiatry more than 4 decades ago.
Through a longstanding collaboration, psychiatrists and anthropologists have assessed the impact of sociocultural context on mental health and elaborated the concept of culture in psychiatry. However, recent developments in ecological anthropology may have untapped potential for cultural psychiatry. This paper aims to uncover how “ecologies” inform patients’ and clinicians’ experiences, as well as their intersubjective relationships. Drawing on my ethnography with Jerome, a carriage driver who became my patient in a shelter-based psychiatric clinic, and on anthropological work about how psychic life is shaped ecologically, I describe how more-than-human relationality and the affordances of various places—a clinic and a stable—influenced both Jerome’s well-being and my perceptions as a clinician. I also explore how these ecologies shaped our different roles, including my dual roles as psychiatrist and ethnographer. In the discussion, I define ecological factors, describe their implications for clinical practice, and suggest how they could be integrated into DSM’s cultural formulation.
The DSM-IV Outline for Cultural Formulation (OCF) was a framework for assessment based on principles of cultural psychiatry. The Cultural Formulation Interview (CFI) for DSM-5 provided a tool enabling wider use of cultural formulation in clinical cultural assessment. Validation to justify the inclusion of the CFI in DSM-5 involved quantitative analysis of debriefing interviews of patients and clinicians for feasibility, acceptability and clinical utility. We now further examine qualitative field trial data from the CFI interviews and the debriefing interviews in Pune, India. Administration of the CFI was followed by routine diagnostic assessment of 36 psychiatric outpatients—11 found to have severe mental disorders (SMD) and 25 with common mental disorders (CMD). Domain-wise thematic analyses of the CFI and debriefing interviews identified recurrent themes based on cultural identity, illness explanatory models, stressful and supportive social relationships, and the impact of political, economic, and cultural contexts. A tendency to elaborate accounts, rather than simply name their problem, and more diverse past help-seeking distinguished CMD from SMD groups. Patients valued the CFI more than clinicians did, and most patients did not consider cultural background differences of clinician-patient relationships to be relevant. Qualitative analysis of CFI data and critical analysis of domain mapping of CFI content to the structure of OCF domains indicated the value of revising the dimensional structure of the OCF. A proposed revision (OCF-R) is expected to better facilitate clinical use and research on cultural formulation and use of the CFI.