MMHA South Australia WorkshopMMHA South Australia WorkshopMonday 17Monday 17thth March 2008 March 2008

AdelaideAdelaide

Culture, Psychopathology, Culture, Psychopathology, Therapy, and Mental Health Therapy, and Mental Health

Service Delivery: Foundations, Service Delivery: Foundations, Issues, DirectionsIssues, Directions

Anthony J. Marsella, Ph.D., Anthony J. Marsella, Ph.D., D.H.C.D.H.C.Emeritus Emeritus ProfessorProfessor

Department of PsychologyDepartment of PsychologyUniversity of Hawaii University of Hawaii

Honolulu, Hawaii 96822Honolulu, Hawaii 96822marsella@hawaii.edumarsella@hawaii.edu

PREFACEPREFACE

(C) AJM-1/1/2001

“ “ Clouds come, Clouds come,

from time to time,from time to time,

to give man a rest to give man a rest from from

looking at looking at the moon.”the moon.”

Basho (1644-1694)Basho (1644-1694)

Japanese Haiku MasterJapanese Haiku Master

Parable of the Monkey and The FishParable of the Monkey and The Fish

A monkey and a fish were caught in a terrible A monkey and a fish were caught in a terrible flood and were being swept downstream flood and were being swept downstream amidst torrents of water and debris. The amidst torrents of water and debris. The monkey spied a branch from an overhanging monkey spied a branch from an overhanging tree and pulled himself to safety from the tree and pulled himself to safety from the swirling water. swirling water.

Then, wanting to help his friend the fish, he Then, wanting to help his friend the fish, he reached into the water and pulled the fish reached into the water and pulled the fish from the water onto branch. The moral of from the water onto branch. The moral of the story is clear: the story is clear: Good intentions are not Good intentions are not enough. If you wish to help the fish, you enough. If you wish to help the fish, you must understand its naturemust understand its nature..

General Goals:General Goals:A.A. To inform participants To inform participants

regarding the regarding the nature, role, and nature, role, and dynamics of ethno-dynamics of ethno- cultural factors cultural factors in the determination in the determination of of PSYCHOPATHOLOGY;PSYCHOPATHOLOGY;

B.B. To inform participants in the To inform participants in the historical, historical, conceptual, conceptual, methodological, and methodological, and empirical empirical foundations issues of foundations issues of ethnocultural aspects ethnocultural aspects of of psychopathology, therapies, and psychopathology, therapies, and service service delivery;delivery;

Specific OutcomesSpecific 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, socio- political 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)Specific Outcomes (Continued)

D.D. Increased awareness and understanding of the Increased awareness and understanding of the role role of ethnocultural factors in the assessment of ethnocultural factors in the assessment of of psychopathology; psychopathology;

E.E. Increased awareness and understanding of the Increased awareness and understanding of the role role of ethnocultural factors in therapy and of ethnocultural factors in therapy and service service delivery systems;delivery systems;

F.F. Increased awareness knowledge of non-Western Increased awareness knowledge of non-Western cultural systems, psychologies, and world cultural systems, psychologies, and world

views;views;

G.G. Increased awareness and understanding of the Increased awareness and understanding of the importance of diversity and its consequences importance of diversity and its consequences and the need to preserve it as an inherent and the need to preserve it as an inherent expression of life: A new orientation.expression of life: A new orientation.

I. NEW CHALLENGES, NEW

FACTS, NEW PROBLEMS AND

ISSUES

WE LIVE IN A GLOBAL AGE:WE LIVE IN A GLOBAL AGE:THE INTERDEPENDENCY OF OUR TIMES  THE INTERDEPENDENCY OF OUR TIMES  

Human survival and well being is now embedded in Human survival and well being is now embedded in a complex and interdependent global web of a complex and interdependent global web of economic, political, social, technical, and economic, political, social, technical, and environmental events, forces, and changes. environmental events, forces, and changes.

The The scale, complexity,scale, complexity, and and consequencesconsequences of these of these events, forces, and changes constitute an events, forces, and changes constitute an important challenge to our individual and collective important challenge to our individual and collective well being by confronting us with an array of well being by confronting us with an array of complex, conflicting, and confusing demands complex, conflicting, and confusing demands and/or opportunities. and/or opportunities.

Our response to this challenge -- as individuals and Our response to this challenge -- as individuals and as societies -- will shape the nature, quality, and as societies -- will shape the nature, quality, and meaning of our lives in the coming century meaning of our lives in the coming century

(Marsella, 1998, p. 289). (Marsella, 1998, p. 289).

GLOBAL CULTURAL CONTEXT OF THE GLOBAL CULTURAL CONTEXT OF THE TWENTY FIRST CENTURYTWENTY FIRST CENTURY

• Globalization/Rapid Social ChangeGlobalization/Rapid Social Change

• Poverty, UnemploymentPoverty, Unemployment

• Environmental Desecration and Environmental Desecration and Depletion of Depletion of Natural ResourcesNatural Resources

• Famine, Starvation, MalnutritionFamine, Starvation, Malnutrition

• Over-Population and Aging PopulationOver-Population and Aging Population (6.25 billion going to 9 billion with 40 (6.25 billion going to 9 billion with 40 years)years)

• International Organized Crime (Drugs) International Organized Crime (Drugs)

• Urban Decay and Collapse of Urban Decay and Collapse of Infrastructure Infrastructure

GLOBAL CULTURAL CONTEXT OF THE GLOBAL CULTURAL CONTEXT OF THE TWENTY FIRST CENTURYTWENTY FIRST CENTURY

• International TerrorismInternational Terrorism

• 30 Ethnopolitical Wars/ Low Intensity 30 Ethnopolitical Wars/ Low Intensity WarsWars

• International Migration International Migration

• Theocratic MovementsTheocratic Movements

• Corruption in Business/GovernmentCorruption in Business/Government

• Refugees and Internally Displaced Refugees and Internally Displaced PeoplePeople

• Public Health Epidemics (AIDS, Malaria)Public Health Epidemics (AIDS, Malaria)

• Human Rights Violations Human Rights Violations

Some “Colorful” FactsSome “Colorful” Facts• Five of six people in the world are of non-Five of six people in the world are of non-

European/Caucasian ancestry. To whom European/Caucasian ancestry. To whom does the world belong?does the world belong?

• The birthrates of whites in many Western The birthrates of whites in many Western nations are falling (also Japan).nations are falling (also Japan).

• More than 50% of the population in every More than 50% of the population in every Arabic country is below age 25.Arabic country is below age 25.

• The world population is 6 billion and will The world population is 6 billion and will move toward 9 billion within a few move toward 9 billion within a few

decades. decades. 90% of the birthrate increases 90% of the birthrate increases are in are in developing countries. developing countries.

Some “Colorful” FactsSome “Colorful” Facts• There are more than 1.3 billion Muslim There are more than 1.3 billion Muslim people in people in the world, and the rates of the world, and the rates of growth growth are are rapidly increasing.rapidly increasing.

• There are 192 nations in the United Nations There are 192 nations in the United Nations but but there are more than 5000 identifiable there are more than 5000 identifiable ethnocultural groups in the world.ethnocultural groups in the world.

• Sizeable portions of ethnic and racial Sizeable portions of ethnic and racial minority minority groups still remain disenfranchised, groups still remain disenfranchised,

marginalized, and impoverished.marginalized, and impoverished.

• Ethnic and racial minority populations in the Ethnic and racial minority populations in the USA USA are increasing through birthrates and are increasing through birthrates and migration.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 Socio-Political (Intra-Psychic/Relations) (Societal/Governmental) Psychological, Behavioral, Collective, National Emotional Problems International Problems

Copyright: AJM-2007-Copyright: AJM-2007-ATLATL

Psycho-Social and Socio-Political LevelsPsycho-Social and Socio-Political Levels  

Individual LevelIndividual Level Collective LevelCollective Level

Future Shock Future Shock Cultural DisintegrationCultural Disintegration

Culture ShockCulture Shock Genocide/Ethnic Genocide/Ethnic CleansingCleansingAlienation/AnomieAlienation/Anomie Surveillance SurveillanceAcculturation StressAcculturation Stress Vigilantism/Hate Vigilantism/Hate CrimesCrimesMeaninglessnessMeaninglessness Social Fragmentation Social FragmentationIdentity Crises Hyper-Religiosity/CultsIdentity Crises Hyper-Religiosity/CultsFear, Anger, Suicide,Fear, Anger, Suicide, Terrorism Terrorism Despair/Hopeless Despair/Hopeless Deviancies DevianciesPsychopathy, GreedPsychopathy, Greed Gangs/Violence Gangs/ViolenceSubstance Abuse Substance Abuse Greed Greed Deviancies Corruption Deviancies Corruption Paranoia, DistrustParanoia, Distrust Family Disintegration Family DisintegrationFanaticismFanaticism Fascism FascismUncertain/ConfusedUncertain/Confused Militarism/Policing Militarism/Policing

Radicalization Radicalization RadicalizationRadicalization

THE PSYCHOSOCIAL CONTEXTS OF HEALTH THE PSYCHOSOCIAL CONTEXTS OF HEALTH AND WELL BEINGAND 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 THE PSYCHOSOCIAL CONTEXTS OF HEALTH AND WELL BEINGAND 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 ofSome Basic Questions in the Study ofCulture and PsychopathologyCulture and Psychopathology

1.1. What is the role of cultural variables in the What is the role of cultural variables in the etiologyetiology

of psychopathology? of psychopathology?

2.2. What are the cultural variations in standards of What are the cultural variations in standards of normality and abnormality?normality and abnormality?

3.3. What are the cultural variations in the What are the cultural variations in the classification classification and diagnosis of and diagnosis of psychopathology?psychopathology?

4.4. What psychometric factors must be considered What psychometric factors must be considered in in the assessment of psychopathology across the assessment of psychopathology across cultures?cultures?

Some Basic Questions (Continued)Some Basic Questions (Continued)

5.5. What are the cultural variations in the What are the cultural variations in the phenomenological experience, phenomenological experience,

manifestation, manifestation, course and outcome of psychopathology?course and outcome of psychopathology?

6. Are all psychiatric disorders culture-bound? 6. Are all psychiatric disorders culture-bound?

• Are there cultural variations in therapy Are there cultural variations in therapy systems? systems?

8. How do we design and offer mental health 8. How do we design and offer mental health services services that are culturally appropriate? that are culturally appropriate?

THE “NEW” MENTAL HEALTH CLINICTHE “NEW” MENTAL HEALTH CLINICForeign Patients - Foreign Foreign Patients - Foreign

ProfessionalsProfessionals ProfessionalsProfessionals

American Filipino American Filipino Pakistani Pakistani NigerianNigerian

PatientsPatients

HispanicHispanic

VietnameseVietnamese

ArabicArabic

NigerianNigerian

KoreanKorean

Multicultural OrientationMulticultural OrientationSue, D. W., & Sue, D. (1990). Counseling the culturally different:

Theory and practice (2nd ed.). New York: Wiley, p. 6.

[Mental health professionals] . . . have a [Mental health professionals] . . . have a personal and professional responsibility to personal and professional responsibility to (a)(a) confront, become aware of, and take confront, become aware of, and take actions in dealing with our biases, actions in dealing with our biases, stereotypes, values, and assumptions about stereotypes, values, and assumptions about human behavior, human behavior, (b)(b) become aware of the become aware of the culturally different client’s world view, culturally different client’s world view, values, biases, and assumptions about values, biases, and assumptions about human behavior, and human behavior, and (c)(c) develop develop appropriate help-giving practices, appropriate help-giving practices, intervention strategies, and structures that intervention strategies, and structures that take into account the historical, cultural, take into account the historical, cultural, and environmental experiences and and environmental experiences and influences of the culturally different client.influences of the culturally different client.

