Just because a phenomenon is not verbally named by a society does not mean that it does not exist. Cultural autism or social muteness is reflected in individual understanding, so that the individual may also be rendered mute. For example, the phenomenon of childhood sexual abuse has always existed. However, it is only in the last decade or so that its prevalence has been generally articulated and acknowledged. Once acknowledged, the survivors of such abuse have come forward in significant numbers to request psychotherapy, and abuse is now given prominence as a major cause of distress. The same applies to many phenomena, such as that labelled shell shock in the First World War or more recent labelling of distress such as posttraumatic stress. Conversely, because a phenomenon is given a verbal label does not mean that it exists. The cultural relativity influencing our conceptions of psychopathology is emphasized by writers such as Szasz (1972) and Marshall (1966) who explore many of the myths behind our understandings of such constructs as psychosis, schizophrenia and mental illness.
Cultural factors influence how and what we see. As Husserl points out, the basic truth of perceptual experience is that what we see is directly dependent upon the perspective from which we see it. Although we are all conscious that there is only one world, we also see it differently, interpret it differently, and attribute different meanings to it at various times. In a process of selection and exclusion, a world-view will be filtered through the hopes and fears, the expectations and the experiences of the individual. The end result is a set of perspectives which have been multiply modified in the transmission. ‘Meaning and interpretation belong together inseparably. Anything which visibly has a meaning is in that same instant invested with an interpretation by each and every onlooker’ (Poole 1972: 6). The fact that we confer meaning on the world, instead of it imposing meaning on to us, implies that we are active participants in this process.
Following Husserl, Poole (1972) and Zukav (1979) point out there is no one single truth but only truths dependent upon the perspective from which we see it. What we term ‘objectivity’ consists of all the beliefs and unquestioned assumptions of a given society. Ignoring this essential fact is a serious error in the theories, clinical practice and research endeavours that describe models of psychopathology, an error reflected in conceptualizations of scientific paradigms and research methodologies. The current scientific paradigm individualizes science and ignores the fundamentally subjective and interactive nature of experience in its quest for so-called ‘objectivity’.
This view, as we have seen in other posts, is emphasized in labelling theory, concerned with societal reactions. Attempting to reduce everything to one reality or unreflectively asserting the importance of one reality over others has many critical implications. It affects the language we use, and ultimately all our thoughts and perceptions. Cultural factors are therefore embedded in and shape what we think we ‘know’. In turn this gives legitimacy to certain forms and content of ‘knowledge’. Sayal (1989), writing on black women and mental health, illustrates some of the issues: there are often sweeping generalizations made about black people, that, for example, ‘passive’ Asian women are subjected to oppressive practices within the family, or that Afro-Caribbean women are strong and dominant.
Stereotypes are accepted as ‘facts’ and are frequently used by mental health workers. Sayal claims that by accepting pathologizing notions about ‘black families’ we collude with the pseudo-science that gives legitimacy to popular racism, since we make presumptions about homogeneity that we do not make about white families. This process is seen at the level of professional ‘science’, for example, in concepts such as ‘ethnicity’ and ‘transcultural psychiatry’. An examination of the studies conducted in this area suggests that most of the studies claiming to be on black family life are actually concerned with poverty. Sayal points out that the poor are frequently identified as ‘ “culturally deprived” . . . so that poverty is discussed as if it is a personal trait rather than a social condition, and deviations from ethnocentric norms are viewed as deprivation’ (1989: 4). A consequence of this is that a high proportion of black children are in care because black women are viewed as unfit for mothering, and until recently as unfit for fostering and adoption. Sayal also describes how psychiatric formulations are made of black-specific mental illnesses, such as ‘West Indian psychosis’. The psychiatric theories which claimed that black genes were causal factors in mental illness have now been substituted by theories which view black culture as a causal factor in mental illness.
