MMHA South Australia Workshop
Monday 17th March 2008
Adelaide
Culture, Psychopathology, Therapy,
and Mental Health Service Delivery:
Foundations, Issues, Directions
Anthony J. Marsella, Ph.D., D.H.C.
Emeritus Professor
Department of Psychology
University of Hawaii
Honolulu, Hawaii 96822
marsella@hawaii.edu
PREFACE
“ Clouds come,
from time to time,
to give man a rest
from looking
at
the
moon.”
Basho (1644-1694)
Japanese Haiku Master
(C) AJM-1/1/2001
Parable of the Monkey and The Fish
A monkey and a fish were caught in a terrible
flood and were being swept downstream
amidst torrents of water and debris. The
monkey spied a branch from an overhanging
tree and pulled himself to safety from the
swirling water.
Then, wanting to help his friend the fish, he
reached into the water and pulled the fish
from the water onto branch. The moral of
the story is clear: Good intentions are not
enough. If you wish to help the fish, you
must understand its nature.
General Goals:
A. To inform participants regarding the
nature, role, and dynamics of ethnocultural factors in the determination
of PSYCHOPATHOLOGY;
B. To inform participants in the historical,
conceptual, methodological, and
empirical foundations issues of
ethnocultural aspects of
psychopathology, therapies, and
service delivery;
Specific Outcomes
A. Increased awareness and understanding of the
terms of reference associated with the study of
ethnocultural factors in psychopathology and
mental health (e.g., culture, ethnocentricity, sociopolitical context)
B. Increased awareness and understanding of the
history of ethnocultural aspects of psychopathology,
therapy, and service delivery;
C. Increased awareness and understanding of the
relationship of ethnocultural factors in the etiology,
epidemiology, manifestation, classification, and
treatment of psychopathology;
Specific Outcomes (Continued)
D. Increased awareness and understanding of the role
of ethnocultural factors in the assessment of
psychopathology;
E. Increased awareness and understanding of the role
of ethnocultural factors in therapy and service
delivery systems;
F. Increased awareness knowledge of non-Western
cultural systems, psychologies, and world views;
G. Increased awareness and understanding of the
importance of diversity and its consequences and the
need to preserve it as an inherent expression of life: A
new orientation.
I. NEW CHALLENGES,
NEW FACTS, NEW
PROBLEMS AND
ISSUES
WE LIVE IN A GLOBAL AGE:
THE INTERDEPENDENCY OF OUR TIMES
Human survival and well being is now embedded in a
complex and interdependent global web of economic,
political, social, technical, and environmental events,
forces, and changes.
The scale, complexity, and consequences of these events,
forces, and changes constitute an important challenge to
our individual and collective well being by confronting us
with an array of complex, conflicting, and confusing
demands and/or opportunities.
Our response to this challenge -- as individuals and as
societies -- will shape the nature, quality, and meaning of
our lives in the coming century
(Marsella, 1998, p. 289).
GLOBAL CULTURAL CONTEXT OF THE
TWENTY FIRST CENTURY
•
Globalization/Rapid Social Change
•
Poverty, Unemployment
•
Environmental Desecration and Depletion of
Natural Resources
•
Famine, Starvation, Malnutrition
•
Over-Population and Aging Population
(6.25 billion going to 9 billion with 40 years)
•
International Organized Crime (Drugs)
•
Urban Decay and Collapse of Infrastructure
GLOBAL CULTURAL CONTEXT OF THE
TWENTY FIRST CENTURY
•
International Terrorism
•
30 Ethnopolitical Wars/ Low Intensity Wars
•
International Migration
•
Theocratic Movements
•
Corruption in Business/Government
•
Refugees and Internally Displaced People
•
Public Health Epidemics (AIDS, Malaria)
•
Human Rights Violations
Some “Colorful” Facts
• Five of six people in the world are of nonEuropean/Caucasian ancestry. To whom
does the world belong?
• The birthrates of whites in many Western
nations are falling (also Japan).
• More than 50% of the population in every
Arabic country is below age 25.
• The world population is 6 billion and will
move toward 9 billion within a few decades.
90% of the birthrate increases are in
developing countries.
Some “Colorful” Facts
• There are more than 1.3 billion Muslim people in
the world, and the rates of growth
are
rapidly increasing.
• There are 192 nations in the United Nations
but
there are more than 5000 identifiable
ethnocultural groups in the world.
• Sizeable portions of ethnic and racial minority
groups still remain disenfranchised,
marginalized, and impoverished.
• Ethnic and racial minority populations in the USA
are increasing through birthrates and
migration.
THE COMPLEXS GLOBAL ECOLOGY OF HEALTH
AND WELL BEING
Global Challenges
(e.g., Hegemonic globalization, Demographic Changes,
Poverty/Famine, Conflict and Violence and
Environmental Disasters)
Diversity Encounters
(Social Markers, World Views, Ways of Knowing, Values, Moralities)
Psycho-Social
(Intra-Psychic/Relations)
Psychological, Behavioral,
Emotional Problems
Socio-Political
(Societal/Governmental)
Collective, National
International Problems
Psycho-Social and Socio-Political Levels
Individual Level
Future Shock
Culture Shock
Alienation/Anomie
Acculturation Stress
Meaninglessness
Identity Crises
Fear, Anger, Suicide,
Despair/Hopeless
Psychopathy, Greed
Substance Abuse
Deviancies
Paranoia, Distrust
Fanaticism
Uncertain/Confused
Collective Level
Cultural Disintegration
Genocide/Ethnic Cleansing
Surveillance
Vigilantism/Hate Crimes
Social Fragmentation
Hyper-Religiosity/Cults
Terrorism
Deviancies
Gangs/Violence
Greed
Corruption
Family Disintegration
Fascism
Militarism/Policing
Copyright: AJM-2007-ATL
THE PSYCHOSOCIAL CONTEXTS OF HEALTH
AND WELL BEING
• We cannot have health and well being where there is
cultural abuse, destruction, and collapse for this
breeds confusion and conflict.
• We cannot have health and well being where there is
oppression and domination, for this breeds anger,
hate, and resentment.
• We cannot have health and well being where there is
humiliation, for this breeds rage and revenge.
• We cannot have health and well being where there is
powerlessness, for this breeds helplessness and
despair.
THE PSYCHOSOCIAL CONTEXTS OF HEALTH
AND WELL BEING
•
We cannot have health and well being where there is
poverty, for this breeds hopelessness and misery.
•
We cannot have health and well being where there is
denigration, for this breeds low esteem and
worthlessness.
•
We cannot have health and well being where there is
racism, sexism, and ageism for this breeds
fragmentation and restrains opportunity and denies
choice.
II. SOME CULTURE
AND
PSYCHOPATHOLOGY
QUESTIONS
Some Basic Questions in the Study of
Culture and Psychopathology
1. What is the role of cultural variables in the etiology
of psychopathology?
2. What are the cultural variations in standards of
normality and abnormality?
3. What are the cultural variations in the classification
and diagnosis of psychopathology?
4. What psychometric factors must be considered in the
assessment of psychopathology across cultures?
Some Basic Questions (Continued)
5. What are the cultural variations in the
phenomenological experience, manifestation,
course and outcome of psychopathology?
6. Are all psychiatric disorders culture-bound?
•
Are there cultural variations in therapy systems?
8. How do we design and offer mental health services
that are culturally appropriate?
THE “NEW” MENTAL HEALTH CLINIC
Foreign Patients - Foreign Professionals
Professionals
American Filipino Pakistani Nigerian
Patients
Hispanic
Vietnamese
Arabic
Nigerian
Korean
Multicultural Orientation
Sue, D. W., & Sue, D. (1990). Counseling the culturally different:
Theory and practice (2nd ed.). New York: Wiley, p. 6.
[Mental health professionals] . . . have a personal
and professional responsibility to (a) confront,
become aware of, and take actions in dealing
with our biases, stereotypes, values, and
assumptions about human behavior, (b) become
aware of the culturally different client’s world
view, values, biases, and assumptions about
human behavior, and (c) develop appropriate
help-giving practices, intervention strategies, and
structures that take into account the historical,
cultural, and environmental experiences and
influences of the culturally different client.
