Why Psychiatry Needs the Anthropologist: A Reflection on 80 Years of Culture in Mental Health

In the first volume of this journal Psychiatry, published in 1938, anthropologist-linguist Edward Sapir penned the commentary “Why Cultural Anthropology Needs the Psychiatrist.” Sapir lamented that anthropology at the time was limited to generalizations about groups, and its scholars exhibited a reluctance to conceptualize the role of the individual when describing culture. Sapir called for more contributions from psychiatry to understand the individual in relation to culture. In this commentary, we take the opportunity to reflect upon how the fields of anthropology and psychiatry have changed in the past 80 years with respect to concepts of culture and the individual. We conclude by flipping Sapir’s question to instead ask: What does a psychiatrist in 2020 need to know about anthropology? In asking what anthropology has to offer psychiatry, the obvious answer might seem to be culture – that key object of anthropological inquiry. While it can certainly benefit psychiatry to take a more nuanced and reflexive approach to culture, here we argue that much of what anthropology has to offer psychiatry of the 21^st Century is considerations of structure, power, and equity.

The origins of cultural psychiatry

Neither the anthropology nor the psychiatry of today would be recognizable to Edward Sapir. In the 1930’s, Sapir built upon linguistic methods to study anthropology. He is remembered for the eponymous Sapir-Whorf hypothesis, which suggests that language is a window onto cognition and that differences across language may shape nonlinguistic cognitive differences (Carroll, 1967; Sapir, 1921). He will be forever misquoted with the claim that there are 100 words for snow in Inuit languages. Sapir was also interested in the contribution of Freudian thinking to anthropology. Sapir called for unification of the fields of anthropology and psychoanalysis, for which he coined the disciplinary name of “cultural psychiatry,” (Sapir, 1938). Sapir was a part of the broader Culture and Personality movement in anthropology, which had grown out of Freud’s applications of psychoanalysis to ‘primitive’ cultures, exemplified by his 1918 publication, Totem and Taboo: Resemblances Between the Psychic Lives of Savages and Neurotics.

The anthropologist Ruth Benedict is the historical torchbearer for the Culture and Personality movement, exemplified in her 1934 publication Patterns of Culture. Benedict, Sapir, and others described configurations of cultures that mirrored personalities. Benedict characterized Native American and First Nations cultures according to personality styles: Pueblo Indians were Apollonian, whereas Plains Indians were Dionysian; the Dobuan were paranoid, and Kwakiutl were megalomaniac (Benedict, 1934). Culture at the time was encapsulated as static and shared among stable groups, and culture was often the object of study among ‘primitive’ populations.

This research was conducted during a political era in which scientific theories were used to justify racism, segregation, and practices such as sterilization according to eugenics and Social Darwinism. The stratification of races was a hallmark of Jim Crow America, as well as Nazi and Fascist movements in Europe. In the same year that Sapir’s commentary was published, Time Magazine named Hitler ‘Man of the Year’, and the Nazis were inspired by U.S. segregation policies including “one drop” racial theories. These political processes reinforced the exotification and objectification of culture of ‘the Other’.

After WWII, the tone of psychiatry and anthropology began to shift. The 1950’s saw the first edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM) (American Psychiatric Association, 1952) and the discovery of chlorpromazine as the medication that heralded the pharmacological redefining of psychiatric care. The 1960’s brought the de-institutionalization movement in the U.S., the waning of psychoanalysis, and the beginning of the anti-psychiatry movement (Shorter, 1997).

Anthropological critiques of psychiatry

French philosopher Michel Foucault (Foucault, 1965), Algerian psychiatrist Frantz Fanon (Fanon, 1963), and others began to turn a critical gaze onto psychiatry and medicine in general as themselves objects of inquiry. Anthropologists critiqued diagnoses as social constructs rather than representing psychiatric pathology. The anthropologist Margaret Mead, a student of Ruth Benedict, challenged biological essentialism underlying gender norms and expectations, and this set the stage for anthropological critiques challenging the psychiatric community’s conceptualization of homosexuality as a mental illness (Mead, 2001). Homosexuality was finally dropped as a psychiatric disorder with the publication of the second edition of the DSM in 1973. (Of note, alongside Sapir’s essay, one of the articles in the inaugural issue of Psychiatry was an analysis of the role of the penis as a non-participating factor in the ‘recipient’ male in a homosexual act (Silverberg, 1938)—hence our earlier suggestion that the psychiatry of today may have surprised Sapir.)

