Ariel Cook

Cross-Cultural Perspectives on Mental Illness & Social Deviance

A Comprehensive Guide to How Different Cultures Define Normal and Pathological Behavior

“The shadow acts like a psychic immune system, defining what is self and what is not self. For different people, in different families and cultures, what falls into ego and what falls into shadow can vary.” – Connie Zweig

This profound insight reveals that what we consider “disordered” or “deviant” is culturally constructed. Just as our psychological shadow contains what our conscious self rejects, cultures collectively determine what behaviors, thoughts, and experiences are acceptable versus pathological.

Key Principle

Mental disorders cluster into recognizable patterns worldwide, but culture profoundly influences how symptoms are expressed, interpreted, what causes are attributed to them, whether people seek help, and what treatments are considered appropriate.

PART I: FUNDAMENTAL CULTURAL FRAMEWORKS

Individualistic vs. Collectivist Cultures

INDIVIDUALISTIC CULTURES (Western Europe, North America, Australia)

Core Values:

  • Personal autonomy and independence
  • Individual achievement and success
  • Self-expression and authenticity
  • Personal rights over group harmony
  • Direct communication

What is Valued:

  • Assertiveness and self-advocacy
  • Standing out and being unique
  • Personal goals over family/community obligations
  • Emotional expression and “speaking your truth”
  • Independence from family

What is Rejected/Pathologized:

  • Excessive dependence on others → “Dependent Personality Disorder”
  • Inability to assert oneself → Social anxiety, avoidant behavior
  • Putting family above personal desires → “Enmeshment,” codependency
  • Suppressing emotions → “Emotional repression,” alexithymia
  • Conformity over individuality → Lack of authentic self

Mental Health Manifestations:

  • Higher rates of depression related to individual failure and achievement pressure
  • Anxiety about not living up to personal potential
  • Identity crises about “finding yourself”
  • Loneliness despite freedom
  • Narcissistic tendencies normalized

Interesting Paradox: In highly individualistic societies like Boston, people with collectivist orientations show higher rates of depression, social anxiety, and obsessive-compulsive symptoms – their cultural values clash with societal expectations.

COLLECTIVIST CULTURES (East Asia, Latin America, Africa, Middle East, Pacific Islands)

Core Values:

  • Group harmony and consensus
  • Family and community obligations
  • Interdependence and relationships
  • Indirect communication to preserve face
  • Respect for hierarchy and elders

What is Valued:

  • Putting family needs first
  • Maintaining social harmony
  • Emotional restraint and self-control
  • Fulfilling role expectations (daughter, son, elder)
  • Bringing honor to family/community

What is Rejected/Pathologized:

  • Selfishness and individualism → Moral failing
  • Direct confrontation → Disrespectful, immature
  • Emotional outbursts → Lack of self-control
  • Abandoning family obligations → Shameful betrayal
  • Standing out negatively → Brings dishonor to family

Mental Health Manifestations:

  • Mental illness seen as family shame rather than individual medical issue
  • Physical symptoms emphasized over emotional ones (somatization) – Asian patients more likely to report dizziness and physical complaints rather than sadness
  • Social anxiety about bringing shame to family
  • Depression from failing to meet family expectations
  • Stress from role conflicts

Important Note: Collectivist cultures may be less likely to view mental health as personal failing, which can encourage help-seeking – BUT stigma about family shame often prevents treatment

PART II: CULTURE-BOUND SYNDROMES

Mental Illnesses That Exist (or Present Differently) in Specific Cultures

Culture-bound syndromes are combinations of psychiatric and somatic symptoms recognized as diseases only within specific societies or cultures, with no known objective biochemical or structural alterations.

EAST ASIAN CULTURES

Taijin Kyofusho (Japan, Korea)

Literal Translation: “Fear of interpersonal relations”

What it is: Intense fear that one’s body, appearance, or actions will offend or embarrass others

Symptoms:

  • Extreme anxiety about:
    • Body odor offending others
    • Blushing causing discomfort to others
    • Eye contact being intrusive
    • One’s presence being burdensome
  • Avoidance of social situations
  • Excessive apologizing

Cultural Context:

  • Japanese culture emphasizes empathy and sensitivity to others’ feelings
  • Concept of “enryo” (restraint/reserve) and not imposing on others
  • Different from Western social anxiety: Focus is on distressing OTHERS, not fear of being judged

Western Equivalent: Social Anxiety Disorder (but focus reversed – fear of what others think of YOU, not fear of harming others)

Hwa-Byung (Korea)

Literal Translation: “Anger illness” or “fire disease”

What it is: Syndrome of suppressed anger leading to physical symptoms, particularly an uncomfortable abdominal mass that cannot be felt

Symptoms:

  • Sensation of mass in abdomen or chest
  • Insomnia
  • Fatigue
  • Panic and fear of impending death
  • Dysphoria
  • Indigestion
  • Generalized aches

Cultural Context:

  • Primarily affects Korean women
  • Related to suppressed anger in hierarchical relationships (especially with in-laws)
  • Korean culture emphasizes emotional restraint, particularly for women
  • Anger considered socially unacceptable to express directly

Western Equivalent: Somatic symptom disorder, depression with somatic features

Neurasthenia / Shenjing Shuairuo (China)

Literal Translation: “Weakness of the nerves”

