Cultural Lens of Mental Health
We began a conversation here that introduced different models and "lenses" through which we can look at mental health. We already dived deep into the biological, psychological, and social lenses. Today we are looking at the Cultural Lens.
Culture and society are entwined concepts, so this categorical division between Cultural and Social lenses is somewhat splitting hairs. But, I think as we read, it will become clear why this difference matters. For our purposes, when we are talking about the Social Lens, we are looking at material conditions that are measurable; income, housing, structural inequality, policy decisions. For the Cultural Lens we are looking at the beliefs, assumptions, language, and history that shape society. A society, that, in turn, reshapes culture. They are linked, they influence each other, they can’t exist without each other. One way to think about it is that culture and society are akin to the biological/psychological or brain/mind splits, where we are defining a difference that exists conceptually more so than it does in actuality.
Culture determines what counts as "normal" behavior. Culture determines whether a particular experience gets understood as an illness, spiritual crisis, a moral failure, or just one of the ordinary variations of life. Culture also shapes whether or not people seek help, what help looks like, where one goes for help, and who is qualified to offer it.
We are grounding our conversation about culture in the "Western cultural tradition." This is the one I was raised in, the one I predominantly live in, and the one whose history I am most familiar with. The "Western cultural tradition" is, roughly, the intellectual and institutional traditions rooted in ancient Greece and Rome, shaped by Christianity, developed through European Enlightenment thought, and exported globally through colonialism and capitalism. There are many sub-cultures within that larger framework. And, obviously, there are many other cultural frameworks throughout the globe. And most of these frameworks increasingly overlap and interact and impact each other.
History of the Cultural Lens
Western society has long had two main approaches to understanding the world, which we can roughly categorize as the supernatural and the scientific. The ancient Greeks were the first in the Western tradition to argue that mental suffering had natural causes rather than supernatural ones. Hippocrates, writing in the 5th century BCE, proposed that conditions like melancholia and epilepsy originated in the body. He originated the idea of the “humours”, the four bodily fluids that dictate health. While his idea wasn’t totally correct, he at least was correct that illness is nautral and not just the will of the gods. Hippocrates opened the door to the idea that health and wellness could be studied and treated as a physical phenomenon (Nutton, 2004).
Around the same time, Plato understood the soul as the seat of reason, and therfore, any departures from reason meant that something was amiss with one’s soul. Aristotle, Plato's student, was more naturalistic but still understood life through the lens of virtue and character. We see with these three the beginning of the tension between our lenses. Mental suffering as biological event versus mental suffering as spiritual event versus mental suffering as moral event.The tension between these lenses is itself a cultural issue, and it runs through the entire history of Western thought about the mind.
As we move forward in time, Christianity rose to prominence through the medieval period. This did not simplify the picture as the church held competing ideas about mental suffering. Severe mental disturbance could be evidence of demonic possession, requiring exorcism. It could also be evidence of spiritual crisis, requiring pastoral care. And it could be understood as a form of suffering that deserved charity and compassion. This led to the need for interpretation. Every experience of “madness” required explanation within a theological framework, and the explanation determined the response (Scull, 2015).
The Renaissance began the process of loosening the church's grip on many areas of intellectual life, but it did not produce a clean break in how mental suffering was understood. As we began our early forays into rigorous scientific inquiry, we also seemed to gain a new anxiety about the boundaries of reason. If reason was what separated humans from animals, and from each other in the social hierarchy, then its loss carried particular weight. Foucault argued that the Renaissance relationship with madness was actually quite complex. During the Renaissance, madness still appeared in dialogue with reason, visible in literature, art, and philosophy. The Enlightenment hardened the distinction between the two (Foucault, 1965). Madness became not just a spiritual problem but a social one (the beginning of the social lens?), and the pressure to confine and manage it followed from that shift (Scull, 2015).
