Vol IV: Is it still relevant to view health from a cultural standpoint? Globalisation, cultural dialogues, and suicide in Japan

Cultural health psychology is a field which investigates health behaviours, and which seeks to link those behaviours to the social context in which they occur; globalisation, on the other hand, is a process which allows cultures to come into increased contact with one another. The process of globalisation has been accelerating at such a rapid pace that many wonder whether it will eventually lead to the eradication and replacement of all local cultures at the expense of a single, global culture. If this so-called cultural homogenization were ever to occur, it may eliminate the necessity of understanding health from a cultural perspective. The present essay will argue, however, that this cultural homogenization will never truly come to be, and that rather than eliminating local cultures, the process of globalisation instead encourages them to evolve and transform in unexpected ways. The unique status of suicide in Japan will also be examined to make these arguments even more evident. It will therefore be concluded that an understanding of health is necessarily incomplete if culture is not also taken into consideration.

Health is commonly regarded as an absence of signs or symptoms of illness or injury, be they objective (e.g. irregular heartbeat or blood pressure) or subjective (e.g. general feeling of physical or psychological malaise) in nature (Sutton, Baum, & Johnston, 2004). In spite of this, academics agree that this definition of health is too dichotomous to be accurate; illness and wellness are not entirely separate terms, as the definition implies, but rather overlap and exist on a con- tinuum. At the centre of the continuum is a neutral state of being, and at opposite ends of the continuum lie optimal wellness and death (Sarafino & Smith, 2010). Thus, the term “health” refers to “a range of positive states of physical, mental, and social wellbeing – not just the ab- sence of injury or disease – characterised by variations in healthful signs and lifestyles” (Sutton et al., 2004). Historically, health and wellness have been understood from a biomedical perspective, but this approach is limited. It was recognised in the 1970’s that psychology and social factors also play a significant role in health, and this realisation allowed for the creation of the field known as health psychology. Health psychology aims to promote and maintain health, prevent and treat illness, identify the causes and diagnostic correlates of health, and to improve health care systems (Sutton et al., 2004). Often, the manner in which these goals can be accomplished varies from culture to culture. Behaviour and thought patterns are affected by the social context in which they occur, and cultural psychology, another field of psychology, seeks to understand precisely how this influence comes about (Bhugra & Bhui, 2007). Culture and psyche indeed merge, and the way by which they influence each other impacts health. Upon this principle is built cultural health psychology, a field which “seeks to describe the diversity of health (and illness) behaviour and link it to the cultural context in which it occurs” (Spielberger, 2004).

With recent innovations in transportation and telecommunication, the pace of globalisation has drastically increased. Globalisation refers to people’s subjective experience of the world shrinking as they become more conscious of it. In other words, it is “constituted by the ever-increasing abundance of global connections and our understanding of them” (Barker, 2012), and it allows for the exchange of ideas across countries and cultures to become more and more widespread. Many academics believe that globalisation will ultimately lead to a reduction in cultural diversity so great that all local cultures will be eradicated and replaced by a single global culture. Given the risk of this eventual “cultural homogenisation,” it stands to reason that we question the relevance and importance of viewing health psychology through a cultural perspective. However, cultural homogenisation may still not take place: culture and health will remain inextricably linked, and must be understood as such. Furthermore, the process of globalisation may not lead to the elimination of local cultures, but instead encourages each culture to evolve and transform in unexpected and unique ways. To better illustrate these points, recent trends in suicide in Japan compared to “the West” will be examined, and the effect of globalisation on this phenomenon discussed.

The Cultural Homogenisation Thesis

Cultural homogenisation is one of the main characteristics of globalisation. It proposes that “the globalisation of consumer capitalism involves a loss of cultural diversity. It stresses the growth of ‘sameness’ and a presumed loss of cultural autonomy” (Barker, 2012). More specifically, cultural homogenisation implies the spread of a way of being, “from musical forms, architecture, and modes of dress to eating habits, languages, philosophical ideas, and cultural values and dispositions” (Inda & Rosaldo, 2008).

