Brit.J. PsychicS.(i977), 530, @ii—ai

Review

Article

Aspects of Transcultural

Psychiatry

ByJOHN L. COX INTRODUCTION Transcultural psychiatry is an elusive con cept, as the definition of culture itself is un certain. However, Kroeber and Kluckhohn (1952)

did attempt

to summarize

164 definitions

of culture: ‘¿Cultureconsists of patterns, implicit,

of and for behaviour

transmitted distinctive

by

symbols,

achievement

constituting of

including

their embodiments

essential

core

of culture

explicit and acquired

human

the

groups,

in artifacts; consists

and

the

of tradi

tional (i.e. historically derived and selected) ideas and especially their attached values; culture systems may on the one hand be considered as products of actions, on the other as conditioning elements of further action.' Culture has been more briefly described as ‘¿learned ways of acting and thinking, which are transmitted by group members to other group members and which provide for each individual ready made and tested solutions for vital life problems' (Walter, 1952). The limitations of such definitions are com mented on by Jablensky and Sartorius (i97@), who observe that culture is often used as a blanket term to cover and obscure economic, political, social, biological or physical environ mental factors, which may be associated with psychological disturbance. Despite these problems ofdefinition, cultural psychiatry has been delineated from social psychiatry to denote the study of mental illness in relation to its cultural environment, and transcultural psychiatry is regarded as an area of research in which the vista of the scientific ob server extends beyond the scope of one cultural unit on to another (Wittkower and Rin, 1965). This definition of transcultural psychiatry pro vides a useful perspective for this review, since

its emphasis on research and scientific observa tion should no longer evoke Rousseauesque ‘¿noblesavage' imagery or the more subtle contemporary accusations of neo-colonialism. The Western perspective of transcultural psy chiatry has been commented on by Chakraborty (i@7@),who also predicted that the transcultural psychiatry of today would become the social psychiatry of tomorrow. This review, however, is not of obscure or exotic

aspects

of transcultural

psychiatry,

but

selects those topics which are of increasing importance for psychiatrists in Britain, whether they are primarily concerned with clinical work, teaching or research. MIGRATION

AND MENTAL

Iw@ss

Analyses of the 1971 census shows that 2'I per cent of the population of Great Britain were born in the New Commonwealth, and that in seven parliamentary constituencies the per.. centage of the population born in the New Commonwealth varied between 15 per cent and 21 per cent (Kohler, 1974). These figures thus

indicate

that

Britain

during

the

last

30

years has become a multicultural society, and that consequently clinical aspects of transcultural psychiatry are a reality for many psychiatrists. The varied reasons for immigration to Britain among the larger minority groups are important and have been succinctly summarized by Krausz (i@u). The majority of the Polish community, for example, were political exiles who chose to remain in Britain after the Second World War, whereas for Asian and West Indian immigrants the economic disadvantages and overpopulation in the home country were two main

factors

which

influenced

their

decision

to emigrate. The inaccuracy of such generaliza tions is illustrated by the particular problems of RI I

212

ASPECTS

OF TRANSCULTURAL

Asians forcibly expelled from Uganda, for, although they are similar to other Asian com munities in Britain with respect to religion, dress and language, their social background, immi gration

experience

and acculturation

problems

have been very different. Temporary immigrants, such as overseas students, may also have specific problems (Anumonye, 1970), and the reasons for the immigration of wives may be very different from those of their husbands. To examine the relationship between immi gration and mental illness is therefore complex, and three principal hypotheses have been described by Murphy (1973a). i.

