CULTURE AND MENTAL ILLNESS
A Client-Centered Approach
Richard J. Castillo
University of Hawaii at West Oahu
INTRODUCTION AND THEORETICAL ISSUES
Mental disorders are easily described but not easily defined. Scientists have come to realize that a mental disorder consists of a highly complex construction of experience involving many factors, with no clear boundary between mental illness and mental health. In the Introduction to DSM-IV (1994) it is stated:
Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. . . . In DSM-IV, there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder. [pp. xxi-xxii]
Thus, in DSM-IV mental disorders are not conceptualized as discrete disease entities.
However, from the 1960s to the mid-1980s, there was a conception held by many researchers that mental disorders were caused primarily by "chemical imbalances" in the brain, stemming from genetic abnormalities. This conception arose primarily because of the limited success obtained from treating mental disorders with psychotropic medications. In this biomedical paradigm, mental disorders were conceptualized as brain diseases and therefore treatment was primarily aimed at treating the disease. This approach is referred to in this book as disease-centered psychiatry.
Presently, however, it has been found that attributing mental disorders primarily to diseases in the brain is too simplistic an explanation to accomodate recent research findings, or to serve as a basis for consistently successful treatment. It is now known that the psychotropic medications currently in use treat symptoms, and not diseases (Guttmacher, 1994). An emphasis on treating a disease rather than on the patient can result in a dehumanization of the patient in psychiatric practice (Brody, 1995; Fleck, 1995).
Some of the information that has been found to be most important in spurring a move beyond the boundaries of disease-centered psychiatry has come from cross-cultural studies of mental illness. For example, the finding that the duration of schizophrenia is shorter, the course is more begnign, and the outcome is better in nonindustrialized societies than in industrialized societies has caused many researchers to reassess their conceptions of schizophrenia (Jablensky & Sartorius, 1988; Jablensky et al., 1992; Jilek & Jilek-Aall, 1970; Karno & Jenkins, 1993; Leff et al., 1992; Rin & Lin, 1962; Sartorius, Jablensky, & Shapiro, 1977; Sartorius et al., 1986; Waxler, 1974, 1979; WHO, 1973, 1979). These cross-cultural findings on schizophrenia are contrary to expectations if the problem is conceptualized as a genetically based, incurable brain disease. The conclusion drawn by researchers who worked on DSM-IV is that culture must play an important role in the duration, course, and outcome of schizophrenia, the extent of which is still unknown. However, the data from cross-cultural studies have been convincing enough for psychiatric anthropologists and other cross-cultural researchers to be involved for the first time in the composition of the DSM (DSM-IV).
The treatment of mental disorders with psychotropic medications on the assumption that this reversed the effects of a genetically based brain disease led to conclusions in assessment and diagnosis that were unwarranted. For example, this disease-centered view of mental illness promoted the conclusion that complete recovery from schizophrenia was unlikely if not impossible. We now know that this is not necessarily true. Complete recoveries from schizophrenia are not unknown in industrialized countries (Angst, 1988; Harding et al., 1987; McGlashan, 1988), but they are significantly more common in nonindustrialized societies. These cross-cultural findings indicate that a complete recovery from schizophrenia is possible, and that schizophrenia needs to be conceptualized in a more complex, holistic fashion.
Thus, the realization has slowly dawned that the etiology, structure, course, and outcome of mental disorders are far more integrated than previously imagined. It is now becoming clear to most researchers that mental disorders need to be defined in a holistic manner including the interactions of the social-cultural environment and the effects of diagnosis and treatment on a human brain with plastic (modifiable) neural networks. All of these factors combine and interact to produce an actual illness experience in a given patient (Castillo, 1991a, 1994c, 1995; Desjarlais, Eisenberg, Good, & Kleinman, 1995; Fabrega, 1989a,b, 1992, 1993a,b, 1994a,b; Fleck, 1995; Gaines, 1992a,b; Gaw, 1993; Good, 1992; Hinton & Kleinman, 1993; Kleinman, 1987, 1988b, 1992; Kleinman & Good, 1985; Lidz, 1994; Littlewood, 1991; Lu, Lim, & Mezzich, 1995; Marsella, 1989; Mezzich, 1995; Mezzich et al., 1992, 1994; Mezzich, Honda, & Kastrup, 1995; Mezzich, Kleinman, & Fabrega et al., 1996).
Therefore, the traditional biomedical paradigm in psychiatry is now being expanded to include the neurobiology of adaptation and learning. This theoretical expansion includes the effects of neuronal changes in the brain resulting from psychotropic medications and psychotherapy, as well as the neurobiological effects of individual and cultural learning.
For example, it is now understood that neuroleptic medications can affect neuronal structures. Neuroleptic medications administered over a longterm cause the brain to adapt to the neuroleptics by upregulation of the dopamine system. This means the brain increases the number of dopamine receptors as well as increasing the avidity with which receptors seek the dopamine (Guttmacher, 1994). Although blocking dopamine receptors with neuroleptics does reduce psychotic symptoms in a majority of patients, leading to shortterm improvement, over the longterm an upregulated dopamine system has the potential of escalating and prolonging the illness. For example, Birley and Brown (1970) found that schizophrenic patients who reduced or discontinued the use of neuroleptics were more likely to relapse without the involvement of stressful life events than patients who had taken no neuroleptics for at least twelve months. In addition, upregulated dopamine receptors in the motor cortex caused by prolonged neuroleptic dopamine blockage cause various kinds of movement disorders such as tardive dyskinesia, characterized by abnormal, involuntary movements. These movement disorders can be viewed by the patient as well as untrained observers as part of the disease. Thus, the effects of treatment can become part of the illness experience of the patient, as well as affecting the course of the disease and the structure of the brain (DSM-IV, 1994).
It has also been discovered that individual learning and memory storage change the neuronal structure of the brain (Kandel & Hawkins, 1992). Because culture determines many aspects of learning, cultural learning also has a biological basis in the brain, and therefore in mental disorders. Thus, it is possible to conceptualize a biological basis for cultural differences in mental disorders.