What it is: Physical and mental fatigue, headaches, difficulty concentrating, dizziness, sleep disturbance, and memory loss

Additional Symptoms:

  • Gastrointestinal problems
  • Sexual dysfunction
  • Irritability
  • Autonomic nervous system disturbances

Cultural Context:

  • Culturally acceptable way to express psychological distress
  • Avoids stigma of “mental illness”
  • Chinese culture encourages suppression of affect and non-dwelling on upsetting thoughts
  • Physical symptoms more acceptable than emotional complaints

Western Equivalent: Depression, anxiety, chronic fatigue syndrome

LATIN AMERICAN / HISPANIC CULTURES

Ataques de Nervios (Puerto Rico, Latin America)

Literal Translation: “Attack of nerves”

What it is: Intense emotional outburst following stressful event, particularly family conflict

Symptoms:

  • Uncontrollable shouting and crying
  • Trembling
  • Heat in chest rising to head
  • Verbal or physical aggression
  • Fainting or seizure-like episodes
  • Dissociative experiences
  • Suicidal gestures

Cultural Context:

  • Culturally recognized and somewhat acceptable response to overwhelming stress
  • Often triggered by death of loved one, family conflict, or witnessing trauma
  • Seen as understandable emotional release, not necessarily pathological
  • More common in women

Western Equivalent: Panic attack, dissociative episode, acute stress reaction (but lacks the cultural acceptance)

Susto (Latin America, especially Mexico)

Literal Translation: “Fright”

What it is: Illness attributed to a frightening event that causes the soul to leave the body, resulting in unhappiness and sickness

Symptoms:

  • Sadness and lack of motivation
  • Appetite disturbances
  • Sleep problems (too much or too little)
  • Troubled dreams
  • Feelings of low self-worth
  • Somatic complaints

Cultural Context:

  • Supernatural explanation: soul becomes separated from body due to fright
  • Requires traditional healing (soul retrieval ceremony)
  • Can occur years after frightening event
  • Recognized across generations in Latino communities

Western Equivalent: PTSD, depression, grief reaction

Mal de Ojo (Latin America, Mediterranean, Middle East)

Literal Translation: “Evil eye”

What it is: Illness caused by being the target of envy or jealousy, resulting in headaches, fever, crying, or anxiety

Symptoms in children:

  • Crying without apparent cause
  • Fever
  • Vomiting
  • Diarrhea

Symptoms in adults:

  • Headaches
  • Fatigue
  • Anxiety
  • Depression

Cultural Context:

  • Belief that envy from others can cause physical/mental harm
  • Particularly vulnerable: beautiful children, pregnant women, successful people
  • Requires spiritual protection (amulets, prayers) and cleansing rituals
  • Not viewed as mental illness but as spiritual attack

Western Equivalent: Anxiety, somatic symptom disorder, but CRITICAL DIFFERENCE – external attribution (someone else’s envy) vs. internal pathology

ARCTIC / CIRCUMPOLAR CULTURES

Pibloktoq (Inuit, Arctic Hysteria)

What it is: Sudden dissociative episode with extreme agitation

Symptoms:

  • Sudden screaming
  • Tearing off clothes
  • Running naked in snow
  • Copying others’ words/actions
  • Throwing objects
  • Brief unconsciousness
  • Amnesia for episode afterward

Cultural Context:

  • Occurs in extreme Arctic conditions
  • May be related to calcium deficiency, vitamin A toxicity, or extreme environmental stress
  • Culturally recognized pattern
  • Person not held responsible for actions during episode

Western Equivalent: Brief psychotic disorder, dissociative episode, seizure disorder

Kayak Angst (Greenland Inuit)

What it is: Sudden panic while alone in kayak

Symptoms:

  • Intense fear of capsizing
  • Dizziness
  • Hyperventilation
  • Sense of doom
  • Physical paralysis

Cultural Context:

  • Related to sensory deprivation and isolation on calm water
  • Specific to hunting culture and survival demands
  • Recognized as occupational hazard

Western Equivalent: Panic disorder, agoraphobia

SOUTHEAST ASIAN CULTURES

Koro (Malaysia, Indonesia, China, Thailand)

Literal Translation: Related to “head of turtle” (retraction)

What it is: Intense anxiety that genitals are retracting into body and will cause death

Symptoms:

  • Panic and fear of imminent death
  • Belief that penis (or breasts/labia in women) is shrinking into body
  • Desperate attempts to prevent retraction
  • Seeking help from others to hold genitals

Cultural Context:

  • Often occurs during epidemics (mass psychogenic illness)
  • Related to beliefs about yin/yang imbalance and sexual vitality
  • Culturally specific body image anxiety
  • Can be triggered by cold, fear, or sexual guilt

Western Equivalent: Panic disorder, somatic delusion, body dysmorphic disorder

Amok (Malaysia, Philippines, Indonesia)

Literal Translation: “Run amok” – origin of English phrase

What it is: Sudden outburst of indiscriminate violence following period of brooding

Phases:

  1. Period of brooding (perceived insult or loss)
  2. Explosive outburst (homicidal violence)
  3. Exhaustion and amnesia

Cultural Context:

  • Traditionally seen as response to shame or dishonor in men
  • Cultural pattern of emotional restraint exploding into violence
  • Historically, warrior culture context
  • Now rare in modernized areas

