Friday, 15 June 2012

Mezzich et al (2009) ‘Cultural formulation guidelines’

Also for the MHRNS transcultural psychiatry group I’ve looked at

Mezzich, J.E., Caracci, G., Fabrega Jr., H. and Kirmayer, L.J. (2009) ‘Cultural formulation guidelines’ Transcultural Psychiatry 46: 383-405

I have never really known what the point of a cultural formulation was. But, a priori, two possibilities strike me depending on one’s view of how deep or how shallow one thinks the relation between culture and mental illness.

1) It might be that one thinks of mental illnesses as pathologies of aspects of an essential human nature such as biological nature or essential features of our rationality or mindedness. If so, cultural variation would overlie this and lead to local differences in the way that such fundamental pathologies are expressed. And then a cultural formulation would be a way of reverse engineering, from locally divergent symptoms, the common underlying causes.

This seems to be the view of Mezzich et al. they say:

The cultural formulation of illness aims to summarize how the patient’s illness is enacted and expressed through these representations of his or her social world. [ibid: 390]


Performing a cultural formulation of illness requires of the clinician to translate the patient’s information about self, social situation, health, and illness into a general biopsychosocial framework that the clinician uses to organize diagnostic assessment and therapeutics. In effect, the clinician seeks to map what he or she has learned about the patient’s illness onto the conceptual framework of clinical psychiatry. [ibid: 391]

The only positive role cultural factors can then play are as contingent resources:

The aim is to summarize how culturally salient themes can be used to enhance care and health promotion strategies (e.g., involvement of the patient’s family, utilization of helpful cultural values). [ibid: 399]

But there might be a more dramatic view of the role of culture in influencing mental illness.

2) It might be that the distinction between surface appearance and underlying pathology cannot be drawn. That is, the various ways one might want to flesh out the underlying notion – for example as biological or some other underpinning notion of universal human nature – might fail. It is unlikely that there is no such thing as biological human nature but it might not, unaided, determine mental pathology because it might not – without education and enculturation, for example – determine mindedness. (Learning a language, for example, seems to be key.) By contrast, a richer notion of human nature, beyond mere biology, may simply fail to be universal.

If so, the two factor model of the first option would fail. A cultural formulation would not merely enable one to dig beneath surface difference to find common pathologies but would be an articulation of the genuinely different ways people can be ill in different cultures. There’s no sign of that in Mezzich’s view.

The competition between the metaphysics of mental illness of positions 1 and 2 merits discussion, at least.