That

victims 2.

certain

mental

disorders

incite

their

to migrate;

That

the

process

of

migration

creates

mental stress, which may precipitate mental illness in susceptible individuals; 3. That there is a non-essential association between migration and other variables, such as age, social class and culture conflict. The testing of these theories could require a knowledge

of the prevalence

of mental

illness

in the country of origin. However, in India, for example, where there may be five million severely psychotic patients receiving no Western medical aid (Carstairs, I973a), and where psychiatric services are inadequate for the needs

@

of the

rural

population

(Neki,

1973),

such data will not usually be available. In East Africa, other limitations of community studies of mental illness would include the difficulties of diagnosing physical illness (Muhangi, 1972), inadequate census data and the presence of linguistically distinct tribes. Orley (z@io, made a unique contribution towards the understanding of neurosis among the Baganda in southern Uganda, and also studied psychiatric morbidity rates in two villages. However, these data, though of great value when evaluating Baganda patients, are of less assistance in the psychiatric management of an overseas student from the north of Uganda or a Ugandan Asian in Bradford. Nevertheless, studies which compare the psychiatric symptomatology of, for example, depression in India (Teja et al, i@7i) or student

PSYCHIATRY

neuroses in Uganda (German and Arya, 1969) with that found in Britain may be of assistance in the clinical management of immigrant patients, despite uncertainty regarding the comparability of the data. Likewise, the study by Burke (i@74) of first admissions to a mental hospital in Jamaica, which showed a high frequency of organic disorders and also described the mental health services of the island, is of benefit to psychiatrists in Britain when assessing Jamaican patients. The problems which con front a Jamaican patient who has been re patriated from Britain are also described and include a deterioration of the mental state, in addition to the stigma of having let his family down (Burke, 1973). The first major study of the relationship of migration to mental illness was a comparison of the hospital admission rate of Norwegian-born immigrants to Rochester State Hospital in Minnesota between i88g and ‘¿928 with both the native-born local population in Rochester and with Norwegians admitted to the Gaustad Mental Hospital in Norway (ødegaard, 1932). The Norwegian-born immigrants in Minnesota were found to have a higher admission rate for mental illness than either the local native born or the population in Norway; and in particular the higher rate of schizophrenia among the immigrants

was not

related

to the stresses

of

immigration but could more readily be ex planed by the schizoid premorbid personality of the patients previous to their migration. The clinical case histories described by ødegaard illustrate also the unique cultural and socio-political aspects of any emigration and the subsequent necessity to locate the epi demiological findings within this specific context. The range of feeling experienced by an immigrant and the development of paranoid attitudes is lucidly described: ‘¿Everywhere you are surrounded by people with strange and unfamiliar ways and customs, and you can

hardly

understand

anything

of what

they

say,

at any rate when they talk to each other. They do not seem to be as friendly and helpful as the people at home, and many of them do their best to profit by your lack of experience. Even if you have not had any disagreeable experience younelf@,your imagination

is stirred

by all

the

stories

you

have

JOHN

heard about how crooked and dangerous

they may

be. You notice that your own appearance, clothing and language points you out to everybody as a greenborn, and a “¿big Swede―at that, and you are frequently met by a mixture of mirth and contempt.

You have no friends, no one to associate with and no money for expensive entertainments—frequently you live under the strain of imminent unemployment. You

are forced

to live

among

the least

attractive

types of Americans, because it is cheap in those sections, and this frequently means a considerable lowering of your previous standard

of life. There are

hundreds of similar things which tend to make you suspicious and bewildered, anxious and lonely. Sexual

adjustment

also

is more

difficult

than

at

home, because of the lack of social connections, and owing to financial difficulties, and the scarcity of women

in the immigrant

population.'

Further support for the selective migration hypothesis for schizophrenic immigrant patients is provided by Mezey (ig6o), who, in a study of Hungarian refugees to Britain after the un successful uprising in 1956, found that schizo phrenic patients had a history of earlier internal migration in Hungary and were more likely to have non-political reasons for emigrating than patients with affective disorders. However, schizophrenia may be precipitated by the stresses

which

are

distinctive

for the

immigrant,

and Bagley (i@7i), in a study of West Indian schizophrenic patients, has shown that when compared with English-born schizophrenic patients and West Indian community controls, ‘¿status striving in a climate of limited oppor tunity' was associated with the onset of the illness. Such studies, which attempt to compare psychiatric morbidity rates between different ethnic groups, have several methodo logical problems to overcome; these include the standardization of the two populations for age and sex, the availability of accurate census data, the need to obtain samples of an ade quate size, and the comparability of psychiatric symptoms across cultures. Those studies, therefore, which show an excess of psychiatric morbidity in an immigrant community, when compared with the native population, must be assessed cautiously. Fisher (1969), in a review of American research, reconsiders the myth that mental illness is higher among negro groups than among