The likelihood of culture-based differences in the brain argues for an essentially anthropolgical viewpoint of mental illness, utilizing anthropology's deliberately holistic perspective and methodology, combining neurobiological, psychological, social, and cultural theories and data. Therefore, this book specifically attempts to embrace a cross-cultural, patient-centered approach to assessment and diagnosis. In a patient-centered psychiatry, rather than diagnosis and treatment of a disease, diagnosis and treatment are concerned with a patient with thoughts, emotions, a social context, and a cultural identity.
Anthropology And The Study of Mental Illness
An interest in mental illness among anthropologists has been present from the early days of the discipline (Marsella, 1993). However, until recently anthropology has had little direct impact on psychiatric theory. Theoretically, psychiatry mostly ignored anthropology up to the 1980s. That is because there was previously the assumption of the psychic unity of humankind. This is the assumption that all people have the same basic brain structure, and therefore universally have the same basic mental processes. It was assumed that even if all people do not think the same things, they still think the same basic way.
However, recent findings in the neurobiology of learning, memory, and cognition clearly indicate that this is not true. For example, the way males and females think is different, probably because of sex hormones affecting the brain during fetal development (Gur, 1995; Kimura, 1992). Also, there are clear findings on the neurobiological differences of learning and memory on the cellular and molecular levels of the brain, constituting to a great extent the biological basis of individuality of consciousness (Kandel & Hawkins, 1992). It follows that the same neurobiological processes operating in learning to create individual differences in the psychobiology of brain and mind also operate at the collective level to create biological differences in the brain across cultures. Thus, the psychic unity of humankind can no longer be assumed on the basis of biological sameness. This has profound implications for the study of mental disorders.
Disease-centered psychiatry assumed the psychic unity of humankind. In the disease-centered paradigm, because of the assumption that the normal brain is structured and functions the same in all people, any differences in brain structure or functioning could be assumed to represent brain disease. Thus, until the discovery of neuronal adaptability in the brain, there was little need to include brain plasticity in conceptions of mental illness. However, we now know that neural structures in the brain are altered in adaptations to emotional stress and trauma, medications, psychotherapy, personal experience, and cultural learning. All of these can affect the the neural networks of the brain and therefore the etiology, structure, and outcome of mental disorders.
The assumption of the psychic unity of humankind was made, sometimes even in anthropology, up until the late 1970s. The cognitive revolution of the 1970s in the behavioral sciences changed that. The discovery was made that learned cognitive schemas of an individual actually construct to some extent his or her subjective experience of the world (Neisser, 1976). Furthermore, the subjective construction of experience can be dramatically different in the same situation among different individuals. The discovery was also made that cognitive schemas are dependent to a very large extent on cultural learning (D'Andrade, 1984). This meant that cultural schemas are formed within the mind-brains of cultural groups. These cultural schemas can cognitively construct a particular behavior as an episode of mental illness, while a different set of cultural schemas can cognitively construct a similar situation as something normal and normative. These differences in cognitive construction result from cultural learning and are based in plastic neuronal structures.
Furthermore, there was the realization among researchers that mental patients could cognitively construct an experience of mental illness one way, while the doctor or folk healer could cognitively construct it in a different way, based on their own set of cultural schemas. The patient could experience the illness as one particular kind of problem, while the clinician could diagnose it as something entirely different. This is the distinction made by medical anthropologists between illness and disease.
Illness and Disease
The psychiatrist and anthropologist Arthur Kleinman introduced the distinction between illness and disease. The term illness refers to the subjective experience of the patient. It is the subjective experience of being sick, including the experience of symptoms, suffering, help seeking, side effects of treatment, social stigma, explanations of causes, diagnosis, prognosis, as well as personal consequences in family life and occupation (Kleinman, 1988a).
In contrast, the term disease refers to the diagnosis of the doctor or folk healer. It is the clinician's definition of the patient's problem, always taken from the paradigm of disease in which the clinician was trained. For example, a disease-centered psychiatrist is trained to diagnose brain diseases, a psychoanalyst is trained to diagnose psychodynamic problems, and a nonwestern folk healer might be trained to diagnose such things as spirit possession or sorcery. In each case, the clinician's diagnosis is the "disease."
In psychiatric anthropology there is no assumption that only disease-centered psychiatrists can diagnose "real diseases." In psychiatric anthropology, the clinician's diagnosis as well as the patient's personal illness experience are cognitive constructions based on cultural schemas.
DSM-IV Historical Background
The modern study of mental illness is not culture-free. The scientific study of mental illness is a product of a particular culture-based intellectual tradition. This can be seen by examining the cultural evolution of psychiatry in the United States. This cultural evolution is readily discernible in the official manuals of the American Psychiatric Association (APA).
DSM-IV is the fourth edition of the APA's offical manual, the Diagnostic and Statistical Manual of Mental Disorders (1994). The original reason for developing a nomenclature for mental disorders was the need to collect statistical information for census purposes. The early systems of classification developed in the late 19th and early 20th centuries had the compilation of census data on the mentally ill as their primary aim. A broader nomenclature was developed by the U.S. Army and Veterans Administration during and after World War II for U.S. servicemen and veterans. Subsequently, the World Health Organization published the sixth edition of the International Classification of Diseases (ICD-6, 1948), including a section for mental disorders that was heavily influenced by the Veterans Administration nomenclature. ICD-6 included 26 categories of mental illness.
DSM-I: The biopsychosocial model. The American Psychiatric Association developed a variant of ICD-6 that was published in 1952. This was DSM-I, and was the first offical manual designed with clinical uses in mind, although its historical background as a statistical manual was evident. DSM-I was based largely on Adolf Meyer's biopsychosocial paradigm of mental illness. The text used the term reaction throughout the manual reflecting the dominant view at the time that mental disorders were reactions of the personality to biological, psychological, and social factors. Thus, the classification system in DSM-I was etiological in structure rather than descriptive. That is, diagnostic categories were generally defined based on the assumed causes of the disorders rather than their symptoms.
