Wednesday, 16 April 2014

Cultural formulation, diagnosis and validity #2

(The draft second section of a draft chapter.)

The two factor model of cultural variation

One way to understand how culture affects mental illness would be to think of the expression of mental illness as the result of two factors: an invariant endogenous factor and a cultural shaping. On this view, mental illnesses either are, or are underpinned by, pathologies of some sort of universal substrate such as an essential human nature. This is the first factor.

Perhaps the most obvious candidate for such a substrate is human biological nature. This would fit a common emphasis within mental healthcare on the centrality of biological psychiatry especially for accounts of the aetiology of mental illness. It would also be consistent with Jerry Wakefield’s analysis of the concept of disorder as a harmful biological dysfunction. Setting aside the role of the value term ‘harm’ for the moment, the first factor in a two factor account of culture-bound syndromes might be a biological dysfunction picked out or explained in evolutionary terms.

Whilst biological nature is the most obvious candidate for the first factor, others are also possible. Consider Louis Sass’ account of Schreber’s delusions in Paradoxes of Delusion [Sass 1994]. The main claim of the book is summarised in an early passage thus:

[Schreber’s] mode of experience is strikingly reminiscent of the philosophical doctrine of solipsism, according to which the whole of reality, including the external world and other persons, is but a representation appearing to a single, individual self, namely, the self of the philosopher who holds the doctrine… Many of the details, complexities, and contradictions of Schreber’s delusional world… can be understood in the light of solipsism. [ibid: 8]

But the elucidation or understanding that Sass seeks isn’t merely aimed at one delusional experience or even at Schreber as a whole. It is meant to shed light more generally on schizophrenia. The reason it can (according to Sass) is that it derives from a general feature of rationality:

[Madness] is, to be sure, a self-deceiving condition, but one that is generated from within rationality itself rather than by the loss of rationality. [ibid: 12]

So one might take the first factor of a two factor theory of cultural psychiatry to be an invariant feature of human mindedness whether biologically unified as a biological dysfunction or not. It might attach to the nature of rational subject-hood however that is biological realised or underpinned. This would form the basis or underpinning of mental illness across cultures and not specific to any one of them.

Cultural variation enters this picture only with the second factor. Culturally invariant pathologies of human nature such as biological nature or essential features of our rationality or mindedness are overlaid by local cultural variation in how they are expressed where ‘expressed’ could carry either or both of two meanings. First, it might mean that standing possibilities for biological dysfunction or failings of rational subjectivity might be differently prompted by different social or geographical contexts. This would be akin to akin to variation in heart disease rates and causes in different cultures and hardly merits the label ‘cultural concept’. (I will return to this possibility a little later and will suggest it is better thought of as a one-factor model.)

The more interesting idea is that variation in ‘expression’ picks out the way in which underlying pathologies might be plastic to the different self-interpretations that different people come to possess and thus the way they feel and are avowed. This would be an example of a cultural idiom of distress in the vocabulary of the DSM-5. But whereas for physical illness, how one understands one’s illness might be thought to be an accidental superficiality compared with the real underlying condition (as understood, perhaps, by the medical profession), one might argue that for mental illness its esse is percipi: how it is perceived at least partly constitutes it. Thus in the case of Sass’ account of schizophrenia, a two factor model would be premissed on the idea that cultural variation might make it difficult to realise that the symptoms reported in different cultures resulted from something like the same failure within rationality. Identifying the common element would require significant interpretative work reflected in a cultural formulation.

I suggested earlier that on a two factor model, mental illnesses either are, or are underpinned by, pathologies of some sort of universal substrate. That difference between these options is the difference between thinking that the alloy of invariant underlying pathology and variant cultural overlay itself comprises what we mean by mental illnesses themselves. One might think, for example, that khyal cap and panic disorder have the same underlying biological mechanism but that the characteristic way in which the former carries its own ontology (ie that subjects think of their distress through the conceptual lens of a wind-like substance) is sufficient to mark it off as a different kind of mental illness. Biological dysfunction is then thought of as the common cause of two distinct illnesses depending on cultural context. On the other hand, one might think that the real illness is whatever is common to khyal cap and panic disorder. It is merely that the form that that illness takes can vary.

Whichever view is taken of whether the first factor is the illness or merely the common underpinning of different illnesses, a two factor view of cultural concepts of mental illness suggests a particular view of the aim of a cultural formulation in psychiatric diagnosis. It is a way of reverse engineering, from locally divergent symptoms, the common underlying causes. The aim of sensitivity to cultural difference would be to find a way to penetrate beneath it to a common substrate appropriate for scientific psychiatric research.

This seems to be the view of Mezzich et al. in their discussion of ‘Cultural formulation guidelines’ when 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. [Mezzich et al 2009: 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]

On their account, the only positive role cultural factors can then play is as a source of contingent health promoting 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]

Mezzich’s view is a half way house between two more radical views of the possibilities for cultural psychiatry both of which of versions of a single factor which I will now outline.