Western Equivalent: Intermittent explosive disorder, brief psychotic episode, dissociative fugue

AFRICAN CULTURES

Brain Fag (West Africa, especially Nigeria)

What it is: Condition affecting students, characterized by cognitive fatigue

Symptoms:

  • Difficulty concentrating
  • Memory problems
  • “Brain tiredness”
  • Head and neck pain
  • Eye pain and vision problems
  • Crawling sensations in head

Cultural Context:

  • Associated with pressures of Western-style education
  • Conflict between traditional knowledge and modern schooling
  • Particularly affects students trying to succeed in competitive academic systems
  • Physical description of mental overload

Western Equivalent: Burnout, adjustment disorder, anxiety disorder

NATIVE AMERICAN / INDIGENOUS NORTH AMERICAN CULTURES

Ghost Sickness (Native American tribes)

What it is: Preoccupation with death and the deceased

Symptoms:

  • Bad dreams about deceased
  • Weakness and loss of appetite
  • Fainting and dizziness
  • Fear and anxiety
  • Hallucinations
  • Loss of consciousness
  • Feeling of suffocation

Cultural Context:

  • Related to spirits of the dead
  • Requires traditional healing ceremonies
  • Connection to grief and unresolved mourning
  • Spiritual imbalance requiring restoration

Western Equivalent: Complicated grief, PTSD, bereavement-related depression

Windigo Psychosis (Algonquian peoples: Ojibwe, Cree)

What it is: Culture-specific fear of becoming a cannibalistic monster

Symptoms:

  • Intense craving for human flesh
  • Fear of transformation into windigo (ice giant monster)
  • Depression and social withdrawal
  • Paranoia
  • In extreme cases, actual cannibalistic behavior

Cultural Context:

  • Related to harsh winter conditions and historical starvation
  • Windigo = supernatural being that embodies greed and cannibalism
  • Deep cultural taboo against cannibalism
  • May have been colonial myth/exaggeration

Western Equivalent: Delusional disorder, psychotic depression, PTSD from starvation trauma

MIDDLE EASTERN CULTURES

Zar (Ethiopia, Somalia, Egypt, Iran, Sudan)

What it is: Spirit possession explaining various symptoms

Symptoms:

  • Dissociative episodes
  • Shouting, laughing, crying
  • Singing
  • Withdrawal
  • Refusal to eat
  • Physical illness

Cultural Context:

  • Primarily affects women
  • Zar spirits require appeasement through rituals
  • Provides explanation for distress and avenue for social support
  • Zar ceremonies create community and give women voice
  • NOT necessarily pathological – can be integrated into life

Western Equivalent: Dissociative disorder, conversion disorder, but CRITICAL DIFFERENCE – culturally sanctioned role vs. pathology

PART III: HOW MAJOR MENTAL ILLNESSES PRESENT ACROSS CULTURES

DEPRESSION

Western Presentation

  • Sadness, crying
  • Guilt and self-blame
  • Hopelessness about future
  • Loss of interest
  • Psychological symptoms emphasized

Asian Presentation

  • Somatic complaints emphasized: headaches, body aches, dizziness, stomach problems
  • Fatigue and weakness
  • Sleep problems
  • Less focus on sadness
  • When asked directly, emotional symptoms are acknowledged

Latin American Presentation

  • “Nervios” (nerves)
  • Physical symptoms
  • Social/relationship problems emphasized
  • Family stress highlighted
  • Less individual guilt, more external attribution

African Presentation

  • “Thinking too much”
  • Body complaints
  • Social problems
  • Spiritual explanations may be sought

Key Insight: Depression exists worldwide with similar core features, but cultural presentation differs based on what symptoms are acceptable to express and how emotional distress is conceptualized.

SCHIZOPHRENIA

Schizophrenia has similar prevalence (about 1%) across all cultures worldwide, suggesting strong biological basis.

Universal Features

  • Delusions
  • Hallucinations
  • Disorganized thinking
  • Negative symptoms

Cultural Variations in Content

Western cultures:

  • Delusions about technology (government surveillance, mind control devices)
  • Paranoid themes about individualistic threats
  • Voices may be insulting or commanding

Hindu/Indian cultures:

  • Religious delusions (gods, demons)
  • Possession themes
  • Family honor themes in paranoia

African cultures:

  • Spirit possession
  • Witchcraft
  • Ancestor spirits

Prognosis Difference:

  • BETTER outcomes in developing/collectivist countries
  • Stronger family support systems
  • Less expressed emotion (criticism) from families
  • Different expectations for independence

ANXIETY DISORDERS

Western Manifestation

  • Fear of judgment and failure
  • Performance anxiety
  • Individual inadequacy
  • Panic about loss of control
  • Agoraphobia about independence

East Asian Manifestation

  • Social harmony concerns
  • Fear of offending others (Taijin Kyofusho)
  • Family disappointment anxiety
  • Academic/achievement pressure
  • Face-saving concerns

Latin American Manifestation

  • “Nervios” – anxiety expressed as nerve problems
  • Family conflict stress
  • Ataques de nervios (attack of nerves)
  • Spiritual explanations (mal de ojo)

POST-TRAUMATIC STRESS DISORDER (PTSD)

PTSD is most directly caused by cultural and social factors (war, genocide, torture). Among Vietnamese, Cambodian, and Laotian refugees, up to 70% met PTSD criteria, compared to 4% in general U.S. population.

