Culture and schizophrenia

The cross-cultural study of schizophrenia is not a new avenue of research. It was opened almost simultaneously with the early formulations of the concept of schizophrenia and developed in the spirit of a recognition of the relationship between psychopathological phenomena and the sociocultural context, exemplified by the classical studies of Durkheim. Some of the founders of modern European psychiatry visited what were then regarded as 'exotic' cultures and returned with observations which on the whole tended to strengthen their theoretical formulations which were based originally on patient populations in European institutions (for example, Kraepelin in Java, 1904; Bleuler in India, 1930). In spite of a great number of insightful and penetrating observations, the methodological aspects of the early research in schizophrenia in different cultures have been criticized for a number of reasons: observers' limited periods of contact with the foreign culture, frequent reliance on evidence that was no better than anecdotal, 'Eurocentric' assessment of the cultural background against which the features of the disorder were described, and lack of uniformity in the diagnostic criteria of schizophrenia. The period between the two world wars was characterized by marked advances in cultural anthropology which resulted in attempts at theoretical formulations of the relationship between psychological adjustment and some essential elements of culture. However, there was only a limited degree of collaboration between this discipline and psychiatry, and conspicuously little was added to the knowledge on schizophrenia. At the same time, empirical studies of the ecology of mental disorder utilizing an epidemiological approach—for example, Faris and Dunham's (1939) study of mental illness in Chicago and Odegaard's (1932) study of psychiatric morbidity among Norwegian immigrants in the USA—were marking milestones on a road which was to attract increasing attention in the decades after the second world war. The influence of the environment on the disease process had long been recognized by clinical psychiatrists in the individual case, but the impact of these studies consisted in the convincing demonstration that ecological factors were consistently and significantly associated with certain disease characteristics in large populations of schizophrenic patients. The systematic inclusion of an ecological and cultural dimension in the study of schizophrenia in recent decades has been the result of a need that has been appreciated mostly by epidemiologically-oriented psychiatrists. It has led to a renewed interest in the closer collaboration between psychiatry and the social sciences. The leading part in this alliance is now sometimes played by the psychiatric epidemiologist and sometimes by the sociologist or cultural anthropologist: this explains the differences of emphasis in a number of studies and the broad spectrum of theoretical approaches, ranging from a recognition of schizophrenia as a biologically founded disease entity, a result of faulty interpersonal relationships (Bateson et al., 1956), a product of social labelling (Scheff, 1966), or an artefact of society's repressive structure (Laing, 1967). Most psychiatrists now accept the assumption that the study of the cultural aspects of schizophrenia can provide important clues to the nature of this disorder—that is, its aetiology, pathology, and response to treatment. Before attempting to examine how well this assumption is supported by the known facts, however, we must refer briefly to two difficulties inherent in this kind of inquiry. In the first place, the scope and content of the concept of culture are difficult to define. Quoting