Talking past each other : Conceptual confusion in ‘ culture ’ and ‘ psychopathology

This article offers a commentary on Hassim and Wagner’s article, Considering the cultural context in psychopathology formulations, published in this issue of the South African Journal of Psychiatry (http://dx.doi.org/10.7196/SAJP.400). It clarifies aspects of the concepts of culture and psychopathology. A distinction is drawn between the content of culture and the demarcation of cultures. The former refers to socially acquired meanings and significances that condition subjective experience and the latter to specific, demarcated cultural groups. It is argued that these two meanings of culture must be kept apart, and that only the former is relevant to the project of understanding the range of cultural influences on mental health problems. This is premised on the idea, arising partially from anthropological critique, that while cultural designations (e.g. Maori or Muslim) might serve as important political and identity markers, they obscure rather than reveal the actual influences the subject is exposed to, and which condition subjective experience as seen through the modulation of distress or symptom formation.


'Culture'
Culture is a complex and multifaceted concept.Not only is it a staple in several academic disciplines such as anthropology, sociology, and cultural studies, it is also common in the vernacular.In anthropology in particular, the concept is central and stands to the discipline in the way that 'power' stands to sociology or 'energy' to physics.Yet for all its importance, culture refuses to be pinned down within a narrow range of uses and definitions.In their famous survey of the concept, Kroeber and Kluckhon provided over 150 definitions of culture available at the time. [2]Neither do the problems of the concept stop at its impossible richness.Since the 1980s, critical voices within anthropology have rejected the way in which culture is used to 'essentialise, exoticise, and stereotype those whose ways of life are being described' , [3] with some voices calling for the abandonment of the concept and others, while aware of its problems, conceding that it cannot be erased from academic and social life.
Given these issues, working with the concept of culture is bound to be difficult.Hassim and Wagner start the paper by endorsing a broadly semiotic definition of culture as a body of beliefs and symbols, [1] yet later appear to be using culture in a different sense.Statements such as 'all cultures experience psychopathology' and 'individuals from minority cultures' (note the plural), suggest a usage denoting groups or populations.These two senses of culture are distinct from each other and it is important that they are kept apart.As I will indicate, it is culture in the first sense that is of relevance to the project of understanding the range of cultural influences on mental health problems; the second use of culture as referring to bounded and demarcated 'worlds' and 'groups' is only partially helpful and can be problematic.We could say that the first definition concerns what culture is -its content -while the second concerns whether the boundary of what culture is can be demarcated and given a name.

ARTICLE The content of culture
In their review, Hassim and Wagner provide a number of important ideas concerning the content of culture, for example: • culture as 'a collection of edicts, passed from community to individual … [and] diffused through language, customs, arts, and symbols' • culture as a 'network of dynamic attributes that direct and train perception, reasoning, interaction, and behaviour' • culture as 'collective practices and joint interpretations of phenomena' .
Culture, whatever else it may be, is socially acquired, and consists in meanings and significances that condition subjective experience, influence behaviour, and permit intersubjective understanding and communication.The question is, how does this occur?In what ways does culture influence our experience?A distinction that I find helpful is between the symbolic and phenomenological dimensions of culture.
Symbolic views originate in the Enlightenment opposition of culture to the body and to nature.This opposition found its way into the discipline of anthropology, and by the 20th century culture came to refer to the 'conceptual and linguistic dimensions of human existence to the exclusion of somatic, sensory, and biological dimensions' . [4]articularly influential in this context has been Geertz's conception of culture as an 'historically transmitted pattern of meanings embodied in symbols, a system of inherited conceptions expressed in symbolic forms by means of which men communicate, perpetuate, and develop their knowledge about and attitudes towards life' . [5] this formulation, culture is an 'interworked system(s) of construable signs' that provides the context within which behaviour, utterances, and social events can be understood among members of a community. [5]More recently, culture has been described as 'shared symbols and meanings that people create in the process of social interaction' , a resource that shapes experience, interpretation, and action, and 'orients people in their ways of feeling, thinking, and being in the world' . [6]Thus conceived, culture invests our experience with meaning and significance, providing a framework for interpretation and permitting a shared experience of the world.
The symbolic approach has been criticised for missing a level of meaningful engagement with the world that precedes representation.Building on a number of concepts from the phenomenological philosophical tradition, anthropologists Csordas [7][8][9] and Jackson [4] put forward a concept of culture which recognises that socially acquired meaning and significance are not limited to representation and are evident in our embodied engagement with the world.Our experience betrays evidence of cultural organisation prior to explicit reflection or thematisation.This can be seen, for instance, in the attribution of salience to aspects of our experience and not others; in the manner in which the environment solicits our intentions through the body; and in the development of subtle perceptual discriminations that accompany the initiation into a social context.Culture is not only a system of symbols but, also, a 'temporally/historically informed sensory presence and engagement' . [8]lture, then, conditions experience in a multitude of ways.These range from symbolic systems and frameworks of interpretation that are relatively explicit and, in principle, open to view, all the way to implicit yet pervasive influences on perception that are pre-reflective yet no less important to how we experience the world.Clearly, the meanings and significances that are socially acquired and influence our experience are not the same everywhere.This brings us to the second issue: Can specific worlds of meaning be demarcated from others?