Growing Antagonism Toward Western
Psychiatry (Chakraborty, 1992)
Even where studies were sensitive, and the aim was to show
relative differences caused by culture, the ideas and tools
were still derived from a circumscribed area of European
thought.
This difficulty still continues and, despite, modifications,
mainstream psychiatry remains rooted in Kraepelin's classic
19th century classification, the essence of which is the
description of the two major "mental diseases ” seen in
mental hospitals in his time -- schizophrenia and manic
depression. Research is constrained by this view of
psychiatry.
Antagonism (continued)
A central pattern of (western) disorders is identified
and taken as the standard by which other (local)
patterns are seen as minor variations. Such a
construct implies some inadequacy on the part of
those patients who fail to reach "standard." Though
few people would agree with such statements, there is
evidence of biased, value-based, and often racist
undercurrents in psychiatry. . . .
Psychiatrists in the developing world . . . have
accepted a diagnostic framework developed by
western medicine, but which does not seem to take
into account the diversity of behavioral patterns they
encounter
(Chakraborty, 1992, p. 1204).
III. THE SOCIOPOLITICAL CONTEXT
OF MENTAL HEALTH
Some Basic Premises
1.
Western mental health approaches and
systems are cultural constructions that
reflects the assumptions, values, and
practices of our dominant Western cultural
context and history. They implicitly support
a Western social, ecnomic, and political
system;
2.
Historically, this dominant Western cultural
context has been driven by a popular
culture committed to individuality, personal
responsibility, materialism, competition,
reductionism, consumerism,
patriarchy,
empiricism, and Protestant ethic.
Some Basic Premises (Continued)
3.
The history, assumptions, knowledge,
values and practices of Western mental
health are being challenged by changing
global conditions, especially increased
contact and interactions with non-Western
ethnic and cultural minorities who have
different cultural constructions of reality.
4.
The world has become a globalcommunity in which our individual and
collectives lives have become
increasingly interdependent. We cannot
avoid contact or interaction
Marsella (C)2001-Hawaii
Basic Premises (Continued)
5.
Mental health appraoches and systems must
respond to this new interdependence – this new
global ecology associated with our changing
times, events, and challenges with a new
flexibility, energy,
determination, wisdom,
commitment.
6.
We must think transformationally! We must ask
new questions and set new horizons!
Responsivity rather than resistance to change
must
become part of our professional
orientation.
7.
We need to be multicultural, multisectoral,
multinational, and multidisciplinary approaches.
Marsella (C)2001-Hawaii
Basic Premises (Continued)
8.
We must be alert to the ethnocentric biases
inherent in Western mental health
approaches and systems and choose to value
the diverse psychologies of the world.
9.
We must resist the hegemonic imposition or
privileged positioning of any national or
cultural psychology;
Marsella (C)2001-Hawaii
Basic Premises (Continued)
11. We must substantially address tra8ining,
research,
and
service
activities
to
accommodate to the new global realities of
our times.
12. We must be prepared to work in new
settings (e.g., refugee camps, war zones,
street corners, disaster zones) as well as in
offices, clinics, and hospitals.
Marsella (C)2001-Hawaii
BASIC PREMISES (CONTINUED)
9.
A professional psychology and science that
requires an increased understanding and use
of non-Western and indigenous
psychologies.
10. This professional psychology and science
requires substantial change in the
educational curriculum and process;
Marsella (C)2001-Hawaii
MULTICULTURAL PSYCHOLOGY
CODE
•
•
•
•
•
•
•
•
•
It is a way of life -- It is not an 8:00 - 5:00 job!
It is a world view
It is committed to diversity, social justice and activism
It is concerned with optimizing communication
It is concerned with empowering individuals,
groups, and nations
It is concerned with offering hope, optimism, and
opportunity
It is concerned with addressing poverty, oppression,
abuse, inequality and locates problems within these
societal contexts
It is ecological, historical, interactional, and contextual
It is political, revolutionary, and progressive
Social Justice and Mental Health
Professionals
(Prilletensky, 1998, p. 6)
. . . when it comes to social justice, mental
health workers are at a loss. This is not
because of a lack of models, but rather
because of a perennial, pervasive, and
unjustified separation between their role as
citizens and their role as professionals.
Social justice, we are told belongs in
the private life of the psychiatrist and the
psychologist, not in their professional role.
Social Justice (Continued)
In the end, psychologists adopt and
propagate a discourse that locates
pathology within individuals, that produces
victim-blaming, and that diverts attention
from issues of social justice because it
reduces social problems to issues of
personal struggle
(Prilletensky, 1998, p. 6; Fox, 1997)
IV. HISTORICAL
FOUNDATIONS
HISTORICAL PERSPECTIVES
ACADEMIC AND PROFESSIONAL SPECIALTIES:
Kraepelin (1904)
Vergleichende Psychiatrie
Devereux (1940)
Primitive Psychiatry
Slotkin (1955)
Culture and Psychopathology
Devereux (1956)
Psychiatric Anthropology
Devereux (1961)
Ethnopsychiatry
Kaelbling (1961)
Comparative Psychopathology
Kiev (1964)
Folk Psychiatry
Wittkower & Rin (1965) Transcultural Psychiatry
Murphy & Leighton (1965)
Cross-Cultural Psychiatry
Weinberg (1967)
Psychiatric Sociology
Kennedy (1973)
Cultural Psychiatry
Kleinman (1977)
The "New" Transcultural Psychiatry
Murphy (1982)
Comparative Psychiatry
(see Kraepelin, 1904)
HISTORICAL PERSPECTIVES
John Locke (1690), in his famous essay,
Concerning Human Understanding, stated:
Had you or I been born at the Bay of Soldania,possibly
our thoughts and notions had not exceeded those brutish
ones of the hottentots that inhabit there. And had the
Virginia king, Apochancana, been educated in England, he
had been perhaps as knowing a divine and as good a
mathematician as any in it; the difference between him
and a more improved Englishman lying barely in this, that
the exercise of his faculties was bounded within the ways,
modes, and notions of his own country, and never
directed to any other or further inquiries.
HISTORICAL PERSPECTIVES
Jean Jacques Rousseau (1749):
All at once I felt myself dazzled by a thousand
sparkling lights. Crowds of vivid ideas thronged into
my mind with a force and confusion that threw me
into unspeakable agitation; I felt my head whirling in
a giddiness like that of intoxication. A violent
palpitation oppressed me.
Unable to walk for
difficulty in breathing, I sank down under one of the
trees by the road, and passed half an hour there in
such a condition of excitement that when I rose I
saw that the front of my waistcoat was all wet with
tears. . . .
Rousseau (Continued)
. . . Ah, if ever I could have written a quarter of what
I saw and felt under that tree, with what clarity I
should have brought out all the contradictions of our
social system! With what simplicity I should have
demonstrated that man is by nature good, and that
only our institutions have made him bad.
(Rousseau, 1749; Quoted in Durant & Durant,
1967, p. 19)
HISTORICAL PERSPECTIVES
Insanity is a part of the price we pay for civilization.
The causes of the one increase with the developments
and results of the other. The increase in knowledge,
the improvement of the arts, the multiplication of
comforts, the amelioration of manners, the growth of
refinement, and the elevation of morals, do not of
themselves disturb men's cerebral organs and create
mental disorder.
But with them come more
opportunities for great and excessive mental action,
more uncertain and hazardous employment, and
consequently more disappointments, more means and
provocations for sensual indulgences, more accidents
and injuries, more groundless hopes, and more painful
struggle to obtain that which is beyond reach or to
effect that which is impossible
(John Jarvis - American Psychiatrist - 1851)
HISTORICAL PERSPECTIVES
(1875-1950 PERIOD)
1.
The study of cross-cultural study of mental disorders using
Western concepts (e.g., neurosis in India, psychosis in Africa).
2.
The study of relativistic standards of normality and
abnormality.
3.
The emergence of international and cross-cultural psychiatric
epidemiological studies.
