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 firstname.lastname@example.org 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 P a ra b le o f th e M o n k e y a n d T h e F is h A m o n k e y a n d a fis h w e re c a u g h t in a te rrib le flo o d a n d w e re b e in g s w e p t d o w n stre a m a m id s t to rre n ts o f w a te r a n d d e b ris . T h e m o n k e y s p ie d a b ra n c h fro m a n o v e rh a n g in g tre e a n d p u lle d h im s e lf to s a fe ty fro m th e s w irlin g w a te r. T h e n , w a n tin g to h e lp h is frie n d th e fis h , h e re a c h e d in to th e w a te r a n d p u lle d th e fis h fro m th e w a te r o n to b ra n ch . T h e m o ra l o f th e s to ry is c le a r: G o o d in te n tio n s a re n o t e n o u g h . If y o u w is h to h e lp th e fis h , y o u m u s t u n d e rsta n d its n a tu re . 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,  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 . . .