医学人类学 13 - Diversity, Culture, and Mental Illness 文化与心理疾病

Culture & Mental Illness

Dsm - Diagnostic and Statistical Manual of Mental Disorders

Biomedical model for mental illness - diagnostic criteria

Current edition is Dsm-5

First published in 1952

Dsm-III, published 1980, transformed psychiatry

Based on observable symptoms

Medicalization of Mental Illness

Social power is embedded in ability to diagnose someone as mentally ill

Examples: Classification of homosexuality as a disease from 1952-1973;

Categorization of shamanic trance as psychosis, etc.

Culture in Dsm-5

Cultural Syndromes - previously “culture-bound syndromes” in Dsm-4

Cultural Idioms of Distress - Culturally shaped ways of expressing distress

Cultural Explanations of Distress - Culturally shaped ways of explaining causes of distress

Cultural Concepts of Distress - 3 main types (Dsm-5)

Cultural Syndromes: Nine “clusters of symptoms and attributions that tend to co-occur among individuals in specific cultural groups, communities, or contexts... that are recognized locally as coherent patterns of experience” (p. 758)

Cultural Idioms of Distress: “Ways of expressing distress that may not involve specific symptoms or syndromes, but that provide collective, shared ways of experiencing and talking about personal or social concerns” (p. 758)

Cultural Explanations of Distress or Perceived Causes: “Labels, attributions, or features of an explanatory model that indicate culturally recognized meaning or etiology for symptoms, illness, or distress” (p. 758)

“Culture-Bound Syndromes”

Sets of behavior or experience, labeled as illness, which only appear in restricted cultural contexts.

First appeared in Dsm-IV (1994), removed from the Dsm-5 in 2013

Examples: Ghost Sickness (Navajo), Hwabyeong (Korea), Spasmophoilie (France), Latah (Malaysia) and “Jumping Frenchmen of Maine” (Maine, 19th Century)

Cultural Script

Expectation - to behave, how we feel, etc. in specific contexts

Scripts to relay on - “what is typical”

Are these “Culture-Bound Syndromes?”

Multiple Personality Disorder / Dissociative Identity Disorder

Attention Deficit Hyperactivity Disorder (ADHD) - specific contexts (children at schools)

Diversity & Cultural Issues in Clinical PSYC

Definitions & Models of Culture 

Defining Culture 

Dsm-5

• Historically primary focus on ethnicity and race

• Broader views of culture recommended more recently

- Ethnographic, demographic, status, or affiliation identities

- Any group that shares a theme or issues

Dsm-5 Definition

• Systems of knowledge, concepts, rules and practices that are learned and transmitted across generations

• examples include language, religion, spirituality, family structures, life-cycle stages, ceremonial rituals, and customs, as well as moral and legal systems

• “...all forms of distress are locally shaped...”

Different Approaches to Culture

- Etic: Focused on Universalities (similarities) among Humans

- Emic: Focused on Culture-Specific Norms

Tripartite Model of Personal Identity

Individual level: Uniqueness, unique aspects of human experience

Group level: Similarities and Differences

Universal level: Homo Sapiens, universal aspects of human experience

Importance of Multiculturalism

Multiculturalism: An approach in clinical psychology emphasizing the appreciation of cultural diversity and awareness of how techniques can be best applied to individuals of various cultural backgrounds.

Identified as the defining issue for the current generation

The 4th force: Emphasizes the importance of considering cultural diversity in all aspects of clinical psychology.

- It can and should influence the work of the first three forces: 1st, Psychoanalysis; 2nd, Behaviorism; 3rd, Humanism (person-centered)

Culture & Clinical Psychology

Cultures shape how clients see their problems

Key questions for clinical psychologists to ask clients:

What do you call your problem (or illness or distress)?

What do you think your problem does to you?

What do you think the natural cause of your problem is?

Why do you think this problem has occurred?

How do you think this problem should be treated?

How do you want me to help you?

Who else (e.g., family, friends, religious leader) do you turn to for help?

Who (e.g., family, friends, religious leader) should be involved in decision making about this problem?

Culture & Dsm-5

- Increased focus on issues related to culture in Dsm-5 relative to earlier editions

- More information on cultural variations of symptoms for specific disorders

- More guidance for clinicians to facilitate awareness of cultures

- Cultural Formulation Interview

16-item semi-structured interview

Questions (open-ended) related to:

• Definition of the Problem

• Perceptions of Cause, Context, and Support

• Factors Affecting Self-Coping & Past Help Seeking

• Factors Affecting Current Help Seeking

Supplementary Modules:

• Questions for gathering more information

• Additional questions for assessing youth, older adults, immigrants, refugees, and caregivers

Examples: Cultural Concepts of Distress

Ataque de Nervios (attack of nerves)

Individuals of Latino, Latina, Latinx descent

Characterized by:

• acute anxiety, anger, or grief

• screaming, shouting, crying uncontrollably

• trembling and feeling of heat in chest/head

• verbal and physical aggression

• dissociative experiences (e.g., depersonalization, derealization, amnesia)

• seizure-like, fainting episodes; feeling out of control

Often occurs as a result of a stressful event relating to the family

- Related conditions in Dsm-5: Panic attack, panic disorder, dissociative disorders, conversion disorder, intermittent explosive disorder, other specified or unspecified anxiety disorder, PTSD.