Growing Antagonism Toward Western Psychiatry (Chakraborty,

1992)

Even where studies were sensitive, and the aim was to show Even where studies were sensitive, and the aim was to show relative differences caused by culture, the ideas and tools relative differences caused by culture, the ideas and tools were still derived from a circumscribed area of European were still derived from a circumscribed area of European thought. thought.

This difficulty still continues and, despite, modifications, This difficulty still continues and, despite, modifications, mainstream psychiatry remains rooted in Kraepelin's classic mainstream psychiatry remains rooted in Kraepelin's classic 19th century classification, the essence of which is the 19th century classification, the essence of which is the description of the two major "mental diseases ” seen in description of the two major "mental diseases ” seen in mental hospitals in his time -- schizophrenia and manic mental hospitals in his time -- schizophrenia and manic depression. Research is constrained by this view of depression. Research is constrained by this view of psychiatry. psychiatry.

Antagonism (continued)Antagonism (continued)

A central pattern of (western) disorders is identified A central pattern of (western) disorders is identified and taken as the standard by which other (local) and taken as the standard by which other (local) patterns are seen as minor variations. Such a patterns are seen as minor variations. Such a construct implies some inadequacy on the part of construct implies some inadequacy on the part of those patients who fail to reach "standard." Though those patients who fail to reach "standard." Though few people would agree with such statements, there is few people would agree with such statements, there is evidence of evidence of biasedbiased, , value-basedvalue-based, and often , and often racistracist undercurrentsundercurrents in psychiatry. . . . in psychiatry. . . .

Psychiatrists in the developing world . . . have Psychiatrists in the developing world . . . have accepted a diagnostic framework developed by accepted a diagnostic framework developed by western medicine, but which does not seem to take western medicine, but which does not seem to take into account the diversity of behavioral patterns they into account the diversity of behavioral patterns they encounter encounter

(Chakraborty, 1992, p. (Chakraborty, 1992, p. 1204).1204).

III. THE SOCIO-III. THE SOCIO-POLITICAL CONTEXT POLITICAL CONTEXT OF MENTAL HEALTHOF MENTAL HEALTH

Some Basic PremisesSome Basic Premises

1.1. Western mental health approaches Western mental health approaches and and systems are systems are cultural constructionscultural constructions that that reflects the assumptions, values, reflects the assumptions, values, and and practices of our dominant Western practices of our dominant Western cultural cultural context and history. They context and history. They implicitly support implicitly support a Western social, a Western social, ecnomic, and political ecnomic, and political system;system;

2.2. Historically, this dominant Western Historically, this dominant Western cultural cultural context has been driven by a context has been driven by a popular popular culture committed to individuality, culture committed to individuality, personal personal responsibility, materialism, responsibility, materialism, competition, competition, reductionism,reductionism,consumerism, patriarchy, consumerism, patriarchy, empiricism, and empiricism, and Protestant ethic. Protestant ethic.

Marsella (C)2001-Hawaii

Some Basic Premises (Continued)Some Basic Premises (Continued)

3. The history, assumptions, knowledge, 3. The history, assumptions, knowledge, values and practices of Western values and practices of Western

mental mental health are being challenged by health are being challenged by changing changing global conditions, global conditions, especially increased especially increased contact and contact and interactions with non-Western interactions with non-Western ethnic ethnic and cultural minorities who have and cultural minorities who have different cultural constructions of different cultural constructions of reality. reality.

4. The world has become a 4. The world has become a global-global-community community in which our individual in which our individual

and and collectives lives have become collectives lives have become increasingly interdependent. increasingly interdependent.

We cannot avoid contact or interactionWe cannot avoid contact or interaction

Marsella (C)2001-Hawaii

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Basic Premises (Continued)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, 7. We need to be multicultural, multisectoral, multisectoral, multinational, and multinational, and multidisciplinary approaches.multidisciplinary approaches.

Marsella (C)2001-Hawaii

Basic Premises (Continued)

8. 8. We must be alert to We must be alert to the the ethnocentric ethnocentric biasesbiases inherent in Western mental health inherent in Western mental health

approaches and systems and choose to approaches and systems and choose to value value thethe diverse psychologies of the diverse psychologies of the world.world.

9. 9. We must We must resist the hegemonic resist the hegemonic imposition imposition or or privileged positioningprivileged positioning of of any national or any national or cultural psychology; cultural psychology;

Marsella (C)2001-Hawaii

Basic Premises (Continued)

11.11. We must substantially address We must substantially address tra8ining, tra8ining, research, and service research, and service activities to activities to accommodate to the new accommodate to the new global realities of global realities of our times.our times.

12.12. We must be prepared to work in new We must be prepared to work in new settings (e.g., refugee camps, war zones, settings (e.g., refugee camps, war zones,

street corners, disaster zones) as street corners, disaster zones) as well as in well as in offices, clinics, and offices, clinics, and hospitals.hospitals.

Marsella (C)2001-Hawaii

BASIC PREMISES (CONTINUED)BASIC PREMISES (CONTINUED)

9.9. A professional psychology and science A professional psychology and science that that requires an increased requires an increased understanding and use understanding and use of non-Western of non-Western and indigenous and indigenous psychologiespsychologies..

10.10. This professional psychology and This professional psychology and science science requires requires substantial change in the substantial change in the

educational curriculum and educational curriculum and processprocess;;

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 Social Justice and Mental Health ProfessionalsProfessionals

(Prilletensky, 1998, p. 6)(Prilletensky, 1998, p. 6)

. . . . . . when it comes to social justice, when it comes to social justice, mental health workers are at a loss. mental health workers are at a loss. This is not because of a lack of This is not because of a lack of models, but rather because of a models, but rather because of a perennial, pervasive, and unjustified perennial, pervasive, and unjustified separation between their role as separation between their role as citizens and their role as citizens and their role as professionals. professionals.

Social justice, we are told belongs Social justice, we are told belongs in the private life of the psychiatrist in the private life of the psychiatrist and the psychologist, not in their and the psychologist, not in their professional role. professional role.

Social Justice (Continued) 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. IV. HISTORICAL HISTORICAL

FOUNDATIONSFOUNDATIONS

HISTORICAL PERSPECTIVESHISTORICAL PERSPECTIVES ACADEMIC AND PROFESSIONAL SPECIALTIES:ACADEMIC AND PROFESSIONAL SPECIALTIES:

Kraepelin (1904)Kraepelin (1904) Vergleichende PsychiatrieVergleichende PsychiatrieDevereux (1940)Devereux (1940) Primitive PsychiatryPrimitive PsychiatrySlotkin (1955)Slotkin (1955) Culture and PsychopathologyCulture and PsychopathologyDevereux (1956)Devereux (1956) Psychiatric AnthropologyPsychiatric AnthropologyDevereux (1961)Devereux (1961) EthnopsychiatryEthnopsychiatryKaelbling (1961)Kaelbling (1961) Comparative PsychopathologyComparative PsychopathologyKiev (1964)Kiev (1964) Folk PsychiatryFolk PsychiatryWittkower & Rin (1965)Wittkower & Rin (1965) Transcultural PsychiatryTranscultural PsychiatryMurphy & Leighton (1965)Murphy & Leighton (1965) Cross-Cultural PsychiatryCross-Cultural PsychiatryWeinberg (1967)Weinberg (1967) Psychiatric SociologyPsychiatric SociologyKennedy (1973)Kennedy (1973) Cultural PsychiatryCultural PsychiatryKleinman (1977)Kleinman (1977) The "New" Transcultural PsychiatryThe "New" Transcultural PsychiatryMurphy (1982)Murphy (1982) Comparative Psychiatry Comparative Psychiatry

(see Kraepelin, 1904)(see Kraepelin, 1904)

HISTORICAL PERSPECTIVESHISTORICAL PERSPECTIVES

John Locke (1690), in his famous essay, John Locke (1690), in his famous essay, Concerning Human UnderstandingConcerning Human Understanding, stated:, stated:

Had you or I been born at the Bay of Had you or I been born at the Bay of Soldania,possiblySoldania,possiblyour thoughts and notions had not exceeded those our thoughts and notions had not exceeded those brutish ones of the hottentots that inhabit there. brutish ones of the hottentots that inhabit there. And had the Virginia king, Apochancana, been And had the Virginia king, Apochancana, been educated in England, he had been perhaps as educated in England, he had been perhaps as knowing a divine and as good a mathematician as knowing a divine and as good a mathematician as any in it; the difference between him and a more any in it; the difference between him and a more improved Englishman lying barely in this, that the improved Englishman lying barely in this, that the exercise of his faculties was bounded within the exercise of his faculties was bounded within the ways, modes, and notions of his own country, and ways, modes, and notions of his own country, and never directed to any other or further inquiries.never directed to any other or further inquiries.

HISTORICAL PERSPECTIVESHISTORICAL PERSPECTIVESJean Jacques Rousseau (1749):Jean Jacques Rousseau (1749):

All at once I felt myself dazzled by a thousand All at once I felt myself dazzled by a thousand sparkling lights. Crowds of vivid ideas thronged into sparkling lights. Crowds of vivid ideas thronged into my mind with a force and confusion that threw me my mind with a force and confusion that threw me into unspeakable agitation; I felt my head whirling in into unspeakable agitation; I felt my head whirling in a giddiness like that of intoxication. A violent a giddiness like that of intoxication. A violent palpitation oppressed me. Unable to walk for palpitation oppressed me. Unable to walk for difficulty in breathing, I sank down under one of the difficulty in breathing, I sank down under one of the trees by the road, and passed half an hour there in trees by the road, and passed half an hour there in such a condition of excitement that when I rose I such a condition of excitement that when I rose I saw that the front of my waistcoat was all wet with saw that the front of my waistcoat was all wet with tears. . . .tears. . . .

Rousseau (Continued)Rousseau (Continued)

. . . Ah, if ever I could have written a quarter of what . . . Ah, if ever I could have written a quarter of what I saw and felt under that tree, with what clarity I I saw and felt under that tree, with what clarity I should have brought out all the contradictions of our should have brought out all the contradictions of our social system! With what simplicity I should have social system! With what simplicity I should have demonstrated that demonstrated that man is by nature good, and that man is by nature good, and that only our institutions have made him bad.only our institutions have made him bad.

(Rousseau, 1749; Quoted in Durant & Durant, (Rousseau, 1749; Quoted in Durant & Durant, 1967, p. 19)1967, p. 19)

HISTORICAL PERSPECTIVESHISTORICAL PERSPECTIVES

Insanity is a part of the price we pay for Insanity is a part of the price we pay for civilizationcivilization. The causes of the one increase with . The causes of the one increase with the developments and results of the other. The the developments and results of the other. The increase in knowledge, the improvement of the increase in knowledge, the improvement of the arts, the multiplication of comforts, the arts, the multiplication of comforts, the amelioration of manners, the growth of amelioration of manners, the growth of refinement, and the elevation of morals, do not refinement, and the elevation of morals, do not of themselves disturb men's cerebral organs and of themselves disturb men's cerebral organs and create mental disorder. But with them come create mental disorder. But with them come more opportunities for great and excessive more opportunities for great and excessive mental action, more uncertain and hazardous mental action, more uncertain and hazardous employment, and consequently more employment, and consequently more disappointments, more means and provocations disappointments, more means and provocations for sensual indulgences, more accidents and for sensual indulgences, more accidents and injuries, more groundless hopes, and more injuries, more groundless hopes, and more painful struggle to obtain that which is beyond painful struggle to obtain that which is beyond reach or to effect that which is impossiblereach or to effect that which is impossible

(John Jarvis - American Psychiatrist - (John Jarvis - American Psychiatrist - 1851)1851)

HISTORICAL PERSPECTIVESHISTORICAL PERSPECTIVES(1875-1950 PERIOD)

1.1. The study of cross-cultural study of mental disorders The study of cross-cultural study of mental disorders using using Western concepts (e.g., neurosis in India, psychosis in Western concepts (e.g., neurosis in India, psychosis in Africa).Africa).

