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Transcultural psychiatry should begin at home

In 1976, transcultural psychiatry can be said to have attained its majority, both because its journal was then 21 years old and because an international congress was devoted to it for the first time. As its name implies, it is concerned not just with international comparisons (Kraepelin's 'vergleichende Psychiatrie') nor with racial differences (the French 'ethnopsychiatrie') but specifically with culture in the anthropological sense, i.e. with values, beliefs, habits and structure which a society passes from one generation to the next. (The 'trans' implies comparison, but of these values, etc.) Not all that gets published in its name shares this concern directly, but there is a general acceptance that culture in the sense given above is capable of affecting mental disorder and its treatment, so that when the term 'transcultural' is attached to a study this implies that one expects (or fears) that cultural factors are affecting the psychiatric picture. Moreover, in the better transcultural studies one regularly finds reference to the ways in which factors of known concern to psychiatry-factors such as family structure, the role of the therapist and the ideal self-image-depend on culture. It is the contribution of such studies to both the practice and the theory of psychiatry which accounts mainly for the steady growth of the field. Yet in this growth there has been a curious paradox. In all other branches of psychiatry, advances in practice and in theory have derived largely from, and have concerned themselves largely with, the major societies of Western Europe and North America. In contrast, the great bulk of the literature on transcultural psychiatry is concerned with other societies, principally African, Asian and Amerindian. This fact is so obvious, even if the authors usually come from Western Europe or America, that it provokes on the one hand the complaint that transcultural psychiatry is perpetuating colonialist attitudes, and on the other hand the question whether the major Western societies have nothing truly cultural to call their own. Two explanations for this state of affairs come readily to mind, both of them carrying the implication that transcultural psychiatry does not need to come nearer home and both of them unsatisfactory on closer examination. The first is that formal studies of a transcultural nature are unnecessary in developed countries, since their cultures are too well known to the psychiatrists practising there. It is when these psychiatrists must deal with people from a foreign culture, so runs this argument, that the guidance of new studies is needed. The second explanation is that we are merely dealing with a confusion of labels, since what goes under the heading of transcultural psychiatry when one is dealing with Asians or Africans is really no different from what goes under the headings of family psychiatry, social psychiatry or descriptive epidemiology when one is dealing with Westerners. Each of these explanations bears some truth, since one is most aware of the need for cultural analysis when dealing with a foreign patient, and since many reports bearing the transcultural label go no more deeply into the cultural roots of phenomena than psychiatric studies of familial and other social factors in developed countries do. Each of them also, however, is insufficient on further examination, and a little library research will show one that they are defensive rationalizations rather than incomplete generalizations. If one reads a paper comparing, explicitly or implicitly, mental disorders in an Asian and a Western society, one will, if lucky, find an attempt to link the excess of conversion hysterias in the former group to the particular Asian culture involved but one