Two versions of a one factor model of cultural variation

The two factor model requires a distinction between surface appearance and underlying pathology. But it might be that this distinction cannot be drawn. That is, the various ways one might want to flesh out the contrast between underlying pathology – for example as biological or some other underpinning notion of universal human nature – and surface appearance might fail. Consider the two versions of the first factor outlined above: biological dysfunction cashed out in accord with evolutionary theory and a pathology of rationality as such. In the first case, drawing a distinction between surface form and underlying invariant function or dysfunction might seem unproblematic in the case of physical illnesses. But in the case of mental dysfunctions there may be no principled way of drawing a distinction between ways of thinking that are problematic within a particular culture and some underlying cognitive function underpinning several different forms. The surface form may simply be the dysfunction. Why? It is unlikely that there is no such thing as biological human nature and hence some shared biological underpinnings for human mentality and cognition. Some such notion, corresponding to what John McDowell calls ‘first nature’, might come free with our identity as an animal species [McDowell 1994: 183]. But it might not, unaided, determine mental pathology because it might not – without education and enculturation, for example – determine the kind of mindedness that mental illness threatens. Mental illness might be a feature of what McDowell calls our ‘second nature’, or, in German, bildung. Perhaps learning a language is necessary for some, at least, forms of mental illness such as thought disorder. Perhaps there is no principled way to factor conditions like depression into those aspects that require conceptual thought or language and mere biological underpinnings.

A one factor model need not imply that there is any cultural variation of mental illness. It might be that our second nature, or rather that aspect of it relevant for the formation of mental illnesses, is universal. If so, mental illness would be akin to heart disease, varying only in external features such as rates and superficial and unimportant local understandings of it. Apparent deeper variation would be a mark of our ignorance, our misdiagnosis. So a conservative version of the one factor model likens mental illness to heart disease with no significant space for cultural variation and no need for a cultural formulation to extract or excavate the underlying commonalities because they are open to view.

On this conservative view, culture-bound syndromes such as khyal cap can have either of two statuses. They are either really other names for universal conditions also picked out by the vocabulary of Western psychiatry such as ‘panic disorder’. Or they do not exist. For example, if it is an essential part of the theoretical apparatus of khyal cap that it is caused by the rising up of a wind-like substance then there is no such condition. Those who self-report it, or its characteristic symptoms, are in some sense in error about their own conditions.

But it is also possible that, because second nature depends on enculturation and because cultures vary, second nature also varies. If so, the richer notion of human nature now in play, beyond mere biology and sufficient for a conception of mental illness, might not be universal. Cultural variation might go ‘all the way down’.

To flesh this example out it will be helpful to consider again but in more detail Sass’ account of schizophrenia according to which it is a failure of rationality from within, or driven by, rationality itself rather than an absence of rationality. The symptoms of schizophrenia are a kind of lived experience f the philosophical stance solipsism according to which only the subject of experience – I – exist. Everything else is merely an idea (for me: one of my ideas). Solipsism is thus idealism whose implicit consequences have been explicitly adopted since if everything that exists is merely an idea only the first person subject of thought (for me: me) can have those ideas. But as Wittgenstein influentially argued, solipsism is strictly nonsensical because it presupposes a contrast between self and other (in the claim that everything is merely an idea) which it cannot consistently draw (since everything is an idea) [Wittgenstein 1929]. Sass, controversially, embraces this further feature of solipsism – that it is nonsense – to shed light on the pathological status of schizophrenia (for criticism of just this point see Read **; Thornton **).

Such an account can be used to illustrate both the conservative and the radical version of the one factor model of cultural concepts. If one thinks that the history of Western philosophy merely illustrates and unpacks conceptual connections implicit in the rationality of any thinker then solipsism is also a standing possibility for any thinker and hence, on Sass’ account, so is schizophrenia as its lived version. That would be a conservative one factor model. Any apparent culturally determined variation in the experience of schizophrenia, such as the specific contents of delusions by contrast with invariant forms, would be merely superficial requiring no great cultural sensitivity to detect. (It is the thought that it is merely superficial which distinguishes this from a two-factor model with its demand for a cultural formulation.)

If on the other hand one thinks that Western philosophy has been driven not merely by the abstract demands of rationality but by historically contingent assumptions about the nature of subjectivity and the connection of mind and world then the temptation towards solipsism will seem to be a merely local cultural matter. At the risk of being glib, had Descartes not existed, there would have been no such thing as schizophrenia.

This version of the one factor model is more radical than the two factor model even though both agree on the need for some sort of cultural formulation. A one factor model of a cultural formulation is more radical because it does not enable one to dig beneath surface difference to find underlying common pathologies but would instead be an articulation of the genuinely different ways people can be ill in different cultures. According to it, there are genuinely different forms of mental illness which need have nothing substantial in common across different cultures. In their account of the role of cultural formulation, Mezzich et al. ignore this possibility.