2.2. The study of relativistic standards of normality and The study of relativistic standards of normality and abnormality.abnormality.

3.3. The emergence of international and cross-cultural The emergence of international and cross-cultural psychiatric psychiatric epidemiological studies.epidemiological studies.

4.4. The popularization of Freudian views of human nature The popularization of Freudian views of human nature ("the ("the negative role of civilization").negative role of civilization").

5.5. The rise and growth of culture and personality studies The rise and growth of culture and personality studies within within anthropology.anthropology.

6.6. Study of culture-bound syndromesStudy of culture-bound syndromes

HISTORICAL PERSPECTIVESHISTORICAL PERSPECTIVESPost-1970 PeriodPost-1970 Period

1. International collaborative studies (e.g., the 1. International collaborative studies (e.g., the World World Health Organization Pilot Study of Health Organization Pilot Study of Schizophrenia).Schizophrenia).

2. Increases in the number of ethnic minority 2. Increases in the number of ethnic minority mental mental health professionals. health professionals.

3. Growing disaffection of non-Western mental 3. Growing disaffection of non-Western mental health health professionals with the ethnocentrism and bias professionals with the ethnocentrism and bias ofof Western psychiatry.Western psychiatry.

4. Increases in social awareness of the 4. Increases in social awareness of the pathological pathological sequalae of racism, sexism, sequalae of racism, sexism, imperialism, colonialism, imperialism, colonialism, and other "isms."and other "isms."

History - History - Post 1970 PeriodPost 1970 Period - Continued - Continued

5. Increases in awareness of the pernicious consequences5. Increases in awareness of the pernicious consequences of war, urbanization, poverty, and other socio-culturalof war, urbanization, poverty, and other socio-cultural phenomena for mental health.phenomena for mental health.

6. A growing awareness of the multiple and interactive6. A growing awareness of the multiple and interactive determinants of psychopathology (e.g., biology,determinants of psychopathology (e.g., biology, psychology, sociology).psychology, sociology).

7. Post-Modern Era emphasis on relativity and subjectivity7. Post-Modern Era emphasis on relativity and subjectivity in human experience (i.e., the social construction ofin human experience (i.e., the social construction of reality- reality- POSITIONS CULTURE AS A CRITICAL POSITIONS CULTURE AS A CRITICAL DETERMINANT OF HUMAN BEHAVIORDETERMINANT OF HUMAN BEHAVIOR))

Emil KraepelinEmil KraepelinComparative Psychiatry (Comparative Psychiatry (Vergleichende Vergleichende

PsychiatriePsychiatrie))

The characteristics of the people should find The characteristics of the people should find expression in the frequency as well as in expression in the frequency as well as in the shaping of the manifestations of mental the shaping of the manifestations of mental illness in general; so that comparative illness in general; so that comparative psychiatry shall make it possible to gain psychiatry shall make it possible to gain valuable insights into the psyche of nations, valuable insights into the psyche of nations, and shall in turn also be able to contribute and shall in turn also be able to contribute to the understanding of pathological to the understanding of pathological psychic processespsychic processes

Emil Kraeplin (1904, p. 9)Emil Kraeplin (1904, p. 9)

Relevant Journals Relevant Journals

Cross-Cultural ResearchCross-Cultural ResearchCultural Diversity and Mental Health Cultural Diversity and Mental Health Culture Medicine, and PsychiatryCulture Medicine, and PsychiatryHispanic Journal of Behavioral SciencesHispanic Journal of Behavioral SciencesInternational Journal of Intercultural RelationsInternational Journal of Intercultural RelationsInteramerican Journal of PsychologyInteramerican Journal of PsychologyInternational Journal of PsychologyInternational Journal of PsychologyInternational Journal of Mental HealthInternational Journal of Mental HealthInternational Journal of Social PsychiatryInternational Journal of Social PsychiatryJournal of Black PsychologyJournal of Black PsychologyJournal of Cross-Cultural PsychologyJournal of Cross-Cultural PsychologyJournal of Health and Social BehaviorJournal of Health and Social BehaviorJournal of Multicultural Counseling and DevelopmentJournal of Multicultural Counseling and DevelopmentJournal of Refugee StudiesJournal of Refugee StudiesMedical AnthropologyMedical AnthropologyPsychologia: The Journal of Psychology in the OrientPsychologia: The Journal of Psychology in the OrientSocial PsychiatrySocial PsychiatrySocial Psychiatry & EpidemiologySocial Psychiatry & EpidemiologySocial Science and MedicineSocial Science and MedicineSouth Pacific Journal of PsychologySouth Pacific Journal of PsychologyTranscultural Psychiatric ResearchTranscultural Psychiatric Research

CULTURECULTURE

CULTURECULTURE

CULTURECULTURE

CULTURECULTURE

VI. VI. CULTURECULTURE

CULTURE CULTURE

THE CULTURE PSYCHOLOGY THE CULTURE PSYCHOLOGY SPECIALTIESSPECIALTIES

Cultural PsychologyCultural Psychology Cross-Cultural PsychologyCross-Cultural Psychology Ethnic Minority PsychologyEthnic Minority Psychology Multicultural PsychologyMulticultural Psychology Indigenous PsychologiesIndigenous Psychologies International PsychologyInternational Psychology Transcultural Mental Transcultural Mental HealthHealth

Multicultural Multicultural CounselingCounseling

Marsella (C)2001-Hawaii

DEFINITION OF CULTUREDEFINITION OF CULTURE

Culture is shared learned behavior and meanings Culture is shared learned behavior and meanings that are socially transferred in various life-activity that are socially transferred in various life-activity settings for purposes of individual and collective settings for purposes of individual and collective adjustment and adaptation. Cultures can be adjustment and adaptation. Cultures can be (1) (1) transitorytransitory (i.e. situational even for a few minutes), (i.e. situational even for a few minutes), (2) relatively enduring(2) relatively enduring (e.g., ethnocultural life (e.g., ethnocultural life styles), and in all instances are styles), and in all instances are (3) dynamic (3) dynamic (i.e., (i.e., subject to change and modification).subject to change and modification). Cultures are represented Cultures are represented (4) internally (4) internally (i.e., values, (i.e., values, beliefs, attitudes, axioms, orientations, beliefs, attitudes, axioms, orientations, epistemologies, consciousness levels, perceptions, epistemologies, consciousness levels, perceptions, expectations, personhood) and expectations, personhood) and (5) externally(5) externally (i.e., (i.e., artifacts, roles, institutions, social structures), and artifacts, roles, institutions, social structures), and (6) shape and construct our realities(6) shape and construct our realities (i.e., they (i.e., they contribute to our world views, perceptions, contribute to our world views, perceptions, orientations) and with this, many of our ideas, orientations) and with this, many of our ideas, morals, and preferences. morals, and preferences.

THE CULTURAL CONSTRUCTION OF THE CULTURAL CONSTRUCTION OF REALITYREALITY

Marsella (1996, 1999)

 

• There is a UNIVERSAL inherent human impulse to There is a UNIVERSAL inherent human impulse to describe, describe, understand, and predict the understand, and predict the

world world through the ordering of stimuli;through the ordering of stimuli;   The human brain responds to stimuli by The human brain responds to stimuli by organizing, organizing, connecting, and symbolizing connecting, and symbolizing stimuli, and in the stimuli, and in the process, generates process, generates patterns patterns of meanings that of meanings that help promote survival, help promote survival, adaptation, and adaptation, and adjustment; adjustment;   ··  This process and product of this activity are, This process and product of this activity are, culturally culturally contextualized, generated, and shaped contextualized, generated, and shaped through through linguistic, behavioral, and socialization linguistic, behavioral, and socialization practices; practices;

CULTURAL CONSTRUCTION OF CULTURAL CONSTRUCTION OF REALITYREALITY

Marsella (1996, 1999) (Continued) 

• Through socialization, individual and group Through socialization, individual and group preferences preferences and priorities are rewarded or and priorities are rewarded or punished thus punished thus promoting and/or modifying the promoting and/or modifying the

cultural cultural constructions of reality (i.e., constructions of reality (i.e., ontogenies, epistemologies, praxologies, ontogenies, epistemologies, praxologies, cosmologies, ethoses, values, and behavior cosmologies, ethoses, values, and behavior patterns). patterns). • The Result: The Result:

A culturally constructed reality that A culturally constructed reality that resists resists change change and does not yield and does not yield well to well to contestations.contestations.

THE PROCESS OF SOCIALIZING THE PROCESS OF SOCIALIZING CULTURAL CULTURAL BELIEFS AND PRACTICESBELIEFS AND PRACTICES (Tart , 1986, pages 92-98)

1.1. Unlimited time (years of exposure)Unlimited time (years of exposure)

2.2. Use of physical force to shape behaviorUse of physical force to shape behavior

3.3. Use of emotional force such love and Use of emotional force such love and affection and fear affection and fear

4.4. Use of rewards for those who conformUse of rewards for those who conform

5.5. Trust in parents because of their Trust in parents because of their omnipotenceomnipotence

Socializing Culture (continued)Socializing Culture (continued)

6.6. Expectations of permanencyExpectations of permanency

7.7. Standards are promoted (shoulds and Standards are promoted (shoulds and don’ts)don’ts)

8.8. Sense of security from group conformity Sense of security from group conformity

9. 9. Everything not permitted is forbidden and Everything not permitted is forbidden and everything permitted is compulsory.everything permitted is compulsory.

PersonPerson

FamilyFamily

EthosEthos

MediaMedia

SchoolsSchools

ReligionReligion

PoliticalPolitical

2. CULTURAL SOCIALIZATION 2. CULTURAL SOCIALIZATION DIAGRAMDIAGRAM

EthoEthoss

Econ

omic

Econ

omic

Social

Social

Structure

Structure

PsychologyPsychology

BiologyBiology

Individualism Materialism

Change

Competition

Violence

Celebrities

Consumerism Hedonism

CULTURAL VARIATIONSCULTURAL VARIATIONS

• Cultures differ in the ways they Cultures differ in the ways they codify codify and know reality. and know reality.

• There are cultural variations in the There are cultural variations in the use use and emphasis of words, and emphasis of words, feelings, feelings, images, visceral, images, visceral, proprioceptive, proprioceptive, skeletal means for skeletal means for handling “reality” handling “reality” content and content and processes. processes.

