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					Cultural Assessment in Mental Health: DSM-IV TR Outline for Cultural Formulation
Francis G. Lu, MD Professor of Clinical Psychiatry, UCSF

INTRODUCTION: ETHNIC AND CULTURAL CONSIDERATIONS
Diagnostic assessment can be especially challenging when a clinician from one ethnic or cultural group uses the DSM-IV classification to evaluate an individual from a different ethnic or cultural group. A clinician who is unfamiliar with the nuances of an individual's cultural frame of reference may incorrectly judge as psychopathology those normal variations in behavior, belief, or experience that are particular to the individual's culture.

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For example, certain religious practices or beliefs (e.g., hearing or seeing a deceased relative during bereavement) may be misdiagnosed as manifestations of a Psychotic Disorder.

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Applying Personality Disorder criteria across cultural settings may be especially difficult because of the wide cultural variations in concepts of self, styles of communication, and coping mechanisms…

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It is hoped that these new features will increase sensitivity to variations in how mental disorders may be expressed in different cultures and will reduce the possible effect of unintended bias stemming from the clinician's own cultural background.

BIAS
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Prejudice Discrimination Racism Sexism Classism Ageism Homophobia Bias Against Religion/Spirituality

“We just can’t know all about 100 cultures, this is hopeless, so why bother?”
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The antidote to the above statement requires both the attitude of humility and the skill of self-reflection. Appreciating the complexities of cultural assessment and formulation requires: Knowing that we don't know rather than making assumptions. Knowing about our biases and prejudices, either intentional or unintentional.

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“We just can’t know all about 100 cultures, this is hopeless, so why bother?”
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Knowing the limits of our knowledge and skills. Knowing when to get a cultural consultation. Despite gaps in our knowledge and skills, we can learn a structured process like the Outline for Cultural Formulation, which can help us frame the cultural issues that impact on diagnosis and treatment.

DSM-IV TR Outline for Cultural Formulation
A. Cultural identity of the individual B. Cultural explanations of the individual’s illness C. Cultural factors related to psychosocial environment and levels of functioning

D. Cultural elements of the relationship between the individual and the clinician E. Overall cultural assessment for diagnosis and care

A.Cultural Identity of the Individual
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Note the individuals’ ethnic or cultural reference groups. For immigrants and ethnic minorities, note separately the degree of involvement with both the culture of origin and the host culture (where applicable). Also note language abilities, use, and preference (including multilingualism).

Cultural Identity—Think Wide
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Ethnicity Race National Origin/Indigenous Culture Migration/Acculturation/Biculturality Language (s) Age Gender Sexual Orientation

Cultural Identity—Think Wide
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Religious/Spiritual Aspects Socioeconomic status Political orientation Disabilities Other aspects of identity

Cultural Identity—Think Deep
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“Asian” encompasses 30 Asian subgroups and 21 Pacific Islander groups. National origin does not define a homogeneous ethnic group. For example, there are 54 distinct ethnic groups in Vietnam. Differences between ethnic subgroups as well as regional differences within countries.

Cultural Identity—Think Deep—Iraq as an example
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Tribal affinity—One of the few characteristics that most Iraqis share; loyalty often ranks higher than religious affiliation. 150 tribes. Ethnicity—Arab (80%), Kurdish (15%), other (5%). Most Kurds are Sunni Muslims. Religion—Muslim 97% (Shiites 65%, Sunnis 35% vs. 15% and 85% of the world’s Muslims), Christian or other 3%.

Cultural Identity—Connect the Dots—the Case of Mr. M.
(Weinreich, et.al., 2003)
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M. lives in a large city in the north of Israel. He defines himself as a Palestinian Christian Arab with Israeli citizenship. As a Palestinian, he shares the fate of his people in Israel, in the West Bank, and in the Palestinian Diaspora, striving for some type of national self-determination.

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As a Christian, M. is historically and theologically connected to Christians all over the world. On the other hand, M. speaks Arabic and considers himself part of the Arab culture, particularly of the local Arab culture, shared by the Muslim and Christian Arabs. M. also holds Israeli citizenship; he has many Israeli Jewish neighbors; is quite fluent in the Hebrew language, and is attracted to many aspects of Israeli Western lifestyle.