The basic assumptions of the biopsychosocial paradigm have been summarized by Mitchell Wilson (1993):
1) that the boundary between the mentally well and the mentally ill is fluid because normal persons can become ill if exposed to severe-enough trauma, 2) that mental illness is conceived along a continuum of severity--from neurosis to borderline conditions to psychosis, 3) that the untoward mixture of noxious environment and psychic conflict causes mental illness, and 4) that the mechanisms by which mental illness emerges in the individual are psychologically mediated (known as the principle of psychogenesis). [1993, p. 400]
In the biopsychosocial paradigm of DSM-I, mental disorders were not discrete, but were seen as the same general psychopathological process manifesting along a quantitative spectrum from mild to severe. Treatment based on this paradigm was psychodynamic in nature rather than biomedical. Thus, therapy was designed to understand and undo the psychogenic causes of the disorders, rather than treat symptoms directly through the use of medications or other biomedical treatment.
DSM-II: Beginnings of paradigm shift. DSM-II, published in 1968, was very similar to DSM-I but eliminated the term reaction. This was the result of a lessening of emphasis on psychological and social etiological factors, and a move toward the biomedical paradigm that occurred after the introduction of lithium and neuroleptic medications during the 1950s and 60s. Biologically oriented psychiatrists were advocating a move toward the disease model, and the paradigm shift to disease-centered psychiatry that occurred in the 1970s is thus first signaled in the changes occurring in DSM-II.
DSM-III: Disease-centered psychiatry. DSM-III, published in 1980, was completely different from its predecessors and represented the culmination of a paradigm shift in psychiatry to the disease-centered perspective. DSM-III instituted a descriptive approach to the classification of mental disorders rather than the etiological approach present in DSM-I and DSM-II. By 1980, the assumption that mental disorders were based in brain diseases had become the dominant paradigm in modern psychiatry. Indeed, according to Robert Spitzer, chairman of the DSM-III Task Force, DSM-III was intended to be a "defense of the medical model as applied to psychiatric problems" (Wilson, 1993). Thus, with the acceptance of the disease-centered perspective, the earlier etiological classification system found in DSM-I and II, which was based on a psychodynamic paradigm that included psychological and social factors, was largely abandoned (Fleck, 1995).
In the disease-centered paradigm there was no assumption of brain plasticity that could be implicated in brain abnormalities resulting from psychological trauma or other forms of adaptation to the environment. There was also no assumption that psychological treatment could affect the structure of the brain. Therefore, training in psychiatry during the 1970s and early 1980s became almost exclusively centered around the use of psychotropic medications and electroconvulsive therapy as the primary treatments.
Also in the disease-centered paradigm, since the brain was viewed in an essentially static fashion in which any brain abnormality could be considered disease, it was believed to be necessary to discover the precise brain pathology that was assumed to underlie each separate disorder. This required that each disorder be accurately and narrowly defined so that researchers could then study the brain physiology and anatomy of afflicted persons in order to uncover the disease responsible for the disorder. This would in turn help define proper biomedical treatment. However, the first step in this process was accurate classification of mental disorders. In DSM-III it was decided that disorders should be classified by descriptive patterns of symptoms, rather than etiology. DSM-III was the first attempt to classify mental disorders along these lines.
In contrast, the patient-centered approach presented in this textbook tends to view mental disorders as psychobiological adaptations to emotional stress and trauma, rather than brain diseases. In this view, mental disorders occur in a brain that is adaptable and plastic in its structure and mental processes. Thus, brain abnormalities can result from the way in which the brain is habitually used or from emotional trauma (Chapter 15).
Reliability. The emphasis in the composition of DSM-III was on reliability. Reliability refers to the ability of separate clincians or researchers to consistently diagnose the same disorder after observing the same pattern of symptoms in patients. If clinicians and researchers can use the same diagnostic instrument, observe similar patients, and arrive at similar diagnoses, then the diagnostic instrument is said to be reliable. Because the underlying goal of DSM-III was to provide accurate classifications of mental disorders for laboratory researchers looking for discrete brain diseases, mental illness in DSM-III was divided into hundreds of separate disorders, each with its own descriptive pattern of symptoms.
However, in the late 1970s there was no existing proof that each of the hundreds of disorders defined in DSM-III was based in a separate brain disease. It was simply assumed in the disease-centered paradigm that each of the disorders could first be defined along descriptive parameters (Fabrega, 1994a). Laboratory research could then provide the empirical evidence to conclusively define the precise brain diseases involved. However, the classification system had to come first.
The disease-centered paradigm in DSM-III was continued in DSM-III-R. DSM-III-R, published in 1987, was a minor revision of DSM-III designed to eliminate inconsistencies in the diagnostic system and to further clarify diagnostic criteria. In DSM-III-R, the same basic classification system was retained from DSM-III, along with the same disease-centered paradigm.
DSM-IV: Beginnings of paradigm shift. DSM-IV, published in 1994, is analogous to DSM-II in that it retains the disease-centered paradigm of its predecessor, but shows enough change in underlying theory to signal a future paradigm shift.
Among the reasons for change in underlying theory is that after thousands of studies and many millions of dollars spent on research, the laboratory confirmation of specific brain diseases as the underlying causes of the hundreds of mental disorders in DSM-IV has not arrived as expected. Of course, numerous brain abnormalities have been found to be correlated with various mental disorders, but none of these have been confirmed to be causing the mental disorders.
Because we now know of the plasticity of the brain, abnormalities that have been discovered could just as easily be the effects of mental disorders as the causes. As a result, included in DSM-IV, in almost all of the major psychiatric categories, listed under the heading of Associated laboratory findings, there is the statement: "No laboratory findings that are diagnostic of [specific disorder] have been identified." This is true even of the major disorders such as schizophrenia and major depression that had been widely publicized as genetically based brain diseases.