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The Codification ofThe Codification of

Human ExperienceHuman Experience

• CognitionCognition

• ImageryImagery

• AffectiveAffective

• VisceralVisceral

• ProprioceptiveProprioceptive

Subjective Experience of Reality:Subjective Experience of Reality:

Language, Experience, and Reality Language, Experience, and Reality

(Marsella, 1978, 1986)(Marsella, 1978, 1986)

• Imagistic, Proprioceptive, Visceral Mediation of Imagistic, Proprioceptive, Visceral Mediation of RealityReality

• Language is metaphorical, poetic, immediate, Language is metaphorical, poetic, immediate, sensory sensory

In this respect, a metaphorical language In this respect, a metaphorical language provides a provides a rich, rich, immediate sensory immediate sensory experience of the world experience of the world that is not diluted by that is not diluted by being filtered through words being filtered through words that distantiate that distantiate the cognitive the cognitive understanding form understanding form the the experience. In a metaphorical language experience. In a metaphorical language system, system, the understanding and the language are the understanding and the language are one. one.

Concrete metaphors link sensory experience Concrete metaphors link sensory experience and and cognition together. cognition together.

Subjective Experience of Reality: Subjective Experience of Reality:

Language, Experience, and Reality (Continued)Language, Experience, and Reality (Continued)

• Communication is based on relational Communication is based on relational negotiation in negotiation in which there are assumptions of which there are assumptions of awareness of awareness of sensitivities, hierarchy, roles sensitivities, hierarchy, roles awareness. Strong awareness. Strong emphasis on reading non-emphasis on reading non-verbal cues and “what is verbal cues and “what is not said.”not said.”

• Unindividuated Self Structure (e.g., Relational, Unindividuated Self Structure (e.g., Relational, Collateral, Diffuse) in which self as process Collateral, Diffuse) in which self as process

and self and self as object become fused. as object become fused.

Contrasting Prototypical Cultural Contrasting Prototypical Cultural PatternsPatterns

DimensionDimension Culture ACulture A Culture BCulture B

1. Self1. Self Individual Individual CollectiveCollective2. Maturity2. Maturity Independence Independence InterdependenceInterdependence3. Style3. Style AssertiveAssertive DeferentDeferent4. Orientation4. Orientation Product/ProcessProduct/Process Process/ProductProcess/Product5. Communicate5. Communicate DirectDirect IndirectIndirect6. Mode6. Mode VerbalVerbal Non-verbalNon-verbal7. Status7. Status EqualityEquality HierarchicalHierarchical8. Effort8. Effort MasteryMastery HarmonyHarmony9. Determinants9. Determinants PersonPerson Destiny/KharmaDestiny/Kharma10. Traditions10. Traditions Change/NewChange/New Preserve PastPreserve Past11. Generations 11. Generations DistinctDistinct ContinuousContinuous12. Knowing12. Knowing FissionFission FusionFusion

ETHNOCENTRISMETHNOCENTRISM

A habitual, and often unconscious, A habitual, and often unconscious, tendency or disposition to evaluate tendency or disposition to evaluate foreign people and cultures by standards foreign people and cultures by standards and practices of one’s own ethnocultural and practices of one’s own ethnocultural group.group.

An inclination to view one’s own way of An inclination to view one’s own way of life as the only proper or moral way with life as the only proper or moral way with a resulting sense of personal and cultural a resulting sense of personal and cultural superiority.superiority.

A sense that one’s own way of believing A sense that one’s own way of believing or behaving is the “true” or “best” way.or behaving is the “true” or “best” way.

ETHNOCENTRISMETHNOCENTRISMOther examples abound: Other examples abound: Toynbee notes that Ancient Persia regarded notes that Ancient Persia regarded itself the center of the world and viewed other nations as increasingly itself the center of the world and viewed other nations as increasingly barbaric according to their degree of distance. China's very name is barbaric according to their degree of distance. China's very name is composed of ideographs meaning "center" and "country" respectively, composed of ideographs meaning "center" and "country" respectively, and traditional Chinese world maps show China in the center. It's also 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 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, the height of the Chinese empire, the Japanese, Koreans, Vietnamese, and Thai also believed China to be the centre of the universe and referred 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 to China as the middle kingdom. To this day, Japan, Korea, and Viet Nam still refer to China as the middle kingdom.still refer to China as the middle kingdom.

England defined the world's meridians with itself on the center line, and 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, to this day, longitude is measured in degrees east or west of Greenwich, thus establishing as fact an Anglo-centrist's worldview. thus establishing as fact an Anglo-centrist's worldview. Native American tribal names often translate as some variant on "the people"; other tribes tribal names often translate as some variant on "the people"; other tribes were labeled with often pejorative names. The were labeled with often pejorative names. The United States has has traditionally conceived of itself as having a unique role in world history—traditionally conceived of itself as having a unique role in world history—famously characterized by President famously characterized by President Abraham Lincoln as "the last, best as "the last, best hope of Earth"—an outlook known as hope of Earth"—an outlook known as American exceptionalism..

http://en.wikipedia.org/wiki/Eurocentrism

ETHNOCULTURAL IDENTIFICATIONETHNOCULTURAL IDENTIFICATION

The extent to which an individual endorses The extent to which an individual endorses and practices a way of life associated with a and practices a way of life associated with a particular cultural tradition. particular cultural tradition.

Ethnocultural identificationEthnocultural identification can be assessed can be assessed by self nomination scales that measure by self nomination scales that measure attitudes/values, behaviors, and attitudes/values, behaviors, and preferences associated with a particular preferences associated with a particular cultural tradition.cultural tradition.

Ethnocultural identificationEthnocultural identification is a dynamic is a dynamic characteristic that may change across characteristic that may change across settings and situations. It is heavily settings and situations. It is heavily determined by generation, historical period, determined by generation, historical period, personal demographic variations. personal demographic variations.

TraditionaTraditionall

WesternWestern HighHigh

Bicultural, Bicultural, Multicultural, Multicultural, SyncreticSyncretic

AcculturatedAcculturated

TraditionalTraditional

LowLowHighHigh

LowLow

Alienated

Ethnocultural Identification Matrix (Modified fromEthnocultural Identification Matrix (Modified fromKitano, 1982)Kitano, 1982)

Integrated Model of Ethnic IdentityIntegrated Model of Ethnic Identity

(Dina Birman, 1994) (Dina Birman, 1994)

Acculturative Identity Behavioral

Style Acculturation Acculturation

TraditionalTraditional TraditionalTraditional TraditionalTraditional

AssimilatedAssimilated Assimilated Assimilated AssimilatedAssimilated

MarginalMarginal Marginal Marginal Marginal Marginal

Blended Bicult.Blended Bicult. Bicultural Bicultural Bicultural Bicultural Instrum. Bicult.Instrum. Bicult. MarginalMarginal Bicultural Bicultural

Integrat. Bicult.Integrat. Bicult. TraditionalTraditional Bicultural Bicultural

Ident. Explor.Ident. Explor. TraditionalTraditional AssimilatedAssimilated

Creating an Ethnocultural Creating an Ethnocultural Identification ScaleIdentification Scale

1.1. Sample Attitudinal Items:Sample Attitudinal Items:

A.A. What ethnocultural group do What ethnocultural group do you you most consider yourself to most consider yourself to be a be a member member of? of?

B.B. How much pride do you have How much pride do you have in in your ethnocultural group?your ethnocultural group?

C.C. Would you be willing to marry Would you be willing to marry outside your ethnocultural outside your ethnocultural

group?group?

Ethnocultural identification Ethnocultural identification (Continued)(Continued)

2.2. Sample Behavioral Items:Sample Behavioral Items:

A.A. Do you speak your group’s Do you speak your group’s language? language?

B.B. Do you eat their food?Do you eat their food?

C.C. Do you participate in their Do you participate in their celebrations? celebrations?

D.D. Do you associate mainly with Do you associate mainly with friends from your group?friends from your group?)

VII. CULTURE AND VII. CULTURE AND PSYCHOPATHOLOGY PSYCHOPATHOLOGY

FOUNDATIONSFOUNDATIONS

CRITICAL ISSUES IN THE STUDY OF CRITICAL ISSUES IN THE STUDY OF CULTURE AND CULTURE AND

PSYCHOPATHOLOGYPSYCHOPATHOLOGY1.1. Conceptual Models Conceptual Models

2.2. ClassifictaionClassifictaion

3.3. Normality and AbnormalityNormality and Abnormality

4.4. Nature Of Personhood and SelfNature Of Personhood and Self

5.5. Mind-Body RelationshipsMind-Body Relationships

6.6. AssessmentAssessment

7. Examples of PTSD & Schzophrenia7. Examples of PTSD & Schzophrenia

8.8. Multiple CausalityMultiple Causality

9.9. Models of IllnessModels of Illness

10.10. Epidemiology across CulturesEpidemiology across Cultures

1. CONCEPTUAL FRAMEWORKS ,

PERSPECTIVES, AND MODELS

FOR UNDERSTANDING PSYCHOPATHOLOGY

PersonPerson

BiologyBiology

PsychologyPsychology

CultureCulture

EnvironmentEnvironment

Multiple Determinants of Human Multiple Determinants of Human BehaviorBehavior

PersonPerson SituationSituation

BehavioBehaviorrBehavior is the continuous and ongoing adjustment by the Behavior is the continuous and ongoing adjustment by the

organism to the simultaneous demands from both the organism to the simultaneous demands from both the personperson and the and the situation.situation. Thus, the determinants of human Thus, the determinants of human behavior reside both behavior reside both withinwithin and and withoutwithout; the determinants ; the determinants withinwithin are constituted from immediate and historical are constituted from immediate and historical influences.influences.

CultureCulture BiologyBiology

EnvironmentEnvironment PsychologyPsychology

Person-Situation Ecological ModelPerson-Situation Ecological Model

Hierarchical Systems ModelHierarchical Systems ModelLEVELLEVEL KNOWLEDGEKNOWLEDGE SAMPLESAMPLE DISORDERSDISORDERS

BASEBASE VARIABLESVARIABLES

SpiritualSpiritual Philosophy, ReligionPhilosophy, Religion Meaning, PurposeMeaning, Purpose MeaninglessMeaningless

MacrosocialMacrosocial Politics, EconomicsPolitics, Economics Poverty, Social Change,Poverty, Social Change,CulturalCulturalSociology, AnthropologySociology, Anthropology UrbanizationUrbanization DisintegrationDisintegration

MicrosocialMicrosocial Family Studies, CommunityFamily Studies, Community Family RelationsFamily RelationsFamily Family Abuse,Abuse,

Studies, Workplace StudiesStudies, Workplace Studies Work AdjustmentWork Adjustment Work Work Stress Stress

PsychosocialPsychosocial Personality TheoryPersonality Theory Self ConceptSelf Concept Low Self Low Self Self TheorySelf Theory Self EsteemSelf Esteem EsteemEsteem

Cognitive/Cognitive/ Cognitive SciencesCognitive Sciences Attention, MemoryAttention, Memory ConcentrationConcentrationBehavioralBehavioral

Sensory/Sensory/ Sensation-MotorSensation-Motor Reaction TimeReaction Time SensorySensoryMotorMotor Performance Performance OverloadOverload

Psycho-Psycho- PsychophysiologyPsychophysiology Orienting ResponseOrienting Response StressStressphysiological physiological EEG, EKGEEG, EKG HyperarousalHyperarousal

Biopsycho-Biopsycho- Neurology, Psychiatry,Neurology, Psychiatry, NeurotransmittersNeurotransmitters Depression,Depression,socialsocial Neurochemistry, AnatomyNeurochemistry, Anatomy AnxietyAnxiety

Ecological Framework for Ecological Framework for Understanding Understanding NegativeNegative Mental Health Mental Health and Wellbeingand Wellbeing