L. COX

whites,

213

and concludes

circumstances

which

that ‘¿despite adverse

are

generally

considered

to predispose towards mental illness, American negroes seem to manifest no higher rates of mental illness than whites'. In Britain, while the increased rate of schizophrenia among West Indians is observed by a number of authors (Bagley, 1975), there is no certain evidence that other psychiatric problems are more common in West Indian immigrants than in the native population. Schizophrenia among Cypriots and Maltese in Camberwell had been noted to be absent (Bagley, 1971), and Coch rane (1977) found a lower rate of admission to mental hospital for Indian and Pakistani patients in England and Wales than for the native population. In a subsequent community study, Cochrane and Stopes-Roe (i@7@) found a lower rate of psychiatric symptoms among Pakistani patients than among either the Indian or the native English communities. This finding is of some importance,

since these authors

gave consider

able attention to the reliability and validity of the translated standardized questionnaires used and to the standardization of the samples. The symptomatology of psychiatric illness in immigrant communities is discussed by several authors, for example the culture-bound content of religious delusions in West Indians (Gordon, 1965), and the paranoid delusions occurring among Polish immigrants (Hitch and Rack, 1976) and West African students in Britain (Copeland,

1968). ACCULTURATION

Although the precise relationship of immigra tion to mental illness remains disputed, there is little doubt that immigrants have experienced a stressful life event and been subject to certain distinctive

housing

social

and

work,

pressures.

Discrimination

for example,

in

are discussed

by Bagley (ig@, 1975), who observes that much of the variance in prejudice maybe due to deeply embedded values in British culture concerning Britain's role as a colonial power. Other stresses, such as split families, single parent families and unemployment are further problems for many immigrants (Community Relations Commission, 1976). Hashmi (1968),

ASPECTS OP TRANSCULTURAL PSYCHIATRY

214

familiar with immigrant communities in Bir mingham, comments specifically on other dli.fficulties, which include sexual problems for single men, religious conflicts, legal problems exacerbated by language problems and the expense of winter clothing. The relationship of the immigrant community to the host community varies considerably among

different

ethnic

groups.

Thus,

West

Indian immigrants generally wish to assimilate with the host society, in contrast to Asians who may retain their distinctive traditional customs and develop a plural accommodation. Harmonious interaction between different ethnic groups is possible if both immigrant and host communities

can accept

these distinctive

ways of

acculturation and absorption of minority groups. However, more frequently there is a disequilibrium

and a tendency

for some specific

types of distintegrative behaviour to appear, such as the breakdown of the immigrants' primary

group,

aggression

in relation

to social

norms and inadequate identification with the absorbing structure (Eisenstadt, ‘¿@). CuL1'u1@r. SHOCK The term ‘¿culture shock', though frequently used, is poorly defined and inadequately studied. Brink

and

Saunders

(1976),

who elaborate

on

fourth phase, ‘¿the effective function phase'. At this stage the individual has worked through his loss and re-established his self-esteem, and may experience reverse culture shock on returning home. Thus culture shock is best regarded as a normal psychological adjustment to an abrupt transition from one culture to another, and may need to be distinguished by the clinician from more morbid psychiatric symptoms, which could require specific therapeutic intervention. Cour'ucAnoN The psychiatrist, like the patient, is a product of his culture, and while it may be hoped that during training he will have been enabled to ascertain the extent to which his cultural back ground determines his attitudes, this insight is never complete. Thus the treatment of a patient from a contrasting culture is a trans cultural dyadic, and for communication to be meaningful, the psychiatrist may need not only to understand his own prejudices but also to accept certain modifications and limitations of his customary clinical style. If this adjustment is not made, the therapist may become over whelmed by his apparent inability to assist, or else treat the patient with an exaggerated concern for cultural nuances. Murphy (1973b) comments on the resistance of European

