Jan-Mar 2010


Vol. 1 No. 1



“Preserving mental health through family and culture”

Shyamanta Das
Assistant Professor of Psychiatry
Silchar Medical College and Hospital

Theme of the 62nd Annual National Conference of the Indian Psychiatric Society (ANCIPS 2010) held at Jaipur from January 17 to 20 was "Preserving mental health through family and culture."

In family psychiatry a family is not regarded merely as a background to be modified to help the presenting patient alone. Family psychiatry accepts the family itself as the patient, the presenting member being viewed as a sign of family psychopathology. [1]

Family psychiatry is not simply family group interviewing, but rather it is a concept of psychiatric practice which in its clinical application utilizes child and adult individual psychotherapy, marital therapy and family therapy in whatever combination or with whatever timing seems clinically best to improve the psychosocial functioning of an entire family.

Viewing the family as the patient while continuing to utilize all of the already well-established therapeutic modalities, has many advantages for patient care and for primary and secondary prevention. [2]

The biopsychosocial model was conceptualized as a medical model that allowed for mutual interaction between the biological and the psychosocial aspects of a person’s life. [3] Modern biological research has elucidated how psychosocial factors influence gene expression [4] and how psychosocial treatments change brain activity. [5] More recently, the concept of "the social brain" has been put forward as a unifying model for how the environment shapes brain development. [6] In these models, the family environment is the most immediate psychosocial milieu.

Improving the family environment has important health implications equivalent to the reduction of risk factors for chronic illness by promoting exercise or a healthy diet. Attention to family resilience offers not just psychiatrists—but physicians in general—new avenues for preventive health care. Patients and families can be given recommendations regarding what constitutes healthy family functioning and referred, if necessary, to workshops or given literature explaining these concepts. Offering early family intervention, such as psychoeducational workshops, is preventative, not just crisis management.

In general psychiatric practice, patients and families can be informed about the role of family factors in the treatment of major mental illnesses and encouraged to seek psychoeducation and support groups. The treating psychiatrist can provide this service or refer the family to a family therapist. Such referrals are common for many serious medical illnesses. [7] In the rest of medicine, family therapists are increasingly becoming part of the medical team in specialties such as rehabilitation, oncology, cardiac rehabilitation, and geriatrics to help bridge the gap between the medical profession and the family’s needs. [8],[9],[10]

Cross-cultural psychiatry is a branch of psychiatry concerned with the cultural and ethnic context of mental disorder and psychiatric services. It emerged as a coherent field from several strands of work, including surveys of the prevalence and form of disorders in different cultures or countries; the study of migrant populations and ethnic diversity within countries; and analysis of psychiatry itself as a cultural product. The early literature was associated with colonialism and with observations by asylum psychiatrists or anthropologists who tended to assume the universal applicability of Western psychiatric diagnostic categories. A seminal paper by Arthur Kleinman in 1977 [11] followed by a renewed dialogue between anthropology and psychiatry, is seen as having heralded a 'new cross-cultural psychiatry'. However, Kleinman later pointed out that culture often became incorporated in only superficial ways, and that for example 90% of DSM-IV categories are culture-bound to North America and Western Europe, and yet the "culture-bound syndrome" label is only applied to "exotic" conditions outside Euro-American society.

It is argued that a cultural perspective can help psychiatrists become aware of the hidden assumptions and limitations of current psychiatric theory and practice and can identify new approaches appropriate for treating the increasingly diverse populations seen in psychiatric services around the world. [12]

The field has, ironically [13], increasingly had to address the process of globalization.

It is said every city has a different culture and that the urban environment, and how people adapt or struggle to adapt to it, can play a crucial role in the onset or worsening of mental illness. [14]

Cross-cultural psychiatry looks at whether psychiatric classifications of disorders are appropriate to different cultures or ethnic groups. It often argues that psychiatric illnesses represent social constructs as well as genuine medical conditions, and as such have social uses peculiar to the social groups in which they are created and legitimized. It studies psychiatric classifications in different cultures, whether informal (e.g. category terms used in different languages) or formal (for example the World Health Organisation's ICD, the American Psychiatric Association's DSM, or the Chinese Society of Psychiatry's CCMD[1]. [15]

As a named field within the larger discipline of psychiatry, cultural psychiatry has a relatively short history. [16] In 1955, a program in transcultural psychiatry was established at McGill University in Montreal by Eric Wittkower from psychiatry and Jacob Fried from the department of anthropology. In 1957, at the International Psychiatric Congress in Zurich, Wittkower organized a meeting that was attended by psychiatrists from 20 countries, including many who became major contributors to the field of cultural psychiatry: Tsung-Yi Lin (Taiwan), Thomas Lambo (Nigeria), Morris Carstairs (Britain), Carlos Alberto Seguin (Peru) and Pow-Meng Yap (Hong Kong). The American Psychiatric Association established a Committee on Transcultural Psychiatry in 1964, followed by the Canadian Psychiatric Association in 1967. H.B.M. Murphy of McGill founded the World Psychiatric Association Section on Transcultural Psychiatry in 1970. By the mid-1970s there were active transcultural psychiatry societies in England, France, Italy and Cuba. There are several scientific journals devoted to cross-cultural issues: Transcultural Psychiatry (est. 1956, originally as Transcultural Psychiatric Research Review, and now the official journal of the WPA Section on Transcultural Psychiatry), Psychopathologie Africaine (1965), Culture Medicine & Psychiatry (1977), Curare (1978), and World Cultural Psychiatry Research Review (2006). The Foundation for Psychocultural Research at UCLA [17] has published an important volume on psychocultural aspects of trauma [18] and most recently the landmark volume entitled Formative Experiences: the Interaction of Parenting, Culture, and Developmental Psychobiology edited by Carol Worthman, Paul Plotsky, Daniel Schechter, and Constance Cummings. [19] The main professional organizations devoted to the field are the World Psychiatric Association Section on Transcultural Psychiatry, the Society for the Study of Psychiatry and Culture, and the World Association for Cultural Psychiatry. Many other mental health organizations have interest groups or sections devoted to issues of culture and mental health.

There are active research and training programs in cultural psychiatry at several academic centers around the world, notably McGill University [20], Harvard University, the University of Toronto, and University College London. Other organizations are devoted to cross-cultural adaptation of research and clinical methods. In 1993 the Transcultural Psychosocial Organization (TPO) was founded. The TPO has come up with a system of intervention aimed at countries with little or no mental health care. They train locals to become mental health workers, often using people who previously have provided mental health guidance of some kind. The TPO provides training material that is adapted to local culture, language and distinct traumatic events that might have occurred in the region where the organization is operating. Avoiding Western approaches to mental health, the TPO sets up what becomes a local non-governmental organization that is self-sustainable, as well as economically and politically independent of any state. The TPO projects have been successful in both Uganda and Cambodia.

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