Cultural Influences on Mental Illness Author(s): Pittu Laungani Source: Economic and Political Weekly, Vol. 24, No.

43 (Oct. 28, 1989), pp. 2427-2430 Published by: Economic and Political Weekly Stable URL: http://www.jstor.org/stable/4395529 . Accessed: 31/07/2011 01:10
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SPECIAL ARTICLES

Cultural

Influences

on

Mental

Illness

Pittu Laungani

A serious considerationof issues of mentalillness and communitycare requiresan examinationof such proBritishand Indianculturethispaper blemsas they exist in differentcultures.Examiningthepremisesunderlying pleads for an interactionbetween culturesin order to adequatelyaddresssuch problems.
INTRODUCTION

SINCE mental illness is defined by some as a form of unconventional behaviour, I too shall break with convention, and start with an old joke. The joke, probably apochryphal, is central to the arguments to be developed in the rest of the paper. It is about two persons who were heard arguing vociferously from their respective balconies in a street called Shambles in York. Two linguistic philosophers-no doubt from the university-who were strolling through the-narrow, congested streets, could not help overhearing their heated arguments. One of them. asked the other, "Do you think they will ever resolve their arguments?" "Leaving aside for the moment, what the term resolve means, the answer to your question is no" replied the second philosopher with smug confidence. "Oh, why not?" "Because they're arguing from different

premises!"
And this brings us right to the heart of the problem. A meaningful study of mental illness across cultures, requires one to understand And share the diverse premises used by each culture in construing, defining, diagnosing, and treating mental illness. Premises imply assumptions. Assumptions refer to commonly held beliefs, attitudes, and values shared by people in a given culture. Each culture, over time, comes to acquire its own notions concerning right and wrong, good and bad, proper and improper, healthy and unhealthy, normal and abnormal. When pressed, why we hold such beliefs dearly and not others, why this is important and that less so, we may be unable to offer plausible explanations. Nonetheless our beliefs and values whose origins are often lost in antiquity, pervade our cultural atmosphere. Like air, we imbibe them, often without a conscious awareness of their origins. The mechanics by which such beliefs are culturally transmitted and internalised are of course open to conjecture. However, it is the sharing or not sharing of such beliefs which, in a sense, brings cultures close to one another, or moves them apart. Clearly, some cultures are 'closer' to one another, and others 'apart. Although geographical location may play a vital role in the closeness or otherwise of cultures, it need not, as is evidenced by the similarities between Britain and Australia, always be the case. And although cultures may be enjoined by a common course of historv, they may yet remain

apart, as is evidenced by the differences between Britain and India. If the underlyingassumptionsconcerning mental illness commonly shared by one culture are not shared by another culture, nor is any serious attempt made to understand them, one is unlikely to learn a great deal about the problem of mental illness within that particularculture.Moreover,if such factorsare not takeninto account, any comparative studies undertaken in other cultures are more likely to create a collage of distorted pictures which may not only, impede our urnderstanding the genesis of of the problem, but may lead to potentially dangerous conclusions being drawn. Some writershave appearedto have swung to the other extreme, and have asserted, that all mental illness is culture-specific. Such a relativisticview is idiosyncratic,and is not supported by firm evidence. Some mental disorders obviously are culture-specific [Draguns 1981;Marsella 1982; Rao 1986]. That people lose controlovertheirlives,that people become distressed, unhappy, and withdraw into a world of their own, unbounded by constraintsof time, space, and reality,that people abandontheirwill to live, seek oblivion in alcohol, resort to uncontrollableand meaninglessacts of crueltyand violence,that people are hauntedby feelings of guilt, remorse, fear, and shame, are all experienceswhich no semantictrick-cyclists could talk theirwayout of. Such eventsexist around us, and one does not, as Rosenhan [1973]pointedout severalyearsago, need the to trainedeye of a psychiatrist see them. The problem is not that these problems do not The problemis exist; they exist everywhere. how one construes them meaningfully.For it is the construction of an experience, its and the meaningone assigns interpretation, to the experiencewhich involvesmaking all sorts of assumptions.It is those assumptions and whichoften are culture-specific, not the experience itself-as has been mistakenly assumed by the cultural relativists.

