Potential Contributions of Cultural-Clinical Psychology to a Revisioned Psychiatry
Andrew G. Ryder, Ph.D.
Department of Psychology, Concordia University
Culture and Mental Health Research Unit, Jewish General Hospital
Yulia E. Chentsova-Dutton, Ph.D.
Department of Psychology, Georgetown University
Cultural psychiatry has long aspired to be more than a subdiscipline of psychiatry, but rather a superordinate perspective that ideally would inform all of mental health research and practice. As mainstream psychiatry is by no means so informed at present, cultural psychiatry necessarily offers a necessary critique. This critique is vital, but it is not enough – it must be accompanied by aspiration, by an alternative vision of what psychiatry ought to be. We will argue here that a revisioned psychiatry is inherently interdisciplinary, and that psychology has an important contribution to make. Cultural psychiatry is in a good position to promote this interdisciplinarity, as it has been conceived this way for decades. The role of psychology is uncertain, however. While psychologists and other disciplines are involved, sometimes deeply, cultural psychiatry is predominantly a collaboration between psychiatrists and anthropologists. One problem is that the psychological approach, both theoretically and methodologically, can be an uncomfortable fit with cultural psychiatry. There are many reasons for this, but central among them is the relative inattention to culture and local context in mainstream psychology, paralleling some of the problems in mainstream psychiatry.
We believe that a revisioned psychiatry demands a revisioned psychology – a contextual psychology that responds to key anthropological critiques and yet remains psychology. We have recently proposed ‘cultural-clinical psychology’ as one such revisioned psychology (Ryder, Ban, & Chentsova-Dutton, 2011). Conceived as a blend of cultural and clinical psychologies, cultural-clinical psychology follows cultural psychology in positing that mind and culture ‘make each other up’ (Shweder, 1990). In keeping with emerging trends in clinical psychology, cultural-clinical psychology further posits that a similar statement can be made about mind and brain. Each level is understood broadly and can be extended, for example: brain to the nervous and endocrine systems; mind to commonly used external tools and close others; culture to artifacts and social institutions. Concepts such as ‘symptom’, ‘syndrome’, ‘trait, and ‘resilience’ are here understood as system properties, rather than residing at a particular level (Chentsova-Dutton & Ryder, in press; Ryder, Dere, Sun, & Chentsova-Dutton, in press). The result is a revisioned psychology, dedicated both to research and to clinical practice, that conceptualizes culture-mind-brain as a single system with multiple, mutually constitutive, levels.
Achieving this ambitious goal will obviate the need for the specifier ‘cultural’. Cultural-clinical psychology would become clinical psychology, as cultural psychiatry would become psychiatry (and cultural psychology would become psychology). Given broader trends strongly favouring biological approaches, however, cultural aspects are emphasized in contrast. For now, the potential contributions of cultural-clinical psychology to a revisioned psychiatry will be evaluated through generativity – does this perspective add new ideas, pointing to new research, leading in turn to new clinical interventions? A full consideration of this question is well beyond our scope here, so we will content ourselves with a single example. We believe the best psychology researchers concern themselves with explanation through underlying processes. This concern could be brought to bear on many of the generative but vaguely specified ideas used in cultural psychiatry. Take for example the ‘symptom pool’, proposed by medical historian Edward Shorter (CITE). The idea that different historical eras and – by extension – cultural contexts have specific symptom pools upon which people draw to convey distress has wide applicability and explanatory power. Psychologists want to know: how does this actually work?
What follows is a psychologically plausible model of the symptom pool. Each claim is supportable through psychological research, although very little research to our knowledge has specifically been designed for this purpose. We begin with the idea that the universe accessible to our perceptions is so complex that we can only attend to that which is meaningful (Peterson). This complexity includes many symptom constituents – experiences that could potentially become symptoms. Indeed, the background noise of such experiences is much greater than we generally realize, including physical sensations, stray thoughts, emotional fluctuations, and interpersonal disturbances, transient dissociations, and even brief quasi-psychotic experiences. Cultural scripts can then help us understand how we navigate this complexity in meaningful ways, some of which pertain to how potentially symptomizable experiences are to be understood. The symptoms themselves emerge in part due to feedback loops: attention to particular experiences increases the frequency and severity of these experiences. Out of the background noise of daily life, or the background chaos of an incipient crisis, emerge full-blown symptoms: pathological system properties of culture-mind-brain (Ryder & Chentsova-Dutton, 2012).
This approach points to research designed to establish the various phases of this psychological model in specific cultural contexts, with specific symptoms and syndromes. Can it also impact directly on clinical practice? To begin with, psychological assessment techniques need to tap into locally relevant symptom pools. If successful, psychology will contribute psychometric rigour, as well as a growing arsenal of methods that range far beyond traditional self-report questionnaires (Ryder et al., 2011). Beyond symptoms, a psychological process model of the symptom pool can guide us to assess the relevant cultural schemas operating in a particular sufferer’s local world. This could lead to techniques designed to assess both the meanings and practices endorsed by a particular person, and also their assumptions about the meanings and practices considered normative in their local worlds. We should also consider how we might assess the loops that generate and maintain symptoms. One possible approach to this might be the ‘chain analysis’ technique used in cognitive-behavioural therapy (CBT), in which a clinician works collaboratively with a client to unpack the event sequences that promote and maintain pathology. Here, successful assessment points the way towards potentially successful treatment.
We believe that knowledge of local symptom pools and the ways in which they operate can direct us to specific clinical interventions. First, by opening up possibilities for discussion, there is the potential to build rapport. Second, and more importantly for our purposes here, a study of the loops operating in the client’s culture-mind-brain provides entry points for intervention. Importantly, these entry points do not have to take place at the same level at which we conceptualize a given problem. Just as a pill can change social behaviours, so too can a psychological intervention change the brain (Ryder et al., 2011). In this case, interventions targeting specific loops have the potential to interrupt a pathological pattern in the culture-mind-brain. Much of this work is already being done in contemporary CBT, as well as in family systems therapy, but attention to the symptom pool broadens our understanding of the different ways this can happen. As befits a discipline committed to research and clinical work, these clinical possibilities require careful evaluation. Generativity in theory and research, with practical benefits for assessment and treatment, are central to the making the case for a cultural-clinical psychology that will make lasting contributions to an emerging revisioned psychiatry.