It is common wisdom in transcultural psychiatry that culture is highly influential in

the presentation and understanding of psychological distress. Thus investigators

comment on the idioms of distress and the explanatory models indigenous to
the specific patient culture. To that end, one of the more frequently discussed
issues is somatization which, it is said, is common in cultures in which mental
health (psy discourse is not prominent in the cultural imagination. !hat this
means, then, is that patients from non"psychologized cultures will have a greater
li#lihood to experience, express, and understand distress somatically.
$omatization is understood as the physicial manisfestion of psychological or
emotional pro%lems. $uch a notion is predicated on a division %etween mind&
where emotions reside and mental life occurs&and %ody, which is where physical
pro%lems occur.

'ne of the %ig issues that has emerged in transcultural or cross"cultural psychiatry
is the de%ate (as it were %etween the anthropologist and the
physician(psychiatrist. The former adopts a cultural framewor#, and hurls a%out
terms such as cultural relativism whereas the latter adopts a medical framewor#,
and ta#es recourse in a scientific enterprise that is, %y definition, universal.
)uriously, in the %ul# of somatization literature, this de%ate is minimally addressed.
*erhaps it will %e useful to ela%orate this de%ate in greater detail, precisely %ecause
it is in the interstices of the relationship %etween anthropology and psychiatry that
the going gets mur#y.
'ne of the #ey aspects of the entire discussion has to do with the place or nature of
culture in psychology and psychiatry. This is evident in the tension %etween
anthropology and psychiatry, %ut it remains complicated and poorly delineated. +
review of most articles in the field shows that culture and its place is assumed %ut
neither explained nor discussed in detail. Indeed, the culture construct itself is
rarely pro%lematized or interrogated, rather it is asserted. ,ut precisely how it fits in
remains inevita%ly mur#y, and all the more so within the psychiatry side of things
given that few psy professionals have indepth anthropological training. !hat this
means, then, is that culture as a construct within psychiatric theory and research is
pro%lematic, to the extent that, as has %een a%ly pointed out, culture and
%iology are polarized or opposed, the idea %eing that culture is the realm of
anthrhopology and %iology the realm of psychiatry. )ulture, then, %ecomes
something&note the reification&that has to %e dealt with. +ll too often one hears
discussions the the effect that the mental disorder has a %iological %asis and thus is
universal (the psychiatry side %ut its expression and explanation are cultural (the
anthropology side.
-irmayer, for his parts, has made a great effort to in effect argue that this is a false
opposition, that the %iological is cultural and the cultural is %iological. .is argument
1
should silence rum%lings from either side, %ut clearly demand a new orientation,
and this orientation is not unli#e the calls from the li#es of -endell who assert that
mind(%ody dualism is spurious. +lthough excellent arguments are made to support
%oth positions, positions which are highly concordant, they would appear to
represent theoretical or academic positions rather than epistemic %ases. *ut
differently, although we may assert that the %iolgical and cultural are not opposed,
in our everyday thin#ing they are, as indeed is the mind"%ody dialectic. To that end
&and this is the position %eing forwarded in this article&the psy fields themselves
are predicated on these oppositions/ as soon as they are wiped away we revert to a
sort of holism that typifies the very non"%iomedical orientations found in most of
the world, non"%iomedical orientations that have never made a formalized
distinction %etween psy and somatic. !hat this means, then, is very simply that %y
definition psychiatry, transcultural or cross cultural or otherwise, is ethnocentric,
which need not %e a pro%lem following 0ichard 0orty1
To say that we must %e ethnocentric may sound suspicious, %ut this will only
happen if we identify ethnocentrism with pig"headed refusal to tal# to
representatives of other communities. In my sense of ethnocentrism, to %e
ethnocentric is simply to wor# %y our own lights. The defense of
ethnocentrism is simply that there are no other lights to wor# %y. ,eliefs
suggested %y another individual or another culture must %e tested %y trying
to weave them together with %eliefs which we already have. !e can so test
them, %ecause everything which we can identify as a human %eing or as a
culture will %e something which shares an enormous num%er of %eliefs with
us. (If it did not, we would simply not %e a%le to recognize that was spea#ing
a langauge, and thus that it had any %eliefs at all. (p. 23
The ethnocentric approach releases us from the the simultaneous pull to on the
one hand supercede our cultural situatedness (to %orrow a hermeneutic notion on
the one hand,
Dualism and Western biomedicine
The %rain is o%4ective and concrete, and many aspects of its functioning can %e
measured. The mind, on the other hand, is su%4ective and a%stract. Its functioning
can %e postulated and approximated, %ut always indirectly. 0ecent advances in
neuroimaging techniques, the neurosciences in general, and the genome have
contri%uted to a general conviction that mental processes can %est %e understood
and explained %iologically. The de%ate as to whether particular psychiatric states
are psychologically %ased or %iologically %ased often serves to further divide
psychiatry from psychology.

