With the mass movements of populations that have characterized the second half of this century, there can be few psychiatrists who do not encounter members of an ethnic minority group in their practice. The principles of transcultural psychiatry are obviously of relevance to this type of psychiatrist-patient interaction, but they are also of central importance even when the psychiatrist and patient share the same ethnic background. This is because within a particular ethnic group there are invariably many subcultures, for example based on religious affiliation, which encompass a diversity of beliefs. It is essential that the psychiatrist be aware of the common belief systems likely to be encountered, not simply to enhance rapport with patients and relatives, but in order to avoid serious mistakes in ascribing pathology to experiences that are accepted as normal by the subculture. For example, it is important to be aware that about half of recently bereaved people experience the image, the voice, or even the touch of the dead person(1) and that 2 per cent of the general population admit to hearing voices.(2) The political repercussions of ignorance of such subcultural phenomena are illustrated by the accusations of misdiagnosis of black patients which have come from both outside and within the profession.
There are two main streams of thought and enquiry that have shaped the development of transcultural psychiatry: social anthropology and psychiatric epidemiology. In a number of ways these disciplines are opposed; the former is concerned with qualitative data and emphasizes cultural relativity, while the latter relies on quantitative data and prioritizes a search for universal disease categories. The tools of the epidemiologist are standardized interview schedules which are linked with definitions of symptoms and signs, and rules for reaching a diagnosis. These have been introduced in an attempt to reduce the subjectivity of the psychiatrist's judgement to a minimum. By contrast, it is the person's subjective experience of illness that is the prime focus of the anthropologist. Consequently the use of standardized psychiatric interviews has been criticized by anthropologists as imposing a Western biomedical model of disease on the rich variety of experience of illness and distress. The conflict between these opposing approaches is probably unresolvable, and they are best viewed as contributing complementary material to our understanding of psychiatric morbidity.(3)
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