Cultural Assessment in Mental Health: DSMIV TR Outline for Cultural Formulation

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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

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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.

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B I A S

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

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We just cant know all about 100 cultures,this
is hopeless, so why bother?

• 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 cant know all about 100 cultures,this
is hopeless, so why bother?

• 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.

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DSM-IV TR Outline for Cultural Formulation

• A. Cultural identity of the individual
•  
• B. Cultural explanations of the individuals
  illness
•  
• C. Cultural factors related to psychosocial
  environment and levels of functioning
•  

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

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A.Cultural Identity of the Individual

• 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).

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Cultural IdentityThink Wide

• Ethnicity
• Race
• National Origin/Indigenous Culture
• Migration/Acculturation/Biculturality
• Language (s)
• Age
• Gender
• Sexual Orientation

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Cultural IdentityThink Wide

• Religious/Spiritual Aspects
• Socioeconomic status
• Political orientation
• Disabilities
• Other aspects of identity

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Cultural IdentityThink Deep

• 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.

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Cultural IdentityThink DeepIraq as an example

• Tribal affinityOne of the few characteristics
  that most Iraqis share loyalty often ranks
  higher than religious affiliation. 150 tribes.
• EthnicityArab (80), Kurdish (15), other (5).
  Most Kurds are Sunni Muslims.
• ReligionMuslim 97 (Shiites 65, Sunnis 35 vs.
  15 and 85 of the worlds Muslims), Christian or
  other 3.

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Cultural IdentityConnect the Dotsthe Case of
Mr. M. (Weinreich, et.al., 2003)

• 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.

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Further Variations on Cultural Identity

• Identity diffusion/conflicts
• Defensive high self-regard
• Indeterminate identity
• Confident identity/openness to various groups

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Cultural Identity --Inquire, Dont Assume

• A persons identity is defined as the totality
  of ones 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).

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Idealistic (Aspirational) Identification

• The extent of ones 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 ones
  ideal self-image.

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Contra-identification

• The extent of ones 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.

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Cultural Identity From Fixed, Singular Entity to
Many Aspects in Flux/Process

• Time--past-present-future
• PlaceInternational and national migration
• SituationAt 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

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Cultural IdentityHow is it important?

• Cultural identity can impact on idioms of
  distress/explanations of illness, stressors and
  supports in the persons 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 persons 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.

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B. Cultural Expressions and Explanations of
Illness

• 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 pathwayhistory and expectations
  (professional and popular sources of care)

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Consumer Centered Assessment

• 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?

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Consumer Centered Assessment

• 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?

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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.

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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 familys face-saving needs, and
• be particularly careful to maintain
• confidentiality.

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Culture Bound Syndromes

• 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.

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Culture Bound Syndromes

• Amok
• Dhat
• Hwa-byung
• Koro
• Latah
• Qi-Gong Psychotic Reaction
• Shenjing Shuairuo
• (Neurasthenia)
• Shen-Kuei
• Shin-byung
• Taijin kyofusho

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Traditional AAPI Beliefs onthe Causality of
Mental Illness

• 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

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Conceptualizations of Mental Illness inPacific
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.

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Traditional Explanatory Models andTreatment
Pathways-Chinese

• Beliefs- Mental illness is caused by a
• lack of harmony of emotions
• or by evil spirits
• 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 andTreatment
Pathways-Japanese

• Beliefs- Mental illness is caused by
• evil spirits often thought not
• to be real illness
• Coping Behaviors
• and Treatment
• Delay or avoid seeking
• use traditional sources of
• care

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Traditional Explanatory Models andTreatment
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 andTreatment
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 orIndigenous Healing Practices

• 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).

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• 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, and
  informational support.

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Axis IV Psychosocial and Environmental Problems

• 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
  persons difficulties have developed

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Axis IV

• Problems with primary support group
• Problems related to the social environment
• Difficulty with acculturation discrimination
• Educational problems
• Occupational problems
• Housing problems

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Axis IV

• 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

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n Commo
Common Stressors Experienced by AAPIs

• 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

• VA National Technical Assistance Center for
  State Mental Health Planning (NTAC) and Uba, L.
  (1994). AsianAmericans Personality patterns,
  identity and mental health. New York, NY The
  Guilford Press.

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Culturally Related Strengths andSupports
Personal Strengths (Hays, 2001)

• Pride in ones 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 ones own group
• Wisdom from experience

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Culturally Related Strengths andSupports
Interpersonal Supports

• 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

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Culturally Related Strengths andSupports
Environmental Conditions

• An altar in ones 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

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D. Cultural elements of the relationship between
the individual and the clinician

• 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).

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1. Cultural Identity of the clinician

• Self-reflection, awareness and understanding of
  ones own personal and professional identity
  development
• Be aware of biases and limitations of knowledge
  and skills that might affect the clinical
  encounter

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2. Cultural Identity of the patient compared to
Cultural Identity of the clinician

• 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

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3. Ongoing Assessment of the cultural elements of
the relationship

• Rapport and respect
• Dealing with stigma and shame
• Empathy
• Communication, verbal and non-verbal
• Transference and Countertransference
• Involvement with significant others, community
  organizations

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Ethnocultural Transference and Countertransference

• Inter-ethnic Transference
• Intra-ethnic Transference
• Inter-ethnic Countertransference
• Intra-ethnic Countertransference

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Inter-ethnic Transference

• Over-compliance
• Denial of ethnicity and culture
• Mistrust, suspicion and hostility
• Ambivalence

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Intra-ethnic Transference

• Omniscient-omnipotent therapist
• The traitor
• The autoracist
• Ambivalence

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Inter-ethnic Countertransference

• Denial of ethnocultural differences
• Clinical anthropologist syndrome
• Guilt/Pity
• Aggression
• Ambivalence

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Intra-ethnic Countertransference

• Over-identification
• Us and them
• Distancing
• Anger
• Survivor guilt
• Hope and despair

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E. Overall Cultural Assessment for
Diagnosis and Care

• The formulation concludes with a discussion of
  how cultural considerations specifically
  influence comprehensive diagnosis and care.

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Overall Cultural Assessment

• Differential Diagnosis
• Phenomenology
• Prevalence
• Course and Outcome
• Treatment Plan
• Biological
• Psychological
• Sociocultural
• Spiritural

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Major Depressive Episode

• 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.

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Major Depressive Disorders

• 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.

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Differential Diagnosis

• 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

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Treatment Planning

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

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Treatment Planning

• Family vs. Individual vs. Group
• Supportive vs. Cognitive-Behavioral vs.
  Insight-oriented
• Sociocultural Approaches
• Public awareness to reduce stigma radio shows,
  health fairs,
• Integrate with Primary Care and other
  specialities Lets 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.

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• 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.

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• 7. Recognize power differentials.
• 8. Use group therapy to create a
  multiculturalenvironment 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.

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Reference

• 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_at_sfphh.org /415 206 8984