4.
The popularization of Freudian views of human nature ("the
negative role of civilization").
5.
The rise and growth of culture and personality studies within
anthropology.
6.
Study of culture-bound syndromes
HISTORICAL PERSPECTIVES
Post-1970 Period
1.
International collaborative studies (e.g., the World
Health Organization Pilot Study of Schizophrenia).
2.
Increases in the number of ethnic minority mental
health professionals.
3. Growing disaffection of non-Western mental health
professionals with the ethnocentrism and bias of
Western psychiatry.
4.
Increases in social awareness of the pathological
sequalae of racism, sexism, imperialism, colonialism,
and other "isms."
History - Post 1970 Period - Continued
5. Increases in awareness of the pernicious consequences
of war, urbanization, poverty, and other socio-cultural
phenomena for mental health.
6. A growing awareness of the multiple and interactive
determinants of psychopathology (e.g., biology,
psychology, sociology).
7. Post-Modern Era emphasis on relativity and subjectivity
in human experience (i.e., the social construction of
reality- POSITIONS CULTURE AS A CRITICAL
DETERMINANT OF HUMAN BEHAVIOR)
Emil Kraepelin
Comparative Psychiatry (Vergleichende Psychiatrie)
The characteristics of the people should find
expression in the frequency as well as in the
shaping of the manifestations of mental illness in
general; so that comparative psychiatry shall
make it possible to gain valuable insights into the
psyche of nations, and shall in turn also be able to
contribute to the understanding of pathological
psychic processes
Emil Kraeplin (1904, p. 9)
Relevant Journals
Cross-Cultural Research
Cultural Diversity and Mental Health
Culture Medicine, and Psychiatry
Hispanic Journal of Behavioral Sciences
International Journal of Intercultural Relations
Interamerican Journal of Psychology
International Journal of Psychology
International Journal of Mental Health
International Journal of Social Psychiatry
Journal of Black Psychology
Journal of Cross-Cultural Psychology
Journal of Health and Social Behavior
Journal of Multicultural Counseling and Development
Journal of Refugee Studies
Medical Anthropology
Psychologia: The Journal of Psychology in the Orient
Social Psychiatry
Social Psychiatry & Epidemiology
Social Science and Medicine
South Pacific Journal of Psychology
Transcultural Psychiatric Research
CULTURE
CULTURE
CULTURE
VI.
CULTURE
CULTURE
CULTURE
THE CULTURE PSYCHOLOGY
SPECIALTIES
Cultural Psychology
Cross-Cultural Psychology
Ethnic Minority Psychology
Multicultural Psychology
Indigenous Psychologies
International Psychology
Transcultural Mental Health
Multicultural Counseling
DEFINITION OF CULTURE
Culture is shared learned behavior and meanings that are
socially transferred in various life-activity settings for
purposes of individual and collective adjustment and
adaptation. Cultures can be (1) transitory (i.e. situational
even for a few minutes), (2) relatively enduring (e.g.,
ethnocultural life styles), and in all instances are (3)
dynamic (i.e., subject to change and modification).
Cultures are represented (4) internally (i.e., values,
beliefs, attitudes, axioms, orientations, epistemologies,
consciousness
levels,
perceptions,
expectations,
personhood) and (5) externally (i.e., artifacts, roles,
institutions, social structures), and (6) shape and
construct our realities (i.e., they contribute to our world
views, perceptions, orientations) and with this, many of
our ideas, morals, and preferences.
THE CULTURAL CONSTRUCTION OF REALITY
Marsella (1996, 1999)
• There is a UNIVERSAL inherent human impulse to
describe, understand, and predict the world
through the ordering of stimuli;
The human brain responds to stimuli by organizing,
connecting, and symbolizing stimuli, and in the
process, generates patterns of meanings that
help
promote
survival,
adaptation,
and
adjustment;
· This process and product of this activity are, culturally
contextualized, generated, and shaped through
linguistic, behavioral, and socialization practices;
CULTURAL CONSTRUCTION OF REALITY
Marsella (1996, 1999) (Continued)
• Through
socialization,
individual
and
group
preferences
and priorities are rewarded or
punished thus promoting and/or modifying the
cultural constructions
of
reality
(i.e.,
ontogenies,
epistemologies,
praxologies,
cosmologies, ethoses, values, and behavior
patterns).
•
The Result:
A culturally constructed reality that
resists change and does not yield
well to contestations.
THE PROCESS OF SOCIALIZING CULTURAL
BELIEFS AND PRACTICES (Tart , 1986, pages 92-98)
1.
Unlimited time (years of exposure)
2.
Use of physical force to shape behavior
3.
Use of emotional force such love and
affection and fear
4.
Use of rewards for those who conform
5.
Trust in parents because of their
omnipotence
Socializing Culture (continued)
6.
Expectations of permanency
7.
Standards are promoted (shoulds and don’ts)
8.
Sense of security from group conformity
9.
Everything not permitted is forbidden and
everything permitted is compulsory.
2. CULTURAL SOCIALIZATION DIAGRAM
Ethos
Individualism
Materialism
Political
Family
Change
Schools
Psychology
Person
Violence
Biology
Media
Religion
Consumerism
Competition
Hedonism
Ethos
Celebrities
CULTURAL VARIATIONS
• Cultures differ in the ways they codify
and know reality.
•
There are cultural variations in the use
and emphasis of words, feelings,
images, visceral, proprioceptive,
skeletal means for handling “reality”
content and processes.
The Codification of
Human Experience
• Cognition
•
•
•
•
Imagery
Affective
Visceral
Proprioceptive
(C) AJM-1/1/2001
Subjective Experience of Reality:
Language, Experience, and Reality
(Marsella, 1978, 1986)
• Imagistic, Proprioceptive, Visceral Mediation of Reality
• Language is metaphorical, poetic, immediate, sensory
In this respect, a metaphorical language provides a
rich, immediate sensory experience of the world
that is not diluted by being filtered through words
that distantiate the cognitive understanding form
the experience. In a metaphorical language
system, the understanding and the language are
one.
Concrete metaphors link sensory experience and
cognition together.
Subjective Experience of Reality:
Language, Experience, and Reality (Continued)
•
Communication is based on relational negotiation in
which there are assumptions of awareness of
sensitivities, hierarchy, roles awareness. Strong
emphasis on reading non-verbal cues and “what is
not said.”
• Unindividuated Self Structure (e.g., Relational,
Collateral, Diffuse) in which self as process and self
as object become fused.
Contrasting Prototypical Cultural Patterns
Dimension
Culture A
Culture B
1. Self
2. Maturity
3. Style
4. Orientation
5. Communicate
6. Mode
7. Status
8. Effort
9. Determinants
10. Traditions
11. Generations
12. Knowing
Individual
Independence
Assertive
Product/Process
Direct
Verbal
Equality
Mastery
Person
Change/New
Distinct
Fission
Collective
Interdependence
Deferent
Process/Product
Indirect
Non-verbal
Hierarchical
Harmony
Destiny/Kharma
Preserve Past
Continuous
Fusion
ETHNOCENTRISM
A habitual, and often unconscious, tendency
or disposition to evaluate foreign people and
cultures by standards and practices of one’s
own ethnocultural group.
An inclination to view one’s own way of life as
the only proper or moral way with a resulting
sense of personal and cultural superiority.
A sense that one’s own way of believing or
behaving is the “true” or “best” way.
ETHNOCENTRISM
Other examples abound: Toynbee notes that Ancient Persia regarded
itself the center of the world and viewed other nations as increasingly
barbaric according to their degree of distance. China's very name is
composed of ideographs meaning "center" and "country" respectively,
and traditional Chinese world maps show China in the center. It's also
important to note that it wasn't just China that bought into this idea. At the
height of the Chinese empire, the Japanese, Koreans, Vietnamese, and
Thai also believed China to be the centre of the universe and referred to
China as the middle kingdom. To this day, Japan, Korea, and Viet Nam still
refer to China as the middle kingdom.
