Culture, as a ubiquitous aspect of life, allows us
to construct our own unique view of the world as individuals and as a part of
the larger human drama.  Knowledge of
this "cultural concept" is especially important in the medical field
as a key component of a successful physician-patient relationship.  In this book, the authors have all
demonstrated expertise in cultural psychiatry as is shown by their impressively
researched presentation of how culture intertwines with and affects mental
health and illness.  In addition,
clinical values are well illustrated through consideration of specific cultural
variables along with application of DSM-IV-TR guidelines as they are used for
cultural formulation of a series of clinical case examples.

The book begins with a historical review of cultural
psychiatry and its evolution over the last several decades including the views
of Kraepelin in 1904 and followed by the contributions of psychoanalysis
described by Freud (1913/1955), dissidents such as Jung and Adler,
neo-Freudians such as Horney (1937) and Fromm (1978), and Engel’s (1980)
biopsychosocial approach to medicine.  
Modern approaches emphasize ethnographic research regarding cultural
variables (Kleinman 1979; Littlewood 1990) with the work of experts in this
field leading to a delineation of transcultural psychiatry as a specialized
field of study.  This chapter reviews
essential definitions of culture along with concepts such as race, ethnicity,
disease, and illness (Alarcon and Ruiz 1995; Cohen 1961; Kleinman 1988).  The authors then move on to describe the
model of cultural psychiatry and the five functions of culture developed by
Alarcon et al. in 1999 as a frame of reference for this topic, and how these
five functions are related to clinical psychopathology.  These five factors include an interpretive
and explanatory tool of behaviors that may or may not constitute clinical entities,
a pathogenic and pathoplastic agent, a diagnostic and nosological factor, a
protective and therapeutic instrument, and an element in the management and
structuring of clinical services.  This
is, to me, the most valuable and useful concept of this chapter.

The second chapter not only contains a wealth of
invaluable information for those new to cultural studies, but also provides
fresh insight and advantageous reorganization of material for those who have
already attained expertise in this area.  
Cultural variables such as ethnicity, gender, sexual identity, age,
religion, socioeconomic status, education, and language are examined along with
their positive and negative effects on cultural identity.  These variables are then viewed within the
context of the previously described model of cultural psychiatry including
their conceptual relationship with the five functions of culture that influence
mental health and illness behaviors. 

 This chapter
also highlights the important concept of heterogeneity within cultural labels
or the "cultures within cultures" that can affect clinical
perceptions and diagnosis.  For example,
the cultural label "American Indian" really refers to people from 260
different language groups and various descendants from North Asia to Siberia
and Alaska.  Although many of these
subgroups do have some common characteristics and beliefs, there are also many
important differences that need to be recognized to really understand the
cultural experience of each person. 
Another, more global example is illustrated by gender differences of
behavior associated with acknowledgment, presentation, or denial of symptoms
such as sadness, anger, or pain.

The authors provide a helpful discussion of the
acculturation process with the attainment of bicultural competence through a
mediation of two cultures. The importance of this concept has been shown by
evidence of less acculturation stress associated with attainment of bicultural
competence.  People can feel comfortable
and function effectively in two distinct cultural contexts with integration of
elements of both cultures.  
Understanding of this process and its various maladaptive variants is an
essential component of clinical assessment and treatment when addressing mental
health issues of immigrant and refuge populations.  Evaluating language and working effectively through a translator,
ethnocultural dietary influences on behavior and mental illness, and culturally
determined variations at the genetic level that may affect medication response
and metabolism are also addressed.

The focus of the third chapter is the use of the
DSM-IV-TR as a tool for cultural assessment and formulation.   This formulation assimilates the patient’s
cultural identity, cultural explanation of illness, cultural factors in the
psychosocial environment, and cultural elements of the relationship between the
patient and clinician into a framework that allows the clinician to understand
and address the cultural uniqueness of the patient in the treatment plan.

Of course, the most enjoyable section of this book
is the presentation of five case studies describing individual patients from
various clinical situations.   The
excellent formulation of these case studies follows the American Psychiatric
Association Practice Guidelines for Psychiatric Evaluation of Adults with
special emphasis on cultural factors in their lives.  Culture is a primary and central piece of the human drama.  Case studies are used in this chapter as a
wonderful learning tool that allow visualization of a person’s life story as a
puzzle, with the cultural piece being centrally located and in contact with all
other pieces as the puzzle spreads out to a complete picture.  If we look at the puzzle with a center piece
missing, the picture is incomplete and the puzzle pieces themselves may not fit
together as they should.  This is the
chapter that really brings together the essence of this book and spotlights the
expertise of the authors.

The last and final chapter provides an excellent but
brief summary of the book content and conclusions.

Academically, I would recommend this book as an
excellent resource for psychiatrists and other mental health care
professionals.  If a reader should so
desire, it is not too cumbersome to read as a whole, and it is also organized
in a manner that would allow students and professionals to just "dip"
into the information more specifically.  
As an individual actively involved in ethnographic and clinical
psychiatric research of immigrant Somali populations, I found the information and
organizational style of this book to be validating of my own findings.   The authors definitely met their group goal
of providing for the advancement of psychiatry with this work. 

©
2003 Deborah L. Scuglik

Deborah L.
Scuglik, M.D., Department of Psychiatry and Psychology, Addiction
Psychiatry, Child and Adolescent Psychiatry, Mayo Clinic

Categories: Ethics, Psychology, MentalHealth