Beginning in the 17th century and accelerating through the 18th and 19th, European societies began removing people with severe mental disturbance from their communities and placing them in institutions. Michel Foucault, in Madness and Civilization (1961/1965), argued that this was not primarily a humanitarian response, but rather it was a cultural and political development. The "great confinement," as he called it, removed from public life those whose behavior violated emerging bourgeois norms of reason, productivity, and self-governance. Madness was not being treated so much as it was being separated and kept hidden from polite society.
Philippe Pinel in France and William Tuke in England are reformers of this era. In the late 18th century, both advocated for removing the chains from asylum patients and replacing physical restraint with what Tuke called "moral treatment." Moral treatment consisted of structured routines, work, religious observance, and the cultivation of self-control. It seems that this an attempt at genuine, humanitarian reform. But, it was also a more sophisticated form of cultural control. The goal was not to understand the patient's experience on its own terms but to reshape it to conform to prevailing norms of behavior and productivity. Recovery meant returning to usefulness (Scull, 2015).
By the 18th century, we are firmly in the era of colonialism and burgeoning capitalism. The standard against which mental suffering was being measured was increasingly an economic one. A person was well when they could work, maintain a household, and fulfill their social obligations. This, too, is a cultural standard, and not a neutral clinical definition. It reflected the values of an industrializing society that had a great deal invested in the orderly functioning of its labor force.
Through the 19th century, the care of people with mental illness was gradually claimed by a new professional class. Physicians working in asylums began organizing, publishing, and asserting that mental suffering was a medical problem requiring medical expertise. In 1844, a group of asylum superintendents founded what would eventually become the American Psychiatric Association. The medicalization of mental health was underway, and with that physicians brought new observational frameworks and a commitment to systematic study. Claiming mental suffering as a medical domain also began the process of displacing the church, the family, and the community as the primary interpreters of that suffering. Suffering now meant treatment from credentialed professional class whose explanatory framework was increasingly biological.
This isn’t necessarily a bad development, but the problem was that the biology wasn't there yet. The ambitions of 19th century psychiatry outran the evidence and science of the time. Emil Kraepelin, the German psychiatrist whose diagnostic categories laid the groundwork for modern psychiatric classification, believed that mental disorders were discrete biological entities that would eventually be explained by brain pathology. His work was enormously influential, shaping how psychiatry organized and named conditions for over a century. But the biological foundations he assumed were coming never fully arrived, and the categorical system he built was constructed on clinical observation and cultural assumption as much as on any established science (Scull, 2015).
What Kraepelin's system did produce was the infrastructure for diagnosis. The idea that mental suffering could be sorted into discrete, nameable categories, each with its own profile of symptoms, course, and prognosis. That infrastructure eventually became the Diagnostic and Statistical Manual of Mental Disorders, the DSM, first published by the American Psychiatric Association in 1952.
The DSM
The DSM is as much a cultural document as it is a scientific one. It is a product of its time, shaped by the assumptions, politics, and institutional interests of the people who produced it. Each edition reflects not just advances in research but shifts in what a particular society, at a particular moment, decided to call disorder.
The first two editions, published in 1952 and 1968, were heavily influenced by psychoanalytic theory (think Freud, the Unconscious, Id Ego, Superego, etc.) They described mental disorders in broad, narrative terms, reflecting the dominant clinical culture of mid-century American psychiatry. DSM-III, published in 1980, was a deliberate break from this tradition. Robert Spitzer, who led its development, wanted a system based on observable, measurable symptoms rather than theoretical constructs. The goal was scientific credibility, compatibility with pharmaceutical research, and a common language that clinicians, researchers, and insurance companies could all use. It was, in many respects, a successful reform. It was also a cultural choice, and it had cultural consequences.
One of those consequences was the medicalization of an expanding range of human experience. Allan Horwitz, in Creating Mental Illness (2002), argued that DSM-III and its successors progressively converted normal human responses to difficult circumstances into diagnosable disorders. Grief, shyness, difficult concentration, adolescent mood swings. The DSM grew with each edition, not primarily because new diseases were being discovered, but because the boundaries of pathology were being redrawn. Change the definition, and more things can fit into it.