Universal symptoms:

  • Intrusive memories
  • Avoidance
  • Hyperarousal
  • Negative mood changes

Cultural Differences:

  • Expression: Somatic in some cultures, psychological in others
  • Causation attributed to: Spirits (Susto), broken soul, curse, vs. brain/stress
  • Treatment sought: Traditional healers, spiritual leaders, vs. psychiatrists
  • Community response: Collective healing vs. individual therapy

PART IV: CULTURAL VALUES & WHAT THEY PATHOLOGIZE

CULTURES THAT VALUE EMOTIONAL RESTRAINT (East Asian, British, Scandinavian)

What is valued:

  • Self-control and composure
  • “Keeping face”
  • Not burdening others with emotions
  • Stoicism
  • Privacy

What is pathologized/rejected:

  • Emotional outbursts → Immaturity, lack of control
  • Oversharing feelings → Inappropriate, attention-seeking
  • Public displays of distress → Shameful
  • Depending on others emotionally → Weakness

Mental health implications:

  • Higher rates of somatization
  • Internalized distress
  • Delay in seeking help
  • Preference for private suffering

CULTURES THAT VALUE EMOTIONAL EXPRESSION (Mediterranean, Latin American, Middle Eastern)

What is valued:

  • Authentic emotional display
  • Passionate expression
  • Strong family bonds
  • Dramatic communication
  • Community support

What is pathologized/rejected:

  • Emotional coldness → Uncaring, suspicious
  • Not expressing grief dramatically → Didn’t love deceased
  • Independence over family → Selfish, cold
  • Calm in crisis → Weird, untrustworthy

Mental health implications:

  • Expressive symptoms more acceptable
  • Community involvement in mental health
  • Emotional expression as release mechanism

CULTURES THAT VALUE HIERARCHY & RESPECT (East Asian, African, Middle Eastern, Latin American)

What is valued:

  • Respect for elders and authority
  • Following traditions
  • Filial piety
  • Knowing one’s place
  • Deference to seniors

What is pathologized/rejected:

  • Questioning elders → Disrespect, arrogance
  • Challenging tradition → Dangerous rebel
  • Egalitarian attitudes → Improper, Western corruption
  • Speaking out of turn → Rude, immature

Mental health implications:

  • Intergenerational conflict causing distress
  • Depression from role strain
  • Anxiety about meeting expectations
  • Immigrant youth caught between cultures

CULTURES THAT VALUE EGALITARIANISM (Northern Europe, parts of North America)

What is valued:

  • Equal treatment regardless of age/status
  • Questioning authority
  • Critical thinking
  • Individual merit
  • Direct communication

What is pathologized/rejected:

  • Blind obedience → Weakness, lack of critical thinking
  • Not speaking up → Passive, doormat
  • Excessive respect for authority → Authoritarian personality
  • Traditional hierarchy → Oppressive, outdated

Mental health implications:

  • Conflict with hierarchical family systems
  • Stress for immigrants from hierarchical cultures
  • Depression from lack of clear social structure
  • Anxiety about making own decisions

PART V: SOCIAL DEVIANCE ACROSS CULTURES

What Counts as “Deviant” or “Disordered”?

SEXUAL BEHAVIOR

Western Liberal Cultures:

  • Acceptable: Premarital sex, cohabitation, homosexuality, divorce
  • Deviant: Pedophilia, incest, bestiality, non-consent
  • Gray Areas: Polyamory, sex work, age gaps

Conservative/Religious Cultures (Various):

  • Acceptable: Arranged marriage, virginity until marriage, defined gender roles
  • Deviant: Premarital sex, homosexuality, adultery, divorce
  • Pathologized: LGBTQ+ identities as mental illness (though removed from DSM in 1973)

Key Point: Homosexuality was in DSM as disorder until 1973. Gender identity disorder controversy ongoing. Culture determines what sexual behavior is “sick” vs. just different.

GENDER EXPRESSION

Western Cultures (increasingly):

  • Acceptable: Wide range of gender expression, transgender identity, non-binary
  • Deviant: Rigid enforcement of gender roles seen as problematic

Traditional Cultures (Many):

  • Acceptable: Clear gender roles, masculine men, feminine women
  • Deviant: Gender non-conformity pathologized as mental illness or moral failing

Indigenous Cultures (Some):

  • Acceptable: Third gender roles (Two-Spirit, Hijra, Fa’afafine)
  • These are HONORED ROLES, not pathology

Fascinating Contrast: What one culture honors, another pathologizes

SUBSTANCE USE

Western Medical Model:

  • Disorder: Addiction, substance use disorder
  • Acceptable: Moderate alcohol, prescribed medications
  • Deviant: Illegal drug use, excess

Native American Traditions:

  • Acceptable: Ceremonial peyote use (religious)
  • Deviant: Recreational use of same substance
  • Disorder: Alcoholism (seen partly as colonial trauma)

Islamic Cultures:

  • Acceptable: No alcohol or intoxicants
  • Deviant: Any alcohol consumption
  • Different from Western “alcoholism” concept: Religious prohibition vs. disease model

HEARING VOICES / VISIONS

Western Psychiatry:

  • Pathological: Hallucinations = psychosis, schizophrenia
  • Treatment: Medication to stop voices
  • Exception: Religious visions sometimes acceptable in religious context