Ta#en together, these elements demonstrate the degree to which mind and %ody
are opposed in !estern %iomedicine. +nd yet, a num%er of current lines of wor#
2
suggest that it precisely the integration of %ody and mind that can lead us away from
a false opposition.

The notion of explanatory pluralism, presented in a recent +merican 5ournal of
*sychiatry article holds that min d and %rain mutually affect each other. +ll people
are em%odied, and as such %iological %eings. Thus all processes mental and
otherwise inevita%ly have %iological correlates. Indeed, the current trend towards
%ody"wor# in trauma therapies (such as 6780 point to the importance of the
integration of mind and %ody for health, however it %e defined.

$omatization is a product of !estern %iomedicine that divides the mental from the
physical, and is the product of an epistemological system that is highly specialized,
the very opposite of more holistic epistemological systems in which there is no
clear division %etween what we call %ody and mind.

9or the cultural psychologist epistemological flexi%ility is essential. This is in part
%ecause of having to adapt to different systems, wor#ing across cultures or
disciplines. Indeed, one of the inherent challenges is the tendency towards
incompati%le epistemological approaches. -uhn argued that scientific paradigms
are often incompati%le, and 9oucault demonstrated that epistemic (cultural
approaches are often incompati%le. Integration of incompati%le systems is, %y
definition, impossi%le. +t the same time, strategies must %e developed %y which to
effectively negotiate the often incompati%le systems. This can %e effectively done
through philosophical hermeneutics, which posits an interpretive model that
prioritizes the influence of %oth interlocutors, and recognizes that communication
is a fundamentally dialogical process
Somatization or medically unexplained symptoms?
It is perhaps all in a name. $omatization explicitly asserts a somatic manifestation of
a psychological or psychiatric phenomenon. 7edically unexplained symptoms, on
the other hand, simply ac#nowledge that no medical explanation has %een located.
+t the same time, the latter nomenclature would presuma%ly infer that a
psychological or psychiatric explanation would %e the next step. )uriously, neither
psychiatry nor psychology fall within the purview of the medicine in question,
further articulating the rather odd nature of the dualism1 psychiatrists are
physicians, psychologists insist that they are medical professionals, and yet the
mental health explanation is not medical.
:umerous reviews and studies tend to suggest that somatization is not specific to
any particular zone or culture, yet that non"6uropeans, or at least certain groups of
non"europeans tend to somaticize more. 'r conversely, that !estern 6uropeans
and :orth +merican opt towards psychologization.
3
,ut a word is need here to explore the relationship %etween idioms of distress and
explanatory models. 0esearch does indeed show that explanatory models do
diverge across cultures, with !estern ones tending more towards %iological and
psychological explanations and non"6uro ones tending more towards social and
supernatural explanations. That %eing said, what does appear to %e the case, then,
is that psychological explanations and expression are more common in the !est,
the upper classes and the !esternized.
In #eeping with -awanishi amongst others, explanatory models and idioms of
distress say nothing a%out a person;s or culture;s capacity nor intelligence, %ut
rather a tendency. This is consistent with 0orty;s perspective in which it is the
conversational context that directs us one way or the other. ,ut it is precisely at this
point that the issue gets complicated, in as much as cultures are %ridgea%le
whereas it would appear that epistemes are not.
Culture or episteme?
-irmayer gives a very culturally sensitive treatment of the topic, %ut the distinction
%etween the physical and the mental is reified and is in effect a truth. +nd yet it is a
truth that -irmayer himself ac#nowledges that is contingent. It is precisely at this
point that the earlier discussion a%out culture %ecomes relevant as we try to tease
out on what the contigency is %ased. +nd it is here that we need to weigh in