IndividualIndividual CulturalCulturalSociopoliticalSociopolitical

DiscontentDiscontent AbuseAbuse ColonializationColonializationDistressDistress DecayDecay ExploitationExploitationDisorderDisorder DestructionDestruction ImperialismImperialismDeviancyDeviancy DislocationDislocation IsmsIsmsDiseaseDisease DisintegrationDisintegration DisempowermentDisempowerment

Ecological Framework for Ecological Framework for UnderstandingUnderstandingPositivePositive Mental Health and WellbeingMental Health and Wellbeing

IndividualIndividual Cultural CulturalSociopoliticalSociopolitical

Health/WellbeingHealth/Wellbeing Revitalization Revitalization ChangeChangeCompetenceCompetence Integration Integration Reform/JusticeReform/JusticeAdaptationAdaptation Coherence Coherence EqualityEqualityMeaning/PurposeMeaning/Purpose Rebuilding Rebuilding CivilityCivilitySpiritualitySpirituality Renaissance Renaissance ReconstructionReconstruction

Psychosocial StressorsPsychosocial Stressors (Marsella, (Marsella, 1988)1988)

Needs Needs Values Roles Status Values Roles Status IdentityIdentity

____________________________________________________________DeprivationDeprivation

____________________________________________________________DenigrationDenigration

____________________________________________________________DiscrepancyDiscrepancy

____________________________________________________________ConflictConflict

____________________________________________________________ConfusionConfusion

___________________________________

The Conditions for Health and Wellbeing The Conditions for Health and Wellbeing Reside in the Total Context of Human Reside in the Total Context of Human Life:Life:

•We cannot have health where there is We cannot have health where there is cultural cultural

destruction, destruction, forfor

this breeds this breeds confusionconfusion and and conflictconflict..

• We cannot have health where there is We cannot have health where there is oppressionoppression, for, for

this breeds this breeds angeranger and and resentmentresentment. .

• We cannot have health where there is We cannot have health where there is powerlessnesspowerlessness, ,

forfor

this breeds only this breeds only helplessness helplessness and and despairdespair..

The Conditions for Health and The Conditions for Health and

WellbeingWellbeing

(Continued)(Continued)

•We cannot have health where there is We cannot have health where there is povertypoverty, for , for

this breeds only this breeds only hopelessnesshopelessness..

•We cannot have health where there is We cannot have health where there is denigrationdenigration, for , for

this breeds this breeds low esteemlow esteem and and worthlessnessworthlessness. .

•We cannot have health where there is We cannot have health where there is racism racism andand

sexismsexism, for, for

this this restrains opportunityrestrains opportunity and and limits choicelimits choice. .

SOCIOCULTURAL PATHWAYS TO DISTRESS, SOCIOCULTURAL PATHWAYS TO DISTRESS, DEVIANCY & DISORDERDEVIANCY & DISORDER

Rapid and Destructive Social ChangeRapid and Destructive Social Change(e.g., cultural change, collapse, abuse, disintegration, (e.g., cultural change, collapse, abuse, disintegration, confusion)confusion)

Social Stress and ConfusionSocial Stress and Confusion(e.g., family, community, work, school, goverrnment (e.g., family, community, work, school, goverrnment

problems)problems)

Psychosocial Stress and ConfusionPsychosocial Stress and Confusion(e.g., marginalized, powerlessness, alienation, (e.g., marginalized, powerlessness, alienation,

anomie)anomie)

Identity Stress & ConfusionIdentity Stress & Confusion(e.g., Who am I, what do I believe)(e.g., Who am I, what do I believe)

Psychobiological ChangesPsychobiological Changes(e.g., anger, hopelessness, despair, (e.g., anger, hopelessness, despair,

fear)fear)

Behavioral ProblemsBehavioral Problems(e.g., suicide, alcohol, (e.g., suicide, alcohol,

violence, violence, substance abuse, substance abuse, delinquency)delinquency)

2. Classification 2. Classification and Diagnosisand Diagnosis

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Terms of Reference Terms of Reference (Mix and Match)(Mix and Match)

LocusLocus DescriptorDescriptorMentalMental Maladjustment Maladjustment Psychological Psychological DisorderDisorderBehavioralBehavioral DiseaseDiseaseBiobehavioral Biobehavioral IllnessIllness

Emotional Emotional DysfunctionDysfunctionPsychiatricPsychiatric MaladaptationMaladaptation

     Nervous         Nervous         DisturbanceDisturbance                       Deviancy Deviancy                      InsanityInsanity                       SicknessSickness                      BreakdownBreakdown

DerangementDerangement

Some Historical ContextsSome Historical Contexts

Hippocrates (460-377 BC): SymptomsHippocrates (460-377 BC): Symptoms

• Mania, Melancholia, & Phrenitis. Mania, Melancholia, & Phrenitis. • The Humoral Theory: Black Bile, The Humoral Theory: Black Bile, Yellow Yellow Bile, Blood, PhlegmBile, Blood, Phlegm

Paracelsus (1493-1531): CausesParacelsus (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 ContextsSome Historical Contexts

Emil Kraepelin (1856-1926) (Father of Emil Kraepelin (1856-1926) (Father of Dx & Dx & Classification)Classification)

• Dementia Praecox - CognitionDementia Praecox - Cognition• Manic-Depressive - Manic-Depressive - Mood/EmotionMood/Emotion• Psychopathic - WillPsychopathic - Will

The DSMsDSM 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?So Why Do We Classify and Diagnose?

• It is the hope that if we can classify It is the hope that if we can classify properly we will be able to know: properly we will be able to know:

(1) (1) cause, (2) onset, (3) display, (4) cause, (2) onset, (3) display, (4) course, course, (5) outcome, (6) (5) outcome, (6)

treatment, treatment, and (7) prevention.and (7) prevention.

• Instead we use it for different Instead we use it for different reasons reasons including: including: (1) insurance (1) insurance repayment, repayment, (2) ward assignment, (2) ward assignment,

(3) declaration (3) declaration of incompetence, of incompetence, (4) communication (4) communication among among professionals (5) satisfy clients professionals (5) satisfy clients and families (6) statistical reports, (7) and families (6) statistical reports, (7)

promote research. promote research. 

What are Some of the What are Some of the Problems?Problems?

• Categories are not exclusive. Lots of Categories are not exclusive. Lots of mixtures mixtures and symptoms overlaps. Dual and symptoms overlaps. Dual DxDx

• Issue of Reliability/ConsistencyIssue of Reliability/Consistency

• Source of informations (e.g, Pt, Family, Source of informations (e.g, Pt, Family, Tests, Tests, Objective Data, Professional)Objective Data, Professional)

• Mixture of Causation and DescriptionMixture of Causation and Description

• Equipotentiality/EquifinalityEquipotentiality/Equifinality

• Ethnocentricity – Bias against Non-Ethnocentricity – Bias against Non-WesternWestern • Multiple Causality Multiple Causality

FormativFormativee

PrecipativePrecipative

ExacerbativeExacerbative

MaintenanceMaintenance

Multiple and Interactive Multiple and Interactive Causality Causality

The Neo-Kraepelinian MovementThe Neo-Kraepelinian Movement(Klerman, 1978)(Klerman, 1978)

• Psychiatry is a branch of medicinePsychiatry is a branch of medicine

• There is a boundary between normal and There is a boundary between normal and sicksick

• There are discrete mental illnessesThere are discrete mental illnesses

• The focus of psychiatric physicians The focus of psychiatric physicians should be should be on biological aspects of on biological aspects of mental illnessmental illness

• There should be an intentional and There should be an intentional and explicit explicit concern with diagnosis and concern with diagnosis and classificationclassification

““The Empowerment of the Medical Model” The Empowerment of the Medical Model”

What are Some of the Problems?What are Some of the Problems? Conflict of Interest Conflict of Interest

Conclusion:Conclusion: Our inquiry into the relationships between Our inquiry into the relationships between DSM panel members and the pharmaceutical industry DSM panel members and the pharmaceutical industry demonstrates that there are strong financial ties between demonstrates that there are strong financial ties between the industry and those who are responsible for developing the industry and those who are responsible for developing and modifying the diagnostic criteria for mental illness. and modifying the diagnostic criteria for mental illness. The connections are especially strong in those diagnostic The connections are especially strong in those diagnostic areas where drugs are the first line of treatment for mental areas where drugs are the first line of treatment for mental disorders. Full disclosure by DSM panel members of their disorders. Full disclosure by DSM panel members of their financial relationships with for-profit entities that financial relationships with for-profit entities that manufacture drugs used in the treatment of mental illness manufacture drugs used in the treatment of mental illness is recommended.is recommended.

What are Some of the Problems?What are Some of the Problems? Conflict of Interest Conflict of Interest

Results: Results: Of the 170 DSM panel members 95 (56%) Of the 170 DSM panel members 95 (56%) had one or more financial associations with had one or more financial associations with companies in the pharmaceutical industry. One companies in the pharmaceutical industry. One hundred percent of the members of the panels on hundred percent of the members of the panels on ‘Mood Disorders’ and ‘Schizophrenia and Other ‘Mood Disorders’ and ‘Schizophrenia and Other Psychotic Disorders’ had financial ties to drug Psychotic Disorders’ had financial ties to drug companies. The leading categories of financial companies. The leading categories of financial interest held by panel members were research interest held by panel members were research funding (42%), consultancies (22%) and speakers funding (42%), consultancies (22%) and speakers bureau (16%). bureau (16%). Psychotherapy and Psychosomatics Psychotherapy and Psychosomatics (2006), 75, 154-160. Financial Ties between DSM-(2006), 75, 154-160. Financial Ties between DSM-IV Panel Members IV Panel Members and the Pharmaceutical Industryand the Pharmaceutical IndustryLisa Cosgrove , Sheldon Krimsky, Manisha Vijayaraghavan, Lisa Cosgrove , Sheldon Krimsky, Manisha Vijayaraghavan, Lisa SchneiderLisa Schneider

Copyright © 2006 S. Karger AG, BaselCopyright © 2006 S. Karger AG, Basel

Many Options – But Not for InsuranceMany Options – But Not for Insurance(More than 300 Systems)(More than 300 Systems)

• Behavioral (e.g., Kanfer & Saslow)Behavioral (e.g., Kanfer & Saslow)

• Syndromal (e.g., Lorr & Klett)Syndromal (e.g., Lorr & Klett)

• Interpersonal/Familial (e.g., Interpersonal/Familial (e.g., Benjamin) Benjamin)

• No Dx (e.g., Rogerian)No Dx (e.g., Rogerian)

• Personality Dimensions (e.g., Personality Dimensions (e.g., Eysenck) Eysenck)

• ICD –10 (WHO)ICD –10 (WHO)

• DSM-IVR (American Psychiatric DSM-IVR (American Psychiatric Assoc.)Assoc.) (Multi-Axial Dx System: Disorder, Personality, (Multi-Axial Dx System: Disorder, Personality, Medical, Medical, Stress Level, Coping) Stress Level, Coping)

Careful and Detailed Description Careful and Detailed Description • Symptom Parameters (i.e., Frequency, Symptom Parameters (i.e., Frequency,

Severity, Duration)Severity, Duration)

• Situation (i.e., When, Who is present, Situation (i.e., When, Who is present, Stop)Stop)

• Antecedents and Consequences (i.e., Antecedents and Consequences (i.e., Starts, Starts, Outcomes)Outcomes)

• Source of Information (i.e., Patient, Source of Information (i.e., Patient, Professional, Family, Others)Professional, Family, Others)