Also in the 1970s, the psychiatrist and anthropologist Arthur Kleinman (Kleinman, 1977) called for “a new cross-cultural psychiatry” to highlight the importance of culture for psychiatry. He established concepts such as explanatory models as a way for clinicians and anthropologists to understand illness experience and help-seeking, as well as the importance of the patient-healer relationship (Kleinman, 1980, 1988). Kleinman’s work earned the attention of the American Psychiatric Association, and the DSM-IV was the first use of the cultural formulation (Mezzich et al., 1999), which has continued through subsequent editions including the current DSM-5 (Lewis-Fernández et al., 2014). Kleinman’s anthropological critique of psychiatry has been echoed through other ethnographic studies, such as Of Two Minds, Tanya Luhrmann’s (Luhrmann, 2000) critique of biomedical psychiatry and its sidelining of psychotherapy. In Harmony of Illusions, Allan Young (Young, 1995) uses historical and ethnographic research to challenge the assumptions of the diagnosis of posttraumatic stress disorder as it was introduced in DSM-III.

Among these medical anthropologists, as well as in other anthropological subdisciplines, there was a rejection of culture as a static property of a group. The end of European colonial rule after WWII and globalization in ensuing decades demonstrated that cultures rapidly change and also that individuals can be part of multiple—even at times conflicting—cultures (Bibeau, 1997). Individuals are part of multiple cultural landscapes (Figure 1a). Moreover, anthropologists turned their attention to intersubjectivity as a concept to illustrate that culture and experience are co-constructed in exchanges among individuals impacted by the expectations and assumptions of both parties in the interaction (Hollan, 2003). Therefore, the anthropologist’s presence impacts how culture is expressed and experienced (Hollan, 1997).

Figure 1.

Models of culture, power, and violence

Another strand of anthropology beginning in the 1980s was critical medical anthropology (Singer, 1989). Critical medical anthropology focuses on how structures and systems shape the encounters of patients with their healthcare providers. A patient-doctor interaction is not independent of the economic and political institutions and policies around them (Baer, Singer, & Susser, 2003), (Figure 1b). Cultural symbols embody and perpetuate power structures through policies and institutions that shape how medicine is practiced. Capitalism-based medicine, for example, shapes how pharmaceutical companies operate, the types of conditions that are prioritized, and the medications and other treatments that are developed (Petryna, Lakoff, & Kleinman, 2006). Critical medical anthropology has been used especially in critiques of drug companies, calling out exploitation through psychiatric drug development and marketing in India, Japan, and the US (Applbaum, 2006; Ecks, 2013; Kirmayer, 2002). Critical medical anthropology also introduced the concept of syndemics, referring to constellations of multiple health problems under specific political and economic vulnerabilities (Mendenhall, Kohrt, Norris, Ndetei, & Prabhakaran, 2017; Singer, 1996).

Structural violence, structural competence

The peace researcher Johan Galtung developed a tripartite model of cultural violence, structural violence, and direct violence (Galtung, 1969), (Figure 1c). Cultural violence refers to the symbols that allow one group to dominate another (Galtung, 1990). These symbols and power structures enable violence, or from a health perspective, they set the stage for diseases disproportionately affecting specific groups. Structural violence is then the institutions and practices that marginalize populations, blockading access to healthcare, education, employment, and other resources. Structural violence is made possible by the symbolic structures of cultural violence. The top of Galtung’s pyramid is direct interpersonal violence, made possible by the vulnerabilities established from the two prior levels. Galtung’s framework demonstrates that cultures are not simply something passed from generation to generation, but rather culture is intrinsic to perpetuated inequity. This also explains evoked cultures as the pattern of beliefs, symbols, and behaviors that are developed to respond to these structural constraints.

The concept of structural violence was adopted by anthropologists Paul Farmer and Jim Kim when studying under Arthur Kleinman, to explain how economics, politics, and history shape health systems and access to care (Farmer, 2003; Kim, Millen, Irwin, & Gershman, 2000). Mental health professionals adopted similar models drawing attention to the social determinants of mental health, highlighting political and economic risk factors that shape social conditions and subsequent mental illness, as well as dictating the care (or lack thereof) available in society (Lund et al., 2018). The focus on structures also led anthropologists in global mental health to support a rethinking of care delivery systems that would assure community-based access to care (Kohrt & Mendenhall, 2016). For example, care can be delivered by community members with common cultural experiences and explanatory models as the patients they serve, thus circumventing structural barriers that come from relying solely on mental health specialists (McLean et al., 2015; Mendenhall et al., 2014).