Some academics hypothesise that cultural homogenisation will result in the establishment of a single global culture, and the eradication of local cultures. Cultural homogenisation is furthermore said to be unidirectional, with the wealthiest and most powerful nations’ cultures threatening to shape the others. The world’s predominant cultural institutions originated centuries ago in Europe, and nowadays are mostly centred in the United States of America (Schiller, 1991), and so the dynamic spread of cultural globalisation is sometimes described as a Western project (Barker, 2012). Some fear the loss of local cultures at the expense of a Western one, a process sometimes denoted as cultural imperialism. Herbert Schiller, one proponent of this thesis, argues that the “industries that serve as the sites for the creation, packaging, transmission, and placement of cultural messages – corporates ones especially – have grown greatly as their importance and centrality to the corporate economy increases” (Schiller, 1991). Some ancient features of human experience, such as speech, dance, ritual, and music remain vital. However, what distinguishes their situation in the industrial-capitalist era are the “relentless and successful efforts to separate these elemental expressions of human creativity from their group and community origins for the purpose of selling them to those who can pay for them” (Ibid.). Cultural creations, according to Schiller, have been transformed in such a way as to facilitate their commercial production and market- ing. With globalisation, it has become possible for these industries to manufacture cultural messages in order to create a “national and international cultural atmosphere”, one which has “grown greatly in size, breadth, and productive capability in the years since World War II” (Ibid.). It should be noted that, though Schiller’s work is more than twenty years old, his ideas are still relevant; the cultural diffusion has only increased since 1991, aided by communication advancements. For instance, as of June 2012, more than 2.4 billion people were connected to the Internet (“World Internet users statistics usage and world population stats,” 2014), representing an increase in users of 566.4% from the year 2000 alone.

In spite of this, many believe that the degree of cultural homogenisation of which Schiller spoke is vastly exaggerated. The global reach of brands and ideas is undeniable, but “their presence alone [need] not signal a deep-seated cultural shift” (Jennings, 2011). The “globalisation as cultural imperialism” argument indeed faces several major difficulties, the most significant of which being that dialogues between cultures have never been unidirectional. So-called “wealthier” and “more powerful” cultures are shaping other cultures just as much as they are being shaped by other cultures themselves. Cultural flows are complex, and not as straightforward as the homogenisation thesis asserts.

Complex Cultural Flows

Cultural discourses always require “interpretation, translation, mutation, adaptation, and ‘indigenisation’ as the receiving culture brings its own cultural resources to bear, in dialectical fashion, upon ‘cultural imports’” (Tomlinson, 2013). Jennings (2011) argues against the idea that homogenisation entails the spread of a single way of life; rather, it is about how people “come into contact with widely shared ideas and products and make them their own.” Consider, for example, the legacies South African apartheid: European influence is evident in nearly all forms of South African cultural expression. American-inspired rap music is prevalent and popular among black South Africans, but it is not merely absorbed mindlessly by the South African people. This non-African musical form acquires a South African flavour before it is exported back to the West (Barker, 2012). It can be argued, then, that in the case of rap music, South Africa influences the United States just as the United States influences South Africa.

Cultural imperialism is a concept that essentially depends on imposition and coercion by one party on another. South Africans, however, listen to rap music and enjoy other forms of Western entertainment by choice. This cultural spread can more accurately be characterized as a form of cultural hybridisation than cultural domination.

Additionally, even if a particular influencing factor interacts with local cultures, each culture will respond to in a unique way. Consider, the worldwide spread of the English language. Due to its prevalence, English words and phrases are often incorporated into different languages, but the degree to which this happens depends entirely on where this language is commonly spoken. The official language of both France and Quebec is French, however, there are more Anglicisms in France French than there are in Quebecois French. One reason may be the confidence of state and cultural institutions in maintaining a minority culture. As Quebec is a French-speaking province in an English-speaking nation, it is hypothesised that French-speaking Quebecois may have more of a reason to protect the so-called integrity of their language than do the French. That not all cultures respond to the same influential factor in the same way is a serious blow to the cultural homogenisation thesis.

It is therefore unlikely that all local cultures are being swallowed and integrated into a single global culture, as the cultural homogenisation thesis suggests. Cultural health psychology’s aim of linking people’s health (and perceptions thereof) with the social context in which they were raised is hardly a useless or unnecessary pursuit. Globalisation increases the need for cultural health psychology. In order to understand the relationships between globalization and cultural health psychology, we turn to look at culture-bound syndromes and their classification in the Diagnostic and Statistical Manual of Mental Disorders (the DSM).

Culture-Bound Syndromes

A vigorously contested, and potentially extreme, example of the influence of culture on health is the concept of culture-bound syndromes. Culture-bound syndromes are “mental conditions or psychiatric syndromes whose occurrence or manifestation are closely related to cultural factors and which thus warrant understanding and management from a cultural perspective” (Tseng, 2006). For example, taijin kyofusho (literally, interpersonal-relations phobia) is a culture-bound syndrome most common in Japan, but also in China and Korea. This is not surprising, as all three countries share some similar cultural aspects (Ibid.). Taijin kyofusho is an anxiety disorder which involves the patient feeling embarrassed about certain aspects of him or herself (e.g., odour, looks, actions, etc.), ultimately leading to a fear of embarrassing others with their presence. This fear is what distinguishes taijin kyofusho from Western anxiety disorders. Asian cultures tend to place importance on the well-being of the group rather than that of the individual (i.e. these cultures are collectivist, which lies in direct opposition to the individualist tendencies of most Western cultures); these cultural differences allow for anxiety disorders to manifest themselves differently in each culture’s populations.

