Simon Dein, PhD
Honorary Senior Lecturer, Department of Psychiatry & Behavioural Sciences, University College London, London, England, UK; E-mail: s.dein@ucl.ac.uk
In this paper, I have focused upon the ethno psychology of depression. The term “ethno psychology” refers to indigenous representations of mind, body, emotion and self. In the past two decades, anthropologists, psychologists and psychiatrists have become increasingly interested in the role of culture for the expression and experience of depression. I shall argue that the constellation of ethno psychological features, deeply rooted in their culture make up of culture members, influences the ways in which individuals experience and express depression, as it does for all emotions. Different cultural conceptions of self and emotion result in variations in the qualitative features of bodily/emotional experience, and thus dysphoric affects cannot be considered the same cross-culturally.
The literature pertaining to culture and depression is still dominated by studies based upon Western-based diagnostic criteria and examines the incidence and prevalence rates of this disorder. While anthropologists tend to view depression as an affect, psychiatrists view it as an affective disorder. Keyes1 asserts that biomedicine is unique as it deals with illness by interpreting experience without reference to the problem of suffering.
Kirmayer2 argues that the Diagnostic and Statistical Manual of Mental Disorders (DSM), reflects cultural values of personal autonomy and to uniqueness of each individual and the significance of personal aims, goals, values and preferences. However, there is a lack of emphasis on interpersonal symptoms. Some have argued that the term “profound distress” may be preferable to the term “depressive disorder”.3 Indeed unlike other medical conditions, Ryder et al4 maintains that depression emerges from a complex interplay of culture, mind and brain which is not reducible to any single level. The experience, meaning and expression of dysphoria – referring to sadness, hopelessness, unhappiness and lack of pleasure – varies across cultural groups.5
Many researchers have noted that the aetiology, expression and maintenance of depressive disorders varies cross-culturally.2,6,7 Culture influences the sources of distress, the form of illness experience, symptomatology, the interpretation of symptoms, forms of coping, the social response to distress and help-seeking. Furthermore it provides a lexicon of affect, rules for displaying emotions, lay theories of emotion and strategies for managing dysphoria. The question arises as to whether depression is one disorder with different cultural disguises, several disorders with one name or a Western culture-bound syndrome? This will be clarified below.
There is a tension between ethnographic and epidemological research methods in this area. Psychiatrists typically deploy epidemiological methodology which focuses on the prevalence of affective disorder, deploy the definitions of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), and assumes that Western based criteria for diagnosing depression can be applied universally.8In contrast, anthropologists examine cultural meaning, social structure and historical change and deploy cognitive psychology, semantic analysis, sociolinguistics and phenomenological methods to bring ‘meaning’ to depression. According to an ethnographic approach, in examining depression cross-culturally, anthropologists and psychiatrists attempt to develop understandings of this phenomenon in diverse cultural groups. The conceptions of depression in that particular culture are then examined and compared to see if they resemble those of Western culture.
Yet, both paradigms have their limitations. Biomedical approaches gloss over the differences in meaning of depression across culture by defining depression a priori. While useful in understanding the experience of depression, this ethnographic approach typically draws on small numbers which limits generalizability. Overall, from a review of the anthropological and cross-cultural literature, emptiness, learned helplessness and ‘soul loss’, as described by Schweder,9 are elements that appear universally across cultures. Other aspects of depression found in Western cultures may not be found in other cultures.3
There are also differences in the way emotion is perceived and understood. Emotion is typically viewed as intrapsychic in Western cultures, whereas it is seen as intersubjective in traditional cultures.
Anthropologists generally agree that emotions are inseparable from cultural systems of meaning and control. Our cultural orientation organizes the experience and interpretation of specific social events, both positive and negative. The cultural context selects which emotions are elaborated; entire domains of emotional knowledge may be elaborated or unelaborated. The occasion to feel one emotion rather than another is always defined in locally culturally specific terms. Concepts of selfhood influence emotional states. Schieffelin,10 focusing on the intersubjective nature of affect, highlighted how among the Kaluli of Papua New Guinea, emotions are expressed to influence others and used to ensure social reciprocity. Since cultural structures exist for Kaluli to recover any losses they incur, the experience of depression is rare.
While some cultures value the expression of extreme sadness, others demonstrate little tolerance of these affects. The types of over/under elaboration may be influenced by social class. For instance while Chinese villagers may express sadness publicly, this is not the case for the middle-class Chinese who will not display this outside close family relations. Such differences in emotional emphasis appear to be deeply rooted in the developmental makeup of cultural members11 or as Geertz12 rightly comments in relation to child upbringing: “He learns, in a sense, a special vocabulary of emotion”.
