Cultural concepts in persuasion and healing

In chapter 5 of Persuasion and Healing, Jerome Frank (1961) developed what was then considered a radical argument-that psychotherapy is essentially a culture-bound activity. In Euro-Western societies, the psychotherapy establishment claims, rightly or wrongly, to be applying science to human behavior. Frank's own investigative work emerged from this tradition, but in trying to make sense of his empirical findings, he recognized that many groups promote similar healing activities grounded in values other than empirical science. Faith healing, shamanistic rituals, cult induction, and even the techniques of coercive interrogation, Frank noted, could be as effective as psychotherapy in inducing shift s in people's assumptive worlds and their related feelings and behavior. Factors that give one person the power to induce change in another include the culturally assigned status of the therapist, the meaning of the patient's symptoms or suffering within a particular context, and the power of the healer to manipulate cultural symbols, be these stethoscopes, charts, and the other trappings of science or the sand paintings of the shaman. Culture, expressed in language, also structures the narratives that psychotherapy helps patients revise. Finally, changes induced by persuasion, such as adopting the beliefs of a cult or expressing the slogans implanted by "thought reform," do not persist in the absence of cultural reinforcement-the sanctions or rewards provided by others in the treated person's reference group. Persuasion and Healing contributed to the development of what has come to be called cultural psychiatry. Although psychotherapy is a legitimate medical treatment in many respects, much of its power derives, not from the biological mechanisms that justify other types of medical care, but from its relation to powerful forces in whichever culture supports it. Cultural psychiatry seeks to maximize the application of these forces, adapting psychotherapy for use in diverse populations. People who find other sources of meaning more compelling and coherent than Western individualism or scientific positivism may respond better to treatments that mobilize different symbols and practices-for example, healing rituals or the involvement of authoritative family members- in their care. In this chapter we intend to demonstrate that even those who adhere to the so-called Western worldview benefit from the insights that cultural psychiatry provides into the implicit cultural processes that daily influence all people's attitudes and behavior. The term culture, what anthropologists define mostly in terms of context and meaning, broadly describes many of the environmental elements that complement the expression of genes and biology invoked by all models of psychopathology (see chapter 4). We define culture as the set of socially transmitted and learned behavioral norms and values or reference points by which members of a particular society construct their unique view of the world and create their own identity. Culture is not static; it changes under the impact of people's actions and historical events and as it is taught by and transmitted from one generation to the next (Favazza and Oman 1984; Haviland 1990). For didactic purposes, in our exploration of cultural psychiatry concepts in Frank's work, we give first priority to the traditional variables of language, religion, gender, social relationships, sexual orientation, moral practices, traditions, beliefs, family structure and functioning, and expressive modes of thought and emotions. In explaining aspects of psychotherapy, culture also encompasses phenomena as varied as technology, financial philosophies, migration, or traumatic memories (Group for the Advancement of Psychiatry 2002). These elements interact and define and redefine individuals, groups, communities, and societies, as they have throughout history. The complex, rich interactions among these variables generate the dynamic, ever changing nature of culture itself. In psychiatry and mental health (including psychotherapy), culture has always shaped eff orts to categorize and help suff erers (Kirmayer et al. 2003). In the late nineteenth century, an organized body of knowledge started to emerge, adopting over the ensuing decades such names as "comparative," "transcultural, " "cross-cultural," and, most recently, cultural psychiatry (Tseng 2001). This discipline deals with the description, defi nition, assessment, and management of conditions that involve aberrant thought or behavior in all human groups, exploring how these conditions refl ect the patterning infl uence of cultural factors, within a biopsychosocial context. Cultural psychiatry uses concepts and instruments from both social and biological sciences to advance a comprehensive understanding of psychopathology and its treatment (Canino, Lewis- Fernandez, and Bravo 1997). In this chapter, as proponents of cultural psychiatry, we comment on the many cultural issues presented and discussed in the first and third editions of Persuasion and Healing (Frank 1961; Frank and Frank 1991). The book provides a particularly rich vein of cultural concepts, some of them innovative and solid, others open to the discussion that original ideas invariably generate. A cultural perspective is essential, both to extend Frank's contributions to the fi eld and to reassess and build on the accomplishments, challenges, and future perspectives of this area of inquiry.