Many of the values we hold in Western society about the goals of psychotherapy are themselves potentially culturally specific. Therapy focuses on the individual with for example, restoring ‘a sense of autonomy’ or ‘taking responsibility for the self’, set as goals of treatment. Other cultures take a different approach to therapy. A Hindu in India might instead be helped to reintegrate within their social group and to restore the sense of interdependence rather than independence.
Our cultural context therefore shapes how we think about psychopathology. What are taken to be ‘facts’ in mental health are culturally determined. Definitions and classifications are not absolute but change across cultures across time. Albee (1996) gives the example of the psychiatric view of homosexuality. The first edition of DSM classified homosexuality as a sexual deviation. However, in 1973 the second edition of DSM was modified when the American Psychiatric Association eliminated the general category of homosexuality as a mental disorder, unless it was distressing to the person concerned. Thus, in the 1970s, thousands of US citizens were changed overnight from being defined as mentally ill to normal.
Psychological distress or symptoms of psychopathology are manifested differently in different socio-cultural contexts. A syndrome traditionally not seen in Western cultures is ‘amok’, where men erupt, following a period of depression and brooding, into a sudden state of frenzied and unprovoked indiscriminate violence ending in exhaustion and amnesia. The condition has traditionally been associated with the Malayan people and was relatively common a few hundred years ago, although rare today. Theorists have speculated that amok was related to the cultural values that placed heavy restrictions on adolescents and adults and the belief in magical possession by demons and evil spirits. There are other culture-bound syndromes (see Westermeyer 1985), and, even when similar psychological problems are seen in different parts of the world, the way a particular syndrome is perceived may vary from culture to culture (Erinosho and Ayonrinde 1981).
The individualization of distress
Even though in the different models of psychopathology there are a variety of theoretical ideas and practical procedures, many of them markedly incompatible with each other, there are nevertheless some general issues common to most models that distinguish them from the socio-cultural model.
A major criticism that may be made of models of psychopathology generally is that they are inherently too individualistic from their theoretical conceptualizations to their practical applications. The reductionist view of science prevalent within our culture is reflected in the empirical research paradigm of contemporary psychology and psychiatry. This research is used to legitimize the current models of psychopathology and confer validity on their theoretical underpinnings.
Chomsky (1968) and Poole (1972) point out that science is inadequate when it focuses on selected parts rather than the totality of problems. Poole defines an adequate science as ‘the study of the totality of problems, objective and subjective, by the whole thinker, taking into account all the evidence, both quantifiable and unquantifiable’ (Poole 1972: 108–9). However the traditional scientific paradigm of empirical research emphasizes an analysis and solution of problems, and ignores wider contextual issues. This type of research into human behaviour is seen, for example, in the geneticists’ quest to isolate genes for happiness, aggression, and so on; as well as in psychiatric and psychological researchers isolating specific symptoms, or specific events of the therapeutic process, or isolating the client and/or therapist from the total subjective context within which therapy takes place. It is questionable whether these different frameworks actually help clients to understand the source of their unhappiness, or merely elevate the notion of illness. Writers such as Masson (1990, 1991), Heath (1992), Smail (1987, 1993) and Szasz (1971) point out the inappropriate therapies and treatments given for conditions of which we do not know the fundamental causes, but which may turn out to be psycho-social in origin. They draw attention to the inappropriate and inadequate view of the nature of the self that ignores political, economic and cultural sources of pain and distress and which avoids any real analysis and criticism of a social order based on inequality of wealth, opportunity and choice. They challenge the view that focuses, simplistically, on individuals and families as the target of intervention. In therapy, while close attention is paid to personal and interpersonal processes, the focus is on the significance of events in particular, isolated contexts. For example, Masson criticizes Freud for his inherently individualistic view in ignoring external sources of distress, stating: ‘Freud is asking us to shift the direction of our attention, from the external to the internal. Freud was perpetuating a tradition that did not begin with him. Its basic characteristics were that it was male-oriented, ethnocentric, sexist, and rigidly hierarchical’ (1991: 208).
