Culture is ubiquitous. We are all culturally and historically bound. Niels Bohr, shortly after receiving the Nobel Prize in Physics for his brilliant elucidation of atomic structure, was asked how it felt to have shown that electrons rotate around a nucleus composed of protons and neutrons. Surprisingly, but insightfully, he told reporters he was not sure if his findings were correct, because they were based on historically and culturally bound assumptions!
If the "objective" findings of atomic physics are molded by the culture of the observer, then clearly human interactions, pathology, wellness, diagnosis, treatment, and all the factors that contribute to the diagnosis and treatment of mental disorders must be similarly understood to be influenced by culture. Being oblivious to this reality is fraught with as much danger as being unaware that psychotherapy is influenced by transference and countertransference or that pharmacotherapy is influenced by the cleverly crafted marketing strategies of pharmaceutical companies.
Recognizing the importance of cultural influences does not mean that we must know everything about every culture. However, it does mean that we need to attend to cultural factors that may have an impact on assessment and treatment if we are to provide state-of-the-art psychiatric services. A training videotape entitled The Culture of Emotions, when supplemented with other efforts to rectify our relative insensitivity to cultural influences, does an excellent job of beginning to address some of the key points in the provision of psychiatric services.
Because the videotape as well as this review are themselves products of our times and culture, it is important that they be "contextualized." Therefore, I will digress briefly to provide background information. As DSM-IV was being finalized, a group of psychiatrists, anthropologists, and sociologists who recognized that the role of culture was underappreciated came together to provide this much-needed perspective. Under the leadership of Juan E. Mezzich, M.D., Ph.D., the DSM-IV task force on cross-cultural issues developed the Outline for Cultural Formulation (OCF) and the Glossary of Culture-Bound Syndromes in time for their inclusion as an appendix in DSM-IV (4).
In The Culture of Emotions, several key members of the task force are interviewed, as are other experts in cross-cultural psychiatry. The videotape offers general commentaries on culture in psychiatry, but, more important, it provides an overview of the OCF and an introduction to the concept of culture-bound syndromes.
The OCF is divided into five subsections, each of which is discussed on the videotape: the cultural identify of the individual, the cultural explanations of the individual's illness, cultural factors related to the individual's psychosocial environment and levels of functioning, cultural elements of the relationship between the individual and the clinician, and overall cultural assessment for diagnosis and care.
On the training video, examples of culture-bound syndromes are given by Roberto Lewis-Fernandez, M.D., who studies and treats ataque de nervios, as well as by Carl Bell, M.D., who describes the phenomenon "the witch is riding you"—isolated sleep paralysis that is experienced by afflicted African Americans as terrorizing "proof" that a hex has been cast on them.
As our society becomes more diverse and multicultural, it is imperative that all psychiatrists familiarize themselves with the principles in the OCF and the Glossary of Culture-Bound Syndromes. Given the need for psychiatry to "get its act together" in terms of its relative neglect of the cultural perspective, this video should be widely used in residency training and postgraduate continuing medical education programs, in my opinion. It is the best summary of the OCF and the glossary that I have seen; it is expertly produced by Harriet Koskoff, and its scientific advisors, Francis G. Lu, M.D., and Dr. Mezzich, have ensured its scientific integrity without interfering with Ms. Koskoff's skillful, expert, and user-friendly video production.
Ideally, our wish to "do the right thing" in treating our patients should be enough to motivate us to learn more about the OCF and the Glossary of Culture-Bound Syndromes. However, in the world in which we live and practice, additional motivators are often required. As stated by Dr. Mezzich in the videotape, "An important general implication of the cultural formulation for future diagnostic systems is to have made it very difficult to plan any new diagnostic system, be this the DSM-V of the American Psychiatric Association or the ICD-11 of the World Health Organization, without paying pointed attention to culture as a fundamental concept of the framework of the system." If American psychiatry wishes to play a key role internationally in the development of psychiatric nosology, then we need to pay attention to Dr. Mezzich's prophetic words.
The "culture of reviewing" compels me to provide some combination of praise and criticism. Thus I offer a brief—and I hope constructive—criticism. First, this videotape is only an introduction to a complex field. I would like to have seen this fact acknowledged and other sources of learning suggested. The tape needs supplementation. Hearing from the experts is an excellent starting point; however, future training tapes are needed that document assessment and treatment of real patients in real settings and that demonstrate how culture molds the experience of illness, of diagnosis, and of treatment, as well as how knowledge of culture leads to improved practice.
Second, I also would like to have seen a discussion of the difference between "race" and "ethnicity." Many—myself included—believe the term "race" has outlived its usefulness, given the ways in which it has been misused. Professor Ashley Montagu (5) wrote eloquently after World War II about how false concepts of "race" had given rise to racism—the false belief that there are highly significant biologically based differences between different groups of people. In sharp contrast, the term "ethnicity," which refers to the minor biological changes that have occurred over millennia as early homo sapiens emigrated from Africa and adapted successfully to new ecological niches as well as to the differences that emerge from differences in cultural evolution, is an extremely important concept without which we cannot understand our diversity, our common humanity, and our place in history.
The Culture of Emotions is an excellent starting point for learning about the role of culture in psychiatry in general and about the OCF and culture-bound syndromes in particular. Although it is not the last word, its widespread dissemination and study can help psychiatry develop competence in this critical area.
Dr. Opler is clinical professor of psychiatry at the New York University School of Medicine. Send correspondence to him at 765 Gramatan Avenue, Mount Vernon, New York 10552 (e-mail, firstname.lastname@example.org). Ian E. Alger, M.D., is editor of this column.