Further Variations on Cultural Identity
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Identity diffusion/conflicts Defensive high self-regard Indeterminate identity Confident identity/openness to various groups

Cultural Identity --Inquire, Don’t Assume
“A person’s identity is defined as the totality of one’s self-construal, in which how one construes oneself in the present expresses the continuity between how one construes oneself as one was in the past and how one construes oneself as one aspires to be in the future.” (Weinreich, 2003).

Idealistic (Aspirational) Identification…
“The extent of one’s idealistic identification with another is defined as the similarity between the qualities one attributes to the other and those one would like to possess as part of one’s ideal self-image”.

Contra-identification…
“The extent of one’s contra-identification with another is defined as the similarity between the qualities one attributes to the other and those from which one would wish to dissociate”.

Cultural Identity— From Fixed, Singular Entity to Many Aspects in Flux/Process
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Time--past-present-future Place—International and national migration Situation—At home with family vs. with friends vs. at work vs. with the healthcare provider Identity as I see myself vs. how others see me Conscious vs. unconscious aspects

Cultural Identity—How is it important?
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Cultural identity can impact on idioms of distress/explanations of illness, stressors and supports in the person’s life, and the cultural elements of the relationship with the healthcare provider. Cultural identity can be a source of support or distress (when conflicted or diffuse) both intrapsychically, interpersonally and in the community and society.

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Clinicians can prematurely close on and make assumptions about the person’s cultural identity, then make erroneous assessments, diagnosis and treatment plans. This could contribute to poorer outcomes, less cost-effectiveness and healthcare disparities. Clinicians will enhance rapport and the therapeutic relationship by being respectful to the whole person including his/her cultural identity.

B. Cultural Expressions and Explanations of Illness
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Idioms of distress Meaning and perceived severity of symptoms in relation to the norms of the cultural reference group Culture-bound syndromes Explanatory models Treatment pathway—history and expectations (professional and popular sources of care)

Consumer Centered Assessment
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What do you think has caused your mental health concern? Why do you think it started when it did? What do you think your mental health concern does to you? How severe do you consider the problem? How has your mental health concern changed over the past week/month/year? What have you been doing or taking so far for this mental for this mental health concern?

Consumer Centered Assessment
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What kind of intervention do you think you should receive? What are the most important results you hope to receive from this intervention? What are the chief problems your mental health concern has caused you? What do you fear most about your mental health concern?

Definition of Somatization
Somatization is the expression of mental distress as symptoms of physical illness when no medical condition cause for illness can be found.

Stigma
The stigmatization of mental illness prevents many individuals and families from seeking help. Clinicians need to be especially sensitive to the cultural shame associated with mental illness, respect the family’s face-saving needs, and be particularly careful to maintain confidentiality.
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Culture Bound Syndromes
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Recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category. Many of these patterns are indigenously considered to be “illnesses,” or at least afflictions, and most have local names. The particular symptoms, course, and social response are often influenced by local cultural factors.

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Some conditions and disorders have been conceptualized as culture-bound syndromes specific to industrialized culture (e.g. Anorexia Nervosa, Dissociative Identity Disorder), given their apparent rarity or absence in other cultures. All industrialized societies include distinctive subcultures and widely diverse immigrant groups who may present with culture-bound syndromes.

Culture Bound Syndromes
Amok  Dhat  Hwa-byung  Koro  Latah  Qi-Gong Psychotic Reaction  Shenjing Shuairuo (“Neurasthenia”)  Shen-K’uei  Shin-byung  Taijin kyofusho
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Traditional AAPI Beliefs on the Causality of Mental Illness
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Common cultural explanations AAPIs believe may contribute to the development of mental illness: Humoral Beliefs Supernatural Intervention Spiritual Beliefs Physical and Emotional Strain and Exhaustion Medical Illness Beliefs Character Weakness

Conceptualizations of Mental Illness in Pacific Islander Cultures
For many cultures of the Pacific there is no direct translation for mental illness because emotional and psychological problems are often integrated holistically with biological, cognitive, and spiritual functions. In Native Hawaiian culture, Hawaiians do not use the phrase mental illness but instead state that pilikia (trouble) occurs. Emotional and psychological concerns are viewed in a broader context as an imbalance that may be occurring in key relationships between the individual, family, natural and spiritual realms.