With the focus on structure and structural violence in health, it is not a surprise that the current generation of anthropologist-psychiatrists have questioned the benefit of focusing solely on patients’ culture in attempting to improve doctor-patient interactions and care. Social, political, and economic structures significantly shape health risks, treatment-seeking, and outcomes for patients. Structural competency refers to the idea that healthcare providers need to understand the resources and constraints of patients, families, and communities (Metzl & Hansen, 2014). This reduces the risk of falsely attributing behaviors such as treatment non-adherence to ‘culture.’ Understanding structure, it follows, should then be a responsibility of healthcare providers.

Such structural competency approaches arose in part as a response to critiques of cultural competency approaches – which can oversimplify notions of culture, stereotype cultural groups, and overlook barriers that patients face in care-seeking that can prove far more significant than cultural considerations (Willen, 2013). While cultural competency places the blame for stigma and inequitable healthcare provision on interpersonal interactions, structural competency reorients the lens to point to structures and systems as ultimately to blame for health inequities (Metzl & Hansen, 2014). Such structural considerations are increasingly making their way into psychiatric care and training.

Today’s psychiatrists, according to structural competency, need to know how to identify and respond to barriers and know the available resources for patients and families. Knowledge of education or legal service referrals is as vital as knowing strains of antibiotic resistant bacteria to watch out for. Jonathan Metzl, one of the developers of the structural competency movement, has examined why White populations in rural America make political and healthcare decisions that increase their vulnerability rather than protecting them against illness (Metzl, 2019). Helena Hansen, the other originator of the movement, has examined how opioid use has been characterized differently in relation to Black vs. White patients (Barry et al., 2010; Hansen, 2017; Hansen, Siegel, Wanderling, & DiRocco, 2016; Mendoza, Rivera, & Hansen, 2019; Netherland & Hansen, 2016).

A critical medical anthropology and structural violence approach maps out why situations like the American opioid crisis happen through the toxic interaction of structural constraints on vulnerable populations, profit as the driving culture of pharmaceutical companies without adequate public and government oversight, and symbolic power of physicians that is easy manipulated. Criminalization has led to mass incarceration of Black heroin users and denial of access to opioid-substitute treatments. In contrast, the framing that prescription opioids—marketed to White doctors and patient populations—are not addictive has led to lack of regulations, massive overprescribing, and death rates comparable to 9/11 happening twice a month for every month in recent years (Hedegaard, Warner, & Miniño, 2017).

Structural thinking should also reach beyond considerations of who can access care. For example, research on who develops mental illness and why would benefit from greater critical awareness of inequitable social structures. Today’s psychiatry is overwhelming focused on neuroscience studies, what anthropologist Rob Whitley refers to as the “supremacy of the ‘bio-bio-bio’ model” (2014: 499). Key theoretical orientations like structural violence and social determinants of mental health can make powerful contributions to this arena by expanding consideration of risks from an individual’s genetics or behavior to broader political, economic, and social ecology (Lund et al., 2018; Patel et al., 2018). For example, anthropologist Elizabeth Carpenter-Song (2019) conducts ethnographic research within rural American communities to detail the ways that structural vulnerabilities lead her informants to cycle in and out of homelessness, substance use, and mental healthcare (Carpenter-Song et al., 2016). This research is particularly apt for informing clinical training because she has collaborated with her informants to develop multimedia narratives that she uses in undergraduate and medical education. The narratives humanize the embodiment of social inequities in experiences of vulnerability, uncertainty, and poor mental health outcomes, and they often point to insufficiencies in current forms of mental healthcare (Kaiser et al., in press).

A second area of mental health research that benefits from a structural orientation is examining who does and does not receives diagnoses. Under-diagnosis and mis-diagnosis can be attributed to a range of social phenomena, from general inaccessibility of healthcare to lack of mental healthcare providers, from society-wide stigma and discrimination to stigma among healthcare providers regarding mental illness (Barry & Huskamp 2011; Corrigan et al., 2014; Kohrt & Harper, 2008; Syed et al., 2003; Thornicroft, 2008). Much recent work in global mental health addresses these shortcomings. For example, in our own work, we have developed stigma-reduction approaches informed by medical anthropology and social psychology that aim to promote mental healthcare provision in primary care settings (Kaiser et al., in press)(Kohrt et al., 2018).