There has been some anthropological work examining the cultural construction of emotional distress in non-Western groups, studying depressive states as local forms of suffering and reflecting a fundamental ‘ethos’ of suffering permeating nearly every aspect of the worldview.13 Western Europeans and North Americans have become better at promoting happiness and detecting human suffering and mental distress, so it can be eliminated though therapy and prevention.
Different cultural traditions of suffering vary according to the salience of this vocabulary of emotion.12 In some cultures, suffering may be valued, for example in Buddhist cultures.14 Through the ‘work of culture’, painful affects are transformed into public systems of meanings and symbols. Finally in many countries, for example Latvia, 6 affective symptoms are seen as moral or social problems rather than medical problems. As Jenkins et al13 assert: “Dysphoric affects cannot properly be considered the same cross culturally, there are culturally distinctive repertoires of distressing experience”.
Individuals in Highland Equador experience pena meaning sadness or suffering. This is characterised by crying spells, poor concentration, anhedonia, social withdrawal, poor sleep and appetite, gastrointestinal and cardiac complaints. Similar to Western depression, it is a response to personal loss. However unlike depression, as Tousignant and Maldonaldo15 assert, it is an appeal, implicitly or explicitly expressed, for payment of an incurred loss and provides an opportunity to restore equity and ensure social reciprocity. While the symptoms of pena may be similar to those in Western depression, the meaning differs. In the local population, pena is seen as both idiom of distress signifying suffering and an illness.
It is important to differentiate grief from depression. Grief can be described as a natural human reaction. It is a universal feature of human existence irrespective of culture, although the form and intensity its expression varies considerably.16 Unlike the person with Major Depressive Disorder (MDD), the majority of recently bereaved individuals are usually not preoccupied with feelings of worthlessness, hopelessness, or unremitting gloom. Rather, self-esteem is usually preserved. The bereaved person can envision a ‘better day’; positive thoughts and feelings are often interspersed with negative ones. While scholars, practitioners, and the public may presume there is something invariantly biological about grieving, grief is shaped by the social context in which it occurs.17 There are striking cultural similarities in grieving. For example, in virtually all cultures most people seem to grieve the loss of somebody close to them.18 Additionally, in virtually all cultures there is a sense among many people, if not all, that a person who has died continues in some way beyond death.18 Nonetheless, cultures differ widely in how loss is defined and in what is considered an appropriate expression of grief; these cultural differences are reflected in what bereaved people say and act.
I shall now examine how different ethno psychological themes impact the experience and expression of ‘depression’.
Anthropologists have examined whether or not all cultural groups distinguish thoughts from feelings and how feelings, appraisals, words and actions hang together in diverse cultural contexts. In some cultures such as Balinese, individuals do not clearly distinguish between thoughts and feelings; they think with their feelings and feel with their thoughts. As the Balinese state: “Laughter makes happiness, it takes sadness out’ and ‘if you only think good thoughts, it is impossible to feel sad”.19 Furthermore, in Balinese folk psychology, there is no sense of unconscious. Rather than being seen as internal, they are held to be generated by specific situations, and like thoughts, can be controlled.20
In some instances these linkages between thought and feeling might not recall what we typically call emotion. Rosaldo21 notes ‘that the cultural/ideational and the individual affective have been construed as theoretically, and empirically, at odds’. As Levy22 attests in his work on emotion among Tahitians, the death of a loved one may be experienced as illness or fatigue rather than emotionalised as sadness. Do Tahitians hypocognisise sadness? Do Euro-Americans emotionalise while other groups somatise? As Lutz23 has pointed out, among the Ifaluk of Micronesia, emotion, thought and body are intimately linked in ethnotheory through their role in illness. In summary, similar experiences are, potentially, emotionalised to different degrees cross-culturally.
Lewis et al24 assert that current views on depression derive from Western concepts of the mind – and body: the mind and body are separate entities. In contrast, in many non- Western cultures, the mind and body are intimately related and mutually constituted. Western psychiatric practice is predicated on a mind- body dualism.25 Models of mental illness typically locate causality either in the mind (e.g. cognitive models of depression) or in the body/brain (e.g. psychiatric explanations of depression as a result of low levels of serotonin, dopamine or noradrenaline). Models that at first glance appear to transcend this dualism (e.g. the biopsychosocial model, psychodynamic models), fail to do so in important respects. In contrast, the mind and body are viewed as integrated in other cultures. In China for instance, illness of the mind cannot be separated from illness of the body.
