Race and Culture in Psychiatry (Psychology Revivals)

Suman Fernando

• Publisher: Taylor & Francis
• Year: 2014
• eBook ISBN: 9781317557685
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

As psychiatry has developed it has proved to be susceptible to the influence of contemporary social and political mores. With its origins in nineteenth-century Europe, psychiatry evolved as an ethnocentric body of knowledge, the vehicle of implicit and overt racism. Originally published in 1988 this author, however, saw no reason why the contemporary psychiatrist should not challenge this ethnocentrism. He provides a critical account of the development of psychiatry in relation to its cultural context and then examined contemporary practice of the time in the light of this development. Throughout, the book is informed by an awareness of issues of race and culture and of their difficult interactions, the author emphasising both the frequency of racist attitudes and the very real cultural distinctions in our society, distinctions that can be used to mask what are actually racist sentiments. What emerges is not just a plea for an anti-racist, culture sensitive psychiatry, but a blueprint for how this can be brought about. He argued that the shift towards community work and social psychiatry could reorientate the profession by confronting it with its social setting and responsibilities. This book represented a significant contribution to this literature for all mental health professionals and social scientists with an interest in this field at the time; the author has gone on to write many more.

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The Culture of Psychiatry

INTRODUCTION

The definition of the term ‘culture’ with reference to societies and people will be discussed in Chapter 3. In this chapter, however, the term ‘culture’ is used in a somewhat different sense. The sociological concept of culture is defined by Therborn (1980) as ‘the ensemble of everyday activities and ideologies of a particular group or class, or as a more general inclusive concept for ideology, science and art and, possibly, other practices studied from the point of view of their production of meaning.’ Psychiatry is both a professional discipline and a social system or institution (as described in the next paragraph); it is the ‘culture of psychiatry’ that gives meaning to its activities as a discipline and to its structure as an institution. Included within its culture are the ideologies and beliefs that determine the way psychiatry functions. Therborn describes an ideology as including both everyday notions and ‘experience’, as well as elaborate intellectual doctrines. In other words, an ideology includes common sense images within society as well as composite systems of belief. Although the terms ‘culture’ and ‘ideology’ are used in similar senses, the former covers a wider field than the latter does.

In a book based on the Reith Lectures broadcast on the BBC, Donald Schon (1971) described at some length the structure of social institutions or systems, the way they resist change, and the need to develop systems that are capable of adaptation. A social system is ‘a complex of individuals which tend to maintain its boundaries and its patterns of internal relationships.’ It contains a structure, theory and technology:

The structure is the set of roles and relations among individual members. The theory consists of the views held within the social system about its purposes, its operations, its environment and its future. Both reflect, and in turn influence, the prevailing technology of the system. The dimensions all hang together so that any change in one produces change in the others.

The structure within the social system of psychiatry consists of professional roles and relationships with attributes of status, commitment to particular theories and ways of working, and a set or sets of values. It is the culture of psychiatry that gives meaning to these values; the ideologies within it determine ways in which the institution functions. Theory within psychiatry is both formal, or official, and informal, or hidden. The former relates to ideals of service, professional codes, etc., and the latter includes notions of maintaining status within society and/or control over patients, as well as ways of seeing people. The technology of psychiatry as an institution is clearly identical with that of the discipline of psychiatry — ways of gathering information, methods of evaluating and examining people, and techniques of intervention in the form of physical, psychological and social treatment.

It is apparent that psychiatry as a discipline is connected with psychiatry as an institution both in its historical development and in its present state. This section is concerned mainly with a particular ideology within the culture of psychiatry, namely the ideology about race, and the extent to which this ideology is a part of the culture of psychiatry both as a discipline and as a social system or institution. The subject will be explored in the first place by considering the historical context in which psychiatry and the ideology about race have developed within Western culture.

HISTORY OF PSYCHIATRY

Any discussion of the history of psychiatry is faced with a need to define psychiatry itself. If considered primarily as a healing art, does it mean the practice of healing through the ages in all parts of the world (Veith, 1970), or should it be limited to modern — ‘scientific’ — psychiatry as a branch of medicine (Ellenberger, 1974) based on a Western medical model of illness? The approach here favours the latter view — with modifications.