the description by Oberg (‘9M)' subdivide culture shock into four phases. Phase i is the psychiatrists to examining the psychopathology ‘¿honeymoon phase', in which the new environ of their own society, and regards transcultural ment is regarded as exciting and new oppor studies which investigate the subsequent distor tunities for work, pleasure and social activities tions of perception as being a most important are welcomed. This is followed by the ‘¿dis contribution to general psychiatry. enchantment phase', in which the individual The patient's understanding of the role of the becomes aware of the problems of the new doctor may also be conditioned by culture environment and may look back with nostalgia bound expectations. Some Asian patients, for to his own cultural norms. Zwingmann (i@7@) example, may expect a psychiatrist to be describes this nostalgic reaction as being due directive and may resent routine psychiatric to separation, with the need to seek gratification inquiry into family relationships. in the past. The feelings of anxiety, irritability Leff (ig@@), using data from the reliability and depression may therefore result from the study of the International Pilot Study of threat to the ego by a loss of social and intra Schizophrenia, found a high correlation between psychic supports. Thus depression in immigrants symptoms of anxiety and depression in patients has been related to a ‘¿loss', similar to that which from developing countries, and explains this may follow a bereavement (Cheetham, 1972). finding by suggesting that patients from these The ‘¿beginning resolution phase', when the countries do not differentiate these feelings individual seeks patterns of behaviour appro as precisely as patients from developed countries. priate to the new setting leads directly to the The absence of a single word to translate ‘¿de

JOHN L. COX pression'

in some

African

languages

has been

used as a partial explanation for the apparent scarcity of patients with a depressive illness in Africa. However, Prince (1968) has put forward other more cogent explanations, which include the reluctance of psychiatrists in colonial days to diagnose depression in the absence of guilt feelings and to recognize depression when ‘¿masked' by numerous physical complaints. Thus, puerperal depression in Ugandan women commonly

physical pression

presented

symptoms, could

with sleep disturbance

although

anxiety

also be described

or

or de

by the patient

in the Luganda vernacular language (Cox, I976b). An understanding of the relationship between emotions and the words or behaviour available to communicate these emotions is central to the adequate assessment of patients from a different culture or language group or who may be using a second language. Such problems may be exacerbated when the doctor himself is using a second language or is working with an un familiar interpreter; and psychiatrists from a culture in which emotions are frequently described and clearly differentiated may tend to overdifferentiate emotions in patients from developing

@

countries

(Leff,

1974).

Some psychologists have argued that language itself shapes thought and causes the difference in the perceived world, and although this Whorfian hypothesis is refuted by Cole and Scribner (ig7i,) the study of psycholinguistics and an awareness of the cultural variations in the verbal and non-verbal expression of emotion is of increasing relevance for psychiatrists. Peck for example, observed that, i@ bilingual patients, the age at which the second language was acquired and the attitude towards it were important in psychiatric evaluation. Thought disorder may also be more difficult to assess when a patient is interviewed in a second language rather than in the mother tongue (Marcos a al, 1973). I@'raiuaE@[email protected] @mPSYCHIATRICSERVICES In the doctor-patient-interpreter relation ship, if reliable information is to be gained or a psychotherapeutic intervention is to be success ful an awareness of the mutual perceptions and

215

the shifting dominance characteristic of such an interview

is of importance.