Traditional Explanatory Models and Treatment Pathways-Chinese
Beliefs- Mental illness is caused by a lack of harmony of emotions or by evil spirits
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Coping Behaviors and Treatment Often try traditional herbs and acupuncture first; healers may be used concurrently to get rid of evil spirits
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Traditional Explanatory Models and Treatment Pathways-Japanese
Beliefs- Mental illness is caused by evil spirits; often thought not to be real illness
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Coping Behaviors and Treatment Delay or avoid seeking use traditional sources of care
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Traditional Explanatory Models and Treatment Pathways-Vietnamese
Beliefs-Depression is sadness  Coping Behaviors and Treatment-Not readily acknowledged because of the stigma; usually try home remedies, spiritual consultations, or Chinese herbs before seeking Western medical care; some use of exorcists; seek help only when problems become acute or obvious; family members try to cheer up or distract the consumer
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Traditional Explanatory Models and Treatment Pathways-Korean
Beliefs-Mental illness is caused by disruption of harmony within an individual or by ancestral spirit coming back to haunt a person because of past bad behavior; result of bad luck or misfortune payback for something done wrong in the past and is considered shameful
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Coping Behaviors and Treatment Many deny problems, resulting in helplessness and depression; not likely to reveal the problem unless asked; may show signs through non-verbal communication and posture; may use shamanism
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Examples of CAM or Indigenous Healing Practices
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Alternative Medical Systems such as ayurveda, homeopathy, naturopathy, acupuncture, cupping, and coining. Mind-Body Interventions such as meditation, hypnosis, dance/music/art therapy, prayer, and mental healing (e.g., Shamanism).

Biologically-based Therapies such as herbal therapies, Atkins/Ornish/Pritkins diets, and vitamins.  Manipulative and Body-based Methods such as osteopathic manipulations, chiropractic, and massage therapy.  Energy Therapies such as qi gong, reiki, therapeutic touch, and magnets.
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C. Cultural factors related to psychosocial environment and levels of functioning.  Note culturally relevant interpretations of social stressors, available social supports, and levels of functioning and disability. This would include stresses in the local social environment and the role of religion and kin networks in providing emotional, instrumental,

Axis IV: Psychosocial and Environmental Problems
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Negative life event Environmental difficulty or problem Familial or other interpersonal stress Inadequacy of social support or personal resources Other problem relating to the context in which a person’s difficulties have developed

Axis IV
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Problems with primary support group Problems related to the social environment
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Difficulty with acculturation; discrimination

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Educational problems Occupational problems Housing problems

Axis IV
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Economic problems Problems with access to health care services Problems related to interaction with the legal system/crime Other psychosocial and environmental problems  War; discord with nonfamily caregivers such as counselor, social worker, or physician

Common Stressors Experienced by AAPIs
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• Pre-Migration Stress • Migration Stress • Post-migration Stress and Culture Shock • Acculturation • Employment/financial status changes • Gender role conflicts • Old age • Social Isolation • Immigration Status • Communication Gaps • Family Role Reversal • High Parental Expectations • Racism, Prejudice, and Discrimination

Culturally Related Strengths and Supports Personal Strengths (Hays, 2001)
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Pride in one’s culture Religious faith or spirituality Artistic abilities Bilingual and multilingual skills Group-specific social skills Sense of humor Culturally-related knowledge and practical skills Culture-specific beliefs that help one cope Respectful attitude toward the natural environment Commitment to helping one’s own group Wisdom from experience

Culturally Related Strengths and Supports Interpersonal Supports
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Extended families, including non-blood related kin Cultural or group-specific networks Religious communities Traditional celebrations and rituals Recreational, playful activities Story-telling activities that make meaning and pass on history of the group Involvement in political or social action group

Culturally Related Strengths and Supports Environmental Conditions
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An altar in one’s home or room to honor deceased family members and ancestors A space for prayer and meditation Foods related to cultural preferences (cooking and eating) Pets A gardening area Access to outdoors for subsistence or recreation

D. Cultural elements of the relationship between the individual and the clinician
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Indicate differences in culture and social status between the individual and the clinician and problems that these differences may cause in diagnosis and treatment (e.g., difficulty in communicating in the individual's first language, in eliciting symptoms or understanding their cultural significance, in negotiating an appropriate relationship or level of intimacy, in determining whether a behavior is normative or pathological).