In the case of schizophrenia, laboratory findings have found abnormalities in brain anatomy and biochemistry in some individuals with schizophrenia. These abnormalities include enlargement of the ventricular system, and indications that excessive activity in the dopamine system may be implicated in schizophrenia. However, no specific brain disease has been found to be the cause of these abnormalities or of schizophrenic symptoms (Chua & McKenna, 1995). For example, it is possible to have enlarged ventricals without schizophrenic symptoms, and schizophrenic symptoms without enlarged ventricals. Many people with schizophrenia do not have enlarged ventricals, and this abnormality is not required for the manifestation of schizophrenic symptoms. Also, this abnormality is modest and there is a large overlap with the normal population. Moreover, no brain abnormality is necessary for making a diagnosis of schizophrenia. A diagnosis of schizophrenia in DSM-IV is made based on the presence of purely psychological symptoms.
Similarly, in the case of major depression, studies have found abnormalities in neurotransmitters associated with depression, but the relationships invlove several neurotransmitters in complex interactions that are not yet understood. As a result, researchers now generally agree that no single neurotransmitter system is involved in a specific and isolated manner with major depression. And again, these abnormalities could be the effects of depression and not the cause. As DSM-IV states, "It appears that the same laboratory abnormalities are associated with a Major Depressive Episode regardless of whether the episode is part of a Major Depressive, Bipolar I, or Bipolar II Disorder" (1994, pp. 323-324). In other words, the same alterations in biochemistry are associated with major depression, bipolar I (manic-depression), and bipolar II (hypomanic-depression). This is contrary to the notion of discrete mental disorders being based in discrete brain diseases.
Furthermore, DSM-IV goes on to state, "Most laboratory abnormalities are state dependent (i.e., affected by the presence or absence of depressive symptoms), but some findings may precede the onset of the episode or persisit after its remission" (Ibid.). Thus, according to DSM-IV, most alterations in brain biochemistry associated with depression are state dependent, that is, dependent on the presence or absence of a depressed mood. Since it is well known that brain biochemistry normally alters with changing moods, including a depressed mood (Pardo, Pardo, & Raichle, 1993), alterations in brain biochemistry occurring with depression can hardly be considered the effects of a brain disease. It is a chicken and egg question. Does the alteration in brain biochemistry cause the depressed mood? Or, does the depressed mood cause the alteration in brain biochemistry? Based on current knowledge, it is not justified to conclude that there is an identifiable brain disease. Therefore, as of now, no specific brain disease has been identified to be the cause of major depression.
As is discussed in Chapter 15, because of brain plasticity, it is possible that a chronically depressed mood of an individual can cause an abnormality in brain biochemistry. The uncertainty caused by the discovery of brain plasticity and adaptation, as well as alterations in brain biochemistry resulting from changes in mood, have prompted many researchers to look beyond biology for the answers to the question: What is a mental disorder? The expansion of DSM-IV to include social and cultural factors is a manifestation of this expanded search on the part of scientists.
If indeed DSM-IV is analogous to DSM-II in signaling the beginning of a paradigm shift, then the future DSM-V should be analogous to DSM-III in establishing a new paradigm within the official diagnostic system. The paradigm that will be at the basis of DSM-V is still unclear at this point, but the postmodernism that has swept through the social sciences in recent years is likely to influence any new paradigm in the study of mental illness. That influence is most likely to come from psychiatric anthropology. Anthropological studies and theory had only a minor impact on the composition of DSM-IV (1994), but enough to signal a change in direction away from disease-centered psychiatry and toward a patient-centered approach. As this book testifies, that influence is likely to increase in the future.
Validity. In contrast to the disease-centered paradigm of psychopathology exemplified by DSM-III that placed great emphasis on reliability, the study of mental illness within psychiatric anthropology has been primarily concerned with validity of categories. While reliability refers to consistency of diagnoses, validity refers to the reality of the diagnostic categories themselves. In other words, is the diagnostic category (e.g., schizophrenia) a real entity independent of our diagnosis, and is the diagnostic category an appropriate means of naming that entity?
For example, neurasthenia, a diagnostic category referring to "tired nerves" and including symptoms of fatigue, anxiety, and various somatic complaints, originated in the United States but is no longer a part of the DSM classification system. Yet, neurasthenia is a very common diagnosis in China (Kleinman 1986, 1988a, b). The question of whether individuals in China really have neurasthenia is a question of validity. Is neurasthenia a valid diagnosis? It may be reliably diagnosed by all of the clinicians in China, but that in itself does not make the diagnosis valid. Likewise, schizophrenia can be reliably diagnosed using DSM-IV diagnostic criteria, but is the category itself a valid one? The answer to that question depends to a great extent on the paradigm held by the person doing the asking.
Psychiatric anthropology, like all of the social sciences, has been greatly influenced by the work of Thomas Kuhn. Kuhn's book, The Structure of Scientific Revolutions (1970) describes how paradigms control scientific research. Paradigms are the highest, most general level in a hierarchy of scientific intellectual structures. A paradigm is a generally accepted view of the nature of a scientific discipline. What the paradigm does is define the discipline in question and set limits on inquiry. All researchers within a discipline with an accepted paradigm assume that the paradigm is correct. They assume that the paradigm is an accurate description of the field of study, and they do not question its basic premises. They only seek to refine problems and answer unanswered questions. These activities are called normal science (Kuhn, 1970).
A paradigm not only defines what kinds of things a scientific discipline contains, but also what kinds of things it does not. For example, in the Middle Ages the discipline of astronomy contained a universe with the Earth in the center, and the Sun, planets, and stars revolving around the Earth. It did not contain an Earth revolving around the Sun. Therefore, all astronomical observations of that time were attempts to more accurately track the movements of the Sun and planets around the Earth.
Thus, a paradigm provides the foundation and limits for the practice of a scientific discipline. Any science that is working within a paradigm is a normal science. The paradigm itself defines what problems are relevant, what methods can be used, what counts as the solution of a problem, and what problems can be assumed to have solutions. These are the only problems that the scientific community working within a paradigm will admit being scientific within their discipline. In a geocentric paradigm, the question of how long it takes the Earth to go around the Sun would never be asked. It would be considered an inappropriate and unscientific question if it was even considered.