Psychiatrists who view their discipline as essentially a healing art within the medical framework consider that ‘scientific’ psychiatry started at the middle of the nineteenth century (Mora, 1970). But medical interest in emotional disturbance and medical influence over the care of the insane goes back much further. A Treatise of Melancholy by Timothy Bright was published in 1586 and Robert Burton’s The Anatomy of Melancholy in 1621. In practical terms, psychiatry may be envisaged as having started in 1632 when a medical governor was appointed to the Priory of St. Mary of Bethlem — an institution which had been taking in lunatics since 1403. However it was in the latter part of the eighteenth century that psychiatry became established as a field of medicine ‘when a new attitude developed towards the mentally ill as a consequence of the new spirit of inner freedom brought about by The Enlightenment.’ (Mora, 1961).

The establishment of asylums in the early part of the nineteenth century was accompanied by a rapid growth in specialisation and professional organisations of psychiatry. In his book Museums of Madness Scull (1979) describes how the building of physical — bricks and mortar — institutions in the early part of the nineteenth century enabled psychiatry to develop as a discipline dominating a social system dealing with the insane:

Prior to the segregation of the mad into specialised institutions, medical interest in, and concern with, the mad was for the most part quite slight. In historical terms, of course, the idea that insanity was a disease was not without precedent. For many centuries, though, the medical approach to lunacy had either been ignored or been forced to compete with theological and demon-ological perspectives.

The new discipline of medical psychology (that developed into psychiatry) was installed in mental institutions and, in turn, formed the ideological rationale for the existence of the asylums (Donnelly, 1983). In Britain, a professional association, The Association of Medical Officers of Asylums and Hospitals for the Insane, was founded in 1841 and its Asylum Journal of Mental Science was published in 1853. The former became the Royal Medico-Psychologi-cal Association and finally the Royal College of Psychiatrists in 1971. The latter became the Journal of Mental Science and then the British Journal of Psychiatry in 1963. The American Psychiatric Association — originally called the Association of Medical Superintendents of American Institutions for the Insane — was established in 1844 (Mora, 1961) and the American Journal of Insanity started the same year (Amdur, 1944). The first comprehensive textbook on psychiatry for clinical training— A Manual of Psychological Medicine by John Bucknill and Daniel Hack Tuke — appeared in 1858. And a few years later, The Physiology and Pathology of Mind by Henry Maudsley (1867) was published — ‘a turning point in English psychiatry’ (Lewis, 1951). Thus, it could be said that the discipline of psychiatry started in the mid-seventeenth century and grew slowly over the years until it emerged, in the early nineteenth century, as a fully fledged (medical) discipline. From then onwards, psychiatry as an institution (linked to the discipline), became recognisable and respectable as a social entity.

In a book analysing perceptions of mental disorder in Western culture, Bennett Simon (1978) shows how modern psychiatry has precursors and analogues in what he terms ‘ancient psychiatry’ as represented in Greek poetry, philosophy and medicine. The West European cultural framework, within which psychiatry has developed, embodied several important notions which determined the path taken by the emerging discipline. In discussing the Cartesian view of a person as a dualism of mind and body which has dominated Western philosophy and scientific thinking for over three hundred years, Gold (1985) writes:

The human body has been conceived as being a purely passive machine driven by mechanical causality. Thus, it is seen as an inanimate entity in itself, having no intentionality nor teleology (these latter properties Descartes attributes to God); in effect the body is seen: ‘tout simple’ as a mere ‘res extensa’. The mind, on the other hand, has been understood as an incorporeal repository of intelligence, consciousness and motivation within the confines of the body i.e. the ‘res cogitans’.