Dealing with these culture-bound syndromes from a diagnostic point of view is controversial. This lies in the representation of culture-bound syndromes in the classification system of the American Psychiatric Association (APA) for abnormal psychology, the DSM. More specifically, the DSM’s descriptive nature raises difficulties for classification. Fitting culture-related specific syndromes into the categories of the existing classification system is problematic because many of these are illnesses “defined or manifested by multiple or heterogeneous clinical psychiatric conditions that are difficult to fit under a single diagnostic entity” (Ibid.). Forcing the culture-related syndromes into such a classification runs the risk of losing the unique cultural meaning of the syndromes (Guarnaccia, 1993). Some academics believe this to be a fundamental problem with the DSM; all disorders (not just the so-called culture-related syndromes) warrant a careful cultural consideration to be reflected in the DSM, because all disorders have a cultural component to some degree (Tseng, 2006). Culture-bound syndromes simply have a stronger cultural component than other syndromes. It has indeed been shown again and again that culture can influence health to a great degree, conditioning people to be either particularly resistant or particularly susceptible to a given malady. For example, patients with schizophrenia have been found to experience vastly different symptoms depending on their ethnicity, and these symptoms have been found to correlate very strongly with cultural factors; models of schizophrenia, therefore, now include culture as a significant etiological or protective factor (Brekke & Barrio, 1997).

The DSM was developed in a Western country, but, with the spread of globalisation, is applied to Westerners and non-Western people alike, regardless of their origin. Ignoring cultural factors when diagnosing and treating health problems may be acceptable when every member of the population is exposed to the same social context. Differences in well-being would then likely be due to some cause or variable which varies from person to person (e.g., genetic predispositions, traumatic past events, etc.). But when cultures vary wildly from person to person, differences in well-being may be at least partially due, to cultural diversity.

Therefore, increased globalisation does not render a cultural approach to health irrelevant, as the cultural homogenisation thesis would argue, because globalisation will not wholly eliminate local cultures. On the contrary, increasing globalisation causes different cultures to come into more contact with one another than ever before, which makes apprehending health problems from a cultural perspective more relevant and important than it has ever been. It is indeed not in spite of globalisation that health psychology should continue to be approached via a cultural perspective, but because of it.

Evolution of Syndromes Through Time

The tendency of globalisation to bring different cultures together exerts one more force on culture which needs to be appreciated: globalisation causes cultures to trans- form and evolve in unique and unexpected ways. Even recognised culture-bound syndromes evolve as the “cul- tural traits or circumstances that contribute to specific syndromes are modified in association with changes in the society” (Tseng, 2006). For instance, the prevalence of taijin kyofusho in Japan has dramatically decreased in association with sociocultural changes occurring in the country (Nishizono, 2005). To better illustrate this notion we can examine the unique form that suicide has histori- cally taken in Japan and how globalisation has affected (but not eliminated) this cultural phenomenon.

In 2009, according to the Japanese Ministry of Health, Labour, and Welfare, 30,707 people (24.4 per 100 000) committed suicide in Japan (Motohashi, 2011). The total has remained higher than 30,000 per year since 1998, thus “posing a serious and urgent challenge for Japanese soci- ety” (Motohashi, 2011).

In the West, suicide is currently seen as ipso facto evidence of mental illness (Young, 2002). However, suicide mani- fests itself somewhat differently in Japan. For instance, the term shinju originally meant a “mutual suicide agreement by lovers in order to prove the genuineness of their love to each other” (Takahashi, Hirasawa, Koyama, Senzaki, & Senzaki, 1998). In recent years, the term’s definition has become looser; it now includes a genuine suicide pact, ex- tended suicide (i.e. assisted suicide followed by suicide) and murder-suicide (where one party kills another with whom he or she has close ties before killing him or herself) (Takahashi et al., 1998). What all of these forms of suicide have in common is the feeling of oneness shared by those involved.