Dhat Syndrome (distress about semen loss)

South Asian cultures

Specifically in biological men

Characterized by:

• Attributing diverse symptoms to semen loss: depression, anxiety, impotence, fatigue, weakness, weight loss

• There is no identifiable physiological dysfunction

- Related conditions in Dsm-5: Major depressive disorder, dysthymia, generalized anxiety disorder, somatic symptom disorder, illness anxiety disorder, erectile disorder, early ejaculation.

Maladi Moun (humanly caused illness or sent sickness)

Haitian communities

Characterized by:

• Belief that interpersonal envy and malice cause people to harm their enemies by sending illnesses (e.g., social and academic failure, psychosis, depression).

• Visible success increases vulnerability (e.g., new job, money)

- Related conditions in Dsm-5: Delusional disorder, persecutory type; schizophrenia with paranoid features

Khyâl cap (wind attcks)

Cambodian communities

Characterized by:

• The belief that levels of Khyâl (a wind-like substance) and blood will rise in the body, causing serious harm (e.g., compressing the lungs resulting in asphyxiation; entering cranium leading to death).

• Often triggered by worrisome thoughts, standing up (dizziness), odors with bad association, entering crowded spaces, driving

- Related conditions in Dsm-5: Panic attacks/disorder, generalized anxiety disorder, agoraphobia, PTSD.

Cultural Competence

• Cultural competence: Ability to work sensitively and expertly with culturally diverse members of a heterogeneous society

• “Counselor’s acquisition of awareness, knowledge, and skills needed to function effectively in a pluralistic democratic society” (Sue & Sue, 2008)

Cultural Self-Awareness

• Learning about one’s own culture, including the values, assumptions, and biases that are associated with it

• Understanding that one’s own viewpoint is unique and idiosyncratic

• Important regardless of the cultural background of the therapist

Privilege

• Unearned advantages conferred because of membership in a dominant group

• Many different examples of privileges ranging from physical safety to media depictions of one’s group to not being denied housing, education, employment because of group membership

“I was taught to see racism only in individual acts of meanness, not in invisible systems conferring dominance on my group.”

Knowledge of Diverse Cultures

• Education about a client’s culture

• Asking for guidance from clients but not placing burden of education upon them

• Recognizing heterogeneity within cultures - Different experiences of different individuals

Understanding Acculturation

• Response or adaptation to a new cultural environment, particularly around:

Adopting elements of the new culture

Retaining elements of the original culture

• Different acculturation strategies

Assimilation同化: reject original culture, accept new culture

Separation分离化: retain original culture, reject new culture

Marginalization边缘化: reject original culture, reject new culture

Integration融合: retain original culture, accept new culture

Clinical skills

• Provide assessments and treatments that are appropriate for a client’s values and life experiences

• Increase familiarity with cultural adaptations of treatment

• Consider issues related to language

• Avoid assumptions and microaggressions

Microaggressions

• Comments or actions made in a cross-cultural context that convey prejudicial, negative, or stereotypical beliefs

- Often focus on race and ethnicity

- Can involve other differences too (e.g., age, gender, economic class, etc.)

• Biases may be unintentional, subtle, and outside of conscious awareness

• Associated with distress and negative mental health outcomes

• Psychologists commit them too

• Can interfere with treatment - May prevent forming a trusting relationship

• Extremely important for psychologists to consider their belief systems and critically examine themselves

Training & Professional Efforts

Professional Efforts to address culture

• Divisions within the APA

Div 35: Psychology of Women

Div 36: Psychology of Religion

Div 44: Psychological Study of Lesbian, Gay, and Bisexual Issues

Div 45: Study of Ethnic Minority Issues

Div 51: Psychological Study of Men and Masculinity

• Scholarly Journals

• APA Ethics Code

Many specific standards related to culture

• Specific Ethical Standards: Boundaries of Competence

Requirement for psychologists to be knowledgeable about factors including age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status and how they may impact treatment.

• General Principles: Respect for People’s Rights and Dignity

Training Psychologists

• Accreditation Requirements for Graduate Programs

- Programs accredited by the APA

- Issues of “Cultural and Individual Differences and Diversity” among the 8 key domains of graduate training

• Doctoral programs:

- Including people of diverse backgrounds among students and faculty

- Educating students about the role of culture in psychology

• Recommendations for graduate training programs:

- Explicitly state a commitment to diversity

- Actively make an effort to recruit graduate students from diverse populations

- Actively make an effort to recruit and retain a diverse faculty

- Make efforts to make the admissions process fair and equitable

- Ensure that students gain awareness of their own cultural values and biases, knowledge of other groups, and skills to work with diverse populations

- Examine all courses for an infusion of a culture-centered approach throughout the curriculum

- Evaluate students on their cultural competence on a regular basis