Models of psychopathology view the cause of distress as being due to some deficit or fault located within the individual’s psyche or biochemistry, or as an inadequacy in coping with external situations rather than the cause of distress being located in the wider context. The different models concentrate on the significance of events in particular isolated contexts; for example, bio-medical models concentrate on a specific symptom, or set of symptoms, while cognitive and behavioural models focus on specific behaviours and dysfunctional thought patterns. In the psychoanalytic model and its derivatives, close attention is given to the unconscious, to transference or shifts in group dynamics, and so on. When wider influences are considered, this is usually confined to issues close to the individual’s immediate context such as a consideration of relationships within the family; or what is described about such circumstances is viewed and interpreted by therapists in symbolic or iconic forms, rather than as the literal or material reality experienced and described by the patient. This has led to serious limitations of the explanatory power of models of psychopathology theories and practical applications that have been derived from them.
The ethos of individualism is also reflected in the institutional and professional cultures of our working environment, and a sociopolitical system that emphasizes individual effort and responsibility. Smail (1993) documents how psychotherapy, psychology and psychiatry have helped shape a culture of individualism where it has become almost impossible for people to differentiate inside from outside, or to attribute the pain they often feel about themselves to its appropriate source. We often wrongly locate the origins or ‘cause’ of our pain as being located inside us and as being a reflection of our own inadequacy or personal failing.
Traditional and contemporary bio-medical and psychological models of psychopathology tend not to recognize that distress is often caused by a person finding that they are unable to meet the requirements of what Smail terms ‘form’. For example, we cannot change homosexuality to heterosexuality. While mental health practitioners no longer expect their clients to be able to alter their sexual preferences at will they still often assume that people have access ‘within’ them to forms of behaviour which are more ‘adjusted’ than those they are currently displaying; and all that is needed is some kind of individualistic enterprise usually framed in terms such as ‘moral effort’, ‘cognitive understanding or restructuring’, ‘emotional insight’ or the ‘medication of choice’ or ‘taking responsibility’.
It is often the absence of form in our rapidly changing mobile society that leads to distress. For example there are few forms to guide our relationships with each other in modern Western society. To acquire new forms when the old ones have disappeared or disintegrated may or may not be possible. When an individual’s experience cannot receive its meaning from an appropriate public form – the result is often pain, including forms of pain such as blame and guilt. People find themselves isolated with feelings, impulses, ideas or thoughts that are not reflected in formal public concepts or meanings. Often they will then seek help from a psychiatric and therapeutic industry only too ready to produce a formal diagnosis for their difficulty.
One implication of this is that symptoms of pathology or variations in the expressions of human distress are not constant, but fluctuate according to what is happening in the social environment. Numerous community studies point out that the prevalence of psychological distress is as great as 18 to 20 per cent of the population. Given these figures, as the work of the American community psychologist George Albee (1996) emphasizes, it is both practically and ethically unreasonable to suggest that the distress of such a high proportion of the population should be viewed as evidence of psychopathology. However, since neither the causes nor cures of distress are, in the socio-cultural model, just an individual matter, clinicians may only alleviate some of the painful consequences of distress. Writers such as Davies (1995), Richards (1995) and Pilgrim (1997) point out that the explanations have limited relevance where there is little or no understanding of the individual’s cultural and social context. Others, such as Pillay (1993) suggest that greater knowledge of the social and economic reality would be more useful in understanding psychological processes, than assuming culturally based psychosis in Afro-Caribbeans and somatization in Asians. As Sayal, states: ‘As a clinician, I think it is crucial to relate personal misery to its environment, history and political context. If you rob a person of their history, you rob them of their sense of self’ (1989: 6).
Tags: American Psychiatric Association, individualization of distress, mental illness, pathologizing notions, Psychological distress, schizophrenia, Stereotypes, symptoms of psychopathology