• Detailed History (i.e., Utero, Birth, Diet, Detailed History (i.e., Utero, Birth, Diet, Sleep) Sleep)

• Test Results and Biases Test Results and Biases

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2A: DSM – IV TR2A: DSM – IV TR ANDAND

CULTURECULTURE

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Use of DSM-IV Across Ethnocultural Use of DSM-IV Across Ethnocultural BoundariesBoundaries

DSM-IV: "A clinician who is DSM-IV: "A clinician who is unfamiliar with the nuances of an unfamiliar with the nuances of an individual's cultural frame of individual's cultural frame of reference may incorrectly judge as reference may incorrectly judge as psychopathology those normal psychopathology those normal variations in behavior, belief, or variations in behavior, belief, or experience that are particular to the experience that are particular to the individual's culture." (Page XXIV - individual's culture." (Page XXIV - DSM IV)DSM IV)

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Cultural Formulation of a CaseCultural Formulation of a Case (Page 843 - DSM-IV)(Page 843 - DSM-IV)

11 Cultural identity: Cultural identity: Reference groups, Reference groups, language language preferences, preferences,

attachment to origin attachment to origin and host and host culturescultures

2.2. Cultural explanations (e.g., nerves, Cultural explanations (e.g., nerves, spirits):spirits):

Meaning, causes, and perceived Meaning, causes, and perceived severity of severity of disordersdisorders

3.3. Psychosocial stressors and levels of Psychosocial stressors and levels of functioning: functioning: Social stressors, Social stressors,

social social supports, level supports, level of of functioning, disabilitiesfunctioning, disabilities

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Cultural Formulation of Case (DSM-Cultural Formulation of Case (DSM-IV)IV)

(Continued)(Continued)

4. 4. Cultural aspects of relationship Cultural aspects of relationship between between patient and clinician: patient and clinician: Status Status differences, differences, problems problems communicating, communicating, level of level of intimacy.intimacy.

5.5. Cultural evaluation of assessment and Cultural evaluation of assessment and care: care: How should cultural How should cultural

considerations considerations be incorporated into be incorporated into diagnosis and diagnosis and treatment plantreatment plan

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CULTURAL VARIATIONS IN THE CLINICAL CULTURAL VARIATIONS IN THE CLINICAL PARAMETERS OF DISORDERSPARAMETERS OF DISORDERS

(From Marsella & Yamada, ,2001)

1.1. Perceived causes, nature, and controlPerceived causes, nature, and control

2.2. Patterns of onsetPatterns of onset

3.3. Manifestation of symptoms Manifestation of symptoms (e.g., guilt, anger, anxiety, somatic)(e.g., guilt, anger, anxiety, somatic)

4.4. Psychological representationPsychological representation

5.5. Disabilities and impairmentsDisabilities and impairments

6.6. Course and progressionCourse and progression

7.7. OutcomeOutcome

Problematic Diagnoses Across Problematic Diagnoses Across CulturesCultures

1.1. Personality Disorders (e.g., Dependent, Personality Disorders (e.g., Dependent, Avoidant, Explosive, Sociopathic)Avoidant, Explosive, Sociopathic)

2.2. Psychotic DisordersPsychotic Disorders

3.3. Substance Abuse and AlcoholismSubstance Abuse and Alcoholism

4.4. Dissociative StatesDissociative States

5.5. Paranoid StatesParanoid States

6.6. Nutrition-Related DisordersNutrition-Related Disorders

SAMOAN CONCEPTIONS OF MENTAL SAMOAN CONCEPTIONS OF MENTAL DISORDERDISORDER

1.1. Ma'i o le mafaufauMa'i o le mafaufau (physical brain (physical brain abnormalities)abnormalities)

2.2. Ma'i aituMa'i aitu (spirit possession) (spirit possession)

3.3. Ma'i valeaMa'i valea (strange, severe, and stupid, (strange, severe, and stupid, improper improper behavior)behavior)

4.4. Excess emotionExcess emotion

Ma'i itaMa'i ita - anger, rage - anger, rageMa'i manatuMa'i manatu - sadness, grief - sadness, griefMa'i popoleMa'i popole - worry - worry

Examples of Culture-Bound DisordersExamples of Culture-Bound Disorders

DisorderDisorder SymptomsSymptoms Location Location

AmokAmok Withdrawal, ExplosiveWithdrawal, Explosive S.E. S.E. Asia/PhilippinesAsia/Philippines

ViolenceViolence

KoroKoro Phobia of PenisPhobia of Penis Chinese Chinese CulturesCultures

Shrinkage Into BodyShrinkage Into Body

LatahLatah Echolalia/EchopraxiaEcholalia/Echopraxia S.E. AsiaS.E. Asia

SustoSusto Loss of SoulLoss of Soul Latin Latin AmericaAmerica

DeliranteDelirante Withdrawal/FatigueWithdrawal/Fatigue CaribbeanCaribbean

PibloktoqPibloktoq Panic/Agitation/AmnesiaPanic/Agitation/Amnesia Artic EskimoArtic Eskimo

Hwa ByungHwa Byung Anger SyndromeAnger Syndrome KoreaKorea

Some Critical Issues forSome Critical Issues for Culture-Bound DisordersCulture-Bound Disorders

1.1. Should “culture-bound” disorders be Should “culture-bound” disorders be considered neurotic, psychotic, or considered neurotic, psychotic, or

personality disorders?personality disorders?

2.2. Should “culture-bound” disorders be Should “culture-bound” disorders be considered variants of “universal considered variants of “universal

disorders” defined by Western disorders” defined by Western views? views?

3.3. Are there taxonomically different Are there taxonomically different “culture-“culture-bound” disorders? bound” disorders?

4.4. Are all disorders “culture-bound” Are all disorders “culture-bound” disorders?disorders?

The Cultural Context of DiagnosisThe Cultural Context of Diagnosis

• While While cultural psychiatrycultural psychiatry aims to understand aims to understand problems in problems in contextcontext, diagnosis is , diagnosis is essentializingessentializing: referring to decontextualized : referring to decontextualized entities whose characteristics can be studied entities whose characteristics can be studied independently of the particulars of a person’s independently of the particulars of a person’s life life and social circumstances. and social circumstances.

• The entities of the DSM implicitly The entities of the DSM implicitly situate human situate human problems problems within the brain or the psychology within the brain or the psychology of the individualof the individual, , while many human while many human

problems brought to psychiatrists are problems brought to psychiatrists are located located in patterns of interaction in families, in patterns of interaction in families, communities, communities, or wider social spheres. or wider social spheres.

The Cultural Context of DiagnosisThe Cultural Context of Diagnosis(Continued)(Continued)

• Ultimately, whatever the extent to which we Ultimately, whatever the extent to which we can universalize the categories of the can universalize the categories of the DSM by choosing DSM by choosing suitable level of suitable level of

abstraction, diagnosis abstraction, diagnosis remains a remains a social social practice that must be studied, practice that must be studied, critiqued, critiqued, and clarified by cultural and clarified by cultural analysisanalysis (Kirmayer, 1998, p. 342). (Kirmayer, 1998, p. 342).

3. Normality and 3. Normality and AbnormalityAbnormality

Relativity in NormalityRelativity in Normality

The cross-cultural investigator must have The cross-cultural investigator must have “an initimate understanding of the normal “an initimate understanding of the normal range of individual behavior within the range of individual behavior within the cultural pattern and likewise understand cultural pattern and likewise understand what people themselves consider to be what people themselves consider to be extreme deviations from this norm. In extreme deviations from this norm. In short, he must develop a standard of short, he must develop a standard of normality with reference to the culture normality with reference to the culture itself, as a means of controlling an itself, as a means of controlling an uncritical application of the criteria he uncritical application of the criteria he brings with him from our civilization.brings with him from our civilization.

AlvinAlvin Hallowell, Hallowell, 1934, p. 21934, p. 2

Neurology-Culture InterfaceNeurology-Culture Interface

Normal Normal BehaviorBehavior

NeurosesNeuroses

PsychosesPsychoses

Cultural Variations in BehaviorCultural Variations in Behavior

NeuropatholoNeuropathologygy

Neurological Neurological PenetrancePenetrance

44. Personhood or . Personhood or SelfhoodSelfhood

Clifford Geertz On Clifford Geertz On PersonhoodPersonhood

The Western conception of the person as The Western conception of the person as a bounded, unique, more or less a bounded, unique, more or less integrated motivational and cognitive integrated motivational and cognitive universe, a dynamic center of awareness, universe, a dynamic center of awareness, emotion, judgment, and action, organized emotion, judgment, and action, organized into a distinctive whole and set into a distinctive whole and set contrastively -- both against other such contrastively -- both against other such wholes and against social and natural wholes and against social and natural background -- is however incorrigible it background -- is however incorrigible it may seem to us, a rather peculiar idea may seem to us, a rather peculiar idea within the context of the world's cultures within the context of the world's cultures (Geertz, 1973, p. 34). (Geertz, 1973, p. 34).

Person

Family

Nature

Gods/Spirits

NATIVE HAWAIIAN NATIVE HAWAIIAN (KANAKA MAOLI)(KANAKA MAOLI) PSYCHIC STRUCTURE PSYCHIC STRUCTURE

Akua/Aumakua

AinaWai

Makani

Ohana

Mana = Life Mana = Life EnergyEnergy

Lokahi = HarmonyLokahi = Harmony

5. Body - Mind 5. Body - Mind - Spirit- Spirit

Body - Mind - Spirit: The Western Body - Mind - Spirit: The Western PerspectivePerspective

RolesRoles FacilitiesFacilities KnowledgeKnowledge

PhysiciansPhysicians HospitalsHospitals MedicineMedicineBodyBody Bio-ScientistsBio-Scientists ClinicsClinics

BiologyBiologySome NursesSome Nurses LaboratoriesLaboratories

AnatomyAnatomy

Mental HealthMental Health Mental HospitalsMental HospitalsPsychologyPsychologyMindMind ProfessionalsProfessionals ClinicsClinics

PsychiatryPsychiatryOffice PracticesOffice Practices TheologyTheology

PriestsPriests ChurchesChurchesPhilosophyPhilosophySpiritSpirit MinistersMinisters ShrinesShrines TheologyTheology

PsychicsPsychics TemplesTemples MysticismMysticism

6. THEORIES OF 6. THEORIES OF ILLNESS ILLNESS

(Murdock, 1969)(Murdock, 1969)

I.I. Theories of Natural CausationTheories of Natural Causation(Any theory, scientific or popular, that (Any theory, scientific or popular, that account for impairment of health as a account for impairment of health as a physiological consequence of some physiological consequence of some experience of the patient in a manner that experience of the patient in a manner that would appear reasonable to modern would appear reasonable to modern science) science)

1.1. InfectionInfection

2.2. StressStress

3.3. Organ DeteriorationOrgan Deterioration

4.4. AccidentAccident

5.5. Overt AggressionOvert Aggression

II. Theories of Supernatural II. Theories of Supernatural CausationCausation

(Any theory that accounts for the (Any theory that accounts for the impairment of health as a result of some impairment of health as a result of some intangible force)intangible force)

1.1. Theories of Mystical CausationTheories of Mystical Causation(Impersonal Force)(Impersonal Force)

A.A. FateFate

B.B. Ominous SensationsOminous Sensations

C.C. ContagionContagion

D.D. Mystical RetributionMystical Retribution

II.II. Theories of Supernatural Theories of Supernatural CausationCausation

(Continued)(Continued)

2.2. Theories of Animistic Causation Theories of Animistic Causation (Personalized Entity) (Personalized Entity)

A.A. Soul LossSoul LossB.B. Spirit AggressionSpirit Aggression

3.3. Theories of Magical Causation Theories of Magical Causation (Actions of Evil Force)(Actions of Evil Force)

A.A. SorcerySorceryB.B. WitchcraftWitchcraft

7. Measurement & 7. Measurement & Assessment IssuesAssessment Issues

across Cultures across Cultures

Equivalency in Assessment Across Equivalency in Assessment Across CulturesCultures

EquivalenceEquivalence refers to the refers to the “equality”“equality” of the of the assessment instruments and procedures across assessment instruments and procedures across cultural boundaries. There are four main kinds of cultural boundaries. There are four main kinds of equivalenceequivalence::

1.1. Linguistic EquivalencyLinguistic Equivalency: Is the language the : Is the language the same? same? This can be accomplished through This can be accomplished through back back translation.translation.