Oyako-shinju is a specific category of shinju consisting of parent-child suicide. Most cases of oyako-shinju are boshi-shinju, wherein a mother kills her children be- fore killing herself. Generally, the children involved in boshi-shinju are of preschool age, and what drives the mother to commit such an act are psychiatric disorders and family conflicts. It should be noted that, though the incidence of murder-suicide is similar across cultures, each culture deals with it differently (Ibid.). Arguably, “the important point in studying the relationship between shinju and Japanese culture is not to focus only on statistical analysis and literature on shinju in Japan and other cultures, but to concentrate on the sympathy Japanese have toward shinju” (Aizawa, 1975). Indeed, parents who commit suicide with their children are pitied, rather than shunned, by the Japanese; this may be due to the collectivist nature of Japanese culture (in contrast with the individualist nature of Western cultures). This means that the boundaries between individuals in Japan can be more blurred than in Western societies, where individuality is prized (Takahashi et al., 1998). According to Japanese logic, the mother does not commit boshi-shinju because of any ill-will she harbours towards the child; rather, the suicidal mother believes that no one can take care of her child as well as her, and she would rather kill the child than leave him or her behind in the world without her. She does not see herself as murdering another person, but rather as murdering a part of herself: hence, the Japanese consider boshi-shinju to be a form of extended suicide rather than murder-suicide. It is the collectivist nature of Japanese society that allows for its people to think in this manner. In contrast, Western society considers the child to be a totally separate entity from the mother, and the concept of oyako-shinju or boshi-shinju would not be accepted as a form of extended suicide, but as murder-suicide (Ibid.). In cases where the mother successfully kills her children, but inadvertently fails to kill herself, Western societies would put her on trial for murder. In Japan, the sentence would “likely be light, if any, and more sympathy would be given to the mother” (Ibid.). Oyako-shinju and boshi-shinju illustrate quite well the collectivist nature of Japanese society.

Within the Japanese social context, the act of suicide is a “positive moral act because the values underpinning it are directly related to a socially pervasive moral belief that any act of self-sacrifice is a worthy pursuit” (Young, 2002). In other words, suicide in Japan is not always seen as a denial of the value of life, but as an affirmation of the value of one’s moral duty to others (Ibid.). Indeed, in Japanese culture, suicide is a means of taking social responsibility for one’s acts. Suicide in Japan thus has a redemptive quality to it. The source of redemption is two-fold: first, it derives its philosophical strength from Confucian teachings about a life of propriety (Ibid.); secondly, it draws on seppuku, a thousand-year-old form of ritualistic suicide performed by samurai who wished to accept responsibility for their actions and mistakes. Seppuku is rarely performed nowadays, but “the values surrounding the act still resonate in the minds of modern Japanese because these values are integral to the Japanese moral ideal of virtue” (Ibid.). Suicide thus becomes another way for the self to be sacrificed for the well-being of the group to which the person be- longs (Ibid.).

Japan, then, is an established collectivist society in which suicide is hailed as a moral act of taking responsibility. Globalisation has not changed the uniqueness of the status of suicide in Japan, but it has transformed it in a particular way. The popularity and reach of the Internet have aided the process of globalisation to such an extent that globalisation and the Internet can almost be considered extensions of one another. In this vein, the trend of Internet group suicide in Japan is an instance of globalisation transforming a culture without eliminating its essence.

Internet group suicide is a relatively new phenomenon wherein strangers connect on the Internet and make plans to commit suicide together (Ikunaga, Nath, & Skinner, 2013). Although this form of suicide is portrayed as a “new” trend in Japanese media, it is important to note its similarity to shinju; Internet suicide, too, consists of a small group of people committing suicide together. The difference is that the individuals who commit suicide together via the Internet are complete strangers (Ikunaga et al., 2013). According to one academic, “an anonymous other who is not intimate is a […] stranger. A person who is not anonymous but also not intimate is an acquaintance. A person who is not anonymous and who is intimate is a friend. […] Now, however, we have the intimate stranger, a person who is anonymous but also intimate” (Tomita, 2005). The availability of the Internet thus allows for a new kind of social relationship to form, the paradoxical “intimate stranger”, wherein “anonymity becomes the basis for intimacy” (Ikunaga et al., 2013).

Conclusions

The cultural homogenisation thesis states that, as the process of globalisation continues, local cultures will eventually merge to form a single global culture, calling into question the relevance and importance of continuing to approach health psychology from a cultural perspective. However, it is unlikely that cultural homogenisation as such will come to be; globalisation will not make cultural health psychology a meaningless pursuit. In fact, globalisation brings different cultures together to such an extent that cultural health psychology is more necessary today than ever. When a society is culturally homogenous, differences in their well-being may be due to some other aspect of their lives and vary according to the individual. However, unshared cultural upbringings can be reasonably asserted as a cause for differences in well-being. Furthermore, globalisation influences and transforms cultures to transform without losing their uniqueness. Japan’s culture remains one of the world’s most unique, despite generations of globalisation. A cultural perspective must be employed in order to understand the changing nature of health for people around the world. Cultural health psychology remains a field of importance because of globalisation, and not in spite of it.

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This article was originally published in the 2015 Spring issue, and can be seen here.
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