The demarcation of cultures
Earlier conceptions of culture emphasised its evolutionary nature.For Tylor in the 19th century, culture consisted in 'knowledge, belief, art, morals, law, custom' . [10]This, however, was viewed through a paradigm of progression, whereby the 'primitive culture' of the 'lower tribes' was considered inferior to the rationally minded and technologically advanced 'European culture' of the 'higher nations' .By the early 20th century, and with the emergence of the doctrine of cultural relativism, evolutionary conceptions of culture would be denounced as ethnocentric and racist.This was most pronounced in the work of Boas and his student Benedict. [11]They transformed the concept of culture in the singular, as a thing which develops in a linear fashion, into cultures in the plural, of which there are many.Their view was that a culture is a holistic entity with internal coherence, and a particular habit or practice can only be made sense of when seen against this whole: what appears to us backward or immoral may be seen differently in relation to the totality of practices, social institutions and conditions.
For the cultural relativists, there were a plurality of unique and demarcated cultural worlds, and this view was seen as a way of countering the discrimination that seemed to follow from the evolutionary view.Their conceptualisation is still very much alive, even if it tends to be qualified by the discourse of 'universal human rights' .Writing in 2002, Benhabib comments: 'Much contemporary cultural politics today is an odd mixture of the anthropological view of the democratic equality of all cultural forms of expression and the Romantic, Herderian emphasis on each form's irreducible uniqueness.Whether in politics or in policy, in courts or in the media, one assumes that each human group "has" some kind of "culture" and that the boundaries between these groups and the contours of their cultures are specifiable and relatively easy to depict.' [12] Since the 1980s, this conception has come to be seen as a problem within anthropology.The idea is that, conceived this way, the concept of culture ends up fixing differences between people in ways that appear innate, rather than learnt, evoking uneasy parallels with the problematic concept of race and the way it is and has been used. [13]It imposes specific demarcations upon groups of people, allowing us to speak of 'a culture' .
The anthropologist Abu-Lughod writes: 'In the process of generalising from experiences and conversations with a number of people in a specific community, the anthropologist may flatten out their differences and homogenise them … [which] makes it easier to conceive of groups of people as discrete, bounded entities, like the ARTICLE "cultures" of "the Nuer, " "the Balinese, " or the "Awlad ' Ali Bedouin, " populated by generic cultural beings who do this or that and believe such-and-such.' [13] This enables us to construct what we believe to be coherent 'cultures' , which facilitates both the separation between self and other, and the reification of the other into a static entity.Thus, for Abu-Lughod, 'the anthropological concept of culture is a reason for the continuing incarceration of non-Western peoples in time and place' [13,14] The implication of this essentialising view of culture is that agency and idiosyncrasy are ironed out.Individual beliefs, values and selfconcepts will be seen as determined by culture with little or even no role for agency and moral choice.