Many Indigenous/Traditional Cultures:

  • Acceptable: Spirit communications, visions, ancestor voices
  • VALUED: May indicate spiritual gift, healer potential
  • Pathological: Only if voices cause harm or distress
  • Treatment: Spiritual training to work with voices, not eliminate them

Example: Hearing deceased grandmother’s voice giving advice

  • Western: Possible hallucination, grief-related psychosis
  • Many Traditional cultures: Normal ancestor communication

SPIRIT POSSESSION

Western Psychology:

  • Pathological: Dissociative identity disorder, psychosis
  • Explanation: Trauma, mental illness
  • Treatment: Therapy, medication

Many African, Caribbean, Latin American, Asian Cultures:

  • Acceptable: Possession during religious ceremonies (Vodou, Candomblé, Santeria)
  • VALUED: Connection to spirits, healing ability
  • Pathological: Only unwanted possession or loss of control
  • Treatment: Spiritual rituals, integration of spirits

Example: Person enters trance, speaks differently, gives advice

  • Western: Dissociative disorder
  • Traditional: Spiritual gift, connection to divine

TALKING TO ONESELF

Western:

  • Concerning: Possible psychosis symptom
  • Acceptable: Occasional muttering, “thinking out loud”
  • Children: More acceptable, should decline with age

Some Cultures:

  • Acceptable: Talking to ancestors, spirits, deceased family
  • Normal: Ongoing conversation with spiritual realm
  • Not pathological unless excessive or distressing

EXTREME GRIEF REACTIONS

Western (Modern):

  • Acceptable: Grief for months, even year
  • Pathological: Prolonged grief beyond ~6-12 months → “Persistent Complex Bereavement Disorder”
  • Expected: Return to functioning relatively quickly

Many Traditional Cultures:

  • Acceptable: Extended mourning periods (years)
  • Required: Specific mourning behaviors and durations
  • Pathological: NOT grieving enough considered disrespectful, concerning

Example: Widow wearing black for years

  • Western Modern: Possibly depression, stuck in grief
  • Mediterranean/Latin: Proper respect for deceased

PART VI: STIGMA, RACISM, AND MENTAL HEALTH

How Stigma Varies by Culture

Stigma is widespread across all cultures, but manifests differently. In Asian cultures, stigma is so extreme that mental illness reflects poorly on family lineage and diminishes marriage prospects for all family members.

Western Stigma

  • Individual shame: “I am broken/weak”
  • Fear of judgment as incompetent
  • Employment concerns
  • Dating/relationship impacts
  • Focus on individual failure

Collectivist Culture Stigma

  • Family shame: “We have brought dishonor”
  • Lineage concerns: Marriage prospects ruined for siblings
  • Community ostracism: Whole family affected
  • Secrecy imperative: Must hide at all costs
  • Greater barrier to treatment: Seeking help = admitting family shame

Result: Only 12% of Asian Americans would mention mental health problems to friends (vs. 25% whites), and only 4% would seek help from psychiatrist (vs. 26% whites).

Racism and Mental Health

Racism and discrimination are stressful events that adversely affect mental health and place minorities at risk for depression and anxiety.

Types of Discrimination:

  1. Major Discrimination: Dramatic events (fired from job, hassled by police, housing denial)
    • Reported by 50% of African Americans vs. 31% of whites
  2. Day-to-Day Discrimination: Micro-aggressions, assumptions, being followed in stores
    • Experienced “often” by 25% of African Americans vs. 3% of whites

Mental Health Impact:

  • Both types strongly associated with depression and anxiety
  • Magnitude similar to death of loved one or job loss
  • Creates chronic stress affecting overall health
  • Contributes to mistrust of mental health system

Clinician Bias

African American patients are subject to overdiagnosis of schizophrenia and underdiagnosis of bipolar disorder, depression, and anxiety.

Examples of Bias:

  • Same symptoms → Different diagnosis based on race
  • African American youth 4× more likely to be physically restrained for same aggressive behavior as white youth
  • Stereotypes influence clinical judgment
  • White therapists rated Black patient with depression more negatively than white patient with identical symptoms

Impact:

  • Misdiagnosis → Wrong treatment
  • Harsher interventions for minorities
  • Reinforces mistrust of system
  • Contributes to disparities in care

PART VII: CULTURAL PATTERNS IN PREVALENCE

Conditions MORE Common in Western/Individualistic Cultures

Eating Disorders (Anorexia, Bulimia):

  • Considered culture-bound to Western cultures emphasizing thinness
  • Individualistic focus on body image
  • Achievement through appearance control
  • Rare in traditional collectivist cultures
  • Increasing in westernized areas

Narcissistic Personality Traits:

  • Individualism encourages self-focus
  • Personal achievement glorified
  • Self-promotion expected
  • “Authentic self-expression” valued
  • What’s pathological vs. cultural norm unclear

Seasonal Affective Disorder:

  • More common in Northern latitudes
  • But also cultural: reduced in cultures with more outdoor winter activity

Conditions MORE Common in Collectivist Cultures

Social Anxiety (Taijin Kyofusho type):

  • Higher social anxiety in collectivist countries
  • Fear of offending/embarrassing others
  • Pressure to maintain social harmony
  • Face-saving concerns

Somatization:

  • Physical symptoms preferred over psychological
  • More culturally acceptable
  • Less stigma
  • Neurasthenia, Hwa-byung patterns

Suppressed Anger Syndromes:

  • Hwa-byung in Korea
  • Related to hierarchical relationships
  • Women especially affected
  • Anger unacceptable to express

Universal Across Cultures

Schizophrenia: ~1% worldwide

Bipolar Disorder: 0.3-1.5% worldwide

Panic Disorder: 0.4-2.9% worldwide

Depression: 2-19% (significant variation suggests cultural/social factors)

PART VIII: POVERTY, VIOLENCE, AND MENTAL HEALTH

People in the lowest stratum of income, education, and occupation are 2-3 times more likely than highest stratum to have mental disorder.