The formal study of a particular paradigm is what prepares a person for membership in a scientific community. That person learns the rules of the paradigm and also what constitutes deviance. From within the boundaries of the paradigm any deviance is thought to be caused by ignorance (incompetence), moral depravity, or mental illness.
Disease-centered psychiatry is one example of a paradigm. In this paradigm, mental disorders were thought to be caused primarily by specific brain diseases. For example, Nancy Andreasen summarized the paradigm of disease-centered psychiatry when this perspective was at the height of its influence in her book The Broken Brain: The Biological Revolution in Psychiatry (1984):
The major psychiatric illnesses are diseases. They should be considered medical illnesses just as diabetes, heart disease, and cancer are. . . . These diseases are caused principally by biological factors, and most of these factors reside in the brain. . . . As a scientific discipline, psychiatry seeks to identify the biological factors that cause mental illness. This model assumes that each different type of illness has a different specific cause. . . . The treatment of these diseases emphasizes the use of "somatic therapies". . . . The somatic therapies used most frequently are medications and electroconvulsive therapy (ECT). Because these diseases are considered to be biological in origin, the therapy is seen as correcting an underlying biological imbalance. [Andreasen 1984:29-31, emphasis in original]
The paradigm of disease-centered psychiatry as outlined above, proclaimed itself as "a scientific discipline" that "seeks to identify the biological factors that cause mental illness." As such, mental disorders were conceptualized as specific biological diseases in the brain with the same ontological status as diabetes or cancer. Therefore, according to this paradigm, these diseases should be the same in all societies regardless of cultural differences.
Within a paradigm, in descending order are lower level intellectual structures called models, theories, and hypotheses. Models are general theories which explain a large part of the field of inquiry within the scientific discipline. Theories are more specific explanations for particular unanswered problems. And hypotheses are the lowest level, the most specific testable explanations for an unanswered problem. Within an established paradigm, all the lower levels must be logically consistent with the higher levels. Therefore, the paradigm controls what questions will be asked, what methods will be used, and what counts as an acceptable answer. Table 1.1 gives an example of a hierarchy of scientific intellectual structures.
Hierarchy of Scientific Intellectual Structures____
1. Paradigm - Disease-Centered Psychiatry (mental disorders caused by specific brain diseases)
2. Model - Psychotic Disorders (disorders caused by specific chemical imbalances)--with complimentary models
3. Theory - Schizophrenia (caused by excess activity in dopamine system)
4. Hypothesis - (schizophrenia is the same disease in all societies)--testable
Anomalies. In normal science the goal is to add to the scope and the precision with which the paradigm can be applied. No one doing normal science is trying to overthrow or undermine the paradigm. No one is looking for anything outside the paradigm (new phenomena or concepts). However, in the course of the routine practice of normal science, new and completely unexpected events or data emerge from the work in completely accidental ways. The researchers will be looking and expecting one thing, based on the paradigm, and something else happens that cannot be explained according to the existing theory, model, or paradigm. This is called an anomaly. A anomaly is a deviation from the usual or normal, something that is not supposed to happen.
An example of an anomaly is the discovery that individuals in nonindustrialized societies generally have a shorter, more benign course and a better outcome for schizophrenia than persons in industrialized societies. According to the paradigm of disease-centered psychiatry, in which schizophrenia was seen as an incurable brain disease, this should not happen. Moreover, in the wealthy industrialized societies where patients have access to the greatest amount and most sophisticated health care facilities and treatments, patients should have the best outcome for their mental disorders. Yet, this is not the case. The discovery of this fact was unexpected and was not predicted by the disease-centered paradigm. The existence of this finding, which has been replicated several times, is an anomaly. Likewise, the repeated inability to identify a specific brain disease as the cause of schizophrenia is also a serious anomaly.
However, discovery begins with the awareness of anomalies. It continues with the exploration of anomalies. Anomalies have to be accomodated into the existing paradigm, or the paradigm itself is threatened. However, paradigms are very resilient and not easily replaced. A paradigm can usually be adjusted to accomodate new knowledge. Alternatively, new methods may replace old methods in research in response to anomalies. Similarly, anomalies may open new areas of research outside of the discipline in which they were discovered. Table 1.2 provides a summary of the steps in accomodation of anomalies.
Steps in Accomodation of Anomalies_____________
1. Awareness of anomaly
2. Observational and conceptual recognition
3. Consequent change in paradigm categories or methods (often resistance)
4. Begin new discipline (if necessary)
Novelty emerges only with difficulty. There is tremendous inertia built up within a paradigm, especially within one that has been successful in the past. Therefore, even being aware of an anomaly can often take time. Expectations defined by the paradigm form scientific schemas that control cognition so that researchers are much more likely to see what they expect to see. Thus, an anomaly is sometimes difficult to recognize.
When an anomaly is recognized, it needs to be accomodated within the paradigm. This may require conceptual changes that can threaten established positions. Therefore, there is always considerable resistance to change within a paradigm. As a result, science can become increasingly rigid. However, paradigms are necessary and good for science because anomalies can only appear against the background of a paradigm.
Paradigm crisis. When anomalies last a long time and penetrate deeply into a pardigm, the scientific discipline affected by the anomaly can be said to be in a state of paradigm crisis. This is because, when an anomaly is a serious one that cannot be resolved, and cannot somehow be accomodated within the existing paradigm, it in effect demands the large scale alteration of the paradigm and major shifts in the problems and methods of normal science.
Science is always trying to bring theory and observed facts into closer agreement. This can be seen as validation or falsification of accepted theory. Of course, normal scientists are trying to validate theory and the existing paradigm. The object is to solve a problem, the solving of which is essential to the validity of the paradigm. One or two failures to solve such an essential problem only discredits the scientists involved and not the paradigm. However, repeated failure, time after time, by the best scientists in field demands alteration in the paradigm.
