12.2.1 Cultural health beliefs.

Beliefs about the etiology of illness vary across cultures and therefore also the treatment offered. For example Chinese and Indian patients have beliefs that mental illness is caused by psychosocial forces and they therefore prefer treatments based on psychosocial practices. By contrast in the West the focus is on the individual patient consistent with cultural values. Cultural health beliefs among members of ethnic groups continue even after migration to countries that provide Western scientific medicine (Cook, 1994). In some parts of India fate or cosmic influence are believed responsible for illness. Such superstitious cultural health beliefs largely determine what people think can be done to cure or mitigate the impact on health (Dalal, Pande, 1999). Studies in Ethiopia (Mulatu, 2000) showed that some people believed that the cause for mental illness was supernatural spirit possession. These cultural thoughts have an obvious negative impact on the patient’s beliefs about their ability to control illness. Helplessness derived from cultural health beliefs make it difficult for the patient to recover from mental illness (Thoresen, 1999).

The effect of cultural beliefs about health can be observed in a study in India (Berry, Dalal, & Pande, 1994). The villagers in the study believed that a mother should eat little food to allow room for the fetus to grow. Such faulty beliefs about nutrition resulted in fetal malnutrition and many subsequent illnesses in the undernourished infants. Responsibility for health care are also to some degree based on cultural beliefs and associated ideologies. In the U.S. it is commonly believed that people should look after themselves as is typical in individualistic cultures. In Cuba on the other hand a public health system looks after all patients and is not based on the ability to pay. Clearly socio-economic status in individualistic societies is the primary factor as to whether a person has access to necessary treatment (Lynch & Kaplan, 1997).

12.2.2 Problems in cultural definitions of abnormality and mental illness

Culture impacts all aspects of mental illness. In some societies patients are reluctant to report psychological distress for reasons of stigma and potential social rejection. Cultural beliefs about mental illness in some cultures in Africa and China encourage patients to report physical symptoms rather than mental distress. On the other hand in individualistic cultures patients convey more psychological distress consistent with cultural values (Kleinman, 1988). These differences in symptom reports have led cultural psychologists to believe that we can only understand abnormal behavior within the cultural context. Talking to spirits may be considered a hallucination in Western societies, but be considered normal for people in Eskimo tribes taking part in shamanistic ceremonies. In the U.S. there are certain Christian religions that practice “speaking in tongues” (glossolalia) that would be considered a clinical sign of delusionary beliefs or psychotic delusions, while totally normal within the religious group. To some extent what is normal or abnormal always has a cultural reference point (Marsella, 1980).

To identify the abnormal by statistical means as rare forms of behavior overlooks the obvious, that unique forms of behavior in one culture may in fact be common in others. More useful is a definition of abnormal behaviors as syndromes of activity and thinking that prevent effective functioning in the family or community. Serious psychotic illness is typically associated with an inability to function in relationships and in turn lead to other dysfunctional behaviors like homelessness. Some writers have defined abnormal behavior as being contrary to the social norms of society. However, that begs the question of what if society is “abnormal” or dysfunctional as in the case of Nazi Germany or the Khemer Rouge in Cambodia. Those who resisted these regimes were abnormally few in numbers, but must be considered human heroes of enormous ego strength and mental health.

Abnormal behavior also cannot be limited to what might be considered eccentric or unusual behaviors, but rather are normal reactions to stress and trauma. Today most textbooks provide categories of mental disorders that are commonly accepted although with cultural modifications (Sarason & Sarason, 1999). The main issues in the classification of psychopathology in cross-cultural psychology is whether the phenomenon is universally present in all cultures, (but variable as to the rate of illness and manifestation of symptoms) or unique to a specific culture. Ethnopsychiatric specialists argue that some disorders are unique to specific societies and therefore can only be understood within the context of that culture (Tseng, 2001).

The Diagnostic and Statistical Manuel of Mental Disorder (DSM) is broadly used to identify categories of mental illness in the U.S. and in other parts of the world. A mental disorder according to the manual refers to behavioral or psychological syndromes that are clinically significant in impacting feelings of distress or that impair functioning in other significant ways. A patient may suffer pain, disability and the freedom to live as an active member of society a result of a valid mental disorder (Mirin, 2002). The DSM diagnostic system utilizes five domains where the first describes clinical symptoms, the second personality disorders, the third examines current medical issues relevant to the mental disorder, the fourth the psychosocial and environmental problems affecting mental disorder, and the fourth the clinician’s report of the overall functioning of the patient

In the DSM the American Psychiatric Association defined mental illness in very comprehensive term. Mental impairment can occur from organic causes where brain functions are impaired as in the case of dementia, in Parkinson or in Alzheimer diseases. Some mental disorders like schizophrenia in its several forms are also thought to have strong organic components. Psychotic behavior can also be produced by drug use, abuse of alcohol, by excessive use of certain sedatives, and abuse of cocaine and hallucinogen inducing drugs. The DSM also describes affective disorders characterized by extreme swings of mood in manic and depressive phases of bipolar patients. Neurotic patients suffer from a variety of anxieties including phobias about objects that pose no actual threat, or when the patient attempt to control life through obsessive behavior, in hypochondria where the patient obsessively worries about health, and in extreme cases in anxiety producing disassociation through multiple personalities.

Other disorders also covered in the DSM refer to the consequences of physiological dysfunction and discusses anorexia and bulimia, insomnia and sexual dysfunction. Personality disorders refer to patients who exhibit sociopathic behavior manifested in obsessive gambling or criminal behavior, the tendency to impulsiveness, and sexual preferences for voyeurism or pedophilia. The DSM also covers criteria of the mentally challenged, developmental disorders like autism, and disorders derived from childhood dysfunction.