Poverty Rates by Ethnicity (US):

  • White Americans: 8%
  • Asian Americans/Pacific Islanders: 11%
  • Hispanic Americans: 23%
  • African Americans: 24%
  • American Indians/Alaska Natives: 26%

Why Poverty Affects Mental Health:

Increased Exposure to:

  • Community violence
  • Unstable housing
  • Food insecurity
  • Family disruption
  • Dangerous neighborhoods
  • Trauma and victimization

Decreased Access to:

  • Quality healthcare
  • Mental health services
  • Social support resources
  • Safe environments
  • Educational opportunities
  • Economic mobility

BUT: Poverty alone doesn’t explain all disparities. Culture, racism, and help-seeking patterns also crucial.

PART IX: KEY INSIGHTS & PATTERNS

What This All Means

1. Normal vs. Pathological is Culturally Defined

The shadow quote is profoundly true: what falls into “ego” (acceptable self) vs. “shadow” (rejected self) varies by culture.

Examples:

  • Hearing ancestor voices: Pathology in West, gift in many indigenous cultures
  • Emotional restraint: Healthy in East Asia, concerning in Western therapy
  • Extended grief: Normal in Mediterranean, “prolonged grief disorder” in DSM
  • Independence from family: Goal in West, betrayal in collectivist cultures

2. Culture Shapes Expression, Not Just Interpretation

It’s not just that cultures interpret the same symptoms differently – culture actually shapes HOW distress is experienced and expressed.

Examples:

  • Asian patients with depression genuinely experience more physical symptoms (somatization)
  • Western patients genuinely experience more psychological symptoms (guilt, hopelessness)
  • Both have depression, but the phenomenology differs
  • This is NOT malingering or cultural performance – it’s genuine embodied experience

Why This Matters:

  • Clinicians must ask about symptoms patients might not spontaneously report
  • Asian patients asked directly DO acknowledge emotional symptoms
  • Treatment must address culturally-specific presentations

3. Mental Illness is Universal; Culture-Bound Syndromes are Specific

Universal Patterns:

  • Schizophrenia, bipolar disorder, and panic disorder show consistent prevalence worldwide
  • Depression exists everywhere but varies in rate (2-19%)
  • Core features recognizable across cultures

Culture-Specific Manifestations:

  • Taijin kyofusho, hwa-byung, ataques de nervios, koro, etc.
  • May be variants of universal disorders OR distinct conditions
  • Reflect specific cultural concerns and values
  • Require culturally-informed treatment

4. Stigma is Universal but Manifests Differently

ALL cultures stigmatize mental illness, but the nature of stigma varies:

Individual Stigma (Western):

  • Personal shame and failure
  • “I am weak/broken”
  • Affects individual’s self-esteem and opportunities

Family Stigma (Collectivist):

  • Collective shame
  • “We are dishonored”
  • Affects entire family’s social standing and marriage prospects
  • GREATER barrier to seeking help

Neither is better or worse – both prevent treatment and cause suffering

5. What One Culture Values, Another Pathologizes

Emotional Expression:

  • Mediterranean/Latin cultures: Expressive mourning = proper respect
  • British/Scandinavian: Same behavior = excessive, possibly pathological

Independence:

  • Western: Living with parents at 30 = failure to launch, dependence
  • Many Asian/Latin cultures: Same = proper family duty and respect

Assertiveness:

  • Western therapy: “Learn to be assertive” = health goal
  • Many collectivist cultures: Assertiveness = disrespect, selfishness

Hearing Spirits:

  • Many indigenous cultures: Gift, healing ability, honored
  • Western psychiatry: Hallucination, psychosis, disease

6. Power Dynamics Shape Diagnosis

Who decides what’s “normal”?

  • Western psychiatry (DSM, ICD) sets global standards
  • Based primarily on Western, white, middle-class norms
  • Other cultural patterns judged against this standard
  • Colonialism’s legacy in mental health definitions

Historical Examples:

  • Drapetomania: “Disease” causing enslaved people to flee (1851)
  • Homosexuality: Mental disorder until 1973
  • “Hysteria” in women: Pathologized female emotion
  • Gender identity: Ongoing debates about pathology vs. diversity

Current Issues:

  • PTSD rates 70% in refugees vs. 4% general population – is this “disorder” or normal response to abnormal trauma?
  • Collectivist values in individualistic society = higher depression
  • Immigrant stress labeled as “adjustment disorder” – whose adjustment?