Some patients prefer an indirect cominunica tion through an interpreter, and if the ethnic background of the doctor is different from that of the patient ‘¿stranger value' (Beattie, 1964) may be an advantage. Walton (1962), for example, has described how the specifIc psycho pathology of African patients can be @lucidated by the interaction with a white therapist. Schlicht, in an analysis of 200 interviews of doctors and social workers from immigrant areas,

commented

specifically

on the frequently

expressed need for adequately trained inter preters. Other recommendations were that information about mental illness should be distributed in Asian languages and that the special dietary requirements and distinctive religious practices pf minority groups should be recognized (Community Relations Commission, 1976). Many of these recommendations have been implemented

in Bradford,

where an Asian out.

patient clinic supervised by Dr Rack and staffed by a multicultural, multidisciplinary team has been established. Although this pioneer unit has not yet been evaluated, there is little doubt that psychiatrists make fewer mistakes and that the quality of psychiatric care for the Asian community is improved. The qualities of a good interpreter have been described

by

Cox

(1976c),

and

include

the

ability to understand the culture of both the psychiatrist and the patient, a thorough know ledge of the languages used, a familiarity with psychiatric terminology, and an unhurried approach. TRAINING OF Ovxasr@s

PsYcmA'ralsrs

Many British departments of psychiatry will continue to have the responsibility of training psychiatrists who intend to work in developing countries, although ideally this training should be in the home country or within a similar cultural area (WHO, 1975). However, if this training in Britain is to be beneficial for the trainee, it should maximize the advantages of such training and minimize the disadvantages. The advantages may include the availability of specialist teachers, detailed clinical supervision

216

ASPECTS OF TRANSCULTURAL PSYCHIATRY

and a planned course of study. On the other hand, the disadvantages of acculturation prob lems and the exposure of the trainee to British psychiatry relevant to Britain should not be overlooked. The overseas trainee may therefore need specific advice as to which aspects of the psychiatric training are of particular relevance in addition to the basic need to acquire universal clinical skills. These training requirements can only be known if there is some knowledge of the demands likely to be made on the overseas psychiatrist on return home, and such informa tion may be available from the trainees them selves or from teachers who have worked in Asia or Africa. Thus Wig (1975) in India has estimated that even if the number of trained psychiatrists doubles to 6oo in the next ten years, there will still only be one psychiatrist for a million of the population, and a psychiatrist in India, therefore, will need the knowledge, skills and attitudes to lead a mental health team. Wig further recommends that centres in Europe and USA which train psychiatrists from developing countries should include courses on transcultural psychiatry and clinical training in the single-handed management of patients. Likewise,

the

East

African

psychiatrist,

on

return from the United Kingdom, will be con fronted by many patients with major psychoses, many students who are eager to learn, few psychiatrists and limited resources, and yet the

constant mental

necessity to supervise health

auxiliaries.

the training

German,

of

in the fore

word to the book by Orley entitled Culture and Mental illness (i@7o), described the clinical demands of the queue of patients at the clinic gate. However, German concludes a compre hensive review of psychiatry in sub-Saharan Africa by emphasizing the similarity of African psychiatry to psychiatry in other parts of the world (German,

1972), and this general

observa

tion is a necessary corrective to any tendency to exaggerate the relevance of cultural factors and so overlook the universal validity of much clinical methodology and descriptive psycho pathology. Nevertheless, the psychiatrist in a developing country will be thrust to the forefront of the planning, training and evaluation of medical auxiliaries in addition to other clinical tasks.

In Uganda the psychiatrist may be involved in the teaching of psychiatric nurses and nursing attendants (Wood, 1970), the supervision of psychiatric

nurses in up-country

‘¿970) and

liaison

with

clinics (Egdell,

wardens

of

university

halls of residence (Cox and Muhangi, 1975). In Tanzania more emphasis is placed on the training

of medical

describes emphasis

a

auxiliaries,

40-hour

and Swift (ig@@)

training

on preventive

course

psychiatry

and

with health

education. The importance of in-service training and the use of illustrated manuals for primary health care workers

is described

by Giel and Harding

(1976) in a review of priorities for mental health care in developing countries. However, Kapur (i@7@) has deliberately emphasized the need to answer certain ‘¿fancyschemes'

important are financed.

