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Editors: Vieda Skultans, John Cox
303 pp Price £14.95 ISBN 1-85302-708-1 (p/b)
London: Jessica Kingsley, 2001 .
The most obvious reason for studying medical anthropology is to care competently for patients from cultures other than your own, and ‘transcultural psychiatry’ is certainly one of the themes of Skultans and Cox's book, particularly the question of how cultural competency can be taught and assessed. For the general reader, however, this is perhaps the least interesting aspect of the work. Much is to be learned from comparisons. We compare the healthy limb with the injured side, healthy controls with patient groups, a new treatment with an established one. Similarly we learn about our own culture by looking at others. It is the exploration of questions about the nature of mental illness and medical practice that makes the book important.
General practitioners know that diagnoses are made in psychological and social as well as physical terms, but in practice and in the International Classification of Diseases the most easily defined aspects are the physical. It is the biomedical definitions of illnesses that allow application of the ICD in every country of the world and account for its success. Psychiatry, however, differs from other branches of medicine. The commonest problems of psychological medicine—anxiety, depression, schizophrenia—do not fit well into the biomedical model, at least at our present state of knowledge, even if we can use drugs to modify them. Other models, particularly from psychology and sociology, are at least as effective in helping us understand these disorders. The criteria for separating normal variation from illness are less clear, and the influence of cultural factors is much more obvious. Despite this, such is the dominance of western culture in medicine that patterns of mental illness tend to be seen as universal and form the basis of international psychiatric classifications. Jadhav provides an historical analysis of the development of the western concept of depression, stimulated by the difficulties of applying it in Indian cultures. This essay shows how culturally bound our modern concept of depression is, evolving from the acadia of medieval monks, through the bittersweet Renaissance melancholia, and influenced by ideas of stress, somatization and protestant guilt.
Medicine is itself an important cultural phenomenon, and three chapters focus particularly on an anthropological analysis of its structures, beliefs and practices. It is uncomfortable for us to be reminded, as Littlewood does in his chapter, of the close link between the spread of western medicine and our western imperialist past. Psychiatry, moreover, is rooted not merely in western culture but in one particular bourgeois post-Judeochristian secular humanist subculture within it. The three chapters which discuss methodological and theoretical issues in the relationship between anthropology and psychiatry are thought-provoking but possibly too abstract unless you are a medical anthropologist or a philosopher of science. The chapter that offers fewest useful insights for the clinical reader is the one that best fits the lay image of anthropology—an account of Cambodian concepts of perinatal mental disorder. Although fascinating as a phenomenon and no doubt valuable to anyone providing obstetric care to Cambodian women, its relevance does not extend much beyond that context.
The book offers not a coherent narrative but a collection of readings, the choice and order of which are unexplained. Most of the chapters raise questions rather than give answers. The material would provide excellent stimuli for discussion of the nature of mental practice. But those who seek a systematic argument, and a ‘solution’ to the interaction of universal biological factors (such as neurotransmitters or psychophysiological functions) and specific cultural contexts (such as religious background) in the experience and manifestations of mental illness, should look elsewhere.