The only time that a paradigm is significantly altered is after a crisis in normal science. This occurs when problems that were considered to be all but solved, like pinning down schizophrenia as a specific brain disease, turn out to be not solved. At this point, more and more attention and energy are devoted to the problem and the most eminent scientists in the field get involved in trying to resolve it. However, when problems that should be solved are not solved, and they do not look like they are going to be solved any time soon, paradigm crisis ensues. At this point, formerly standard methods and expectations are called into question, and researchers begin looking outside the paradigm for answers.
This is a transition from normal science to what Kuhn calls extraordinary science. Psychiatry went through a period of extraordinary science during the paradigm shift that occurred between DSM-II (1968) and DSM-III (1980). It appears that psychiatry has now entered another period of extraordinary science. The period of extraordinary science is an exciting time for scientists because of the possibility of applying new ideas and methods to the most difficult problems in the discipline.
However, even during a period of extraordinary science, scientists still want to have a paradigm operating. Even if the existing paradigm needs changing, they will not simply abandon it. They will maintain their faith in the parts of the existing paradigm that still work and provide reasonable answers. They will cautiously move beyond that to address problems that could not be solved within the boundaries of the old paradigm. This is what is presently happening in psychiatry.
A new paradigm is at least a partial reconstruction of a scientific discipline and can include alterations in basic theoretical generalizations and methods of research. There will usually be a great overlap in the problems that can be solved between new and old paradigms, but the means of solution to problems can be very different. When the transition is complete, the field will have changed its theoretical construction of the field, its methods, and sometimes even its goals. This is illustrated by the paradigm shift occurring in psychiatry between the publication of DSM-II and DSM-III. DSM-II heralded the beginning of a paradigm shift toward the disease-centered paradigm. With the publication of DSM-III, the shift was complete. Psychiatry had redefined itself. Rather than the biopsychosocial paradigm that preceded it, the disease-centered study of mental illness was now almost exclusively a biological science, akin to neurology. Its methods of research were now almost exclusively biological. And its research goals were to discover and successfully treat the specific biological causes of mental disorders.
The changes in DSM-IV (1994), especially the introduction of cultural factors, are an expansion beyond the traditional boundaries of disease-centered psychiatry. However, the underlying structure in the diagnostic system has been retained from DSM-III. The cultural information in DSM-IV is, in effect, "tacked on" to the pre-existing classification structure based on the disease-centered paradigm. This is due to the inherent conservatism of science and the undesirability of abandoning structures and methods that have proven to be valuable. The classification system in DSM-III was instrumental in allowing researchers to compare data on similar patterns of symptomatology. This was a great advance in the scientific study of mental illness. However, at some point in the future, researchers will have to move beyond this classification system with its emphasis on reliability, and devise a system that emphasizes greater validity. This will be a major challenge for future research.
When paradigms change, the disciplines defined by the paradigms also change. Familiar objects in the discipline all of a sudden look different. Of course, the objects themselves have not changed. Only the cognitive schemas representing those objects have changed. Phenomenologists and cognitive psychologists have demonstrated that objects are cognized within cognitive schemas. There are no things-in-themselves in the construction of cognition. Figures 1.1-1.3 are well-known multi-stable phenomena. Figure 1.1 can be seen as a vase or faces. The necker cube in Figure 1.2 can be seen in different positions, and Figure 1.3 can be a flat-topped pyramid or a hallway. The objects themselves remain the same, only the cognitive schemas change, and with them, the experiences of the objects. Thus, natural objects are to a certain extent "in the eye of the beholder."
The German philosopher Edmund Husserl (1962) is generally credited as being the founder of phenomenology. Phenomenology is concerned with the study of phenomena, that is, the mental construction of cognition out of raw sensory data. A phenomenon is an experience of an object by a subject. In phenomenology, it is the experience of the object that is the phenomenon, not the object itself. A subject does not know the object itself, only the experience of the object. This is because of what phenomenologists call intentionality.
Intentionality is the processing that goes on in the brain between perception and cognition. In phenomenology, perception is distinguished from cognition. Perception is the intake through the sensory mechanisms of raw sensory data. Cognition is the end product of brain processing, that is, knowledge of an object. The mental processing of sensory data (intentionality), turning sensory data into cognition is the primary object of study of phenomenology.
Phenomenology rejects the naive realism inherent in some empirical methods of the natural sciences, including disease-centered psychiatry. That is because the empiricism employed in these methods ignores the effects of intentionality. Phenomenologists realize that the subject only knows the experience of the object and not the object itself. Thus, the subject and what is known are not separate. The subject constructs to varying degrees the experience of the object, and therefore, the knowledge of the object.
Phenomenologists conceptualize a phenomenon in what can be called a noetic pole. This can be visualized metaphorically as a physical pole with two ends--the noesis (cognizer) and the noema (cognized). Husserl used the Greek terms noesis and noema deliberately to avoid using the terms subject and object. Using the terms subject and object implies two separate entities. The noetic pole is a single thing, an experience with two ends.
Because of intentionality, cognition is being partially structured by past experience. Based on knowledge that is already stored in longterm memory, the cognizer automatically and precognitively intends what he or she will experience. The concept of intentionality recognizes the assimilation and influence of values, attitudes, and knowledge bases that people acquire and carry with them. This collection of knowledge that people carry with them in the neural networks in their brains structures a continuous use of cognitive schemas in the construction of experiences. These cognitive schemas impose form, content, and meaning onto raw sensory data, turning that data into a cognition--that is, knowledge of the world.
Because the cognitive schemas are largely based on cultural patterns of thinking and personal experience, and in the case of scientists, professional training, what a person experiences is a construction based on these factors influencing intentionality. Thus, the object-in-itself may remain unknown.