the harmfuleffects whichthe use of the termj has had on society in generaland on the person so labelled in particular.However,as 1 have pointed out elsewhere[Laungani1976] a problemwhich strikesat the veryheartand mind of every society cannot be made to disappearthroughthe dubious mechanisms of denial. It remains. Nonetheless, the two anti-psychiatrists despite their assault on or traditionalpsychiatry, perhapsbecauseof it, haveraisedseriousconcernswhich otherwise may havepassed unnoticed.They have, in a sense, succeeded in arousing a greater public awarenessand concern for the issues related to mental illness-not the least of which is trying to understandwhat mental illness actually means to the individual, to society, and to those in the caring professions. Researchers are often known to disagreewith one another. Sometimestheir disagreementsare over fundamentals, but moreoften than not thev quarrel overminor, even trivial issues, not the least being over problemsof definitions.As an exanmple, one might quote the serious but ratherpointless efforts of the psychologisLs Miles [1957]who in the context of writirg on intelligence, discovered twelve definitions of the word definition! A searchfor exact definitions is like the search for El Dorado-only to be found in Voltaire's Candide! Popper [1972] warns us not to be misled by such trivial pursuits!

Arguably,notions of healthand illnessare by no means clearly defined concepts. To most psychiatriststrained in the west, they are rooted in the medical and the biological sciences.To some they are culturallycreated evaluations. Others see them as socially definedcategories,or as privatephenomenal experiences individuals.A few,of Marxist of persuasion, construe them as deliberateattempts by the 'ruling classes' to wit, the psychiatriststhemselves-to persecute and incarceratethe weak and helpless members of society. Rightly or wrongly,the medical model has continuedto exercisethe greatest Even within a single culture, opinions influencein conceptionsof illnessand health vary as to what constitutes mental illness, in western society. And it is the medical and how the term itself shall be defined. In model on which the fundamental training the west, the term mental illness has been programmes for psychiatrists are based. the subject of considerable'controversy, Belief in the medical model and/or its which has often been quitebitter.Some anti- variants is strongly ingrained in. western psychiatrists such as Thomas Szasz in thinking. It arisespartlyout of its historical America, and R D Laing in Britain, even associationswith medicine,partlyout of the tried during the sixties, to talk it out ofl impact which Freud, himself a doctor of Szasz by denyingits veryexistence, medicine(and so werehis disciples),has had existence; and Laing'and his disciples, by pointing tot on westernthinking,and, by implication,on 2427