England defined the world's meridians with itself on the center line, and
to this day, longitude is measured in degrees east or west of Greenwich,
thus establishing as fact an Anglo-centrist's worldview. Native American
tribal names often translate as some variant on "the people"; other tribes
were labeled with often pejorative names. The United States has
traditionally conceived of itself as having a unique role in world history—
famously characterized by President Abraham Lincoln as "the last, best
hope of Earth"—an outlook known as American exceptionalism.
http://en.wikipedia.org/wiki/Eurocentrism
ETHNOCULTURAL IDENTIFICATION
The extent to which an individual endorses and
practices a way of life associated with a particular
cultural tradition.
Ethnocultural identification can be assessed by
self
nomination
scales
that
measure
attitudes/values, behaviors, and preferences
associated with a particular cultural tradition.
Ethnocultural
identification
is
a
dynamic
characteristic that may change across settings
and situations.
It is heavily determined by
generation,
historical
period,
personal
demographic variations.
Western
High
Bicultural,
Multicultural,
Syncretic
Acculturated
Traditional High
Low
Alienated
Traditional
Low
Ethnocultural Identification Matrix (Modified from
Kitano, 1982)
Integrated Model of Ethnic Identity
(Dina Birman, 1994)
Acculturative
Style
Identity
Acculturation
Behavioral
Acculturation
Traditional
Traditional
Traditional
Assimilated
Assimilated
Assimilated
Marginal
Marginal
Marginal
Blended Bicult.
Bicultural
Bicultural
Instrum. Bicult.
Marginal
Bicultural
Integrat. Bicult.
Traditional
Bicultural
Ident. Explor.
Traditional
Assimilated
Creating an Ethnocultural
Identification Scale
1.
Sample Attitudinal Items:
A.
What ethnocultural group do you
most consider yourself to be a
member of?
B.
How much pride do you have in
your ethnocultural group?
C.
Would you be willing to marry
outside your ethnocultural group?
Ethnocultural identification (Continued)
2.
Sample Behavioral Items:
A.
Do you speak your group’s
language?
B.
Do you eat their food?
C.
Do you participate in their
celebrations?
D.
Do you associate mainly with
friends from your group?)
VII. CULTURE AND
PSYCHOPATHOLOGY
FOUNDATIONS
CRITICAL ISSUES IN THE STUDY OF
CULTURE AND PSYCHOPATHOLOGY
1. Conceptual Models
2. Classifictaion
3. Normality and Abnormality
4. Nature Of Personhood and Self
5. Mind-Body Relationships
6. Assessment
7. Examples of PTSD & Schzophrenia
8. Multiple Causality
1. CONCEPTUAL FRAMEWORKS ,
PERSPECTIVES, AND MODELS
FOR UNDERSTANDING
PSYCHOPATHOLOGY
Multiple Determinants of Human Behavior
Culture
Biology
Person
Environment
Psychology
Person-Situation Ecological Model
Culture
Biology
Person
Environment
Situation
Psychology
Behavior
Behavior is the continuous and ongoing adjustment by the
organism to the simultaneous demands from both the person and
the situation. Thus, the determinants of human behavior reside
both within and without; the determinants within are constituted
from immediate and historical influences.
Hierarchical Systems Model
LEVEL
KNOWLEDGE
BASE
SAMPLE
VARIABLES
DISORDERS
Spiritual
Philosophy, Religion
Meaning, Purpose
Meaningless
Macrosocial
Politics, Economics
Sociology, Anthropology
Poverty, Social Change,
Urbanization
Cultural
Disintegration
Microsocial
Family Studies, Community
Studies, Workplace Studies
Family Relations
Work Adjustment
Family Abuse,
Work Stress
Psychosocial Personality Theory
Self Theory
Self Concept
Self Esteem
Low Self
Esteem
Cognitive/
Behavioral
Cognitive Sciences
Attention, Memory
Concentration
Sensory/
Motor
Sensation-Motor
Performance
Reaction Time
Sensory
Overload
PsychoPsychophysiology
physiological
Orienting Response
EEG, EKG
Stress
Hyperarousal
Biopsychosocial
Neurotransmitters
Depression,
Anxiety
Neurology, Psychiatry,
Neurochemistry, Anatomy
Ecological Framework for Understanding
Negative Mental Health and Wellbeing
Individual
Cultural
Sociopolitical
Discontent
Distress
Disorder
Deviancy
Disease
Abuse
Decay
Destruction
Dislocation
Disintegration
Colonialization
Exploitation
Imperialism
Isms
Disempowerment
Ecological Framework for Understanding
Positive Mental Health and Wellbeing
Individual
Health/Wellbeing
Competence
Adaptation
Meaning/Purpose
Spirituality
Cultural
Revitalization
Integration
Coherence
Rebuilding
Renaissance
Sociopolitical
Change
Reform/Justice
Equality
Civility
Reconstruction
Psychosocial Stressors (Marsella, 1988)
Needs
Deprivation
Denigration
Discrepancy
Conflict
Confusion
Values
Roles
Status
Identity
______________________________
______________________________
______________________________
______________________________
______________________________
___________________________________
The Conditions for Health and Wellbeing
Reside in the Total Context of Human Life:
•We cannot have health where there is cultural destruction, for
this breeds confusion and conflict.
• We cannot have health where there is oppression, for
this breeds anger and resentment.
• We cannot have health where there is powerlessness, for
this breeds only helplessness and despair.
The Conditions for Health and Wellbeing
(Continued)
•We cannot have health where there is poverty, for
this breeds only hopelessness.
•We cannot have health where there is denigration, for
this breeds low esteem and worthlessness.
•We cannot have health where there is racism and sexism, for
this restrains opportunity and limits choice.
SOCIOCULTURAL PATHWAYS TO DISTRESS,
DEVIANCY & DISORDER
Rapid and Destructive Social Change
(e.g., cultural change, collapse, abuse, disintegration, confusion)
Social Stress and Confusion
(e.g., family, community, work, school, goverrnment problems)
Psychosocial Stress and Confusion
(e.g., marginalized, powerlessness, alienation, anomie)
Identity Stress & Confusion
(e.g., Who am I, what do I believe)
Psychobiological Changes
(e.g., anger, hopelessness, despair, fear)
Behavioral Problems
(e.g., suicide, alcohol, violence,
substance abuse, delinquency)
2. Classification and
Diagnosis
(C) AJM-1/1/2001
Terms of Reference
Locus
(Mix and Match)
Mental
Psychological
Behavioral
Biobehavioral
Emotional
Psychiatric
Nervous
Descriptor
Maladjustment
Disorder
Disease
Illness
Dysfunction
Maladaptation
Disturbance
Deviancy
Insanity
Sickness
Breakdown
Derangement
Some Historical Contexts
Hippocrates (460-377 BC): Symptoms
•
•
Mania, Melancholia, & Phrenitis.
The Humoral Theory: Black Bile, Yellow
Bile, Blood, Phlegm
Paracelsus (1493-1531): Causes
•
•
•
•
•
Lunatici - caused by the moon phases
Insani - inherited
Vesani - impure foods or beverages
Melancholii - constitution
Obsessi - devil or demons or evil forces
Some Historical Contexts
Emil Kraepelin (1856-1926) (Father of Dx &
Classification)
•
•
•
Dementia Praecox - Cognition
Manic-Depressive - Mood/Emotion
Psychopathic - Will
The DSMs
DSM I (1952)
DSM II (1968)
DSM III (1980)
DSM IIIR (1997)
DSM IV (1994)
DSM – IVR (2000)
DSM –IV (2007-2001): Defense Mechanisms,
Bio-Markers, Family)
So Why Do We Classify and Diagnose?
• It is the hope that if we can classify
properly we will be able to know: (1)
cause, (2) onset, (3) display, (4)
course, (5) outcome, (6) treatment,
and (7) prevention.
• Instead we use it for different reasons
including: (1) insurance repayment,
(2) ward assignment, (3) declaration
of incompetence, (4) communication
among professionals (5) satisfy clients
and families (6) statistical reports, (7)
promote research.
What are Some of the Problems?