7. Context Matters More Than Behavior

Same behavior, different meaning:

Person talking to deceased loved one:

  • Context A: At gravesite, occasionally, for comfort → Normal grief
  • Context B: Constantly, interfering with function, distressing → Complicated grief/psychosis
  • Context C: In Día de los Muertos ceremony → Cultural/spiritual practice
  • Context D: As medium in spiritualist church → Religious role

Person in trance state:

  • Context A: Vodou ceremony → Expected religious experience
  • Context B: Random parking lot → Possible dissociative disorder
  • Context C: Meditation retreat → Spiritual practice
  • Context D: After trauma → PTSD symptom

8. Migration and Acculturation Create Unique Stressors

The “Immigrant Paradox”:

  • Recent Mexican immigrants (despite poverty) have BETTER mental health than U.S.-born Mexican Americans
  • Protective factors: Strong cultural identity, family support, traditional values
  • Acculturative stress increases over time

U-Shaped Pattern of Immigration:

  • Year 1: Euphoria and hope
  • Years 2-3: Disenchantment, stress, highest symptoms
  • Year 3+: Gradual improvement

Intergenerational Conflict:

  • Children acculturate faster than parents
  • Youth caught between two cultures
  • Neither fully accepted in either culture
  • Depression, anxiety, identity issues

Refugee Trauma:

  • Up to 70% PTSD in Southeast Asian refugees
  • Pre-migration trauma + post-migration stress
  • Loss of homeland, culture, identity, status
  • Torture, genocide, war trauma

9. Family Structure and Mental Health

Expressed Emotion (EE) Research: Critical finding: HIGH criticism/hostility from family → higher relapse in schizophrenia

BUT cultural differences:

Mexican American families:

  • Emotional DISTANCE and lack of warmth predict relapse
  • Criticism less predictive
  • Warmth and involvement protective

White American families:

  • CRITICISM and hostility predict relapse
  • Distance less predictive
  • Involvement sometimes problematic

Implication: Family therapy must be culturally adapted – what helps in one culture may harm in another

10. Racism as a Mental Health Crisis

Racism is a chronic stressor comparable to:

  • Death of loved one
  • Divorce
  • Job loss

Types of Racism Affecting Mental Health:

Institutional Racism:

  • Discrimination in housing, employment, healthcare
  • Overdiagnosis of schizophrenia in African Americans
  • Underdiagnosis of depression and bipolar in minorities
  • Physical restraints used 4× more on Black youth

Interpersonal Racism:

  • Microaggressions daily
  • Being followed in stores
  • Assumptions about competence
  • “Where are you REALLY from?”

Internalized Racism:

  • Negative stereotypes internalized
  • Impacts self-worth
  • Affects identity development
  • Contributes to depression and anxiety

Results:

  • Higher rates of hypertension in African Americans linked to racism
  • Perceived discrimination associated with depression, anxiety, distress
  • Mistrust of mental health system
  • Delays in seeking treatment

PART X: TREATMENT IMPLICATIONS

Cultural Competence in Mental Health Care

What Doesn’t Work

1. One-Size-Fits-All Treatment

  • Evidence-based treatments developed on primarily white populations
  • No ethnic-specific analyses in clinical trials for bipolar, depression, schizophrenia, ADHD
  • Extrapolated to all populations without testing

2. Ignoring Culture

  • “I don’t see color” approach
  • Treating everyone “the same”
  • Missing culturally-specific symptoms
  • Imposing Western values as universal health

3. Stereotyping

  • Assuming all members of ethnic group are identical
  • More variation WITHIN groups than BETWEEN groups
  • Individual differences in acculturation
  • Intersectionality of identities

What Does Work

1. Cultural Formulation DSM-5 includes “Cultural Formulation Interview” to assess:

  • Cultural identity
  • Cultural explanations of illness
  • Cultural factors in psychosocial environment
  • Cultural elements of relationship between patient and clinician
  • Overall cultural assessment

2. Culturally Adapted Interventions

  • Incorporate cultural values and beliefs
  • Use culturally relevant examples
  • Include family when culturally appropriate
  • Respect cultural healing practices
  • Adapt communication styles

Examples:

  • CBT for depression adapted for Chinese Americans: Include family, address shame, incorporate Chinese concepts
  • Trauma treatment for refugees: Address pre-migration trauma, loss of homeland, cultural identity
  • Substance abuse treatment for Native Americans: Incorporate traditional healing, address historical trauma

3. Ethnic Matching

  • Many minorities prefer therapists of same race/ethnicity
  • Ethnic match programs show better outcomes
  • BUT: Culturally competent white therapist better than incompetent matched therapist
  • Cultural competence matters more than ethnic match alone

4. Integrated Approaches

  • Allow concurrent traditional healing practices
  • Traditional healers work alongside mental health professionals
  • Native American programs: Medicine men + psychiatrists
  • Latino programs: Curanderos + therapists
  • Not either/or but both/and

5. Address Social Determinants

  • Mental health treatment alone insufficient
  • Address poverty, discrimination, violence
  • Community-based interventions
  • Advocacy and systemic change

Questions for Culturally Informed Assessment

1. How does the patient understand their problem?

  • Medical/biological?
  • Spiritual/religious?
  • Social/interpersonal?
  • Supernatural/cursed?
  • Punishment/karma?

