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

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


1
Cultural Assessment in Mental Health DSM-IV TR
Outline for Cultural Formulation
  • Francis G. Lu, MD
  • Professor of Clinical Psychiatry,
  • UCSF

2
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. 
3
  • 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.

4
  • 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

5
  • 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.

6
B I A S
  • Prejudice
  • Discrimination
  • Racism
  • Sexism
  • Classism
  • Ageism
  • Homophobia
  • Bias Against Religion/Spirituality

7
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.

8
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.

9
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
  •  

10
  • D. Cultural elements of the relationship between
    the individual and the clinician
  •  
  • E. Overall cultural assessment for diagnosis and
    care

11
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).

12
Cultural IdentityThink Wide
  • Ethnicity
  • Race
  • National Origin/Indigenous Culture
  • Migration/Acculturation/Biculturality
  • Language (s)
  • Age
  • Gender
  • Sexual Orientation

13
Cultural IdentityThink Wide
  • Religious/Spiritual Aspects
  • Socioeconomic status
  • Political orientation
  • Disabilities
  • Other aspects of identity

14
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.

15
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.

16
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.

17
  • 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.

18
Further Variations on Cultural Identity
  • Identity diffusion/conflicts
  • Defensive high self-regard
  • Indeterminate identity
  • Confident identity/openness to various groups

19
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).

20
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.

21
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.

22
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

23
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.

24
  • 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.

25
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)

26
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?

27
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?

28
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.

29
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.

30
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.

31
  • 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.

32
Culture Bound Syndromes
  • Amok
  • Dhat
  • Hwa-byung
  • Koro
  • Latah
  • Qi-Gong Psychotic Reaction
  • Shenjing Shuairuo
  • (Neurasthenia)
  • Shen-Kuei
  • Shin-byung
  • Taijin kyofusho

33
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

34
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.

35
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

36
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

37
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

38
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

39
  • 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

40
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).

41
  • 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.



42
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.

43
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

44
Axis IV
  • Problems with primary support group
  • Problems related to the social environment
  • Difficulty with acculturation discrimination
  • Educational problems
  • Occupational problems
  • Housing problems

45
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

46

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.

47
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

48
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

49
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

50
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).

51
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

52
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

53
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

54
Ethnocultural Transference and Countertransference
  • Inter-ethnic Transference
  • Intra-ethnic Transference
  • Inter-ethnic Countertransference
  • Intra-ethnic Countertransference

55
Inter-ethnic Transference
  • Over-compliance
  • Denial of ethnicity and culture
  • Mistrust, suspicion and hostility
  • Ambivalence

56
Intra-ethnic Transference
  • Omniscient-omnipotent therapist
  • The traitor
  • The autoracist
  • Ambivalence

57
Inter-ethnic Countertransference
  • Denial of ethnocultural differences
  • Clinical anthropologist syndrome
  • Guilt/Pity
  • Aggression
  • Ambivalence

58
Intra-ethnic Countertransference
  • Over-identification
  • Us and them
  • Distancing
  • Anger
  • Survivor guilt
  • Hope and despair

59
E. Overall Cultural Assessment for
Diagnosis and Care
  • The formulation concludes with a discussion of
    how cultural considerations specifically
    influence comprehensive diagnosis and care.

60
Overall Cultural Assessment
  • Differential Diagnosis
  • Phenomenology
  • Prevalence
  • Course and Outcome
  • Treatment Plan
  • Biological
  • Psychological
  • Sociocultural
  • Spiritural

61
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.

62
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.

63
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

64
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

65
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

66
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.

67
  • 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.

68
  • 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.

69
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
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