• Categories are not exclusive. Lots of mixtures
and symptoms overlaps. Dual Dx
• Issue of Reliability/Consistency
• Source of informations (e.g, Pt, Family, Tests,
Objective Data, Professional)
• Mixture of Causation and Description
• Equipotentiality/Equifinality
• Ethnocentricity – Bias against Non-Western
• Multiple Causality
Multiple and Interactive Causality
Maintenance
Exacerbative
Formative
Precipative
The Neo-Kraepelinian Movement
(Klerman, 1978)
• Psychiatry is a branch of medicine
• There is a boundary between normal and sick
• There are discrete mental illnesses
• The focus of psychiatric physicians should be
on biological aspects of mental illness
• There should be an intentional and explicit
concern with diagnosis and classification
“The Empowerment of the Medical Model”
What are Some of the Problems?
Conflict of Interest
Conclusion: Our inquiry into the relationships between
DSM panel members and the pharmaceutical industry
demonstrates that there are strong financial ties between
the industry and those who are responsible for developing
and modifying the diagnostic criteria for mental illness.
The connections are especially strong in those diagnostic
areas where drugs are the first line of treatment for mental
disorders. Full disclosure by DSM panel members of their
financial relationships with for-profit entities that
manufacture drugs used in the treatment of mental illness
is recommended.
What are Some of the Problems?
Conflict of Interest
Results: Of the 170 DSM panel members 95 (56%) had
one or more financial associations with companies in the
pharmaceutical industry. One hundred percent of the
members of the panels on ‘Mood Disorders’ and
‘Schizophrenia and Other Psychotic Disorders’ had
financial ties to drug companies. The leading categories of
financial interest held by panel members were research
funding (42%), consultancies (22%) and speakers
bureau (16%). Psychotherapy and Psychosomatics
(2006), 75, 154-160. Financial Ties between DSM-IV
Panel Members and the Pharmaceutical Industry
Lisa Cosgrove , Sheldon Krimsky, Manisha Vijayaraghavan, Lisa
Schneider
Copyright © 2006 S. Karger AG, Basel
Many Options – But Not for Insurance
(More than 300 Systems)
• Behavioral (e.g., Kanfer & Saslow)
• Syndromal (e.g., Lorr & Klett)
• Interpersonal/Familial (e.g., Benjamin)
• No Dx (e.g., Rogerian)
• Personality Dimensions (e.g., Eysenck)
• ICD –10 (WHO)
• DSM-IVR (American Psychiatric Assoc.)
(Multi-Axial Dx System: Disorder, Personality, Medical,
Stress Level, Coping)
Careful and Detailed Description
• Symptom Parameters (i.e., Frequency,
Severity, Duration)
• Situation (i.e., When, Who is present, Stop)
• Antecedents and Consequences (i.e., Starts,
Outcomes)
• Source of Information (i.e., Patient,
Professional, Family, Others)
• Detailed History (i.e., Utero, Birth, Diet, Sleep)
• Test Results and Biases
2A: DSM – IV TR
AND
CULTURE
(C) AJM-1/1/2001
Use of DSM-IV Across Ethnocultural
Boundaries
DSM-IV: "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." (Page XXIV DSM IV)
(C) AJM-1/1/2001
Cultural Formulation of a Case
(Page 843 - DSM-IV)
1
Cultural identity: Reference groups,
language preferences, attachment to origin
and host cultures
2.
Cultural explanations (e.g., nerves, spirits):
Meaning, causes, and perceived severity of
disorders
3. Psychosocial stressors and levels of
functioning: Social stressors, social
supports, level of functioning, disabilities
(C) AJM-1/1/2001
Cultural Formulation of Case (DSM-IV)
(Continued)
4.
Cultural aspects of relationship between
patient and clinician: Status differences,
problems communicating, level of
intimacy.
5.
Cultural evaluation of assessment and
care: How should cultural considerations
be incorporated into diagnosis and
treatment plan
(C) AJM-1/1/2001
CULTURAL VARIATIONS IN THE CLINICAL
PARAMETERS OF DISORDERS
(From Marsella & Yamada, ,2001)
1.
Perceived causes, nature, and control
2.
Patterns of onset
3.
Manifestation of symptoms
(e.g., guilt, anger, anxiety, somatic)
4.
Psychological representation
5.
Disabilities and impairments
6.
Course and progression
7.
Outcome
(C) AJM-1/1/2001
Problematic Diagnoses Across Cultures
1.
Personality Disorders (e.g., Dependent,
Avoidant, Explosive, Sociopathic)
2.
Psychotic Disorders
3.
Substance Abuse and Alcoholism
4.
Dissociative States
5.
Paranoid States
6.
Nutrition-Related Disorders
SAMOAN CONCEPTIONS OF MENTAL
DISORDER
1.
Ma'i o le mafaufau (physical brain abnormalities)
2.
Ma'i aitu (spirit possession)
3.
Ma'i valea (strange, severe, and stupid, improper
behavior)
4.
Excess emotion
Ma'i ita - anger, rage
Ma'i manatu - sadness, grief
Ma'i popole - worry
Examples of Culture-Bound Disorders
Disorder
Symptoms
Location
Amok
Withdrawal, Explosive
Violence
S.E. Asia/Philippines
Koro
Phobia of Penis
Shrinkage Into Body
Chinese Cultures
Latah
Echolalia/Echopraxia
S.E. Asia
Susto
Loss of Soul
Latin America
Delirante
Withdrawal/Fatigue
Caribbean
Pibloktoq
Panic/Agitation/Amnesia
Artic Eskimo
Hwa Byung
Anger Syndrome
Korea
Some Critical Issues for
Culture-Bound Disorders
1.
Should “culture-bound” disorders be
considered neurotic, psychotic, or
personality disorders?
2.
Should “culture-bound” disorders be
considered variants of “universal
disorders” defined by Western views?
3.
Are there taxonomically different “culturebound” disorders?
4.
Are all disorders “culture-bound” disorders?
The Cultural Context of Diagnosis
• While cultural psychiatry aims to understand
problems
in
context,
diagnosis
is
essentializing: referring to decontextualized
entities whose characteristics can be studied
independently of the particulars of a person’s
life and social circumstances.
• The entities of the DSM implicitly situate human
problems within the brain or the psychology
of the individual,
while
many
human
problems brought to psychiatrists are
located in patterns of interaction in families,
communities, or wider social spheres.
The Cultural Context of Diagnosis
(Continued)
• Ultimately, whatever the extent to which we
can universalize the categories of the
DSM by choosing suitable
level
of
abstraction,
diagnosis
remains
a
social practice that must be studied,
critiqued, and clarified by cultural
analysis (Kirmayer, 1998, p. 342).
3. Normality and
Abnormality
Relativity in Normality
The cross-cultural investigator must have “an
initimate understanding of the normal range of
individual behavior within the cultural pattern
and
likewise
understand
what
people
themselves consider to be extreme deviations
from this norm. In short, he must develop a
standard of normality with reference to the
culture itself, as a means of controlling an
uncritical application of the criteria he brings
with him from our civilization.
Alvin Hallowell, 1934,
Neurology-Culture Interface
Neuropathology
Psychoses
Neuroses
Normal Behavior
Cultural Variations in Behavior
Neurological
Penetrance
4.
Personhood or
Selfhood
Clifford Geertz On Personhood
The Western conception of the person as a
bounded, unique, more or less integrated
motivational and cognitive universe, a dynamic
center of awareness, emotion, judgment, and
action, organized into a distinctive whole and
set contrastively -- both against other such
wholes and against social and natural
background -- is however incorrigible it may
seem to us, a rather peculiar idea within the
context of the world's cultures (Geertz, 1973,
p. 34).
