This collection of papers is largely historical in nature. It offers the reader a solid background in the concerns, arguments, strategies, and results of efforts by psychiatrists and others to integrate cultural considerations into the DSM-IV and, more broadly, diagnosis and treatment. The time period it covers is approximately twenty years, from 1981 to 2001, with a few original papers included that don't state their creation date. For anyone who believes that questions of context, culture, minority status, and ethnicity within illness experience and interpretation are still pressing and salient, this book can serve as a reference guide and teaching tool.
The anthology's stated focus is on the theory and implementation of Cultural Formulation, an approach to diagnosis and treatment that numerous scholars and researchers worked on in conjunction with the development of DSM-IV. It begins with an excellent theoretical article by Juan Mezzich that explains how psychiatric nosology differs from natural taxonomies. Mezzich sets out several problems facing psychiatric diagnosis and persuasively argues that an accurate understanding of the nosology of mental distress and illness requires systematic attention to cultural differences and the embeddedness of Western values and biases in the DSM and the practice of psychiatry. In a chapter by Byron Good and Mary-Jo DelVecchio Good, the authors focus on the need for cultural competence, an idea that back in the mid-1980s, was just beginning to receive attention. By situating symptoms of mental illness within medical anthropology, Good and Good highlight the social production of psychiatry, 'on the use of culturally distinctive meaning systems to interpret personal and social realities, on cultural idioms of distress and modes of discourse, and thus processes through which forms of illness are generated, constructed as social realities, and maintained or treated" (p. 30). They clarify and motivate reasons for understanding problems of validity as integrally bound up in cultural and racial matrices that can lead to bias and error, however inadvertently. In general, Part I of this book is very useful for training residents and others. It makes clear who the central informants of cultural values should be and why; how a multiaxial approach would utilize cultural information and why; and why the very embeddedness of culture renders difficult the clinician's and patient's task of interpreting one another.
In terms of analysis and theory, Part I is clearly the strongest section. But for application of the theory, readers will find Part IV on clinical case illustrations very useful. Each chapter in this section works through a particular case from 'Clinical History' to 'Cultural Formulation' and, without much elaboration, demonstrates the importance of cultural and contextual considerations in diagnosis and treatment. I especially found Chapter 18, by Maria Oquendo and Ruth Graver, interesting for its attention not only to patient experiences of racial discrimination and minority status but also its sensitivity to the complexity of therapist conundrums in addressing these issues. In this case, Oquendo and Graver describe a patient who bonds with and trusts the therapist on the basis of skin color, thereby believing she is more likely to be understood in her anguish about having been a victim of racism. Oquendo and Graver point out, though, that such trust can be fairly superficial and can make it difficult for clinicians to distinguish between a patient's experiences of racism and her internalized feelings of inferiority. Wanting not to pathologize or minimize the social context of mental distress, clinicians walk a fine line between validation of social causes and attention to personal low self-esteem. This chapter and other case studies of Cultural Formulation would be greatly beneficial to training and discussion with residents and clinicians.
The middle two sections are less exciting and so I have less to say about them. Readers will find nuggets of great worth there, such as in Lloyd Rogler's article, 'Framing Research on Culture in Psychiatric Diagnosis'. Rogler raises the extremely difficult and pressing question, Can diagnosis and research be systematic and still retain the pluralistic qualities of culture and cultural differences? A chapter by Francis Lu, Russell Lim, and Juan Mezzich is a potentially rich one that attempts to address a consistent problem in psychiatric literature: the elision of adequate definitions of culture, ethnicity, and race. Yet even here the authors offer only superficial, or 'thin', definitions that fail to capture what is most problematic and messy about each of these concepts individually and, especially, all of them when they intersect. Their definition of 'race' as biological especially is disappointing. Granted, this chapter was originally published in 1995, when less was known about the social production of the concept of 'race' and the lack of scientific evidence for the existence of 'races', but that suggests that the editors would have done better to ensure that that chapter was updated to reflect 21st century understandings of racialization. Still, Parts II and III will give readers an appreciation for the enormous difficulties that the Cultural Formulation project faced and the disappointment of seeing much of their efforts ghettoized into an axis or appendix instead of being threaded throughout the manual. Those chapters provide a realistic discouragement but, hopefully, not significant enough for people to abandon the goals and values of the Cultural Formulation.
All in all, though, this is a valuable book for anyone who is interested in theoretical aspects of the project of incorporating culture and context into the DSM and who wants to find out what has already been tried, both successfully and not. Cultural Formulation--the anthology and the project--represents a dedicated and systematic attempt to integrate culture and context into the DSM.
© 2010 Nancy Nyquist Potter
Nancy Nyquist Potter is a Professor of Philosophy at the University of Louisville and President of the Association for the Advancement of Philosophy and Psychiatry. Her most recent book is Mapping the Edges and the In-between: A Critical Analysis of Borderline Personality Disorder (Oxford University Press 2009). She is currently working on issues of socialization and racialization in the diagnosis of Oppositional Defiant Disorder and Conduct Disorder.