The view of the body as a machine constructed from different parts has promoted the growth of biological sciences and physiology, thereby directing medical research into the investigation of bodily disorders. This has paid off tremendously in the development of medical science — at least as far as bodily illness is concerned. However the Cartesian view of nature has hindered the ability of science to tackle some biological problems that are concerned with psychic phenomena and the total functioning of human beings. According to Lewins and Lewontin (1985):

This great success of the Cartesian method and the Cartesian view of nature is in part a result of a historical path of least resistance. Those problems that yield to the attack are pursued most vigorously, precisely because the method works there. Other problems and other phenomena are left behind, walled off from understanding by the commitment to Cartesianism. The harder problems are not tackled, if for no other reason than that brilliant scientific careers are not built on persistent failure.

Although scientific medicine enabled physicians to gain detailed insights into intimate mechanisms of the human body and to develop complicated and sophisticated technologies for intervention at a mechanical level, the Cartesian concepts inherent in it had a dehumanising effect through its view of the person as a physiological mechanism (Gold, 1985).

As the medical speciality of psychiatry developed, it naturally took on a bio-medical view of illness; mental disorder was attributed to somatic causes; and a medical — as opposed to religious — dominance over madness was established (Scull, 1981):

This somatic emphasis is particularly unsurprising when we recall that to adopt a perspective which allowed disorders of the mind/soul to be the aetiological root of insanity threatened to call into question the soul’s immortality and with it the very foundations of Christianity, or to lend substance to the notion that crazy people were possessed by Satan or the subjects of divine retribution — which, of course, made them better candidates for the ministrations of ecclesiastics than for those of physicians.

Thus, psychiatry took over the mind which — as the soul — had belonged to religion. Naturally there developed a growing acceptance that mind was a function of the brain. The German school of somatic psychiatry looked for the causes of mental illness in specific changes of bodily function or structure, to be understood in mechanistic terms. Since natural causation is implicit within the medical model of illness (Siegler and Osmond, 1974), aetiology was sought in natural events — injuries, defects, infections, etc — that happen to people rather than incidents that are caused by others. As psychological theories of the working of the mind were generated, the notion of psychopathology — pathological changes affecting the mind analogous with changes affecting the body — developed. These psychological theories too were within the Cartesian framework but used concepts borrowed from Newtonian physics such as forces, energy and mechanisms. Altschule (1965) describes how ‘ego-psychology’ was developed by introspective psychology and the ‘ego’ given ‘a real existence’ when introduced into clinical psychiatry in the mid-nineteenth century. He quotes from a description of the ‘ego’ in a book by Griesinger (1845) which constitutes ‘a landmark in psychiatric thinking’:

The solid, constant nucleus of individuality can be sought nowhere but in the strong complexes which have been combined to form das Ich, The nucleus may be shaken in the emotions but not destroyed; what else can be affected in the emotions than that group of ideas, das Ich? Das Ich can be detached and can disintegrate completely ….

Although Descartes had suggested that the mind should be studied by introspection while the body was studied by methods of natural science, psychologists adopted both methods for studying the mind resulting in the two major schools of psychology — the structuralists (studying the structure of mind) and the behaviourists who analysed behaviour and ignored the mind as originally conceptualised.

The psychoanalytic theories of Freud had an enormous influence on psychiatry at the end of the nineteenth century and well into the twentieth. But these too did not break out of the mould set by the scientific thinking of the time. According to Capra (1982):

As in Newtonian physics so also in psychoanalysis, the mechanistic view of reality implies a rigorous determinism. Every psychological event has a definite cause and gives rise to a finite effect, and the whole psychological state of an individual is uniquely determined by ‘initial conditions’ in early childhood. The ‘genetic’ approach of psychoanalysis consists of tracing symptoms and behaviour of a patient back to previous developmental stages along a linear chain of cause-and-effect relations … The strictly rational and mechanistic approach made it especially difficult for Freud to deal with religious, or mystical experiences … In the Freudian model there is no room for experiences of altered states of consciousness that challenge all the basic concepts of classical science. Consequently, experiences of this nature which occur spontaneously much more frequently than is commonly believed, have often been labelled as psychotic symptoms by psychiatrists who do not incorporate them into their conceptual framework.