NATIVE HAWAIIAN (KANAKA MAOLI) PSYCHIC STRUCTURE
Lokahi = Harmony
Gods/Spirits
Nature
Family
Person
Ohana
Makani
Mana = Life Energy
Aina
Wai
Akua/Aumakua
5. Body - Mind Spirit
Body - Mind - Spirit: The Western Perspective
Roles
Body
Mind
Spirit
Facilities
Knowledge
Physicians
Bio-Scientists
Some Nurses
Hospitals
Clinics
Laboratories
Medicine
Biology
Anatomy
Mental Health
Professionals
Mental Hospitals
Clinics
Office Practices
Psychology
Psychiatry
Theology
Priests
Ministers
Psychics
Churches
Shrines
Temples
Philosophy
Theology
Mysticism
6. THEORIES OF
ILLNESS
(Murdock, 1969)
I.
Theories of Natural Causation
(Any theory, scientific or popular, that account for
impairment of health as a physiological
consequence of some experience of the patient in
a manner that would appear reasonable to
modern science)
1.
Infection
2.
Stress
3.
Organ Deterioration
4.
Accident
5.
Overt Aggression
II. Theories of Supernatural Causation
(Any theory that accounts for the impairment of
health as a result of some intangible force)
1.
Theories of Mystical Causation
(Impersonal Force)
A.
Fate
B.
Ominous Sensations
C.
Contagion
D.
Mystical Retribution
II. Theories of Supernatural Causation
(Continued)
2.
Theories of Animistic Causation
(Personalized Entity)
A.
B.
3.
Soul Loss
Spirit Aggression
Theories of Magical Causation
(Actions of Evil Force)
A.
B.
Sorcery
Witchcraft
7. Measurement &
Assessment Issues
across Cultures
Equivalency in Assessment Across Cultures
Equivalence refers to the “equality” of the assessment
instruments and procedures across cultural boundaries.
There are four main kinds of equivalence:
1.
Linguistic Equivalency: Is the language the same?
This can be accomplished through back
translation.
2.
Conceptual Equivalence: Is the concept the same?
The meaning of dependency in Japan is
different than the meaning of dependency
in the USA.
3.
Scale Equivalence: Cultures differ in their response
to different scale formats (i.e., true-false,
Likert, semantic differential)
4.
Normative Equivalence: Are there cultural group
norms for the instrument?
Other Considerations in Self-Report
Assessment Situations
(Marsella, et al (2000). Culture and Personality. Am. Beh. Sci)
The simple fact of the matter is that asking self-report questions is a
complex task that is made even more complex when psychologists
move across cultural boundaries to ask questions of people whose
perceptions of the task and whose motivations to participate differ
from those on whom the scale was constructed. These perceptual
and motivational differences include:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Desire to conform socially
Fear of possible persecution
Concern for giving the “right” answer rather than an accurate
answer
Desire to please authorities
Limited self awareness and insights
Confusion with the perceived meaning and implication of
terms and words used in the questions
Variations in the construction of personhood and personality
8. TWO EXAMPLES OF
ETHNOCULTURAL
CONSIDERATIONS
IN
PSYCHOPATHOLOGY
A. PTSD
PTSD Interactional Model
Marsella, 1994
Traumatic
Event
Perceptual Experience
Person
1. Genetic
Vulnerablity
1. Category
Natural/Man
Disasters
Accidents
Crimes/Violence
War
2. Content
Stress Reaction
Intense and
Painful
Arousal
Control
Intensity
Duration
Predictability
3. Pre-Morbid
Personality
(e.g., Hardiness,
Resiliency)
Life Event
Deprivation
Physical
3. Parameters
2. Early Experience
Vulnerability
Bio-Behavioral Responses
PTSD
Depression
Psychosis
Dissociation
4. Mood and
Physical
Health
5. Social
Resources
Urban Child and Youth Trauma in South Central LA
Timnick, C. (1989). "Children of Violence," Los Angeles Times Magazine (pp. 6, 8, 10):
•“They shoot somebody everyday," "I go in and get under the bed
and come out after the shooting stops.“
•"My daddy got knifed when he got out of jail," and "My uncle got
shot in a fight-there was a bucket of his blood. And I had two
aunties killed and of them was pushed off the free-way and there
were maggots on her."
•"It's like the violence is coming down a little closer." "We don't
come outside a lot now.“
• "Just three people [in my family] died." "I been seein' two of
them' (as haunting ghosts at night).
•"How about the cemetery?' (in response to teacher's request for
ideas for a field trip).
•'Her eyeball was in her shoe" (boy witnessed woman's mutilated
body).
CROSS-CULTURAL VARIATIONS IN THE
CLINICAL PARAMETERS OF PTSD
(From Marsella, et al, [1996] Ethnocultural Aspects of PTSD.
Washington, DC: APA Press)
1.
Patterns of onset
2.
Manifestation of symptoms
(e.g., guilt, anger, anxiety, somatic)
3.
Disabilities and impairments
4.
Course and progression
5.
Outcome
Cross-Cultural Considerations in PTSD
•
Diagnosing PTSD Across Cultures: Idioms of Distress,
Translation, Meaning of Nightmares?
• Nature of Trauma(s): Role of Destiny, Religion,
Collective Trauma)?
• Universal Symptoms: Re-Experiencing and Arousal
Symptoms (Hard-wired). These may vary in
frequency, severity, and duration as a function of
individual and cultural group processes.
• Cultural Symptoms: Avoidant symptoms may be more
influenced by life experience. Dissociation may be
a protective device in some groups.
Cross-Cultural Considerations (Continued)
•
Disability : Disability from PTSD may vary
independently of symptomatology.
•
Perception of Personal Responsibility.
•
Treatment with non-Western methods: For example
Sweat Lodge, Morita, Chanting.
•
Vulnerability to Trauma
1.
2.
Accumulation: Marginalization, Identity,
Racism, Low Self-Esteem, plus Trauma
High Stress Culture ("Sick Society"): Cultural
disintegration, prominent violence,
prominent substance abuse, few social
supports, alienation/anomie.
Cross-Cultural Considerations
(Continued)
•
Nature and Meaning of Trauma
1.
Codification: (i.e., cognitive,
affective, proprioceptive, visceral)
2.
Meaning of term
3.
Antecedents and consequences
4.
Social response to trauma
victim/survivor (e.g., rape victim)
5.
Behavioral implications
Cross-Cultural Considerations
(Continued)
•
Motivation to seek professional
assistance and related help-seeking
behaviors
•
Responsivity to psychotherapy and
psychopharmacology
TWELVE COMMON
TREATMENTS FOR PTSD
PROBLEMS
1.
Personal Narration (i.e., Trauma Story)
2.
Relaxation Therapies
3.
Psychodynamic (Insight & Catharsis)
4.
Critical Incident Stress Debriefing (Education and
Normalization)
5.
Cognitive Behavior Therapy
TWELVE COMMON TREATMENTS (Continued)
6.
Eye Movement Desensitization Therapies (EMDT)
7.
Basic Problem Solving and Information Sharing
8.
Medications (e.g., Anti-Depressants)
9.
Nutritional Approaches
10.
Socialization and Recreation Activities
11.
Scriptotherapy (i.e., Writing)
12.
Behavior Therapies (e.g., Imagery, Desensitization)
The Power of Social Support
The sheer will to survive cannot take the place of
the strength one derives from outside support,
real or imagined.
This is why those on the
outside of any catastrophe who work for one’s
return . . . are the strongest lifeline imaginable,
the most powerful motive for staying alive. Thus
the inner will to stay alive depends to a large
measure on the help one receives from the
outside; these are inextricably woven.
Bruno Bettleheim (1960). The informed heart. London: Penguin Books.
(C) AJM-1/1/2001
PHARMACOTHERAPY FOR PTSD AND
STRESS-RELATED DISORDERS
1.
Antidepressants (Tricyclics, SSRI)
2
Clonidine (Alpha Adrenoreceptor (Blocks
noradrenalin reducing arousal levels and
nightmares)
3.
Minor tranquilizers (e.g., Benzodiazepines)
4.
Major tranquilzers (e.g., Haldol, Mellaril,
Risperdone)
B. SCHIZOPHRENIA
SOME CULTURAL DETERMINANTS OF
SCHIZOPHRENIA
1.
Cultural concepts of personhood, and the related
implications of this for individuated versus
unindividuated definitions of selfhood and reality;
2.