Economic and Political Weekly October 28, 1989 1

western psychiatry, but more importantly and psychological disorders. Such claims out-of the fundamentalassumptions which were seldom taken seriously by western underlie such ready acceptance. It is these scientists. They were dismissedas wild, unfundamental assumptions which form the substantiatedexaggerations.In 1969, Neal premises which distinguish western ap- Miller, a famous behaviouralpsychologist, proachesfrom easternapproaches,or more successfully trained his white, middle-class specifically,Britishapproachesfrom Indian rats to lower and raise their blood-pressure approachesto mental illness. Four such in- by selective reinforcement [Miller 1969]. terrelatedpremisesor factors which distin- What was good enough for his rats, Miller guish British culture from Indian culture decided,was surelygood enough for his colhave been hypothesised. The four factors lege sophomores!Thus Millerfound that he are: voluntary could trainhis studentsto exercise ... Spiritualism (1) Materialism control over their autonomic responses. (2) Individualism ... Communalism Suddenly the claims made by the yogis ... Determinism (3) Free will Miller'sperbeganto acquiresome credulity. ... Emotionalism (4) Cognitivism forming rats did the trick. They opened the It should be noted that the two concepts doors to.yoga In Americanuniversities,and into alteredstales of consciousness, each factorarenot dichotomous; research underlying they areto-beunderstoodas extendingalong followed by its applications into techniques a continuum, starting at, say, materialism of bio-feedback became respectable. The notion of materialism is a relatively at dne end, and extendinginto spiritualism at the other. It is suggested that the salient unimportant concept in Indian thinking. attitudes, values and behavioursof groups The external world to Indians is not comof people may be more materialism-oriented posed of matter.The externalworld is seen and less spiritualism-oriented;and vice- as being illusory. It is maya. Unfettered by versa. In fact, the salient values and materialistic boundaries, the Indian mind behaviourscan be representedat any point resorts to explanations where material and natural along the continuum, and may, over time, spiritual,physicaland metaphysical, change in eitherdirection.Before discussing and supernatural explanations.of phenoeach factor, it needs to be pointed out that mena co-exist with one another. What to a the concepts to the left of each factor are westernmind, weaned'onAristotlean logic, more applicableto the Britishand those on nourishedon a scientific diet, socialised on the right to the Indians. Let us now examine materialismand positivism, might seem an leavesan Indian contradiction, irreconcilable each concept briefly. To Materialism refers to a belief in the mind relativelyunperturbed. a westerner existence of a material world, or a world if A is A, A cannot then be not-A; If dysenmatter try is caused by certain forms of bacteria, What constitutes composedof matter. is itself debatable, but nonetheless any ex- it cannot then be due to the influenceof the planations of phenomenarangingfrom the 'evil-eye. The two are logically and emto lunar cycles to lunacy fall withiu the piricallyincompatible.But contradictions materialist framework.That the scientific Indians are a way of life. A is not only A, temperamentin the west has been greatly but undercertainconditions, A may be notinfluenced by a belief in a materialistic A. Do not quarks have their own quirks, as framework is evident in its reluctance to Heisenberg pointed out in his famous in paperon indeterminacy quantum entertain any explanations which are non - research 1930].However, materialor supernatural.Non-materialex- theoryin 1972?[Heisenberg planatioAs are treated at best with scep- tnis extremely fundamental principle has ticistn,and at worstwith scorn.The fewwho been pushedaside in orderto perpetuatethe steer away from materialisticexplanations, myth of scientific certainty.In other words, comprise the very small minority within Indians believe the external world to be iltraditional psychiatry. Because their con- lusory without actually knowing it, the know it to be illusory,withoutactributions within the mainstream of westerners psychiatryappear to be questionable, they tually believingit. Indian beliefs and values The roundthe notion of spiritualism. are sadly,not evenaccordedthe statuswhich revolve mightbe givento an enfant'terrible'Anyone ultimate purpose of human existence is to offering such explanationsof phenomenais transcendones illusory physical existence, the in dangerof incurring wrathof the scien- renouncethe world of materialaspirations, tific community.For such explanations fall and attain a heightened state of spiritual com- awareness;Any activity which is likely to withinthe purviewof thepre-scientific, munities or in other words, superstitious, promote such a state is to be encouraged. Let us takeanotherexample.For instance, and backwardsocieties to be found mainly in underdeveloped,third-world countries. a woman living in India may accept a firmLet us consideran exampleto illustratesuch ly establishedsystemof folk 'theories'as to forms of thinking in western society. For what constitutes illness and its causes. The several hundred years, yogis in India have belief system which she takes for grantedis made claims about their abilities to alter the one which is culturallyaccepted in her their states of consciousness at will, bring- country. To her, the dysentry in her child ing their autonomic nervo-usstates under might seem to be the definite influence of voluntarycontrol. Yogicexercisesor asanas the 'evil-eye', and although it may be as they are called, were claimed to have diagnosed as due to bacteria by an Indian therapeuticeffects for a varietyof physical dootor trainedin westernmedicine,her view 2428

would be unlikelyto be subjectedto ridicule. The two views-the natural and the supernatural-would resideside by side, pills, potions, and amulets, mixing freely with antibiotics. Overtime, the woman in question may come roundto believingthat herchild's illness was caused by armies of unknown, view unseen'germs.Thus the bacteriological might ultimately come . to prevail. But whether she does or does not come round to accepting the bacteriological view, her own views concerning the causes of her child's illness are the ones which find ready acceptance among her own people and within her own community. In England however, the same Asian woman would find herself out of step, and out of sympathy-with the addeddangerof finding her own sanity being questioned explanawereshe to persist in supernatural tions of her child'sillness. The problemgets compounded even furtherwhen it comes to mentalillness.Whilein generalmedicineone might be able to hint at definite causal relationships, can one everbe certainabout the genesis of menitalillness? Let us now turn to individualism... comfeatures munalism.One of the distinguishing of westernsociety is its increasingemphasis on individualism.The British family structure, particularlyfrom the post-warperiod onward has undergone a dramaticchange. has The nuctearfamily structure come to be recognised as the norm. With the gradual increasein one-parent families-at present around8 per cent-the presentnuclearfamily structure,over the ensuing years,is likely The conto change even more dramatically. cept of individualism has been the subject of considerable debate among western thinkers [Bellah 1985; Lukes 1973; Spence 1985; Waterman1981]. It has been argued by some of the writersmentionedabovethat the notions of individualismare incompatible, even antithetical with communal interests.Self-realisationwhich is the basis of individualism,conflicts with communal interests,and it becomesdifficult, evenwithin a Marxist framework[referDavid Archard 1987] to reconcile the conflict. How does the notion of individualismafof fect our understanding mentalillness?To start with, mental illness within an individualistic frameworkis perceivedas being primarilyan individualproblem.Doubtless there are consequences for the individual's rapidlydiminishingfamily, and for society, but those are of secondary considerations. Secondly, more often than not, the individual is held responsiblefor his/her problem. "You'vegot yourself into a mess, you get yourselfout of the mess'"is the unvoiced, yet clearly understood value judgment pronounced on the individual concerned. And in the absence of any evident contributory factors which might explain the disorder, blame is apportioned on the individual.He or she had a 'weak'personality, he or she behaved stupidly, abominably, could not cope with stress, etc, may well be the the pejorativelabels which form part oxf