2.2. Conceptual EquivalenceConceptual Equivalence: Is the concept the : Is the concept the same? same? The meaning of dependency in The meaning of dependency in Japan is Japan is different than the meaning of different than the meaning of dependency dependency in the USA. in the USA.

3.3. Scale EquivalenceScale Equivalence: Cultures differ in their : Cultures differ in their response response to different scale formats (i.e., to different scale formats (i.e., true-false, true-false, Likert, semantic differential)Likert, semantic differential)

4.4. Normative EquivalenceNormative Equivalence: Are there cultural : Are there cultural group group norms for the instrument? norms for the instrument?

Other Considerations in Self-Report Other Considerations in Self-Report Assessment SituationsAssessment Situations

(Marsella, et al (2000). Culture and Personality. Am. Beh. Sci)(Marsella, et al (2000). Culture and Personality. Am. Beh. Sci)

The simple fact of the matter is that asking self-report simple fact of the matter is that asking self-report questions is a complex task that is made even more complex questions is a complex task that is made even more complex when psychologists move across cultural boundaries to ask when psychologists move across cultural boundaries to ask questions of people whose perceptions of the task and whose questions of people whose perceptions of the task and whose motivations to participate differ from those on whom the motivations to participate differ from those on whom the scale was constructed. These perceptual and motivational scale was constructed. These perceptual and motivational differences include:differences include:

(1) (1) Desire to conform sociallyDesire to conform socially(2) (2) Fear of possible persecutionFear of possible persecution(3) (3) Concern for giving the “right” answer rather than an Concern for giving the “right” answer rather than an accurate accurate answeranswer(4)(4) Desire to please authoritiesDesire to please authorities(5) (5) Limited self awareness and insightsLimited self awareness and insights(6)(6) Confusion with the perceived meaning and implication Confusion with the perceived meaning and implication of of terms and words used in the questionsterms and words used in the questions(7)(7) Variations in the construction of personhood and Variations in the construction of personhood and personalitypersonality

8. TWO EXAMPLES 8. TWO EXAMPLES OF ETHNOCULTURAL OF ETHNOCULTURAL CONSIDERATIONS CONSIDERATIONS

IN IN PSYCHOPATHOLOGYPSYCHOPATHOLOGY

A. PTSD

PTSD Interactional ModelPTSD Interactional ModelMarsella, 1994Marsella, 1994

Traumatic Traumatic EventEvent

PersonPerson

Stress Stress ReactionReaction

1. Category1. Category

Natural/Man Natural/Man

DisastersDisasters AccidentsAccidents Crimes/ViolenceCrimes/Violence

WarWar

2. Content2. Content

Life EventLife Event DeprivationDeprivation PhysicalPhysical

3. 3. ParametersParameters

ControlControl IntensityIntensity DurationDuration PredictabilityPredictability

1. Genetic 1. Genetic VulnerablityVulnerablity

2. Early -2. Early - ExperienceExperience VulnerabilityVulnerability

3. Pre-3. Pre-MorbidMorbid PersonalityPersonality

(e.g., (e.g., Hardiness, Hardiness,

Resiliency)Resiliency)

4. Mood and4. Mood and PhysicalPhysical HealthHealth

5. Social 5. Social ResourcesResources

Bio-Behavioral Bio-Behavioral ResponsesResponses

PTSD PTSD DepressionDepression

PsychosisPsychosis DissociationDissociation

Intense and Intense and Painful Painful ArousalArousal

Perceptual ExperiencePerceptual Experience

Urban Child and Youth Trauma in South Central LAUrban Child and Youth Trauma in South Central LATimnick, C. (1989). "Children of Violence," Los Angeles Times Magazine (pp. 6, 8, 10): Timnick, C. (1989). "Children of Violence," Los Angeles Times Magazine (pp. 6, 8, 10):

•““They shoot somebody everyday," "I go in and get under They shoot somebody everyday," "I go in and get under the bed and come out after the shooting stops.“the bed and come out after the shooting stops.“

•"My daddy got knifed when he got out of jail," and "My "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. 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 And I had two aunties killed and of them was pushed off the free-way and there were maggots on her." the free-way and there were maggots on her."

•"It's like the violence is coming down a little closer." "We "It's like the violence is coming down a little closer." "We don't come outside a lot now.“don't come outside a lot now.“

• "Just three people [in my family] died." "I been seein' "Just three people [in my family] died." "I been seein' two of them' (as haunting ghosts at night). two of them' (as haunting ghosts at night).

•"How about the cemetery?' (in response to teacher's "How about the cemetery?' (in response to teacher's request for ideas for a field trip).request for ideas for a field trip).

•'Her eyeball was in her shoe" (boy witnessed woman's 'Her eyeball was in her shoe" (boy witnessed woman's mutilated body).mutilated body).

CROSS-CULTURAL VARIATIONS IN CROSS-CULTURAL VARIATIONS IN THE THE CLINICAL PARAMETERS OF CLINICAL PARAMETERS OF

PTSDPTSD(From Marsella, et al, [1996] Ethnocultural Aspects of PTSD.

Washington, DC: APA Press)

1.1. Patterns of onsetPatterns of onset

2.2. Manifestation of symptoms Manifestation of symptoms (e.g., guilt, anger, anxiety, somatic)(e.g., guilt, anger, anxiety, somatic)

3.3. Disabilities and impairmentsDisabilities and impairments

4.4. Course and progressionCourse and progression

5. Outcome

Cross-Cultural Considerations in Cross-Cultural Considerations in PTSDPTSD

• Diagnosing PTSD Across Cultures: Diagnosing PTSD Across Cultures: Idioms of Idioms of Distress, Distress, Translation, Meaning of Nightmares?Translation, Meaning of Nightmares?

• Nature of Trauma(s):Nature of Trauma(s): Role of Destiny, Religion, Role of Destiny, Religion, Collective Trauma)?Collective Trauma)?

• Universal Symptoms: Universal Symptoms: Re-Experiencing and Re-Experiencing and Arousal Arousal Symptoms (Hard-wired). These Symptoms (Hard-wired). These may vary in may vary in frequency, severity, and frequency, severity, and duration as a function of duration as a function of individual and cultural individual and cultural group processes.group processes.

• Cultural Symptoms: Cultural Symptoms: Avoidant symptoms may be Avoidant symptoms may be more more influenced by life experience. influenced by life experience. Dissociation may be Dissociation may be a protective device in some a protective device in some groups.groups.

Cross-Cultural Considerations Cross-Cultural Considerations (Continued)(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. Accumulation: Marginalization, Identity, Racism, Low Self-Esteem, plus

Trauma2. High Stress Culture ("Sick Society"):

Cultural disintegration, prominent violence, prominent substance abuse, few social supports, alienation/anomie.

Cross-Cultural Considerations Cross-Cultural Considerations (Continued)(Continued)

• Nature and Meaning of TraumaNature and Meaning of Trauma

1.1. Codification: (i.e., cognitive, Codification: (i.e., cognitive, affective, affective,

proprioceptive, visceral)proprioceptive, visceral)

2.2. Meaning of termMeaning of term

3.3. Antecedents and Antecedents and consequencesconsequences

4.4. Social response to trauma Social response to trauma victim/survivor (e.g., rape victim/survivor (e.g., rape

victim)victim)

5.5. Behavioral implicationsBehavioral implications

Cross-Cultural ConsiderationsCross-Cultural Considerations (Continued)(Continued)

• Motivation to seek professional Motivation to seek professional assistance and related help-assistance and related help-

seeking seeking behaviorsbehaviors

• Responsivity to psychotherapy Responsivity to psychotherapy and and psychopharmacology psychopharmacology

TWELVE COMMON TWELVE COMMON TREATMENTS FOR PTSD TREATMENTS FOR PTSD

PROBLEMSPROBLEMS

1.1. Personal Narration (i.e., Trauma Story)Personal Narration (i.e., Trauma Story)

2.2. Relaxation TherapiesRelaxation Therapies

3.3. Psychodynamic (Insight & Catharsis) Psychodynamic (Insight & Catharsis)

4.4. Critical Incident Stress Debriefing (Education Critical Incident Stress Debriefing (Education andand

Normalization)Normalization) 5.5. Cognitive Behavior Therapy Cognitive Behavior Therapy

TWELVE COMMON TREATMENTS TWELVE COMMON TREATMENTS (Continued)(Continued)

6.6. Eye Movement Desensitization Therapies Eye Movement Desensitization Therapies (EMDT)(EMDT)

7.7. Basic Problem Solving and Information Basic Problem Solving and Information SharingSharing

8.8. Medications (e.g., Anti-Depressants) Medications (e.g., Anti-Depressants)

9.9. Nutritional Approaches Nutritional Approaches

10.10. Socialization and Recreation ActivitiesSocialization and Recreation Activities

11.11. Scriptotherapy (i.e., Writing)Scriptotherapy (i.e., Writing)

12.12. Behavior Therapies (e.g., Imagery, Behavior Therapies (e.g., Imagery, Desensitization) Desensitization)

(C) AJM-1/1/2001

The Power of Social SupportThe Power of Social Support

The sheer will to survive cannot take the The sheer will to survive cannot take the place of the strength one derives from place of the strength one derives from outside support, real or imagined. This is outside support, real or imagined. This is why those on the outside of any why those on the outside of any catastrophe who work for one’s return . . . catastrophe who work for one’s return . . . are the strongest lifeline imaginable, the are the strongest lifeline imaginable, the most powerful motive for staying alive. most powerful motive for staying alive. Thus the inner will to stay alive depends to Thus the inner will to stay alive depends to a large measure on the help one receives a large measure on the help one receives from the outside; these are inextricably from the outside; these are inextricably woven.woven.

Bruno Bettleheim (1960). The informed heart. London: Penguin Bruno Bettleheim (1960). The informed heart. London: Penguin Books.Books.