Because intentionality is an automatic process that requires no effort on the part of the cognizer, the result of the process--the cognition-- appears to be completely natural and real. The object invariably appears in cognition as a completely separate entity with its own qualities independent of the cognizer, even though the cognizer has been an active participant in the construction of the experience, shaping the form, content, and meaning of the object cognized. The person thus grasps the experience as true and real. This can occur even if the object cognized is something wholly created by the person. For example, a hallucination can be experienced as something true, real, and separate from the cognizer.
Furthermore, if a group of people similarly cognize something, even if it is something they have completely created by their own group mode of thinking, they can collectively validate its existence as something true and real by comparing and confirming the similarity of their experiences (reliability). For instance, the reality of tribal gods is regularly confirmed by the consistency and similarity of experiences of the tribespeople. This does not mean that the tribal gods actually exist outside the collective intentionality of the tribespeople (validity). However, the gods are as real as any other object in the natural world for the tribespeople. This collective cognitive process of treating a human-made product as if it was something possessing its own independent reality in nature is called reification.
The term reification comes from the verb to reify (to make real). It occurs when people are collectively projecting onto an object a level of reality it does not actually possess. Yet the people themselves are not aware that it is their own collective cognitve process accomplishing this. They believe in the things they experience. In this way they are good empiricists and naive realists. The problem is, intentionality is highly variable. As a result of the variability of intentionality arising from brain plasticity, objects unique to certain cultures, such as tribal gods, can be created and experienced as absolutely real. Also, natural objects can be collectively reified into a variety of different experiences in different cultures, each contradicting the other. Yet, each of them will appear completely true and real to the people in that culture.
Natural attitude. Societies always possess a wide range of reifications which identify them as a unique cultural group. Collectively they experience the world in their own special way. A societey's own unique cultural way of experiencing the world is known in phenomenology as their natural attitude. The term natural attitude refers to the way someone "naturally" experiences the world. "Naturally" is put in quotes because the way the person is experiencing the world is not actually natural at all, but cultural. Because of brain plasticity, collective intentionality, and the creation of reifications, what appears to be a "natural" experience is actually a cultural construct unique to that group of people. Nevertheless, to the individual, the experience is completely "natural." Therefore, the natural attitude is the cognitive style, based in plastic neural networks and cultural learning, that individuals and groups use to create and maintain their own unique experience of the natural world.
Cultural Meaning Systems
A culture is the sum total of knowledge passed on from generation to generation within any given society. This body of knowledge includes language, forms of art and expression, religion, social and political structures, economic systems, legal systems, norms of behavior, ideas about illness and healing, and so on. This body of knowledge is always organized in a systematic fashion so that it can be easily passed on and is internally logical. These systems are referred to in anthropology as cultural meaning systems (D'Andrade, 1984). Cultural meaning systems are analogous to scientific paradigms, but much larger. A cultural meaning system generally structures cognitive reality for an entire society.
Categories of experience are embedded in cultural meaning systems. These meaning systems vary among societies. Therefore, universal categories of experience may be valid in some instances, but not all, and all supposedly universal categories are suspect. Cultural anthropologists prefer emic (indigenous) categories of experience rather than etic (nonindigenous) ones. This is because etic categories may be based on western cultural schemas (e.g., DSM categories of mental disorders), and therefore possibly inappropriate for use in nonwestern societies.
Four Functions of Cultural Meaning Systems
There are four functions of cultural meaning systems, that occur in all societies, and can be conceptualized as occurring in a particular sequence.
1. Representational function. Cultural meaning systems enable individuals within a cultural group to represent the world symbolically to themselves and to others. Every cultural meaning system must fulfill this function for the persons in a group to operate as a social organization. It allows them to communicate information. Without this ability they would be unable to function as a group. This is the representational function of cultural meaning systems.
Nonhuman societies also have systems of communication, but human societies are unique in the extensive elaboration of communication by means of symbols. The word symbol is used here as a technical term coming from semiotics, the study of signs (Peirce, 1962). Signs are objects that represent something else. In semiotics, there are three kinds of signs: 1) icons; 2) indexes; and 3) symbols.
The first type, an icon, is a sign that actually looks like the thing it represents. An example would be a photograph, a drawing, or a statue of a person. An icon actually resembles the thing that it represents. Icons are familiar to anyone who uses a personal computer employing a graphic user interface.
The second type of sign, the index, is slightly different. An index does not look like the thing it represents, but has a direct connection to it. In many cases, an index may be something that was physically connected to the represented object at some time. An example is a cross for Christians. The cross represents Jesus because there was a direct physical connection at one time. However, a cross with a crucified Jesus on it (a crucifix) is an icon, something that resembles what it represents. A plain cross is an index, something that has a direct connection to the thing it represents.
The third type of sign, the symbol, is completely different. A symbol has no logical connection whatsoever to the thing it represents. A symbol is an arbitrary sign. It is used simply out of convention, and its use results primarily out of historical accident. Examples of symbols are the words you are reading at this moment. These words only have meaning because you know how to read English. Languages are almost exclusively systems of symbols. Without knowledge of the symbols on this page (words and letters), and the rules for putting them together, all you would cognize on this page are black marks on a white page.
All of the objects that you see on this page are arbitrary signs. Different arbitrary signs could have been used in their place and would have worked just as well as long as you understood the system. For example, the letters of the English alphabet are replaceable by other symbols which could work just as well as long as everyone knows and agrees on what they mean. The same can be said about words. The word tree is used in the English language to represent the object "tree." However, there is no logical connection between the word tree and the object that it represents. We could have used the word automobile to represent a tree and it would have worked just as well. The word automobile is not required to mean "self moving." That is a meaning attributed to it by a symbolic system called a language which is actually a historical convention developed by accident and consensus over many centuries.
However, for the person brought up within a particular symbolic system, the information contained in that system seems completely natural, true, and self-evident. When in fact, most of it is arbitrary. The logic and meaning of symbolic systems are mostly contained within the boundaries of the system. Outside the system, the meanings and associations between objects will be different. What makes this important, is the fact that most of the information that exists in human cultures is encoded in symbolic systems. Thus, the information is largely arbitrary in its arrangement and meaning, and only makes sense if you know the cultural meaning system.