Economic ana Political Weekly October 28, 1989

victim-blamingrituals. In a society which functions on an individualisticphilosophy, people are socialised into accepting such evaluative judgments of themselves by others. Indiansocietyon the other hand has been and continues to be community-oriented [Kakar1981;Lannoy 1976; Laungani 1981; 1988; Mandelbaum 1972]. Most Indians grow up and live in an extended family network. The structuraland functionalaspects of the extended family, and the social and psychologicalconsequencesof living within it have been discussed elsewhere[Laungani 1988]. Suffice it to say that Indian society cannot be seen in other than familial and communalterms. It is and has been for centuries a family-oriented, and communitybased society. Consequently when a problem-financial, medical, psychiatric, or whatever-affects an individual, it affects the entirefamily.The problembecomes one of concern for the whole family. Seldom does one see personalised'private' problems. It may be of passinginterestto note herethat Indians often use the collective term we in their everydayspeech. The use of the term we or hum does not in anyway signify the It royalor the papalprerogative. signifiesthe suppression of one's personal ego into the collective ego of one's family and community. One speaks with the collectivevoice of others,and in so doing gains their approval. A community in India is not just a collection of individuals gathered together for a common purpose.A communityin the sense in which it is understoodin India has several common features.People withina group are united by a common caste-rank, religious grouping, and linguistic and geographical boundaries. The members within a community generallyoperate on a rankingor a hierarchical system. Elders are accorded special status within the community, and their importantrole is veryclearlyrecognised. Eldersare generallydeferredto. On importantissues the membersof a community may meet and confer with one another,and any decisions takenare often bindingon the rest of the memberswithin the community. In the event of a person being perceivedas being mentally ill, initially it falls upon the individual's familyto look afterand support the individual concerned. Should that become difficult, it then becomes the responsibility of the community members to offer support. However, it needs to be pointed out that in order for an individual to stay part of the community,it is expected that the individualwill submitto communal norms, and will not deviate to an extent where it becomes necessary for the deviant to be ostracised or declared an outcaste. Without one's caste, a Hindu is nothing. A nobody. His identity is ascribed around his caste. This brings us to the factor free will... determinism.While there appears to be no satisfactoryend in sight to the philosophical debateconcerningfreewill and determinism which has been with us for over two thouEconomic and Political Weekly

sand years, the notion of free will is never more stronglysubscribedto than in western society. This explains partly the extreme hostility which Skinner's theories have aroused because of his deterministicviews concerning human behaviour.Free will implies respo-nsibility one's actions. Thus for while free will allows an idividual to as it were, take 'credit' for his/her successes, it makesit incumbentupon him to also accept blame for his failures and mishaps. This featureof westernsociety entraps a person into his or her own existentialpredicament. Theredoes not appearto be an easy wayout. Indians, by virtue of subscribing to a viewof life are,in a teleological deterministic sense at least, preventedfrom taking final responsibility for their own actions. The notion of determinism plays an extremely crucial role in Indian thinking. The law of karma which involves determinism and fatalism has shaped the Indian view of life over centuries. In its simplest form, the law of karma states that happinessor sorrowthere is no equivalent word for depression in Hindi or in Sanskrit-is the predetermined effect of actions committed by him sometimeseitherin his presentlife or in one of his numerous past lives. Things do not happen because we make them happen. Things happen because they were destined to happen. If one'spresentlife is determined by one's actions in one's previous life, it follows then that any illness-mental or physical-that strikes an individual in a family, was destined to happen. This takes away the sting and the stigma from suffering. No blameis apportionedto the afflicted individual; it was his or her karma. Determinism thus engenders a spirit of passive, if not resigned, acceptance.This preventsa person from plunging into an abyss of despair-a state from which the British, because of their fundamental belief in the doctrine of free will, cannot be protected. The main disadvantage of determinismand there are many-lies in the fact that it often leads to a state of existential, and in certain instances, moral resignation, compounded by a profound sense of inertia. One