The clearest illustration of how cultural assumptions operate inside the DSM is homosexuality. It was listed as a mental disorder in DSM-I and DSM-II, reflecting cultural attitudes of the time. It was removed in a 1973 revision due to sustained political organizing by gay rights activists, internal advocacy within the American Psychiatric Association, and a membership vote. Ronald Bayer documented this in Homosexuality and American Psychiatry (1981), showing in careful detail how this diagnostic category reflected the cultural consensus rather than any stable clinical finding. (There is a great This American Life episode about this)
This is not an argument against the DSM, or that psychiatric diagnosis has no value. Diagnosis can open doors to treatment, reduce self-blame, and it provides a shared language for these experiences. The point is that the categories are not discovered in nature. They are constructed inside a cultural moment, by people with particular assumptions and interests, and they carry those assumptions with them into clinical practice, insurance reimbursement, pharmaceutical research, and into the greater cultural understanding.
Cross-Cultural Perspectives: Disease and Illness
This post already has a lot of information to process. The asylum, the professionalization of psychiatry, the DSM, the medicalization of mental health, etc. The main takeaway is that these are developments that happened in a specific cultural context. And this framework is how we discuss and treat mental health in the “West.”
Arthur Kleinman, a psychiatrist and anthropologist at Harvard, spent decades documenting what happens when that assumption meets the actual diversity of human experience. His concept of explanatory models, developed through fieldwork in China and Taiwan in the 1970s and 1980s, showed that patients and clinicians routinely bring different frameworks to the same clinical encounter. A patient might understand their suffering in terms of spiritual imbalance, family obligation, or disrupted social harmony. This can cause issues when the “Western” clinician is working from a biomedical framework that has no categories for any of that. Kleinman argued that good clinical care required eliciting and taking seriously the patient's own explanatory model, rather than simply overwriting it with a diagnostic category. His book The Illness Narratives (1988) was, and is, an important text in cross-cultural psychiatry.
Kleinman also introduced a distinction between “disease” and “illness”. He defines disease as the biological or physiological process as understood by medicine. Illness is the human experience of suffering, shaped by culture, relationships, and meaning. Western biomedicine has historically focused on disease and treated illness as secondary. For the person sitting in a clinic, the illness, the suffering, is usually the focus.
One of the most striking illustrations of this comes from research on voice hearing. In the West, hearing voices is understood primarily as a symptom of serious mental illness, most commonly schizophrenia. It carries significant stigma, and the clinical response is typically pharmacological. Tanya Luhrmann, a psychological anthropologist at Stanford, conducted research across the United States, Ghana, and India asking people who heard voices to describe their experiences. American voice hearers tended to describe their voices as intrusive, threatening, and a sign of a medical issue. Voice hearers in Ghana and India were more likely to describe their voices as the voices of family members or God, as interactive relationships rather than symptoms. Luhrmann and colleagues found that the cultural context in which voice hearing occurred shaped not just how people interpreted their experiences but the character of the experiences themselves. The voices people heard reflected the frameworks their cultures gave them for understanding what the voices were (Luhrmann et al., 2015).
Another example would be dyslexia. The “disease” of dyslexia is a biomedical condition which interferes with the ability to learn to read or write. This condition would likely not cause any issue in pre-literate societies.
Limitations of the Cultural Lens
The cultural lens is an important reminder that all the lenses bring assumptions, and we shouldn’t mistake assumptions for universal facts. Likewise, the cultural lens has its own assumptions and limitations.
The first is the risk of relativism. If all frameworks for understanding mental suffering are culturally constructed, it can start to seem like none of them are more valid than others. That conclusion doesn't hold up. Some experiences are genuinely debilitating regardless of cultural context. Severe psychosis, profound depression, the aftermath of trauma. The cultural lens helps us understand how those experiences are interpreted and responded to. It does not dissolve the suffering itself.