2. Constructive function. As a result of representing the world to themselves and to each other by means of systems of symbols, that is, communicating to each other, people create cultural entities. A cultural entity is something created by the social agreement that something counts as that entity. By telling stories and making up explanations of the world, people create the subjective and intersubjective world they inhabit. This is the constructive function of cultural meaning systems. Thus, cultural meaning systems construct things--things that would not exist without the meaning system that created them (e.g., tribal gods).
For example, there are certain behaviors that people go through that count as getting married. If you think about what people do at a wedding ceremony, you will recognize it as a culture based ritual, that is, a scripted pattern of behavior that has the power to construct something. In this ritual there is a set of constitutive rules, which if followed have the power to bestow reality. In our culture, the couple stands before an official who says the proper words (symbols). There is the exchange of rings (symbols). And, as if by magic, the two who were a moment ago not married, are now married. And as long as we all agree to it, then we make it real. The couple behave toward each other and the society as if they are married. The society behaves toward the couple as if they were married. And by our collective actions and intentionality, we create the marriage. To create divorce we essentially do the same thing--in reverse. As long as we all agree that something counts as a particular object, we can with our collective intentionality, create the object. Some of the things that cultural meaning systems have created include private property, deviance, prestige, nationality, even family, and racial categories.
Now consider the diagnostic classification system in DSM-IV as an example. This is essentially the same system of classification devised for DSM-III. Many of the criteria for DSM-III disorders were simply derived by committee consensus. That is, a group of experts communicated with each other and collectively decided on what constituted the presence of a particular disorder (Spitzer, 1991). For example, in DSM-IV, the diagnosis of schizophrenia requires the presence of schizophrenic symptoms for at least six months duration. Prior to six months, DSM-IV specifies schizophreniform disorder as the proper diagnosis, and prior to one month, brief psychotic disorder. Why is it six months instead four months, or twelve months? Is six months somehow based on scientifically significant data? Unfortunately, no. Six months is more than simply a convenient number, but it represents only a committee's best guess at what constitutes the serious mental disorder known as schizophrenia. However, thousands of clinicians all over the world use these diagnostic criteria in a way that can reify the concept into an entity possessing a higher level reality than it actually deserves. Thus, DSM-IV is operating as a set of constitutive rules that have the power to create cultural entities. Thus, many of the diagnostic categories in DSM-IV are potentially cultural entities, that is, objects created by the social agreement that something counts as that entity. The objects-in-themselves may be something quite different without the supporting cultural meaning system, its set of constitutive rules, and the collective intentionality used to experience and collectively validate them.
For example, it is interesting to note that no adequate descriptions of schizophrenia appear before about the year 1800. When examining historical records and ancient literature no mention of anything that resembles the current conception of schizophrenia appears (Barlow & Durand, 1995). Of course, madness or serious mental illness existed before this time, but the symptomatology and course of illness associated with schizophrenia appears to be associated with the advent of a modern cultural meaning system. The fact that the least modernized societies, most removed economically and culturally from western culture, have on average the shortest course and best outcome for schizophrenia may be related to the apparent absence of modern schizophrenia in premodern western culture. It is possible that a modern cultural meaning system is related not only to the diagnosis of schizophrenia, but to the presence of schizophrenia.
3. Directive function. Because people create cultural entities, those entities then become part of the cultural environment and impact on people's lives and direct their behavior. This is the directive function of cultural meaning systems.
For example, in India people have created the caste system. The caste system is a cultural construction that directs persons in their behavior. In India, if a person is born into a high caste family, he or she is obligated to behave according to the rules governing that particular caste, for example, avoiding eating meat.
Similarly, cultural entities such as diagnostic categories can also direct one's behavior. For example, being diagnosed with a particular disease may require a patient to seek out a particular form of treatment or therapy. Likewise, a diagnostic entity may be conceptualized in the cultural meaning system to direct society to behave toward a patient in a particular way, perhaps to help, stigmatize, or to avoid the patient (e.g., AIDS). Thus, the cultural meaning system is directing the behavior of the patient, clinicians, and also others in the social environment.
4. Evocative function. Because cultural meaning systems create cultural entities, which in turn direct behavior, they also evoke certain emotions. This is the evocative function of cultural meaning systems.
For example, having your property stolen may make you angry; graduating from college may make you happy; and having a death in the family may make you grieve. The cultural meaning system provides rules for how to feel because it defines what a particular situation means. For example, a death in the family may indicate that grief is appropriate for some specified period of time, or that no grief is indicated, or even that celebration is indicated, depending on the cultural meaning system.
Cultural meaning systems may also provide the most emotionally meaningful things in a person's life. People do not usually realize it, but many of the things that are most emotionally meaningful in life, for example, things that evoke the greatest passion, happiness, and sadness, are cultural entities created by cultural meaning systems.
Take a fictional story as an example. Pretend you are a married female college student, and your dream is to go to medical school. However, in order to get high enough grades you spent so much time studying that you neglected your husband, and he started secretly seeing another woman. Eventually, you found out about it, and at first got angry. Then you got depressed. As a result of your depression you did poorly in your school work and were not accepted to medical school. This made you even more depressed. As a result of the depression, your husband decided you were no longer fun to be around, and he left you for his new girlfriend. This made you even more depressed. The situation got so bad that you felt suicidal. It got so bad that you had to go to a psychiatrist who told you that you were suffering from a brain disease, a genetically caused chemical imbalance in the brain. He gave you medication which you had to take in order to control your brain disease and you ended up getting labeled mentally ill, which made getting into medical school even more difficult.
What do you think about this woman's situation? If you analyze it carefully you will see that this woman was a victim of her own cultural meaning system. Everything that happened to her, as well as her passionate emotions, resulted from her cognitive and emotional involvement with cultural entities, from the marriage to the brain disease, that is, things created by a social agreement that something counts as that entity. What is significant is that everyone inside that cultural meaning system usually believes that it is all absolutely real.