2. What does the patient call the problem?

  • Depression vs. nervios vs. thinking too much?
  • Anxiety vs. susto vs. being cursed?
  • Cultural idioms of distress

3. What caused it (in patient’s view)?

  • Stress? Genetics? Spiritual? Interpersonal conflict?
  • Suppressed emotions? Evil eye? Imbalance?

4. What makes it better or worse?

  • What has patient already tried?
  • Traditional remedies? Prayer? Isolation? Family?

5. What does the patient fear most?

  • Death? Shame? Family dishonor? Going crazy?
  • Loss of control? Becoming burden? Hospitalization?

6. Who should be involved in treatment?

  • Individual only?
  • Family? Which family members?
  • Community? Religious leader?
  • Traditional healer?

7. What does help/healing look like?

  • Symptom removal?
  • Spiritual peace?
  • Family harmony?
  • Return to functioning?
  • Acceptance?

PART XI: CHALLENGING QUESTIONS

Ethical Dilemmas in Cross-Cultural Mental Health

Dilemma 1: Respecting Culture vs. Universal Human Rights

Scenario: Woman from culture where female subservience is norm is depressed but attributes it to being “bad wife.”

Questions:

  • Do we respect cultural values even if they contribute to distress?
  • Is empowerment therapy imposing Western values?
  • What if patient wants to conform to cultural norms?
  • Where is line between cultural respect and reinforcing oppression?

Dilemma 2: Pathology vs. Spiritual Experience

Scenario: Person hears voices they interpret as ancestors guiding them. Voices are supportive, not distressing.

Questions:

  • Is this psychosis requiring treatment?
  • Whose cultural framework do we use?
  • What if person functions well?
  • Do we medicalize spiritual experience?

Dilemma 3: Family vs. Individual

Scenario: Young adult wants independence; family sees as betrayal. Patient is depressed.

Questions:

  • Support individuation (Western value) or family cohesion (collectivist value)?
  • What if supporting patient damages family relationships?
  • Can we find middle ground?
  • Who defines “healthy”?

Dilemma 4: Evidence-Based Treatment vs. Cultural Practices

Scenario: Patient with depression wants traditional healing, not medication/therapy.

Questions:

  • Do we insist on evidence-based treatment?
  • What if traditional treatment is “working” for patient?
  • Can we integrate both approaches?
  • Who decides what counts as “evidence”?

PART XII: FUTURE DIRECTIONS

What Needs to Change

1. Research

  • Include diverse populations in clinical trials
  • Conduct ethnic-specific analyses
  • Study culture-bound syndromes rigorously
  • Fund research on culturally adapted treatments
  • Include diverse researchers

2. Training

  • Require cultural competence training
  • Address implicit bias
  • Teach about culture-bound syndromes
  • Include diverse case studies
  • Emphasize humility and curiosity

3. Practice

  • Use Cultural Formulation Interview
  • Ask about cultural background and beliefs
  • Involve families appropriately
  • Respect traditional healing
  • Advocate for systemic change

4. Systems

  • Recruit diverse mental health professionals
  • Fund culturally specific programs
  • Reduce structural barriers
  • Address racism and discrimination
  • Make services accessible and affordable

5. Conceptual

  • Question whose “normal” is standard
  • Recognize power dynamics in diagnosis
  • Embrace complexity and ambiguity
  • Hold tension between universal and specific
  • Stay humble about cultural knowledge

CONCLUSION: THE SHADOW IS CULTURAL

Returning to Connie Zweig’s insight about the shadow as “psychic immune system, defining what is self and what is not self” – this operates at the cultural level just as powerfully as the individual level.

Every culture has a collective shadow:

  • What behaviors, thoughts, emotions are acceptable vs. rejected
  • What experiences are honored vs. pathologized
  • What expressions are healthy vs. sick
  • What suffering is valid vs. weakness

No culture has it “right”:

  • All cultures stigmatize mental illness
  • All cultures have blind spots
  • All cultures pathologize some human experiences
  • All cultures privilege some voices over others

The challenge:

  • Recognize universals (real suffering exists)
  • Honor specifics (culture shapes expression)
  • Question assumptions (whose normal?)
  • Remain humble (we don’t know everything)
  • Address power (who decides?)
  • Reduce suffering (ultimate goal)

Final Insight: Mental illness and social deviance are both biologically real and culturally constructed. The brain is universal; meaning is cultural. Suffering is real; what we call it and how we address it varies.

Our task is to honor both the universal humanity in psychological suffering AND the profound cultural diversity in how that suffering is experienced, expressed, interpreted, and healed.

FURTHER READING

Books:

  • Arthur Kleinman: The Illness Narratives (1988)
  • Laurence Kirmayer: Cultural Consultation (2012)
  • Joseph Gone & Joseph Trimble: American Indian Mental Health (2012)
  • Lillian Comas-Díaz: Multicultural Care (2012)

Key Articles:

  • DSM-5 Cultural Formulation Interview
  • Surgeon General’s Report: Mental Health: Culture, Race, and Ethnicity (2001)
  • WHO studies on cross-cultural schizophrenia outcomes

Documentaries:

  • Crazywise (2017) – Alternative views on psychosis
  • The S Word (2017) – Suicide across cultures

“The shadow acts like a psychic immune system, defining what is self and what is not self. For different people, in different families and cultures, what falls into ego and what falls into shadow can vary.”

This is not just true – it’s profound. Our individual shadows are shaped by our cultural shadows. Healing requires recognizing both.