Cultural Child and Adolescent Psychiatry

G. Pirooz Sholevar

Introduction

Cultural child and adolescent psychiatry consists of a body of theoretical and technical knowledge that informs high quality psychiatric evaluation, treatment and assessment of developmental process across cultural and language barriers to children, adolescents, and families. Clinicians are increasingly called upon to evaluate or treat patients from multiple cultural and linguistic groups. In our multicultural American society, treating a patient who speaks a different language or holds beliefs at variance with the majority culture requires the knowledge and skills that constitute cultural psychiatry (1). Cultural psychiatry defines the impact of culture on psychiatric evaluation and diagnosis and provides guidelines for culturally competent and sensitive psychiatric treatment and systems of care (1,2,3). It is characterized by introducing the vast diversity of human experience into an understanding of the complexities of mental health and illness.

Cultural psychiatry has evolved consistently throughout the past century. Initially and at the beginning of the twentieth century it was primarily concerned with comparison of manifestations of mental disorders in different cultures and countries. It described the exotic and special features of different syndromes and disorders discovered in Africa, the Far East, and other non-Western countries. The descriptions were based on a universalist (and Western) viewpoint of psychiatry and mental disorders. In the mid-twentieth century prominent anthropologists such as Ruth Benedict, Margaret Mead, and Bronislaw Malinowski incorporated psychoanalytic constructs into their cultural investigations of the impact of culture on personality development and disorders (4). This highly productive collaboration between psychiatry and anthropology also included Emile Durkhiem’s landmark study on suicide and George Herbert Mead’s Symbolic Interactionalist Theory.

The interest in sound methodological measures in the mid-twentieth century resulted in the construction of a number of crossculturally validated epidemiological and diagnostic instruments. Recent findings based partially on such methodology have resulted in a gradual shift from a universalist viewpoint to a more culturally specific perspective (1,2,5).

The value orientation theory was originally proposed by Kluckhohn (6). It is based on variations in generalized cultural values. According to Kluckhohn, there are three possible variations in solution to the problems of time (past, present, future); activity (doing, being, being-in-becoming); relationship in groups (individual, collateral, linear); man–nature relationship (harmony-with-nature, mastery-over-nature, subjugated-to-nature); and basic nature of man (neutral/mixed, good, evil).

Cultures vary widely in these dimensions. For example, American culture emphasizes a future time orientation, a “doing” mode of activity, an “individualistic” relational orientation focusing on autonomy; mastery over nature; and the nature of man as neutral or mixed. Using this now-dated typology, Spiegel (7) pointed how Southern Italians in contrast are oriented toward present, being, collateral relational view, subjugation by nature and a mixed view of human nature, while Southern Irish are oriented toward present, being, lineal relationships, subjugation by nature and the evil nature of man. In their views, the contrast between variable value orientations can create interpersonal tension and conflicts, such as in a crosscultural marriage.

The cultural relativist perspective of current cultural psychiatry is in contrast to the universalist one, and asserts that cultural values and meanings are relative to and embedded in their cultural context and cannot be measured against a universal system. It uses locally meaningful categories to describe indigenous syndromes, their phenomenology, and native explanatory models based on an ethnographic perspective (8). They make strong attempts to avoid the categoricalfallacy.

Category fallacy refers to application of a category that is valid within one cultural context to a culture where the category has no diagnostic validity or relevance. It stems from a universalist approach to assigning meaning to behaviors transculturally. In contrast, cultural relativists propose that cultural meanings and values are relative and fundamentally embedded in their cultural context. The latter perspective is referred to as emic, in contract to the former approach, known as ethic, which applies Western diagnostic categories to another cultural context (8).

Definitions

Culture consists of those patterns of behavior, acquired and transferred over time, which prescribe the norms, customs, roles, and values inherent in political, economic, religious, and social aspects of family life. Culture provides the set of rules and standards that guide people’s actions, makes their behavior understandable to one another, and helps to explain individuals’ relationships to their sociobiological context.

Ethnicity refers to the sense of belonging and having a rootedness in history that reaches beyond religion, race, or national or geographic origin. Ethnicity is our basic identity—who we are in relation to other human groups. It frames our manner of dress, style, and communication through language and rituals, as well as how we feel about life, death, and illness (9,10). The concept is derived from the Greek work ethnos, or people of a nation. We are born with an ethnic identity. Throughout life we experience and adopt different cultures, thereby living with expectations and values from both a majority culture (i.e., the American culture) and minority culture—our culture of origin. We carry with us both the values, assumptions, traditions, and worldviews transmitted over generations within our ethnic group and the concurrent—sometimes competing—view of the cultural
context in which we live. As noted by McGoldrick et al. (10

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