questions before These questions

are concerned with a knowledge of available helping agencies and their conceptual frame work, as well as information concerning the threshold for consultation and reasons for choosing traditional or modem healers. These questions were studied in a village on the west coast of India, and Kapur concluded that to use basic health workers as the main mental health personnel was unlikely to succeed and that

teaching should be given to popular healers, whether they were modern doctors or traditional healers. In Nigeria, Harding (i@i@) has observed the concern of traditional healers for their patients and has recommended regarding drug and electroconvulsive

that advice therapies

and the recognition of organic disorders could be usefully

provided.

However,

some psychia

trists remain dubious of such collaboration fear that psychiatric

services will be devalued

and as

the practices of traditional healers are sanctioned and formalized

(Workneh

and Giel, 1975).

A psychiatrist who is returning to a deve loping country may need a thorough training in both general medicine and organic psy chiatry. In addition, he may require certain specific skills, such as giving electroconvulsive therapy with or without an anaesthetic, and experience of a variety of administrative and group

therapies.

Carstairs

(1973b)

has suggested

that specific optional questions on tropical medicine could be included in the Membership

JOHN L. COX examination

trists, and questions psychiatry some time

of the Royal

College

of Psychia

it would be the writer's opinion that on some aspects of transcultural would encourage trainees to devote to the study of topics which may be

of practical importance clinical practice in Britain

during subsequent or overseas. Trainees

who may not have the benefits of a planned course of instruction in transcultural psychiatry could nevertheless prepare for such questions by reading major publications in the field. Useful reference

books would

include

the CIBA

symposium (1965) and Transcultural Psychiatr, by Kiev (1972), in addition to the research and review

articles

in scientific

217

been found

to be a useful method

(1972)

has

trained

described

the

need

to help immigrants

lems and provide social services. RESEARCH

for social

in

workers,

with personal

information

PROBLEMS

prob

concerning

IN TBAx5cUITuRAI.

PSYCHIATRY

journals.

The training of overseas psychiatrists, whether or not they intend to remain in Britain, is an important aspect of present-day psychiatry, and the poor performance of such doctors in professional examinations is causing increasing concern. Mahapatra (ig74) has shown that language difficulties alone are not an adequate explanation for the high failure rate, and a preliminary analysis, carried out by the present author, of the first-year departmental examina tions at Edinburgh showed that, despite having similar theoretical and clinical training to British psychiatric trainees, overseas clinical assistants performed less well. British-born psychiatrists may also need to acquire specific knowledge, skills and attitudes, if they are intending to work in immigrant areas in Britain. Supervised clinical experience in eliciting those aspects of a psychiatric history likely to be of importance in an immigrant patient may therefore be necessary, as well as the development of skills in the evaluation of both physical symptoms and non-verbal beha viour. Familiarity with the use of an inter preter may also be gained during training, and an insight into the doctor's own prejudice or positive discrimination could be of considerable value. Sensitivity to the problems of immigrants may be acquired as a medical student by an elective period in a developing country, or as a trainee psychiatrist during a planned rotation to an overseas hospital. Multidisciplinary semi nars, in which the cultural experience of trainees is used and relevant articles are reviewed, have

of teaching

Edinburgh (see Carstairs, 1973b). The nursing profession also is aware of the need for a knowledge of cultural factors, more especially as they relate to illness behaviour and communication (Brink and Saunders, 1976); and in social work the recruitment of more black professionals has been advocated. Cheetham

Problems psychology

likely to occur in cross-cultural studies

have

been

described

by

Brislin et al (i@7@), who discuss the uncertainty regarding

the

equivalent

meaning

of similar

words in different cultures, and the bias result ing from varying attitudes of respondents to an interview

procedure.