Cross-cultural studies indicate a high prevalence of somatic symptoms in depressed and anxious patients in non-Western cultures. Symptom attribution, a key element in the concept of somatization – is an interpretive process, strongly influenced by cultural factors.26 In many parts of the world and in ethnic minority populations in the USA, the distinction between psychic and somatic is far from obvious.
Cultural psychiatrists typically report emphasis on somatic symptoms among East Asians who are profoundly distressed, particularly Chinese who often present with the symptom of low energy.27 Affective and cognitive symptoms are de-emphasised in favour of somatic symptoms including: heart ache, bodily aches pains, chronic fatigue, sleeplessness and weakness.28,29 While the exact cause of this phenomenon remains unknown, it is likely that social factors such as better access to healthcare, Chinese traditional medicine and political censure of symptoms during the Cultural Revolution5 play a part. However, European American cultural scripts that emphasise emotion similarly remain to be explained.
These stereotypical presentations appear to be changing over time in China; for example, neurasthenia is giving rise to more emotional expressions of depression possibly as a result of globalisation. Similar patterns have been observed among South Asians.Rao et al30 note that a number of clinical research studies have found evidence that patients from Western and non-Western countries express both somatic and psychological symptoms. Although somatic and psychological symptoms may co-exist, patients may be more conditioned to express more of one type of symptom, somatic or psychological, over the other; depending upon the nature of the illness and the patients’ cultural contexts. Rao et al investigated the influence of Westernization, stigma, severity of symptoms, and other factors on the symptom presentations of 60 South Indian psychiatric patients, employing both open-ended and symptom-directed interviewing methods. More Westernized participants and those reporting higher symptom severity scores, tended to present a more psychological balance of symptoms. The study concluded that the Westernization occurring in non-Western countries, such as through globalization, can impact an individual’s expression of distress.
Dere et al31 examined cross-cultural aspects of alexithymia – a multifaceted personality construct referring to a general deficit in the ability to identify and describe emotional states. Alexithymia has been linked to a number of psychiatric illnesses. The phenomenon has been critiqued as heavily rooted in ‘Western’ norms of emotional expression, but it has not received much empirical attention from a cultural perspective. These authors hypothesised that Externally Oriented Thinking (EOT) is more strongly shaped by cultural values than two other components of alexithymia: Difficulty Identifying Feelings (DIF) and Difficulty Describing Feelings (DDF). The study of Euro-Canadian and Chinese-Canadian students found that cultural differences in alexithymia may be explained by culturally – based variations in the importance placed on emotions, rather than deficits in emotional processing. The study also raises questions about the measurement and meaning of EOT, particularly from a cross-cultural perspective.
The definition of depression is imbued with Western cultural assumptions. First, Western views reflect a value of feeling good about the self as a normal way of being. Second, since Western culture with Cultures in North America and Western Europe emphasise individualistic and autonomous views of the self, depressive symptoms are seen to derive from internal disturbances. In contrast, cultures that emphasise collectivistic selves, depression may be attributed to interpersonal factors and emphasise interpersonal obligations. In the West, depression is seen as deriving from psychological or biological processes. On the other hand, non-Western cultures do not consider mind as separate from body but rather as intimately related and this is reflected in more holistic treatments deployed.
Chiao and Blazinsky32 propose that those from more collectivist cultures are more likely to value social harmony over individualism and support behaviours that increase group cohesion and interdependence. Furthermore, collectivist cultures may give individuals, who are genetically susceptible to depression an implied or expressed social support, which buffers them from depressive episodes. Yoo33 explored whether, and how, ethnicity and individualism-collectivism are related to depressive symptomatology and attitudes towards seeking professional help using a comparison of university students. Eighty-eight American college students and 95 South Korean college students participated in the study. Canonical correlation analyses revealed that low ratings on vertical individualism in American culture are related to more positive attitudes toward seeking professional help.
Genetic predisposition to depression may be moderated by collectivist cultural factors. Way and Lieberman34 reviewed recent work demonstrating a robust cross-national correlation between the relative frequency of variants in these genes and the relative degree of individualism-collectivism in each population. The authors postulate that collectivism may have developed and persisted in populations with a high proportion of putative social sensitivity alleles because it was more compatible with such groups.