%etween culture and episteme, %etween anthropology and epistemology. The
difference relates, of course, in part on how we understand the culture construct in
human experience, and it would appear that many of the definitions or approaches
used leave culture a secondary and often contradictory or even incoherent position
(to the extent that anthropologists at one point argued for the a%andonment of the
construct.
-irmayer concludes his two part review of somatization stating1
The dichotomy %etween mental and physical experience that gives rise to
the whole pro%lem of somatization is not simply a reflection of a peculiar
!estern epistemology. !herever people experience the %ody;s privations,
and confront its mortality, they are moved to speculate on the perfecta%ility
and permanence of the immaterial mind. <et it is always the %ody that wins
in the end, pulling us down into the dar#ness of sleep. There are cultures
that fight this reality of the %ody and those that accept or em%race it. In
these ethical postures the deeper significance of somatization may %e sought
(p. =>?.
+nother perspective -awanishi (?@@= suggests that
4
In the same way, somatization may not %e a pro%lem attri%uta%le
to an intrinsic property of the patient. It may not have %een a
medical pro%lem until the society started to %elieve that the human
mind is a separate entity from the %ody and that people ought to
express their psychosocial distress in psychological terms. 6mergence of
such a symptom as somatization may depend on the social process in
which medical reality or meaning is constructed %y a highly medicalized and
psychologized society (p. =A.
Vexing questions for diagnosis
$tudies on somatization across cultures inevita%ly raise the question as to the
patient;s real diagnosis. This returns us to the conundrum1 if we as# for the real
diagnosis we clearly assume that there is one, which shouts the hegemony of
!estern %iomedicine.
.ermeneutics of diagnosis or diagnostic %ias
In an early review, -irmayer noted the tendency of researchers (and presuma%ly
clinicians to try to separate out(distinguish the physical from the mental to the
exclusion of studying the relationship %etween the two.
The diagnostic process involves the identification on the part of the psychiatrist&
using the tools of the trade&of the mental disorder of the patient %ased on the
symptoms reported %y the latter. Thus diagnosis consists of the patient;s reported
symptoms which are elicited %y the psychiatrist who then organizes them in such a
way as to come up with the diagnosis. 6vidently, the elicitation process is not
universal, and is in part guided %y the the initial vision. That is, what the patient
reports will guide the direction the interview will ta#e, given that the psychiatrist will
explore certain possi%ilities and as# questions %ased on what previously reported
symptoms indicate are the possi%le mental disorders.
Thus we can identify three aspects of psychodiagnosis which can %e impacted %y
cultural difference. (? The patients symptom presentation, which here can
include %oth the expression and the explanation, (= the psychiatrist;s interview
methodology or style, and (3 the diagnostic system which guides %oth the
interview and su%sequently the diagnosis itself.
*rior to further discussion, it will %e helpful to specify a few terms and how they
relate to the issues to %e discussed. The field of transcultural psychiatry is itself in a
sense a misnomer, or at least misleading, %ecuase culture is only one component of
the overall field. Thus it is perhaps useful to specify some of the different
5
components and how they relate to psycosocial development, mental health, and
psychiatric diagnosis.
+s noted, the expression and explanation of mental distress can vary culturally. In
addition, the entire understanding of the therapeutic transactions that is, what is
expected of the treatment process etc. is also cultural. ,ut not uniquely so. In some
cases it may simply %e that in a given country of origin health care services and
particularly mental health care services are simply not availa%le. It is not that it is
culturally different, as such, rather than there is no custom of such a type of
treatment %ecause it is not availa%le. This %egins to demonstrate the complex