takes no proactivemeasures;one merelyaccepts the vicissitudesof life without qualm. Occasionally, explanations are sought in terms of caste-contamination. The maintenance of caste-purityis an important requirement among Hindus. If a seriouscasteintertaboo is violated, for instancethro.ugh caste marriage,when a Brahminmarries a Sudra, any mental illness within the family, is then attributed to the violation of the caste-taboo. Relief from mental illness may involvethe initiation of elaborate'purification' rituals and ceremonies. Anthropologists have also discussed the importance of magical explanations in mental illness. Thus mental illness may be due to any of the threeinterrelated categories,viz, sorcery, bewitchment,and evil spirits. The belief in magical explanations is wide-spread, and persons speciallyqualified to removespells, exorcise evil-spirits such as bhoots, balas,

and shaitans, are summoned the family members of the afflicted person. It is obvious that the genesis of the problem is seen more in religious, social, and culturaltermsthan in psychiatric inedical or terms. Therefore it does not make a great deal of sense for Indiansto consult psychiatrists for cures. It is thereforehardlysurprising that westerntype of psychiatry made has hardly any impact in India. There is little reason why it should. How many people could even afford the services of a psychiatrist? A token offering to one of the many deities,a visit to the local priest,a pilgrimage to a well-knownshrine,or darga, a meeting with a guru in whose curative powers the family has unshakablefaith, aresome of the familiar therapeutic routes taken by the family membersof the afflicted person. Occasionally, the family may consult with an astrologer,undertakea visit to a shaman, or a well-knownpir. Psychiatristsin India, it is obvious, do not have the specialised and important role to play in the treatment of mental disorders,which they often do in the west. A psychiatristis one of many in the long queue of consultants-and by no means at the head of the queue. Accordingto VenkobaRao [1986]mental illness in India is estimated to affect some two to sevenpersonsper 1000population in India. Given the presentpopulation of over 800 million people in India, it would seem thereforethat betweentwo and four million are affected by mental illness of one form or other.Venkoba Rao [1986]points out that the ratio of psychiatrists to the general population is a little over one psychiatrist to everymillionpeople!Thereareonly about 45 mental hospitals in the entire country. There is hardlyany undergraduate training in psychiatry the medicalschools.The picin ture of westernpsychiatryin India is bleak. On the other hand, the WHO report [1978]points out that thereare over 108colleges of indigenous medicine in India, with over 5,00,000 practitioners of one of the following indigenous forms of healing: Ayurveds, Unani, and Yoga. Yoga appears to be the most popular form of treatment used in psychological disordersall over the country.
The last factor, cognitivism. . . emotiona-

lism is concernedwith the way in which the Britishand the Indiansconstruetheirprivate and social worlds.In broadtermsit has been suggestedby Pande [1968]that Indiansocieand ty is relationship-centred, Britishsociety, These different work-and-activity-centred. constructions of their private and social worlds are not accidental cultural developments. They stem from their inheritanceof their different philosophical legacies. A relationship-centred society is more likely to operate on an emotional mode. In such a society, feelings and emotions are not repressed,and their expressionin generalis not frowned upon. Crying, dependence on others-both in females and males-excessive emotionality are not in any way considered as signs of weakness. Above all, in
2429