Receiving a diagnosis is also premised on the availability of appropriate screening tools, which is rarely the case outside of mainstream European and US populations. Anthropologists are increasingly highlighting the need for screening tools to not only be translated but culturally adapted and locally validated (Kaiser et al., 2013; Kohrt et al., 2011; Weaver & Kaiser, 2015). Anthropologists are ideally situated both to conduct linguistic and cultural adaptation but also to attend to the ways that power relations inform such processes. For example, we have found that cultural adaptation processes must work to avoid inadvertently excluding the voices of less-powerful or stigmatized individuals such as women or those experiencing psychiatric disability (Kaiser et al., 2019; Kohrt et al., 2016). Finally, while most of this research focuses on lack of access to care, there are also important biases in terms of diagnoses being inappropriately applied. For example, Johnathan Metzl (2010) describes how black civil rights protesters were systematically labeled schizophrenics in a pattern much more reflective of political than clinical goals.

What does a psychiatrist in 2020 need to know about anthropology?

With all of these shifts in culture and mental health, it may seem difficult to identify what a psychiatrist in 2020 needs to know about anthropology. Fortunately, the lessons of the past 80 years have some central tenets:

1. Culture is not static and singular, but rather a landscape of experienced, internalized, and expressed norms, values, behaviors, and systems of meaning-making. The first step is not assuming that there is a single culture that a patient has that will dictate psychiatric illness presentation and response to care. Rather the psychiatrist needs to engage with the patient to learn about the cultural landscape in which they live, their different communities, relationships, values, and how these have changed over time. In an ideal world, every psychiatrist could complete a DSM-5 Cultural Formulation Interview with every patient and her/his family members to learn about their cultural landscape. However, even when that is not possible, there is benefit to avoiding a myopic focus on a singular overriding cultural identity.

2. Intersubjectivity dictates that when we are considering culture or cultural issues, we must look to ourselves as much as to the other individual. Both play a role in that system, and from an intersubjectivity standpoint, we need to keep in mind what we evoke from another individual. This is one aspect captured when attending to transference and countertransference. It is also part of the fourth element of the Cultural Formulation Interview. Techniques such as mindfulness for healthcare providers can promote such reflexivity. Together these can be helpful to reflect upon our role in evoking and shaping the cultural landscape.

3. Structural competency is needed to understand the resources and constraints a patient and her/his family encounter in medical care and daily life. At a minimum, psychiatrists need to consider the context of patients as this has impact—potentially modifiable—on aspects of evoked culture. In addition, knowledge of resources is required to respond to structural constraints to assure the feasibility and acceptability of care. A critical eye on the health system can also challenge assumptions about care systems. For example, collaborating with non-specialists for comprehensive care plans may facilitate recovery.

4. Finally, it is important to have a critical eye about being on the right side of history in 80 years. From a critical medical anthropology standpoint, what current practices and models may be the result of political and economic factors that actually put health at risk? Similar to homosexuality, will there be diagnoses that we no longer consider a psychiatric pathology? As with lobotomies and opioids, will there be treatments we realize are ineffective, inhumane, and harmful? As a field, we cannot practice psychiatry with an uncritical gaze and wait for political decisions and official policies to change our clinical behavior. We should examine currently how our practices are shaped by politics and economics. We are indoctrinated to spend a great deal of time thinking about malpractice lawsuits; what if we put equal energy into thinking critically about the field, the diagnoses, and the drug practices arising from the culture of American capitalism?

Despite all of the changes that have occurred in the past 80 years, we still run into a core challenge that Sapir (1938) highlighted: that anthropology concerns itself with the society and psychiatry with the individual. As anthropologists increasingly collaborate with cultural psychiatrists and global mental health practitioners, we continue to run into this disciplinary tension. For example, anthropologists often seek to identify idioms of distress that are widely understood and can be used to facilitate clinical communication, adaptation of screening tools, and recruitment into interventions. Psychiatrists, in many ways, are less limited by the need to identify what will work best for entire communities or populations. The clinical encounter provides the space to focus on the individual: to understand the patient’s preferred language and framing of their distress, to have a discussion that ensures mutual understanding, and to adapt each clinical encounter to the patient.

We encourage psychiatrists to use the clinical space to consider both the ways that a patient’s culture/s affect their preferred care but also the myriad ways that the structures in which they are embedded shape the possibilities for their care and health outcomes. And we encourage psychiatrists to look beyond the individual patient to the broader systems and structures of which they – as clinicians – are a part, to consider what changes will make for a more reflexive, critically oriented future in psychiatry.