relationship %etween the different components.
To fully understand the importance of cultural difference we also need to
elucidate the relationship %etween our various #ey concepts and the human
individual. Indeed, part of the pro%lem with this very issue is that culture is
essentially an anthropological concept that psychiatry has attempted to
incorporate, and it is not always such an easy 4o%. +ll too often culture is reified as
4ust another varia%le, which may %e reasona%le for research purposes when
running a regression analysis, %ut at a fundamental philosophical and
epistemological level such a view is pro%lematic, %ecause it thus fails to capture the
very u%iquitousness of culture. ,ecause culture is so very omnipresent it is also
very specific and su%4ective, and of course rarely noticed. )ulture, our individual
culture, forms the %asis of our perceptual and experiential and interpretive filters,
and it is through our filters that we perceive and experience and interpret the world.
To %e sure, interpretation, experience, and perception cannot %e separated and
part of the same overall process, they simply perhaps draw attention to different
aspects of the overall process. This is the classic hermeneutic circle. !e ma#e
sense of the world on the %asis of what we already #now, %ut what we already #now
limits the sense we can ma#e of the world.
The notion of culture as tradition in this respect is perhaps useful/ all too often we
see culture as a thing, and o%4ect, that neatly explains human %ehavior as a
varia%le, rather than as a fundamental part of who and what we are.
BCpez and Duarnaccia (=EE2 hold that . . . culture is manifested %etween people
and is highly social in nature (p. =?. 'ur relationship with culture is dialogical, 4ust
as it impacts us we are the constituents of culture. To that end it is always changing
and in flux, and that flux is directly related to how we are as cultural %eings.
Dadamer used terms such as tradition and historically effected consciousness
and historicity which all point to the utter centrality of culture in the interpretive
process. *ut differently, we are %orn into an already existing tradition or culture,
and it is %y way of our tradition that we engage with the world. +nalogous to sense
perception, we rely on our culturally formed pre4udices to interpret the world, and
6
yet our pre4udices limit what we #now, and indeed, how we #now. +t any rate, from
the perspective on interpretive or hermeneutic anthropology, all of our
engagements with the world are predicated on our cultural context. This is not to
say that we are doomed to su%4ectivism, %ut rather that we can never fully escape
from our own historicity.
0ace is another of the concepts that have an impact on psychiatric diagnosis. There
is no shortage of research in the area of health disparities that indicates that racial
&or phenotypic&difference accounts for considera%le variation in %oth diagnosis
and treatment. 0ace is a%out phenotype, it is a%out an ar%itrary mar#er of
difference
The notion of pre4udice is central here.
.ermeneutics is fundamentally concerned with interpretation. !hereas the earlier
approaches were focused on the development of methodologies for the correct
interpretation of religious texts, su%sequent approaches deviated from this, arriving
at Dadamer who re4ected the quest outright, rather, his interest was in the
interpretive process. !hereas the former where #nown as methodological
hermeneutics Dadamer;s approach is philosophical. 'ne of his concerns was what
he called the enlightenment pre4udice against pre4udice, that is, the idea that
pre4udice or preunderstanding&was a %ad thing, and that methods should %e
developed %y which to avoid the interference of pre4udice and get to the things
themselves. Dadamer re4ected this perspective %ecause he considered that we are
always historically effected that is to say, we are interpreting creatures and our
interpretation is inevita%ly influenced %y what we already #now. Thus any method
itself will influence the interpretive process. 9urthermore, he considered that the
interaction itself has an impact on the participants, interaction is thus dialogical,
meaning that we impact what we perceive and what we perceive impacts us.
If we return to the diagnostic system
7