It is recognised that the absence of both autonomy and social support (relatedness) are two important etiologic pathways to MDD. However, cross-cultural researchers note that the implications of autonomy and relatedness for mental health vary across cultures. Several studies have indicated that satisfaction of the need for autonomy predict emotional well-being in everyday life35 and the effective regulation of emotions.36 There is evidence that the amount of autonomy required to maintain optimal emotional functioning is influenced by cultural contexts.37 In individualistic cultures, there may be a greater need for autonomy than for relatedness; the reverse may be the case in collectivistic cultures.38 According to the proponents of SelfDetermination Theory (SDT), autonomy (along with relatedness and competence) is a basic human need that must be fulfilled for optimal functioning and subjective well-being.39 Autonomy, as defined by SDT researchers, refers to regulation by the self or self-regulation.40
Emotional states are understood in more detail in light of cultural knowledge. Chentsova-Dutton et al3 distinguish normative cultural scripts from deviant cultural scripts. The former express the ways in which a person in a given cultural milieu perceives, thinks feels and acts in ways that are experienced as normal and are seen by others as normal. The latter comprises ways in which individuals in particular cultural groups deviate from these norms. Yet they do so in ways which are culturally understandable. In any given cultural group, deviant the scripts may change overtime with a new form emerging through migration and globalisation. While describing unusual/undesirable states, perceptions, thoughts, feelings and actions, they retain a certain degree of familiarity for people living in that cultural milieu; they indicate that the person’s experience is abnormal while simultaneously helping the individual and those around him make sense of the experience. Cultural scripts of profound distress allow individuals to focus on some affective/ somatic changes (emotions, perceptions, thoughts and bodily sensations) rather than others and allow for the communication of these changes. Sudden changes that are alarming and deeply troubling are made more understandable through these cultural scripts. At times however, some experiences such as psychotic like phenomena differ from deviant cultural scripts and others may have difficulty in understanding them. The extent to which the individual experience fits with cultural scripts impacts the illness experience. Being labelled as mentally ill may result in stigma, while at the same time confer understanding and permit treatment.41
Concepts of normality may be differentially viewed depending upon cultural context. There is emerging evidence that cultural scripts for profound distress vary cross-culturally. Western Europeans and North Americans cultural contexts encourage higher levels of negative emotions and depressive symptoms than their Central and Western Europeans and North Americans counterparts. As a result, depressive symptoms may be viewed as normative in Western Europeans and North Americans contexts. Turvey et al42 compared attitudes towards depression in South Korea, Russia and the USA. Though there existed wide variation between countries in attitudes about depression, the majority of each endorsed items reflected a medical model of depression. Korean and Russian participants endorsed the view of depression as a personal weakness more than participants in the USA. In a similar way, Dura Villa et al43 observed that Spaniards were unlikely to view symptoms of depression triggered by negative life events, such as the illness of a family member, as pathological.
There is emerging evidence that there is cultural variability in the ways that different cultures encourage and value positive emotions. Positive emotions are considered functional and desirable in European-American contexts44 and are an important component of European normative cultural scripts for optimal functioning. This is particularly the case for high arousal states such as euphoria or excitement and self-focused states such as pride.45 Contrastingly, in East Asian contexts, positive emotions are not encouraged and individuals minimise negative emotions less than in European-American cultural contexts.46 Low arousal affective states such as peacefulness and calmfulness are valued more highly than high arousal positive states in East Asian contexts, possibly as a result of the cultural emphasis on interdependence. Finally, there is evidence that South Asians are more likely to experience negative feelings during positive situations than individuals in European-American groups.46
In the above sections, I have discussed how various ethno psychological factors impact upon the experience and presentation of emotional distress. I would argue that while dysphoric mood appears to be a fairly universal response to loss and adversity, DSM depression is only one variant of this and is dependent on a culturally specific conceptualisation of self, autonomy and mind body dualism. We would concur with Marsella47: “That cultural factors constitute an important context for all aspects of depressive experience and disorder and must be considered if an accurate understanding of depression is to be achieved”. Despite this, the literature pertaining to culture and depression is still dominated by studies based upon ‘Western’- based diagnostic criteria and examine the incidence and prevalence rates and/or levels of depressive symptoms in different countries.
We need to differentiate the role of culture and language in the experience and expression of emotion. Language is a central medium for the communication of emotional and physical well-being alongside emotional and physical distress. Research in Anthropology and Linguistics has highlighted cultural differences in the relative focus on the body in emotion discourse.48 There is some interesting anthropological work suggesting relationships between language, embodiment, metaphor and the expression of emotional distress, particularly somatization.49
Future work in this area requires detailed ethnographic research on mood, and its emic conceptualizations in diverse cultures examining the complex interplay of culture, language, mind and brain. Research should focus upon the relationship of depression to local contexts with ethnographic research describing patterns of shared cultural meaning, experience and behaviour, through the deployment of in-depth interviews and participant observation among patients. Through this, we can elicit the analytic categories through which individuals perceive suffering.
