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Clinicians and institutions increasingly recognize the role of culture in caring for individuals and families affected by mental illness (1–3). However, with few exceptions (4), the mental health research literature has paid scant attention to the role culture plays in defining the phenomena that researchers study, in helping to identify both the gaps in research agendas and why they occur, and in shaping research paradigms. Paying attention to culture and to cultural differences can help mental health professionals abandon egocentrism in favour of cosmopolitanism. Culture Shapes Study PhenomenaA great deal of research comparing distress across cultures is based on the implicit assumption that disorders described in official nomenclatures such as the DSM or ICD occur more or less universally and do not vary in form. In contrast to this universalistic perspective on mental disorder, cultural relativists (5–9) assert that culture is powerful enough to create unique forms of mental suffering in different societies. Arguments about universalism and relativism continue to rage in research circles. Prior to the American Psychiatric Association (APA) publication of the DSM-IV (10), I received an invitation to a conference jointly sponsored by the APA and the US National Institutes of Mental Health (NIMH). The conference was organized to help ensure that this fourth version of psychiatric nomenclature would be more culturally sensitive than its predecessors. The colleague issuing the invitation is a well-known expert in the meeting ground between psychiatry and anthropology; he stressed that it was particularly important that I attend because the conference organizers wanted to ensure representation from both universalists and relativists. When I asked him what I was, he told me I was a universalist: “You believe that mental illnesses happen everywhere and in the same form.” Simplistic generalizations often incite emotively coloured and sometimes less-than-optimally collegial responses, and this interaction was no exception. I told my colleague that the issue was not, and should not be, one of belief. Rather, it should be subject to empirical investigation and to interpretation based on data. I pointed out that most research results are consistent with the proposition that many conditions which Western mental health experts call mental illnesses are ubiquitous, and that similarities in expressions of distress are more impressive than are differences (see, for example, 11–17). Constraints on human physiology and cognitive process probably limit the varieties of human suffering to a finite number of symptoms and symptom complexes—many, if not all, of which may be recognizable across cultures (11,12,14,15,18). Nevertheless, culture still makes a difference. Culture dictates whether and how symptom complexes are defined—as illnesses, metaphysical occurrences, or artifacts of everyday life (19–21). Sociocultural forces such as expectation and attitudes regarding expendability play an important role in defining illness, if not in creating illness phenomena. To illustrate the point, I offer the following personal experiences. In the late 1960s and early 1970s, I worked as lead investigator with colleagues from the World Health Organization (WHO) and the University of Dakar on a study of mental health among the Serer, a tribal group in Northern Senegal (22–26). As in many other places in Africa, desertification and overpopulation were forcing Serer youth to leave their traditional homes in rural villages and migrate to cities such as Dakar, Senegal’s industrial and political capital. Our study’s guiding hypothesis was that the acculturative stress (see 27,28) consequent to rapid urbanization would jeopardize mental health. As a first step in developing the study’s mental health measures, we interviewed indigenous healers, attended healing ceremonies, and visited healing shrines to determine whether there was any match between Western and indigenous conceptualizations of psychiatric disorder. There were striking overlaps: clusters of behaviours described in the DSM-III (the dominant diagnostic system at the time) under labels such as schizophrenia and other psychoses, mental deficiency, and epilepsy not only occurred among the Serer but were considered illnesses requiring treatment (23–25). Although the Serer lexicon contained no terms describing “milder” conditions such as anxiety disorders, that situation would soon change. Several years after the study finished, I returned to Senegal. Before we left Dakar for an informal return visit to the villages, my guide, Thierry, shared some misgivings. “Beiser,” he said, “you should know that when we go back to the villages, people are going to have questions for you, and you need to have answers. They want to know why so many people got sick after the study.” To my considerable relief, there was no postsurvey epidemic of mental disorders in the villages. The people complaining of illnesses characterized by sleep disturbances, digestive upsets, relentless fatigue, vague feelings of apprehension, and periods when they felt like crying had complained about the same symptoms 3 years earlier. The difference was that they had not considered themselves sick at the time of the survey. Now, they did. The surveys had been major events in the villages. Typically, the study teams stayed for 2 to 3 days, conducting interviews, taking chest x-rays with elaborate portable equipment, and drawing blood samples to test for malaria and anemia. As a partial quid pro quo for the villagers’ cooperation, the medical team tried to examine and treat current cases of illness. Since we had been able to obtain antibiotic samples from various drug companies, we performed a few “miracles”: some people who might have died as a result of severe respiratory infections or febrile meningitis recovered instead, thanks to our medications. After the survey came to an end and the medical expertise and impressive paraphernalia disappeared, the villagers apparently made a few deductions. First, there appeared to be resources available to some people elsewhere that were not available to them, and these resources could make people feel better. Second, if conditions that had seemed hopeless were in fact curable, perhaps there were also cures for more mundane problems, such as sleeplessness, apathy, and vague anxieties. The fact that the University of Dakar research team had asked about these phenomena within the context of a health survey conveyed the message that experts from far away thought they were illnesses. If they were illnesses, then there were probably cures for them, just as there were for severe fevers (26). Attitudes about expendability can also powerfully determine definitions. Although there was some overlap between what the Serer called “illnesses of the spirit” and DSM-classified mental disorders, the Serer lexicon contained no category resembling dementia. At first, I suspected that people did not live long enough to become mentally enfeebled. However, watching children guide old people who had lost their way around their small villages disabused me of that thought. A condition that Westerners consider an illness and that has achieved wide currency under such overly inclusive labels as Alzheimer’s disease was an apparent phenomenological reality in rural Senegal, but one that the villagers did not consider to be an illness. My Serer informants explained that the phenomenon had a name, which translated roughly as “becoming a child again.” The term did not, however, denote an illness, nor was it a metaphor. The Serer believed in reincarnation: sometimes, people overstayed their time on earth and, literally, became children again before they had the chance to be reborn in a physical state that matched their behaviour. Their helpless behaviour resulted from a natural accident and not from an illness. Although Serer elderly with dementia needed help, just as children do, the village was able to provide support for many of their needs. Further, despite being otherwise enfeebled, many old people remembered stories from the past and were often skilled in recounting them. In a culture in which oral transmission is the only means of ensuring historical memory, the elderly have a significant and enduring role. The Serer elderly were not expendable. North American towns and cities have no baobab trees under whose shade children gather to listen to stories recorded only in the heads of elders. A society on the move, North America has evolved a culture that stresses independence, often to the detriment of the elderly, enfeebled or not. With no particular role, the elderly become increasingly expendable. If they develop disabilities with care needs that exceed the capacity of small households, they become a social burden. Biotechnology holds the promise of help, or even future cures, for elderly people afflicted with forgetfulness and confusion; however, the contrast between becoming a victim of dementia in North America and “becoming a child again” among the Serer highlights the importance of culturally determined social roles and of social exclusion in defining the purview of mental health. Cultural context helps explain whether a particular condition is ignored by a particular society or whether it is officially categorized—as a religious violation, as criminal behaviour, or as an illness (20,21,24).
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