Culture influences the experience and expression of distress from its inception. While Western psychiatry has identified several universal patterns of distress, there are significant geographical variations in the prevalence, symptomatology, course and outcome of psychiatric illness. Indirect evidence suggests that cultural differences in the recognition, labelling and interpretation of deviant behaviour affect the outcome of major psychiatric disorders as well as milder forms of distress. Emotion theory and the cultural concept of the person provide links between social and cognitive processes that contribute to the natural history of emotional distress. However, many current studies of ethnopsychology confound psychology (mechanisms of behaviour) and meta-psychology (theories of the self). Further advances in understanding the impact of culture on distress depend on the development of psychological and social theory that is neither ethnocentric nor naive about the wellsprings of action. Three arenas for further study are identified: (1) the handling of the gap between experience and expression; (2) the labelling of deviant behaviour and distress as voluntary or accidental; and, (3) the interpretation of symptoms as symbols or as meaningless events. Attention to these themes can guide re-thinking the assumptions of Western psychological and social theory.