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International book review: Selected review from PsycCRITIQUES on Cultural Formulation: A Reader for Psychiatric Diagnosis
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Culture clashes between psychiatric tribes
A review of Cultural Formulation: A Reader for Psychiatric Diagnosis by Juan E. Mezzich and Giovanni Caracci (Eds.)
Lanham, MD: Jason Aronson, 2008. 288 pp. ISBN 978-0-7657-0489-4 (hardcover); ISBN 978-0- 7657-0607-2.
Review by Pádraig Collins
Culture clashes abound in this journey into psychiatric diagnosis and formulation. The central conflicts do not lie, however, between nation states or races but rather between the differing tribes in psychiatry itself. Mezzich and Caracci certainly deserve immense admiration for willingly straying into territories where biological determinists and nosological pedants normally hunt. I do hope the cross-cultural friendships they will invariably have formed during this journey provide the support they will need to survive the assaults of their more traditional psychiatric colleagues.
Why do I predict such enmity? Well, if not entirely ignored — the usual fate of most challenges to a dominant paradigm — Cultural Formulation: A Reader for Psychiatric Diagnosis forms part of a body of work that questions certain fundamental tenets in psychiatric diagnosis, that is, that psychiatric disorders exist across cultures in universal, categorizable forms, deriving from shared biological commonalities, identifiable using a common list of symptoms, and treatable using the same "evidence-based" treatments. This essentially is an ahistorical, acultural understanding of mental health distress.
While certain concessions to the obvious limitations of such an approach have been made through the introduction in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM–IV; American Psychiatric Association, 1994) of Axes IV and V, these axes have been, as noted by Lewis- Fernández (Chapter 8, referencing Guarnaccia, 1996), commonly ignored in the search for the singular "true" diagnosis. Similarly, as well documented by Good and Good (Chapter 2), cultural factors have commonly been seen as producing exotic manifestations of the true disorders or bizarre, rare disorders in their own right — requiring special treatments — rather than a core and defining element of all psychiatric distress.
To their credit, Mezzich and Caracci begin by attempting to position this book closer to the mainstream by encompassing some material reflecting more traditional concerns in psychiatry. The opening chapter by Fabrega on psychiatric diagnosis is a densely written exposition of the challenges of taxonomy. It treats mental health disorders as a particularly slippery form of illness to categorize but does not in any way question its fundamentally biological nature. This highlights one of the main challenges psychiatry constantly faces — how to keep itself within the fold of traditional medicine (for the power, status, and professional security inherent in such a membership) while dealing with an area so different in its nature from physical illness.
I fear that Mezzich and Caracci's efforts in this regard may be a somewhat optimistic attempt to reach out toward their more biology-oriented colleagues. As the book progresses and the closer the subject matter is examined, as with psychiatry itself, the clearer the need becomes to move away from biological determinism. Consequently, while other chapters seem also to insist that the present systems of diagnosis are entirely compatible with a more holistic cultural formulation, the authors cannot but highlight the deficiencies in traditional diagnosis. The complaint appears to be that the more one develops an understanding of the complexity of how culture permeates the expression, understanding, and the very nature of psychiatric disorders, the more inadequate standard diagnostic tools appear.
Many of the chapter authors emphasize the value of embracing formulation as a more useful ally when dealing with the murky world of mental health distress and its cultural components. They argue that formulation's natural emphasis on developmental and environmental factors, as well as on constitutional predispositions, frees the clinician to weave an understanding of cultural factors through the professional opinion in a manner that the straitjacket of categorical diagnosis does not permit.
However, as social psychological research teaches us (cf. Sherif & Hovland's "latitude of acceptance" model of persuasion, 1961), if a new stance is pitched too far from where the mainstream opinion lies, then it will be rejected. Consequently it is reassuring to see Mezzich and Caracciuse one of the most persuasive tools available in influencing clinicians — that of the clinical case study. The last five chapters illustrate vividly how cultural factors lie at the core of understanding psychiatric disorders and how this understanding can make us therapeutically much more powerful. However constrained by the frameworks of our training, we all hope, as clinicians, that our wish to benefit our clients will allow us to make changes in ourselves and in our thinking when confronted with convincing new information. Mezzich and Caracci clearly are members of the tribe who believe that sociocultural factors are central to understanding the origin and expression of mental health distress. They will need some potent medicine, however, if they are to overcome the hostility of surrounding tribes. This book is one source of powerful juju in this regard. In its own way, it's a revolutionary book cloaked in establishmentarian language. I hope it becomes required reading both for students and consultants of psychiatry such that when DSM-V emerges, psychiatry's own cultural revolution will have rescued cultural formulation from the appendices and placed it in its rightful position at the center of the diagnostic framework.Ψ
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Guarnaccia, P. J. (1996). Comments on culture and multiaxial diagnosis. In J. E. Mezzich, A. Kleinman, H. Fabrega, & D. L. Parron (Eds.), Culture and psychiatric diagnosis: A DSM–IV perspective. Washington, DC: American Psychiatric Press.
Sherif, M., & Hovland, C. (1961). Social judgment: Assimilation and contrast effects in communication and attitude change. New Haven, CT: Yale University Press.