1. Cultural Identity of the clinician
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Self-reflection, awareness and understanding of one’s own personal and professional identity development Be aware of biases and limitations of knowledge and skills that might affect the clinical encounter

2. Cultural Identity of the patient compared to Cultural Identity of the clinician
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Cultural identity variable comparisons for similarities and differences Move from categorical approach to understanding of self-construal Factor in the context of the clinical encounter Problems in the clinical encounter, assessment and treatment that might arise from similarities and differences

3. Ongoing Assessment of the cultural elements of the relationship
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Rapport and respect Dealing with stigma and shame Empathy Communication, verbal and non-verbal Transference and Countertransference Involvement with significant others, community organizations

Ethnocultural Transference and Countertransference
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Inter-ethnic Transference Intra-ethnic Transference Inter-ethnic Countertransference Intra-ethnic Countertransference

Inter-ethnic Transference
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Over-compliance Denial of ethnicity and culture Mistrust, suspicion and hostility Ambivalence

Intra-ethnic Transference
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Omniscient-omnipotent therapist The traitor The autoracist Ambivalence

Inter-ethnic Countertransference
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Denial of ethnocultural differences Clinical anthropologist syndrome Guilt/Pity Aggression Ambivalence

Intra-ethnic Countertransference
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Over-identification Us and them Distancing Anger Survivor guilt Hope and despair

E. Overall Cultural Assessment for Diagnosis and Care
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The formulation concludes with a discussion of how cultural considerations specifically influence comprehensive diagnosis and care.

Overall Cultural Assessment
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Differential Diagnosis  Phenomenology  Prevalence  Course and Outcome Treatment Plan  Biological  Psychological  Sociocultural  Spiritural

Major Depressive Episode
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Culture can influence the experience and communication of symptoms of depression. Underdiagnosis or misdiagnosis can be reduced by being alert to ethnic and cultural specificity in the presenting complaints of a Major Depressive Episode.

Major Depressive Disorders
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…Depression may be experienced largely in somatic terms, rather than sadness or guilt. Complaints of weakness, tiredness or “imbalance” (in Chinese and Asian cultures)…may express the depressive experience.

Differential Diagnosis
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Major Depression vs. Bipolar vs.with Psychotic features Dysthmia Adjustment Disorder with Depression Anxiety and Somatoform Disorders Medical Conditions-Cardiac, diabetes, others Substance-Induced Mood Disorder Neurasthenia Other Condition that May be a Focus of Clinical Attention

Treatment Planning
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Medications
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Follows diagnosis Negotiate treatment plan Start low, go slow, but usual doses may be needed Combine with herbal medicine and acupuncture?
“Be the Tiger Balm oil at the first interview.” -Evelyn Lee, Ed D

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Psychotherapy
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Treatment Planning
Family vs. Individual vs. Group  Supportive vs. Cognitive-Behavioral vs. Insightoriented Sociocultural Approaches  Public awareness to reduce stigma: radio shows, health fairs,  Integrate with Primary Care and other specialities: Let’s work together!  Alliance with churches, community organizations
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Key Concepts to Examining Intervention Strategies (Hays, 2001)
1. Develop knowledge of culturally relevant therapies and strategies, and adapt mainstream approaches (e.g., psychodynamic, humanistic/existential, behavioral, family systems therapies) to the cultural context of the consumer. 2. Consider religion and spirituality as a potential source of strength and support.

3. Become familiar with nonverbal expressive therapies, and obtain additional training when appropriate.

4. Use family systems interventions whenever possible. 5. Conceptualize “family” broadly to include gay, lesbian,bisexual or transgender (GLBT) parents/partners, single parents, elders, relatives, and non-kin family members.

6. Be willing to see individual members of subsystems of the family on an as-needed basis.

7. Recognize power differentials.
8. Use group therapy to create a multicultural environment in which consumers can learn from others, practice behaviors, and obtain support. 9. Intervene at sociocultural, institutional, and political levels when appropriate and possible. 10. Set goals, develop treatment plans, and choose interventions in collaboration with consumers. 11. When medications are prescribed, be aware of ethnic and age-related differences in metabolism and cultural expectations regarding medications.

Reference
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www.fanlight.com for description of “The Culture of Emotions” videotape and two other videotapes with Irma Bland and Evelyn Lee. Venues, 3 reviews, study guide and annotated bibliography. Francis.lu@sfphh.org /415 206 8984


				
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