The second is romanticization. The voices research is sometimes read as an argument that non-Western frameworks for understanding mental illness are simply better than Western biomedical ones. Luhrmann's work doesn't support that conclusion. It supports the more modest claim that cultural context shapes experience, and that the Western biomedical framework is not the only legitimate one. Communities that understand voice hearing as spiritual experience are not necessarily providing better care. They may be providing different care, with different tradeoffs.
The third is that the cultural lens, applied carelessly, can tip into stereotyping. Cultures are not monolithic. They contain internal disagreements, generational shifts, and individual variation. Assuming that a person's cultural background determines how they experience or understand their suffering is its own form of reductionism.
The fourth is the WEIRD problem, which the psychological lens post already named. Cross-cultural psychology has expanded significantly in recent decades, but the research base is still heavily weighted toward Western populations. The cultural lens is most valuable when it is comparative, and that requires research from a much wider range of cultural contexts than the field has historically prioritized.
Implications for Therapy
What does the cultural lens mean for what actually happens in a therapy room?
The first implication is that the therapist's framework is not neutral. Every clinician brings cultural assumptions into the room. Good clinicians can recognize their worst cultural biases, but we can’t shed all of our cultural programming. Western psychotherapy developed in a specific cultural context and carries that context with it. The values embedded in most therapeutic approaches; individual autonomy, insight, verbal self-expression, the importance of the self as a unit of analysis, are not necessarily universal human values. They are culturally specific ones, and they fit some clients better than others.
The second is that a client's explanatory model matters clinically. Kleinman's point has practical implications. A client who understands their depression as a spiritual crisis, or as a response to disrupted family harmony, or as the result of a hex, is working from a framework that is meaningful to them, and that framework will shape whether they engage with treatment, how they interpret their symptoms, and what kind of help they are willing to accept. A therapist who ignores that framework will be less effective than one who takes it seriously (Kleinman, 1988).
The third is that shame and stigma are cultural products. The reluctance many people feel about seeking mental health treatment reflects the cultural messages about what it means to need help, to be unable to cope, to have a mind that doesn't work the way it “should”. Those messages vary across cultures and communities, so understanding where a particular client's coming from is part of understanding what they are carrying into the room.
The fourth is that recovery is a cultural concept. What it means to be well, to function adequately, to have a life worth living, is shaped by cultural expectations about productivity, relationships, independence, and meaning. A therapist who holds only one cultural definition of recovery will inadvertently impose it on clients for whom it doesn't fit. Good clinical work requires some flexibility about what the destination looks like.
Closing
The cultural lens adds an important question missed by the biological, psychological, or social frameworks we have already looked at. Whose assumptions are built into this picture, and whose are left out?
For clinicians, this means staying curious about the frameworks clients bring into the room, and staying honest about the frameworks we bring ourselves. Culture is not just background noise, it is a huge part of the picture.
The next lens we will look at is the consumer lens, which examines how market forces have shaped what mental health care is, who it is for, and what counts as getting better.
References
Bayer, R. (1981). Homosexuality and American psychiatry: The politics of diagnosis. Princeton University Press.
Foucault, M. (1965). Madness and civilization: A history of insanity in the age of reason (R. Howard, Trans.). Pantheon Books. (Original work published 1961)
Horwitz, A. V. (2002). Creating mental illness. University of Chicago Press.
Kleinman, A. (1988). The illness narratives: Suffering, healing, and the human condition. Basic Books.
Luhrmann, T. M., Padmavati, R., Tharoor, H., & Osei, A. (2015). Differences in voice-hearing experiences of people with psychosis in the USA, India and Ghana: Interview-based study. The British Journal of Psychiatry, 206(1), 41--44. https://doi.org/10.1192/bjp.bp.113.139048
Nutton, V. (2004). Ancient medicine. Routledge.
Scull, A. (2015). Madness in civilization: A cultural history of insanity, from the Bible to Freud, from the madhouse to modern medicine. Princeton University Press.