The work of the behaviourists affected psychiatry in the twentieth century. The mind, which other psychologists had conceptualised as a ‘thing’ analogous to the body, was denied by the behaviourists. The schools of behaviourism and psychoanalysis ‘differed markedly in their methods and their views of consciousness but nevertheless adhered, basically, to the same Newtonian model of reality’ (Capra, 1982).

Just as a mechanistic view of life and Newtonian physics determined the concepts used in Western psychology in the nineteenth century and the early part of the twentieth, the physical world became the model for understanding the social world (Shweder and Bourne, 1984): Physical metaphors (noted earlier) were used by social scientists to describe social events and systems. In the course of reviewing the history of psychiatry in Britain, Howells (1975) noted that ‘materialism slowly but surely steered medicine away from psychopathology and left the psychiatrist in isolation, an alienist.’ He reckoned that ‘these three hundred years (i.e. from 1600 to 1900) deserve to be termed the dark age of psychiatry.’

Thus, by the early part of the nineteenth century, the ‘culture of psychiatry’ had been established: A mechanistic view of life, a materialistic concept of mind, a segmented approach to the individual, and a model of illness which assumed a bio-medical change and a natural causation. As neurology developed to take over the domain of brain disease, psychiatry, in keeping with the bio-medical approach to illness, looked for causes of illness within the individual psyche — in pathology of the psyche as opposed to pathology of the soma. The social context in which illness occurred was largely disregarded and the notion of illness being caused by relations within a social group did not become a part of psychiatric tradition (White and Marsella, 1984). Psychiatry took on Western thinking about normality; mental health was perceived as relating to psychological and behavioural qualities (Marsella, 1984) with a dualistic approach to the human person, rather than one that encompassed a harmony in relationships and a holism of somatic and psychological functioning. Materialism dominated over a spiritual approach to life.

Once established as an institution and a professional discipline, psychiatry developed in various ways. Physical restraint of earlier years gave way in the early part of the nineteenth century to moral treatment. In the eighteenth century, theories of causation of insanity had been adopted for their metaphorical and visual aptness rather than on the basis of empirical facts (Skultans, 1979), but the approach changed at the turn of the century. The ideologist school in Paris held that scientific theory should be based on accumulative analyses of data (Rosen, 1946). Philippe Pinel (1809) allied himself with the ideologists and restricted his research to ‘those symptoms and signs which are recognisable by the senses and which are not susceptible to vague reasoning’ — thus preparing the way for modern psychiatry (Woods and Carlson, 1961). Moral treatment, as a means of manipulating the mind, developed side by side with physical treatment, as a means of acting on the brain, and thereby affecting mental processes. Various classifications of mental disorder (disease) appeared; psychological theories influenced the way they were conceptualised but classifications were based primarily on empirical observations. And then in the mid-twentieth century, the social sciences brought to bear on psychiatry its considerable body of theory and information, latterly questioning the concept of ‘mental disease’ itself. However, the diagnosis of ‘illness’ and the nosology of mental disorder has remained a central feature of psychiatric theory and practice.

In analysing the situation in the nineteenth century, Robert Cas-tel (1985), Professor of Sociology at the University of Paris, states:

To say that nineteenth century psychiatric knowledge is uncertain of its foundations signifies that it possesses only a weak autonomy in relation to other systems of interpretation, and hence that it is permeable to non-medical norms, and ready to interpret within the framework of an extra-medical synthesis, representations which have no theoretical relation with medically founded knowledge.

Thus, social values and ideologies present in the society at large permeated into psychiatry to influence its development in various ways. Cultural ideas about ‘proper’ feminine behaviour have shaped the definition and treatment of female insanity (Showalter, 1987). According to Skultans (1979), ‘throughout two centuries female sexuality was seen as an...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Table of Contents
• Dedication
• Introduction
• 1. The Culture of Psychiatry
• 2. Current Psychiatry
• 3. Cross-cultural Research
• 4. Socio-cultural Psychiatry
• 5. Racist Psychiatry
• 6. The Race-Culture Argument
• 7. A Blue-print for Change
• References
• Index