The relationship between a person’s culture, psychiatric presentation and psychiatric empiricism has been debated for several decades, but a text that attempts to provide a comprehensive framework for clinicians concerning the provision of care has not been as forthcoming. There have been other examples; Tseng’s Handbook of Cultural Psychiatry from 2001 springs to mind. However, the scope of the current text is broader, more contextualized and aimed not just at clinicians. Bhugra, currently the President of the Royal College of Psychiatrists and Professor of Mental Health and Cultural Diversity at the Institute of Psychiatry in London, and Bhui, Professor of Cultural Psychiatry and Epidemiology at St Bartholomew’s Hospital, London , are two British-based psychiatrists who have attempted to fill that gap by bringing together academics and clinicians from many (albeit mainly Western) countries to provide both theoretical and practical perspectives, and consider not simply presentations, but experiences of mental illness. As a result aspects of trauma, intellectual disability, sexual dysfunction, the refugee experience are all considered in depth and with some sensitivity.
The editors contend that cultural psychiatry is concerned with “understanding the impact of social and cultural differences and similarities on mental health and its treatments”. It is perhaps the last point, the impact on treatments, that is one of the most significant and important aspects of this book, and something that has not really been articulated in quite the same way before.
The aim of the book is to help all those involved in mental health care to “provide appropriate, sensitive and acceptable services for different cultural groups”. And while it may appear to be written by psychiatrists (qualifications and disciplines are not generally provided) it is not solely for psychiatrists. The different chapters are scholarly, but accessible to most people with a basic understanding of the area and the interface of psychiatric and sociological concepts. They are not overly technical and are arranged thematically which helps the reader negotiate the text as a whole -- it is after all intended to be a textbook and not necessarily read in sequence or as a thesis.
There are six major parts to the text: Theoretical background; Culture and Mental Health; Culture and Mental Disorders; Theoretical Aspects of Management; Management of Special Groups; and Cultural Research and Training. Of these, the first provides a useful overview of the concepts and history of the subject, but adds in useful chapters on spirituality and health inequalities.
The second emphasizes not just explanatory models, but health and the importance of identity formation, acculturalization and cultural consonance -- what is it like to be a stranger in a strange land, how are second and third generations affected?
The third is mainly devoted to disorders and the fourth and fifth concern themselves with treatment and management.
The final chapter looks more to the future and tries to locate psychiatry in a changing world in which not only the demographics, but the mobility and flux in society are becoming very different from even two or three decades ago. What is called the “biology-society dialectic” is yet to play out fully, and perhaps it never will or never should. Cultural identity is fluid, as perhaps is psychiatry’s response.
Readers of the book will find it practical and down to earth, tolerant and humane, sensitive and cogent. In the main the authors convey a sense of grounded practice that recognizes the interplay between the personal manifestation of illness and social factors. The book is not very prescriptive, but does provide a number of cautions that clinicians should consider, and certainly does not see itself as the final word -- indeed it is a work in progress and cultural psychiatry may well become one of the most significant areas of care and research in mental health. It is interesting to speculate how a revision of this text will look in the light of the forthcoming DSM-V.
There are some areas that could have been developed more, but they are few. Even so, there is not a great deal of space devoted to aspects of rehabilitation and recovery, even though it is acknowledged that a sense of cultural integration and identity is important to health and well-being. Some specific aspects of the refugee experience that present themselves to clinicians, such as war, terror, torture and persecution may have deserved more than one chapter. And it may have been interesting to gain more insights from workers in the developing world. Indigenous populations do not feature large, Africa and South America are not mentioned at all and India, Taiwan, Lebanon and Sri Lanka are the only non-Western countries to contribute, even if the authors have a wider experience.
In conclusion it can be fairly said that this book represents a major step forward in the understanding, recognition and care offered in one of the most important areas in the future of psychiatry.
© 2009 Mark Welch
Mark Welch, Ph.D., British Columbia, 2009