(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]
and
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.