October 28, 1989 1

a relationship-centred society, no agenda of shared commonalities is necessary for the cultivation of a relationship.Since feelings and emotions-both positive and negative-are expressed easily, there is little danger of treading incautiously on others' sensibilities or vulnerabilities. Given the extended-familystructureof relationships, emotional outbursts are, as it were, 'taken on board' by the family members.Often the emotional outbursts are symbolic, even ritualistic. Theyserveno functionother than the relief which such outbursts bring. No special atmospheric situations need to be created-as is the case in westernsocietyfor the releaseof emotional feelings,and the consequenthandlingof emotionaloutbursts. In a work-and-activity-centred society, people are more likely to operate on a cognitive mode, where the emphasis is on rationality,logic, and control. Public expression of feelings and emotions-particularly among the middle classes-is often frowned upon. It causes embarrassment,and in certain social classes, is even seen as being quite vulgar.In such a society, relationships are formed on the basis of shared commonalities. One is expected to work at a relationship-in a marriage, in a family situation,with one'scolleaguesat work, and even with friends at a social level. Even at dinner parties-to use an Americanismone is expectedto 'sing for one'sdinner',and one's performance at table, determines whether the person shall be 'written off', kept on ice, or reinvited. Obviously in a work-and-activity-centred society, a need arises for the creation of professional and semi-professionalsettings which permitthe of legitimateexpression specific feelingsand emotions, and their handling by experts trained in the specific area. Thus one sees in westernsocietythe growthof bereavement counsellors, cancer counsellors, aids counsellors,marriage guidancecounsellors,famirational-emotive and ly therapists, therapists, last but not the least, psychotherapistsand psychoanalysts. It is only in a work-andactivity-centred society that one observesthe splittingup of human feelingsand emotions into their specialisms! It would seem thereforethat in the west, one has to work at one's emotions! Finally, although it sounds a truism to suggest that no cultureor no society has all the answersconcerningthe veryserious and debilitatingproblemsof mental illness, this fact is often forgottenor ignoredby research workersand psychiatristsin the west. If one is to seriously consider the issues of mental illness and of communitycare,one needs to learn about other communities. It is only when culturesmeet, exchangeideas, and expressa genuinewillingnessto learnfromone another, that one might find tentative answersto the questions which concern us all. The west could do well to rememberthat "thereare more things in heavenand earth, than are dreamt of in their philosophyi' 2430

References
Archard, D, 'The Marxist Ethnic of SelfRealisation: Individuality and Community' in J D G Evans (ed), Moral Philosophy and Contemporary Problems, Cambridge University Press, Cambridge, 1987. Bellah, R N, Habits of the Heart: Individuation and Commitment in American Life, Berkeley, University of California Press, 1985. Draguns, J G, Psychological Disorders of Clinical Severity' in H C Triandis and R W Brislin (eds), Handbook of CrossCultural Psychology, Vol 5, Allyn and Bacon, Inc, Boston, Mass, 1981. Heisenberg, W, The Physical Principles of the Quantum Theory, UWiversity California of Press, 1930. Kakar,S, The Inner World-A Psychoanalytic Study of Children. and Society in India' Oxford University Press, Delhi, 1981. Lannoy, R, The Speaking Tree,Oxford University Press, 1976. Laungani, P, 'Ethical Problems in Psychiatry', paper read at the British Psychological Society Conference, York University, York, September, 1976. - 'Doing Research in India, Bulletin, British Psychological Society, 34, 1981, pp 4-5. - Accidents in Children-An Asian Perspective, Public Health, (in press) 1988. Lukes, S, Individualismn, Basil Blackwell, Oxford, 1973. Mandelbaum, D G, Society in India, Vol 2, Berkeley: University of California Press, 1972.

Marsella, A J, 'Depressive Experience and Disorder Across Cultures' in H C Triandis and R W Brislin (eds), Handbook of CrossCulturalPsychology, Allyn and Bacon, Inc, Boston, Mass, 1982. Miles, T R, 'On Defining Intelligence, British Journal of Educational Psychology, 27, 1957, pp 153-165. Miller, N E, 'Learning of Visceral and Glandular Responses Science, 163, No 3866 (January 31, 1969), pp 434-435. Pande, S, 'The Mystique of ,'Western' Psychotherapy: An Eastern Interpretation The Journal of Nervous and Mental Disease, 146 (June), 1968 pp 425-432. Popper, K, Objective Knowledge: An Evolutionary Approach, Oxford, The Clarendon Press, 1972. Rao, V, 'Indian and Western Psychiatry: A Comparison' in J L Cox (ed), Transcultural Psychiatry, Croom Helm, 1986, pp 291-305. Rosenhan, D L, 'On Being Sane in Insane Places', Sciences January, 19, Vol 179, 1973, pp 250-258. Spence, J T, 'Achievement American Style: The Rewards and Costs of Individualism', American Psychologist, 40, 1985, pp 1285-95. Waterman, A A, 'Individualism and Interdependence'. American Psychologist, 36, 1981, pp 762-773. WHG Report, The Promotion and Development of Traditional Medicine, WHO Technical Report Series No 622 (Geneva, WHO), 197g.

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