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Elements of Culture and Mental Health: Critical Questions for Clinicians

edited by Kamaldeep Bhui. London, Royal College of Psychiatrists Publications, 2013, 94 pp., $30.00 (paper).

Reviewed by Rudra Prakash, M.D., D.F.A.P.A.
Am J Psychiatry 2013;170:933-933. doi:10.1176/appi.ajp.2013.13050597
View Author and Article Information

The author reports no financial relationships with commercial interests.

Nashville, Tenn.
Dr. Prakash is Clinical Professor of Psychiatry, Vanderbilt University, Nashville.

Accepted May , 2013.

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A world leader in cultural psychiatry and a psychoanalyst, Dr. Bhui is Professor of Cultural Psychiatry and Epidemiology at University of London. As editor, Dr. Bhui has done an amazing job of packing a wealth of information in 20 chapters, only 94 pages, and with 17 contributors, including him. The chapters are “essays” about clinical scenarios written for “improving the quality of care for culturally diverse populations” (p. ix). The authors shed light on obstacles and dilemmas that clinicians commonly face and offer tips for overcoming them. I was struck by Dr. Bhui’s astute observation that “placing emphasis on education rather than personal development or on technical knowledge rather than emotional engagement with patients can be counterproductive, and may become an obstacle to improving quality” (p. ix). The book nicely addresses the powerlessness and bewilderment of practitioners in confronting common questions, such as, What do we need to do and how do we do it? The authorship of this book is diverse: service users, practitioners, teachers, and researchers. The need for seeking out further information and individual and group professional development primarily motivated Dr. Bhui in putting together this masterpiece.

On a very topical subject, trauma-focused therapy for war survivors, Rachel Tribe, Professor of Psychology, encourages busy practitioners to think beyond the posttraumatic stress disorder and individual; she elucidates concepts such as collective trauma—coping at a collective level—and war-time spirit—emboldening by a sense of collective engagement when every layer of community is threatened by an ongoing war, unlike a solitary incident (e.g., a plane crash). She also alludes to the emerging debate about the appropriateness of application of Western nosological systems in cultures and communities that have “their own descriptors and ways of managing distress” (p. 2). It was enlightening and frightening to know the statistics—43.7 million people forcibly displaced by war and conflict worldwide as of 2010—as cited by her. She forces the reader to have a broader perspective. In this context, she also goes on to cite another source rightly cautioning that “being a refugee is not a diagnosis” (p. 3).

Generally, the cultural lens is used to account for variations in the expression of mental illness. However, Faisal Sethi, a psychiatrist, highlights additional and important dimensions that can be grouped as ethnopsychopharmacology. Biologically oriented psychiatrists will surely benefit from this section.

Cognitive-behavioral therapy (CBT) is currently one of the most widely used forms of therapies. Rathod et al. highlight challenges in adapting CBT across cultures that not only take into account culturally sensitive translation, but also communication styles. Clinical scenarios also include situations warranting delivery of therapy through interpreters, and the book offers helpful tips for optimizing therapeutic outcome. Likewise, the book touches upon culture-specific modifications in the orientation of psychotherapy. Dr. Adil Qureshi has written well on a more familiar aspect of culture: its impact on evaluation, assessment, and diagnosis.

While each essay is full of insights that will empower the practitioners, I found commentaries on Eurocentric diagnostic categories and power relations inherent in medical systems particularly thought provoking. The concerns as expressed with regard to diagnoses seem to assume new proportions as DSM-5 has arrived. With regard to power relations, the authors argue that the “power and authority in psychiatry are largely in the possession of psychiatrists, unidirectional and static” and go on to encourage them to use the same “positively with patients…so that they interfere as little as possible in the lives of their patients” (p. 63). Several realities are, however, fast emerging in the United States; increasingly, nurse practitioners, psychologists, and primary care physicians are sharing the so-called power and authority in the delivery of psychiatric care.

For the analytically oriented practitioners, the editor, also an analyst, offers food for thought in his discussion on race and racism in the transference. The insights as offered may also be applicable to increasingly more common settings of practice (pharmacotherapy) and patient-provider pairings (cross cultural, cross racial, cross ethnic). The book ends with a much needed comment on religion, spirituality, and mental health. However, the book opens a conversation that every mental health specialist must engage in and ask: What can knowledge of patients’ culture do to the understanding of patients’ suffering and healing? The book will help with gaining that understanding.

In summary, the book represents a treasure trove of readily usable knowledge. All chapters are well referenced and easily readable. I strongly recommend it to all practitioners and, in particular, mental health trainees.

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