He recommends

the use

of the ‘¿plausible rival hypothesis' the research.

throughout

If to these research requirements logists are added those specifically psychiatric cross-cultural research,

of psycho relevant to such as the

reliable definition of mental illness and the need to relate the findings to the delivery of psychiatric services (Kiloh, 1975), then the doubts expressed by Kessel (1965) as to the value of international

comparisons

in psychiatric

epidemiology seem well justified. Four studies are, however, selected for further discussion, in order to illustrate the methodo logical problems which arise and to demonstrate how the researchers attempt to cope with them. The Cornell-Aro Mental Health Project was a collaborative study of psychiatric morbidity among

the

Yoruba

in Nigeria,

and

involved

both Nigerian and American researchers (Leigh ton et at, 1963). Its aims included the develop ment of an interview method, which could identify and estimate prevalence of mental disorder

in a society very different

to the culture

in which ‘¿Western' psychiatry evolved. Other aims were: to gather background data regard ing the frequency and social disablement of mental disorder in the Yoruba people; to

218

ASPECTS OF TRANSCULTURAL

measure trasting

integration and disintegration in con communities; and to test the hypo

thesis that sociocultural disintegration is causally related to mental disorder; and that culture change

produces

sociocultural

disintegration.

The report of the project discusses practical problems, such as the need to obtain co-opera tion of villagers by talking with village chiefs and providing medicines, and the need to avoid samples being biased towards the selection of co-operative villagers. The difficulties of translating the questionnaire and the use of interpreters

are also briefly

mentioned.

Although the total samples were rather small, the authors demonstrated the wide prevalence of mental disorder in Yoruba villagers. Thus 27 per cent of@ men and 19 per cent of 57 women under the age of 39 years had certain psychiatric morbidity, and comparison with the Stirling County study in the USA showed that this morbidity was higher in Stirling County than in Yoruba villages. The attempt to evaluate the relationship of psychia tric

morbidity

to

measures

of

health

if they lived in villages

with high indices

of disintegration. The authors discuss this finding as it relates to the more traditional and less flexible role of female Yoruba villagers and describe disintegration

the limitations of the measures in Nigerian villages.

detailed attention to the training of partici pating psychiatrists, the intra-centre reliability was satisfactory, and, with the exception of Washington and Moscow, so was the inter centre reliability. It was thus possible to describe

of

a group

of concordant

schizophrenic

patients in each centre for whom there was agreement

between

the clinical

and

computer

diagnosis, and who also were in those clusters which selected out schizophrenic patients. This result is of importance, since it demonstrated that in each centre schizophrenia could be distinguished from affective psychoses, and that subsequent studies of schizophrenia in con trasting

cultures

could

be meaningfully

com

pared. Thus research on the relationship of life events to the onset of schizophrenia could be replicated in non-Western countries, and the influence of family structure and kinship patterns on emotionality in the home could be evaluated in countries where family organization

might be very different. Many

integration

showed that women were more vulnerable than men to a deterioration of their mental

PSYCHIATRY

of the methodological

problems

pre

viously described have been circumvented by Carstairs and Kapur in their study of pychiatric morbidit, in a coiistal village in Soul/i India (1976). Three

communities

within

the village

of Kot@.

were selected for study: the Brahmins, the Bants and the Mogers. These communities had the same religion, language and health facilities, yet differed

on certain

important

specific variables.

The Brahmins were patrilineal agriculturists, The International Pilot Stud, of &hizoplzrenia the Bants matrilineal agriculturists and the Mogers matrilineal fishermen. The Indian (World Health Organization, 1974), though similar to the Cornell-Am study in so far as it Psychiatric Survey Schedule was specially was intended as a springboard for further designed for the study and included the require research, is nevertheless very different in its merit of an interview with a close relative and aims. It was designed to demonstrate the also, when necessary, a physical examination. practicability of establishing sufficient co Psychiatric symptoms were most frequently operation between nine research centres in reported among female Bants, 43 per cent of different countries, and by using the Present these women reporting one or more symptoms, State Examination translated into seven lan whereas male and female Brahmins had the guages to demonstrate with satisfactory reli least psychiatric symptoms. Of specific interest ability symptoms of schizophrenia in countries was the finding of a higher rate of psychiatric morbidity among married women from matri with contrasting cultures. The inherent problems of translation are lineal castes who had changed to a ‘¿patrilineal fully described with reference to the work of pattern', in which the husband and wife live Spilka (1968), and the limitations of the method together. Thus women more than men were of back translation discussed. As a result of particularly vulnerable to a change in residence