1. The emerging field of ethno psychology, in Catherine Lutz’s words, is “concerned with the way in which people conceptualize, monitor, and discuss their own and other’s mental and/or behavioral processes”. It roughly resembles what western psychologists refer to as ‘personality’. The field builds on the previous work of anthropologists such as Gregory Bateson, Margaret Mead and Ruth Benedict. White50 defines ethno psychology as the study of how individuals within a cultural group conceptualize the self, emotions, human nature, motivation, personality, and the interpretation of experience. It can be viewed as a local lay psychology used to understand experience. The way a cultural group interprets affective experience is related to how the group conceptualizes the body and its processes, self and personhood.
Misra51 states:
“The current Western thinking of the science of psychology in it prototypical form, despite being local and indigenous, assumes a global relevance and is treated as a universal mode of generating knowledge. Its dominant voice subscribes to a decontextualized vision with an extraordinary emphasis on individualism, mechanism, and objectivity. This peculiarly Western mode of thinking is fabricated, projected, and institutionalized through representation technologies and scientific rituals and transported on a large scale to the non-Western societies under political-economic domination. As a result, Western psychology tends to maintain an independent stance at cost of ignoring other substantive possibilities from disparate cultural traditions. Mapping reality through Western constructs has offered a pseudo understanding of the people of alien cultures and has had debilitating effects in terms of misconstruing the special realities of other people and exoticizing or disregarding psychologies that are non-Western. Consequently, when people from other cultures are exposed to Western psychology, they find their identities placed in question and their conceptual repertoires rendered obsolete”.
Ethno psychological themes include indigenous concepts of the self and autonomy, the categorisation of emotions, the predominance of particular emotions in a given society, interrelations of particular emotions, the identification on specific situations in which particular emotions arise, and the bodily experience of particular emotions. Understanding depression across cultures necessitates knowledge of indigenous conceptualisations of dysphoric affect i.e. an ethno psychology of depressive affect.
2. According to Lindholm20 anthropologists have been reluctant to engage with the study of emotion, heeding to Durkheim’s and Mauss52 warning that emotions cannot be properly studied on account of the fact that they fluid, mixed, not easily defined and impossible to analyze. Furthermore, emotion has been viewed in North America and Western Europe as a natural force, arising in the core of the individual and falling therefore within the disciplinary realm of psychology and physiology, rather than within the domain of anthropology with its focus upon shared culture and symbols. In their quest to gain professional legitimacy they have favoured a masculine meaning centred and cerebral model of research rather than any serious study of Traditional emotions have been seen as irrational, with women being driven by them. This assertion has little in the way of empirical proof. However anthropologists have long relied upon emotional relationships in their fieldwork deploying empathy, trust and rapport to gain their informants’ trust.
It is now over 140 years since Darwin wrote the Expression of the Emotions in Man and Animals. He argued there that emotional expressions were biologically innate, were evolutionary adaptive, were important in communication and that humans expressed emotions in their faces in exactly the same way across the world regardless of their or culture. Despite increasing anthropological evidence that culture has a significant influence on emotion, there is physiological and evolutionary evidence that emotions are not infinitely malleable, nor totally cognitive, nor completely relational.20,53 I would agree with Schweder,54 an advocate of the interpretive relativist view of culture, who asserts: ‘it is ludicrous to imagine that the emotional functioning of people in different cultures is basically the same. It is just as ludicrous to imagine that each culture’s emotional life is unique’.
While much of the anthropological work on emotion was conducted some time ago,19,21,22,23,50,54-56 recently there has been resurgent interest in this area, although as Beatty57 notes, there has been a ‘shift of emphasis in psychological anthropology away from emotion in favor of “subjectivity,” “embodiment,” “personhood,” and “experience”. This has fruitfully complicated the issues, making emotion one of a set of interrelated problemaspects rather than a distinct topic or explicit focus of interest’.58,59,60 Unlike previous work on emotion e.g. Lutz and White61 this recent interest takes account of dissolution of the subject and the critique of the notion of ‘culture’ resulting from globalization, social mobility and postmodernism. Anthropological accounts are now seen as situated, limited and partial.
As Geertz62 notes, it is not just ideas but emotions as well which should be seen as cultural artefacts. Emotions may be conceptualised in very different ways in different cultures. For example Lutz63(p 212) argues that many Western views of emotion maintain that emotions are ‘singular events situated within individuals’. In contrast, using fieldwork data from the Ifaluk of the Caroline Islands of Micronesia, Ifaluk views of emotion emphasise ‘exchanges between individuals’. Other ethno psychological studies suggest that small scale sociocentric cultures experience emotion not as private and inner motivation but rather as a consequence of the enactment of specific public roles, and emphasise formal obligations and social relationship.20
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