Metaphors of culture
Dissatisfaction with the view of culture as a self-contained, bounded entity has lead to a number of alternative metaphors. [15]Culture has been described as a 'resource' [6] and a 'tool-kit' of 'symbols, stories, rituals, and world-views, which people may use in varying configurations to solve different kinds of problems' . [16]It is thus not a monolithic entity that completely over-determines individual agency, but neither is it a set of transparent rules that individuals can use at will.As the discussion of the content of culture above indicates, culture traverses this scale of determinism/agency.
Another metaphor for culture is that of an 'ecosystem' .While cultures do differ, writes Midgley, [17] they 'differ in a way which is much more like that of climactic regions or ecosystems than it is like the frontiers drawn with a pen between nation states.They shade into one another.And in our own day there is such continuous and all-pervading cultural interchange that the idea of separateness holds no water at all.' It appears, then, that culture -the meanings and significances that comprise culture -cannot be demarcated, set apart and given a label.
Hassim and Wagner are right in pointing out that 'cultural groups are not disconnected, and overlap other cultures' . [1]However, I would take issue with the utility and integrity of the very idea of a cultural 'group' , whether we call it Nuer, Pentecostal, Maori or Muslim.While it is true that such labels serve as important identity and political markers, analytically, however, they obscure more than they reveal.
If we are interested in the meanings and significances that condition subjective experience, then we are interested in the actual meanings and significances that the subject is exposed to in all their richness and idiosyncrasy.This may or may not include the perception -by the subject -that he or she is 'Jewish' or 'Lakota' or 'Kurdish' as a primary orientation of meaning.This is why, in order to have a deep understanding of culture, there is no real substitute for in-depth fieldwork of the kind anthropologists engage in, or, indeed, of the kind we all engage in and through which we are unaware experts in our own social world.

Final comments
In this commentary I have attempted to shed some light on the concept of culture.Once we abandon the idea of cultural 'groups' and embrace a view of culture as consisting in meanings and significances that can only be grasped through in-depth engagement, and communicated in 'thick descriptions' , then it will become evident that questions such as 'what is the outcome of schizophrenia in India' or 'what are the symptoms of depression in Nigeria' are so general that their utility is mainly epidemiological.In addition, it is important to appreciate that the terms 'schizophrenia' and 'depression' are themselves already elaborated in specific idioms and codes, and are not outside of or beyond culture.
Hence, the project of investigating the interplay between culture and psychopathology is, essentially, concerned with understanding the ways in which subjective experience is conditioned by particular meanings and significances.This is demonstrated through a focus on, for instance, the modulation of distress or symptom formation.The typology listed by the authors viz. the pathogenic, psychoselective, etc., effects of culture is helpful here. [1](See Barrett 2004 [18] for an excellent example of ethnographic work done in this framework.) Finally, in terms of incorporating culture into the formulation of psychopathological phenomena, I conclude with Hassim and Wagner's welcome suggestions: '… comprehensive investigation into the patient's complaints initiate, and accrue, opulent description … This enriches clinician understanding of the phenomenon, as well

The concept of psychopathology
The concept of 'psychopathology' , like culture, is complex and problematic, but due to space considerations, I will only present a few brief comments.Hassim and Wagner define psychopathology as 'mental illness or anguish, or signs of behaviours and occurrences which may denote mental illness or psychological wounding' . [1].This definition shifts the burden from the term 'psychopathology' to the equally problematic term 'mental illness' , leaving us without a clearer handle on just what we want to examine in relation to culture.Notwithstanding the important debates on the concept of 'mental disorder' (see, for example Bolton, 2008 [19] ), a possible strategy is to propose that, for the purpose of examining the interplay with culture, we will take 'mental disorder' to mean those conditions in the psychiatric manuals.However, we still need to specify those aspects of the conditions that we want to investigate in relation to culture.In general, the conditions manifest either in socially problematic behaviour or distress and disability, or both together; these are the reasons these conditions arouse psychiatric or, more generally, health-related interest.But it is the subjective state underlying these various presentations that is the primary focus of psychiatry and includes the emotions, cognitions, and experiences that underpin the problematic presentation.Reconceived, primarily, as the subjective state underpinning the presentations that brought an individual before psychiatry, the matter becomes the investigation of the ways in which culture modulates and shapes subjective experience.