219

JOHN L. COX pattern, and the authors provide evidence that their higher rate of psychiatric morbidity, when compared with @womenwho had not changed, was consequent to the social disruption rather than a precipitant of it.

health services. The development of methods of psychiatric evaluation which are both reliable and

valid

for different

immigrant

groups

is of

considerable importance, but can only proceed if relevant clinical observations are also docu mented. Thus transcultural psychiatric research can In a prospective study of psychiatric morbidity include not only those studies which attempt to and childbearing in Ugandan women, the complex compare psychiatric morbidity between different relationship between cultural factors, psychiatric illness and maternal child health services was countries, but also research which studies the effect on psychiatric morbidity of change in a readily apparent (Cox, 1976a). For an African woman, childbearing may be regar4ed as that measurable component of culture or the indi vidual who moves culture. Other research may which ‘¿defines her existence' (Collomb et al, be initiated and sustained by the evident 1972) or ‘¿creates the parents' (Lambo, 1972). Collomb contrasts this attitude with that of contrasts between the cultural background of Western society, where a child may be seen as the researchers and that of the population being an impediment, although Mead (1967) has studied. observed that the western cultural pattern is COMMENT also to give special value to each baby and to recognize the right to live regardless of defects. This review has selected those aspects The marital status of the women in the Uganda of transcultural psychiatry which are of study was found to be an. important variable; increasing relevance for psychiatrists in separated women having a high risk of ante Britain. However the cultural perspective and natal psychiatric morbidity. In the puerperium practical experience of the writer has inevitably a depressive illness was diagnosed in 9.7 per been reflected in the choice of topics for in cent of the sample women. The majority elusion. Several aspects have been omitted, of these women, however, did not attend a and during the next decade there could be post-natal clinic and would not usually have important advances in the understanding of received any Western psychiatric treatment, cultural differences in the response to neuro and some women may have received traditional leptic drugs, more precise evaluation of non treatments for ‘¿amakiro';a traditional illness in verbal communications and the development of which the mother is said to want to eat the baby, community psychiatric services more sensitive and which is believed to be caused by promis to the distinctive needs of minority groups. cuity during pregnancy (R.oscoe, igi i; Orley, Thus when the vista of the scientific observer ‘¿970; Cox, i976b). does extend from one cultural unit into another Thus in both Western and Kiganda culture important contrasts may become apparent and the events of childbirth are given special clinical practice be improved. significance, and should a mother become At the present time, many such observers mentally ill during the puerperium this illness have been trained in the West. However, with is given a specific name even though@its symp the development of post-graduate training in toms may be similar to psychiatric illnesses other countries, this will change, and some occurring at other times. aspects of Western psychiatry will be scrutinized and their cultural origins become more In Britain there has been a tendency in some apparent. community research to exclude immigrants from REPERENOES the study because of language difficulties and ANUMo?wE,A. (1970) African Students in Alien Cultures. other cultural problems. The presence of sizeable New York: Black Academy Press Inc. immigrant communities, however, makes these BAGLEY, C. (1971) The social aetiotogy of schizophrenia exclusion criteria a serious drawback, and limits in immigrant groups. Inte@nationa1 Journal @f Social the practical relevance of such studies for mental Psychiatry, 17, 292—304.

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J L Cox BJP 1977, 130:211-221. Access the most recent version at DOI: 10.1192/bjp.130.3.211

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