Cultural concepts regarding the nature and causes
of abnormality, discomfort, disorder, deviance,
and disease, and those regarding the nature and
cause of normality, health, and wellbeing;
3.
Cultural concepts and practices regarding health
and medical care and prevention; attitudes toward
illness and disease;
4.
Cultural concepts and practices regarding breeding
patterns and lineages;
Cultural Determinants of Schizophrenia
(Continued)
5.
Cultural concepts regarding pre-natal care,
birth practices, and post-natal care,
especially in such areas as nutrition and
disease exposure;
6.
Cultural concepts and practices regarding
socialization, especially family, community,
and religious institutions, structures and
processes;
Cultural Determinants of Schizophrenia
(Continued)
7.
Cultural concepts and practices regarding
medical and health care especially with
regard to the number and types of healers,
doctors, sick-role
statuses, etc.
8.
Cultural stressors such as rates of sociotechnical change, socio-cultural
disintegration, family disintegration,
migration, economic development,
industrialization, and urbanization;
Cultural Determinants of Schizophrenia
(Continued)
9.
Culturally-related patterns of deviance and
dysfunction including trauma (PTSD), substance
abuse, violence and crime, social isolation,
alienation/anomie, and the creation of
pathological and deviant subcultures;
10.
Cultural stressors related to the clarity, conflicts,
deprivations, denigrations, and discrepancies
associated with particular needs, roles, values,
statuses, and identities;
Cultural Determinants of Schizophrenia (Continued)
11.
Cultural stressors related to socio-political factors
such as racism, sexism, and ageism and the
accompanying marginalization, segmentalization,
and underprivileging
12.
Cultural resources and coping patterns including
institutional supports, social networks, social
supports, and religious beliefs and practices.
13.
Cultural exposure to various risk conditions such
as communicable diseases (e.g., viruses), toxins,
dietary practices, population density, poverty,
homelessness.
POTENTIAL REASONS FOR MORE NEGATIVE COURSE
AND OUTCOME OF SCHIZOPHRENIA (PSYCHOTIC
DISORDERS) IN DEVELOPED COUNTRIES 1
1.
Schizophrenia is considered to be a biological
disease that is relatively immutable to life
circumstances;
2.
Causes of schizophrenia are considered to be within
the individual. Personal control and responsibility is
assumed;
3.
High social rejection and stigma attached to
schizophrenia;
4.
Individual burdens are demanding because family
resources are not often present;
Reasons for Negative Outcome In Developed
Countries (Continued)
5.
Patient is often hospitalized and isolated from family
and community. Custodial care, in disguised
forms, is present, and is the norm;
6.
Financial incentive to continue the sick role (i.e.,
disability payments, insurance payments) are
numerous and easily available;
7.
Stressors are numerous and supports are minimal;
Reasons for Negative Course in Developed
Countries (Continued)
8.
Competency levels required for normal functioning
are very high and very demanding upon social and
intellectual skills and abilities (e.g., bank accounts,
tax forms, housing, automobile maintenance,
literacy skills);
9.
Religious systems and spiritual concerns are often
inadequate;
10.
Co-morbidities are numerous and complex (e.g.,
substance abuse, alcohol, trauma)
CENTRAL ARGUMENT
• Schizophrenia is not a single
disorder and
our
continued
conception of it as such
hinders
progress in dx, treatment, and
prevention.
• Schizophrenia is a group of disorders
of differing
etiology,
pathology,
expression,
and
treatment
responsivity.
• It is time for a change
Schizophrenia:
Too Many Variations
1. Multiple and Interactive Etiologies
2. Multiple and Interactive
Pathologies (Disease Sites)
3.
Multiple and Interactive
Expression Patterns
4. Multiple Treatment Responsivities
PATHOLOGY, ETIOLOGY, EXPRESSION,
& THERAPY RESPONSIVITY POSSIBILITIES
• 1. Etiology
•
•
•
•
•
•
•
•
A.
B.
C.
D.
E.
F.
G.
H.
•
I.
Genetics (Polygenic)
Fetal Viral Infection - 2nd Trimester
Brain Injury (e.g., Anoxia, Toxins)
Maternal Antibodies
Trauma
Social Isolation/Deprivation
Stress-Diathesis Theory
Stigma
Poverty/Class/Cultural Disintegration
PATHOLOGY, ETIOLOGY, EXPRESSION,
& THERAPY RESPONSIVITY POSSIBILITIES
•2. Pathology
•
•
•
•
•
A.
B.
C.
D.
E.
•
G.
•
Cortical Hypofrontality
•
Temporal Lobes •
Cerebellum
Ventricles (Shrinkage)
Corpus Callosum •
F.
Thalamus
Temperolimbic System
H.
I.
J.
K.
Basal Ganglia
Hippocampal Region
Neurochemical
Circuitry
Cerebral Asymmetry
PATHOLOGY, ETIOLOGY, EXPRESSION,
& THERAPY RESPONSIVITY POSSIBILITIES
• 3. Alternative DX/Expressive Patterns
•
•
•
•
•
•
•
•
•
A.
B.
C.
D.
E.
F.
Positive/Negative/Mixed
Process/Reactive
Type I/Type II
Paranoid/Non-Paranoid
Acute/Chronic
Clinical Subtypes (e.g., Paranoid,
Disorganized)
G.
Good/Poor Premorbid Adjustment
H.
Schneiderian/Non-Schneiderian Signs
I. Bleulerian versus Kraepelinian
PATHOLOGY, ETIOLOGY, EXPRESSION,
& THERAPY RESPONSIVITY
POSSIBILITIES
• 4. Treatment Responsivity
•
•
•
•
•
•
•
•
A.
B.
C.
D.
E.
F.
Traditional Neuroleptics
(e.g., Chlorpromazine, Haloperidol)
Recent Neuroleptics
(e.g., Risperidone, Clozapine)
Psychosurgery
Psychotherapy
Psychosocial Rehabilitation
Orthomolecular Therapy
VIII. CULTURE &
THERAPY
Issue # 1
What is universal about
different forms of therapy
and healing?
(C) AJM-1/1/2001
The PSYCHOTHERAPY
EQUATION:
Outcome = Function of:
Disorder
Therapy
Therapist
Client/Patient
Time
Payment
(C) AJM-1/1/2001
COMMON ELEMENTS OF ALL
THERAPY/HEALING SYSTEMS
1.
Assumptions about the nature and
causes of problems;
2.
Assumptions about healing
context/setting requirements;
3.
Require elicitation of particular
expectations, emotions, behaviors;
(C) AJM-1/1/2001
COMMON ELEMENTS OF THERAPY
(CONTINUED)
4.
Requirements for activity level and
participation levels and/or roles for
patient, family, and therapist;
5.
Specific requirements for training and
skill expertise of therapist.
(C) AJM-1/1/2001
Issue #2
What is cultural about
therapy/healing?
(C) AJM-1/1/2001
What is Cultural About Therapy?
(Patient Perspective)
1.
2.
3.
4.
5.
6.
7.
Patient’s conception of health and illness;
Patient’s expectations about what will or
should occur in therapy;
Patient’s definition of the patient or illness
role;
Patient’s perception of therapist;
Patient’s motivation to comply;
Patient’s language and communication mode
preferences;
Patient’s resources.
(C) AJM-1/1/2001
What is Cultural About Therapy?
Therapist Perspective
1.
2.
3.
4.
5.
Therapist conceptions of illness and
health;
Therapist’s therapy system
Therapist’s perception of patient
Therapist’s language and
communication style
Therapist’s training
Examples of Non-Western Therapy and
Healing Systems (Marsella, 1982)
1.
Naikan Therapy (Japanese)
2.
Morita Therapy (Japanese)
3.
I-Ching (Chinese)
4.
Ho’oponopono (Hawaiian)
5.
Voodou (Caribbean)
6.
Sweat Lodge/Vision Quest (American
Indian)
7.
Expressive Therapies (Art, Dance, Singing)
8.
Yoga (Hindu)
Examples of Healers/Therapists
1.
2.
3.
4.
5.
6.
7.
8.
9.
Mudangs (Korea)
Herbolarios (Philippines)
Kahunas (Hawaii)
Dukhuns (Indonesia)
Santerias (Latino)
Curanderos (Latino)
Shamans (Widespread)
Temple Masters and Priests (Buddhism,
Taoism)
Faith Healers (Fundamentalist Christianity)
Non-Western Medical Health Systems
1.
Ayurveda
2.
Chinese Medicine (Korean, Japanese)
3.
Tibetan Medicine
4.
Unani (Arabic)
5.
Indigenous (Australian Aboriginal, American
Indian, Native Hawaiian )
6.
Shamanistic Medicine
(C) AJM-1/1/2001
The Codification of
Human Experience
• Cognition
•
•
•
•
Imagery
Affective
Visceral
Proprioceptive
(C) AJM-1/1/2001
Issue # 3
Are there different
therapy/healing principles
in various cultural
therapies?
(C) AJM-1/1/2001
Principles of Healing in Different
Therapies (Marsella, 1982)
1.
Insight
2.
Information
3.
Catharsis
4.
Faith
5.
Reduction of uncertainty, anxiety, fear
6.
Relocation of locus of
control/attribution
(C) AJM-1/1/2001
Principles (Continued)
7.
Reconstruction of “reality”
8.
Guilt reduction/release and penance
9.
Cultural re-embeddedness and
identification
10. Suggestion
11. Instill hope and meaning making
12. Specific behavioral activities and skill
(C) AJM-1/1/2001
Principles (Continued)
13. Interpretation
14. Persuasion
15. Social Support
16. Mobilization of immune system and
endorphin system
17. Understanding & Empathy
18. Expression
(C) AJM-1/1/2001
Shou-Jing Versus Talk Therapy
Ann Shu-Ping Lin (2000). Why counseling and not shou-jing?
Cross-cultural Psychology Bulletin, 10-15.
“I do not know how to communicate with the
experts. He told me that I have some kind of
disease in my mind but I think I am okay. He kept
asking me to express my feelings toward the
earthquake, but I feel embarrassed if I tell people
my own feelings. . . . I went to a Master in the
temporary temple and she taught me how to deal
with the situation. How to calm my anxieties
through worship and helping others. How to accept
grief as an arrangement of the gods. You know that
our people have done so many wrong things.” (p.1011)
(C) AJM-1/1/2001
IX. MENTAL
HEALTH
SERVICE
DELIVERY
Barriers to Mental Health Service
Utilization by Ethnocultural Minorities
1.
2.
3.
4.
5.
6.
7.
Availability, accessibility, acceptability;
Cultural incongruity (e.g., language,
communication, health beliefs);
Coordination with other services;
Presence of staff from similar
backgrounds (Also opposite of this);
Financing and costs
Absence of outreach and follow-up
Iatrogenic problems
Multicultural Accommodation in Mental
Health Service Delivery
1.
Availability, accessibility, and
acceptability of services;
2.
Language resources;
3.
Knowledge of idioms of distress,
alternative diagnostic systems,
therapy systems;
4.
Knowledge of outcome criteria for
disorder (e.g., distress, disorder,
deviancy -- health, problem
solving, coping, competence);
Cultural Accommodation Service
Delivery (Continued)
5.
Emphasis on problem-solving rather
than diagnostic labels
6.
Broad range of services (continuity of
care, outreach, follow-up, indigenous
healers, family);
7.
Assessment equivalence;
8.
Continual cultural sensitivity training,
evaluation and accountability;
Cultural Accommodation Service
Delivery (Continued)
9.
Adjustable payment options
10. Knowledge and practice of
ethnopsychopharmacology
11. Design of physical environment of
building and grounds
12. Use of indigenous healers and
therapies
Training for Cultural Competency
(Some Ideas from Hansen, Pepitone-Arreloa-Rockwell,
& Greene, 2000)
1. Cultural Sensitivity
A. Write cultural biography
B. Identify Agents (Power and
Privilege)
C. Targets (Those Without)
(ADDRESSING Acronym)
Cultural Competence
(Continued)
2. Learn about cultures
A.
Read
B.
Travel
C.
Workshops/Courses
Cultural Competence Continuum
Assessment (Miguel Tirado (2000)- Others)
Culturally Resistance (Condone race
discrimination, discourage cultural
variation)
Culturally Unaware (Ignore cultural
considerations)
Culturally Conscious (Tokenism, selective
policies)
Culturally Insightful (Ad Hoc hiring in crisis track
according to ethnicity)
Cultural Versatile (Anticipatory, incentives,
policies, monitor)
MH Professional Cultural Competence
Continuum (Tirado, 2000)
Knowledge
of Patients
PracticeRelated Beh
Attitudes
toward
Diversity
Practice
Patterns
CR
CU
(Res)
(Unaw)
CC
(Consc)
CI
(Insig)
CV
(Versat)
MH Professional Cultural Competence
Continuum (Tirado, 2000)
CR CU
(Res)
Human
Resource
Capacity
Policies and
Procedures
Monitoring
(Unaw)
CC
CI
(Consc)
(Insig)
CV
(Versat)
X. MULTICULTURAL
COMPETENCIES
Eighteen Multicultural
Competencies
Hansen, Pepitone, Greene (2000) Multicultural competencies.
Professional Psychology: Research and Practice, 31, 652-660.
1. Knowledge of history and
manifestations of such issues as oppression,
prejudice, marginalization and their
psychological sequalae.
2.
Knowledge that family structures, gender
roles, values, and beliefs differ across
cultures and affect personality formation
and developmental outcomes and
manifestations of mental and physical
illness.
Eighteen Multicultural Competencies
(Continued)
3.
Knowledge of how cultural variables
influence the etiology and manifestation of
mental illness.
4.
Knowledge of normative values illness,
help-seeking, world views of groups to be
treated.
5.
Ability to evaluate emic and etic hypotheses.
6.
Ability to design and implement non-biased
treatment plans.
Eighteen Multicultural Competencies
(Continued)
7.
Ability to initiate and explore
differences between the therapist and
client, and to incorporate these into
treatment.
8.
Knowledge of culture-specific
disorders and dx categories.
9.
Knowledge of culture specific assessment
procedures and tools.
10. Ability to establish rapport and convey
empathy .
Eighteen Multicultural Competencies
(Continued)
11. Knowledge of how to assess variables of
special relevance to identified groups (e.g.,
culture orientation, acculturation, culture
shock, discrimination).
12. Ability to ascertain effects of therapist-client
language differences on assessment and
treatment.
13. Ability to modify assessment tools for use
with specified groups.
Eighteen Multicultural Competencies
(Continued)
14. Ability to explain results in a culturallysensitive and contextual way.
15. Ability to assess one’s own
multicultural competence.
16. Ability to critique epistemologies,
concepts, methods, instruments, and
results based on assumptions related
to a group and to propose alternatives.
Eighteen Multicultural Competencies
(Continued)
17. Knowledge of how psychological
theory, methods of inquiry, and
professional practices are culturally
embedded.
18. Ability to thoughtfully critique
multicultural approaches in
mental health.
XI. CLOSING
THOUGHTS
The Brighter Future . . .
For the real question is whether the “brighter
future” is really always so distant. What if, on
the contrary, it has been there for a long time
already, and only our blindness and weakness
has prevented us from seeing it around us and
within us, and kept us from developing it.
(Vaclav Havel, 1994)
On The Importance of Cultural Diversity
What sets worlds in motion is the interplay of
differences, their attractions and repulsions. Life
is plurality, death is uniformity. By suppressing
differences and peculiarities, by eliminating
different civilizations and cultures, progress
weakens life and favors death. The ideal of a
single civilization for everyone, implicit in the
cult of progress and technique, impoverishes and
mutilates us. Every view of the world that
becomes extinct, every culture that disappears,
diminishes a possibility of life.
Octavio Paz (The Labyrinth of Solitude,
1978)
The life so short,
the craft so long to learne.
Geoffrey Chaucer
(c. 1340-1400)
THE END . . .