PHARMACOTHERAPY FOR PTSD AND PHARMACOTHERAPY FOR PTSD AND STRESS-RELATED DISORDERSSTRESS-RELATED DISORDERS

1.1. Antidepressants (Tricyclics, SSRI)Antidepressants (Tricyclics, SSRI)

22 Clonidine (Alpha Adrenoreceptor Clonidine (Alpha Adrenoreceptor (Blocks (Blocks noradrenalin reducing arousal noradrenalin reducing arousal levels and levels and nightmares)nightmares)

3.3. Minor tranquilizers (e.g., Minor tranquilizers (e.g., Benzodiazepines)Benzodiazepines)

4.4. Major tranquilzers (e.g., Haldol, Major tranquilzers (e.g., Haldol, Mellaril, Mellaril, Risperdone)Risperdone)

B. SCHIZOPHRENIAB. SCHIZOPHRENIA

SOME CULTURAL DETERMINANTS OFSOME CULTURAL DETERMINANTS OFSCHIZOPHRENIASCHIZOPHRENIA

1. 1. Cultural concepts of personhood, and the Cultural concepts of personhood, and the relatedrelated

implications of this for individuated versus implications of this for individuated versus unindividuated definitions of selfhood and unindividuated definitions of selfhood and

reality;reality;

2.2. Cultural concepts regarding the nature and Cultural concepts regarding the nature and causescauses

of abnormality, discomfort, disorder, of abnormality, discomfort, disorder, deviance,deviance,

and disease, and those regarding the nature and disease, and those regarding the nature and and

cause of normality, health, and wellbeing;cause of normality, health, and wellbeing;

3.3. Cultural concepts and practices regarding Cultural concepts and practices regarding health health

and medical care and prevention; attitudes and medical care and prevention; attitudes towardtoward

illness and disease;illness and disease;

4.4. Cultural concepts and practices regarding Cultural concepts and practices regarding breedingbreeding

patterns and lineages;patterns and lineages;

Cultural Determinants of Cultural Determinants of Schizophrenia Schizophrenia

(Continued)(Continued)

5.5. Cultural concepts regarding pre-natal Cultural concepts regarding pre-natal care, care, birth practices, and post-natal birth practices, and post-natal care, care, especially in such areas as especially in such areas as nutrition and nutrition and disease exposure;disease exposure;

6.6. Cultural concepts and practices Cultural concepts and practices regarding regarding

socialization, especially family, socialization, especially family, community, community, and and religious institutions, religious institutions, structures and structures and processes;processes;

Cultural Determinants of Cultural Determinants of SchizophreniaSchizophrenia(Continued)(Continued)

7.7. Cultural concepts and practices Cultural concepts and practices regarding regarding medical and health care medical and health care especially with especially with regard to the regard to the number and types of healers, number and types of healers, doctors, doctors, sick-role sick-role statuses, etc.statuses, etc.

8.8. Cultural stressors such as rates of Cultural stressors such as rates of socio-socio- technical technical change, socio-change, socio-cultural cultural disintegration, family disintegration, family disintegration, disintegration, migration, economic migration, economic development, development, industrialization, industrialization, and urbanization;and urbanization;

Cultural Determinants of Cultural Determinants of SchizophreniaSchizophrenia(Continued)(Continued)

9.9. Culturally-related patterns of deviance andCulturally-related patterns of deviance anddysfunction including trauma (PTSD), dysfunction including trauma (PTSD),

substancesubstanceabuse, violence and crime, social isolation,abuse, violence and crime, social isolation,alienation/anomie, and the creation ofalienation/anomie, and the creation ofpathological and deviant subcultures;pathological and deviant subcultures;

10.10. Cultural stressors related to the clarity, Cultural stressors related to the clarity, conflicts,conflicts,

deprivations, denigrations, and discrepancies deprivations, denigrations, and discrepancies associated with particular needs, roles, associated with particular needs, roles,

values,values,statuses, and identities;statuses, and identities;

Cultural Determinants of Schizophrenia (Continued)Cultural Determinants of Schizophrenia (Continued)

11.11. Cultural stressors related to socio-political Cultural stressors related to socio-political factorsfactors

such as racism, sexism, and ageism and thesuch as racism, sexism, and ageism and theaccompanying marginalization, accompanying marginalization,

segmentalization,segmentalization,and underprivilegingand underprivileging

12.12. Cultural resources and coping patterns Cultural resources and coping patterns includingincluding

institutional supports, social networks, socialinstitutional supports, social networks, socialsupports, and religious beliefs and practices.supports, and religious beliefs and practices.

13.13. Cultural exposure to various risk conditions Cultural exposure to various risk conditions suchsuch

as communicable diseases (e.g., viruses), as communicable diseases (e.g., viruses), toxins,toxins,

dietary practices, population density, poverty,dietary practices, population density, poverty,homelessness.homelessness.

POTENTIAL REASONS FOR MORE NEGATIVE COURSEPOTENTIAL REASONS FOR MORE NEGATIVE COURSEAND OUTCOME OF SCHIZOPHRENIA (PSYCHOTICAND OUTCOME OF SCHIZOPHRENIA (PSYCHOTICDISORDERS) IN DEVELOPED COUNTRIES DISORDERS) IN DEVELOPED COUNTRIES 11

1.1. Schizophrenia is considered to be a biological Schizophrenia is considered to be a biological disease that is relatively immutable to lifedisease that is relatively immutable to lifecircumstances;circumstances;

2.2. Causes of schizophrenia are considered to be withinCauses of schizophrenia are considered to be withinthe individual. Personal control and responsibility isthe individual. Personal control and responsibility isassumed;assumed;

3.3. High social rejection and stigma attached to High social rejection and stigma attached to schizophrenia;schizophrenia;

4.4. Individual burdens are demanding because family Individual burdens are demanding because family resources are not often present;resources are not often present;

Reasons for Negative Outcome In DevelopedReasons for Negative Outcome In DevelopedCountries (Continued)Countries (Continued)

5.5. Patient is often hospitalized and isolated from familyPatient is often hospitalized and isolated from familyand community. Custodial care, in disguisedand community. Custodial care, in disguisedforms, is present, and is the norm;forms, is present, and is the norm;

6.6. Financial incentive to continue the sick role (i.e.,Financial incentive to continue the sick role (i.e.,disability payments, insurance payments) aredisability payments, insurance payments) arenumerous and easily available;numerous and easily available;

7.7. Stressors are numerous and supports are minimal;Stressors are numerous and supports are minimal;

Reasons for Negative Course in Developed Reasons for Negative Course in Developed Countries (Continued)Countries (Continued)

8.8. Competency levels required for normal functioningCompetency levels required for normal functioningare very high and very demanding upon social andare very high and very demanding upon social andintellectual skills and abilities (e.g., bank accounts,intellectual skills and abilities (e.g., bank accounts,tax forms, housing, automobile maintenance, tax forms, housing, automobile maintenance, literacy skills);literacy skills);

9.9. Religious systems and spiritual concerns are oftenReligious systems and spiritual concerns are ofteninadequate;inadequate;

10.10. Co-morbidities are numerous and complex (e.g.,Co-morbidities are numerous and complex (e.g.,substance abuse, alcohol, trauma)substance abuse, alcohol, trauma)

CENTRAL ARGUMENTCENTRAL ARGUMENT

• Schizophrenia is not a single Schizophrenia is not a single disorder and disorder and our continued our continued conception of it as such conception of it as such hinders hinders progress in dx, treatment, and progress in dx, treatment, and prevention.prevention.

• Schizophrenia is a group of Schizophrenia is a group of disorders of disorders of differing etiology, differing etiology, pathology, pathology, expression, and expression, and treatment responsivity. treatment responsivity.

• It is time for a changeIt is time for a change

Schizophrenia:Schizophrenia:

Too Many VariationsToo Many Variations 1. Multiple and Interactive 1. Multiple and Interactive

EtiologiesEtiologies

2. Multiple and Interactive 2. Multiple and Interactive Pathologies (Disease Pathologies (Disease

Sites)Sites)

3.3. Multiple and Interactive Multiple and Interactive Expression PatternsExpression Patterns

4. Multiple Treatment 4. Multiple Treatment Responsivities Responsivities

PATHOLOGY, ETIOLOGY, EXPRESSION,PATHOLOGY, ETIOLOGY, EXPRESSION,& THERAPY RESPONSIVITY& THERAPY RESPONSIVITY

POSSIBILITIESPOSSIBILITIES• 1. 1. EtiologyEtiology

• A.A. GeneticsGenetics (Polygenic)(Polygenic)• B.B. Fetal Viral Infection - 2nd Fetal Viral Infection - 2nd

TrimesterTrimester• C.C. Brain Injury (e.g., Anoxia, Toxins)Brain Injury (e.g., Anoxia, Toxins)• D. Maternal AntibodiesD. Maternal Antibodies• E.E. TraumaTrauma• F.F. Social Isolation/DeprivationSocial Isolation/Deprivation• G.G. Stress-Diathesis TheoryStress-Diathesis Theory• H. Stigma H. Stigma • I. I. Poverty/Class/Cultural Poverty/Class/Cultural

DisintegrationDisintegration

PATHOLOGY, ETIOLOGY, EXPRESSION,PATHOLOGY, ETIOLOGY, EXPRESSION,& THERAPY RESPONSIVITY POSSIBILITIES & THERAPY RESPONSIVITY POSSIBILITIES

•2.2. PathologyPathology•

• A.A. Cortical HypofrontalityCortical Hypofrontality• B.B. Temporal Lobes Temporal Lobes • C.C. CerebellumCerebellum• D.D. Ventricles (Shrinkage)Ventricles (Shrinkage)• E.E. Corpus CallosumCorpus Callosum

F. ThalamusF. Thalamus• G. Temperolimbic G. Temperolimbic SystemSystem

• H. H. Basal GangliaBasal Ganglia

• I. I. Hippocampal Hippocampal RegionRegion J. J. Neurochemical Neurochemical

Circuitry Circuitry• K. Cerebral K. Cerebral

Asymmetry Asymmetry

PATHOLOGY, ETIOLOGY, EXPRESSION,PATHOLOGY, ETIOLOGY, EXPRESSION,& THERAPY RESPONSIVITY POSSIBILITIES& THERAPY RESPONSIVITY POSSIBILITIES

• 3.3. Alternative DX/Expressive PatternsAlternative DX/Expressive Patterns• A.A. Positive/Negative/MixedPositive/Negative/Mixed• B.B. Process/ReactiveProcess/Reactive• C.C. Type I/Type IIType I/Type II• D.D. Paranoid/Non-ParanoidParanoid/Non-Paranoid• E.E. Acute/ChronicAcute/Chronic• F.F. Clinical Subtypes (e.g., Paranoid, Clinical Subtypes (e.g., Paranoid,

Disorganized)Disorganized)• G.G. Good/Poor Premorbid AdjustmentGood/Poor Premorbid Adjustment• H.H. Schneiderian/Non-Schneiderian SignsSchneiderian/Non-Schneiderian Signs• I. Bleulerian versus KraepelinianI. Bleulerian versus Kraepelinian

• 4.4. Treatment ResponsivityTreatment Responsivity

• A.A. Traditional Neuroleptics Traditional Neuroleptics • (e.g., Chlorpromazine, Haloperidol)(e.g., Chlorpromazine, Haloperidol)• B.B. Recent Neuroleptics Recent Neuroleptics • (e.g., Risperidone, Clozapine)(e.g., Risperidone, Clozapine)• C.C. PsychosurgeryPsychosurgery• D.D. PsychotherapyPsychotherapy• E.E. Psychosocial RehabilitationPsychosocial Rehabilitation• F.F. Orthomolecular TherapyOrthomolecular Therapy

PATHOLOGY, ETIOLOGY, PATHOLOGY, ETIOLOGY, EXPRESSION,EXPRESSION,

& THERAPY RESPONSIVITY & THERAPY RESPONSIVITY POSSIBILITIESPOSSIBILITIES

VIII. CULTURE & VIII. CULTURE & THERAPYTHERAPY

Issue # 1Issue # 1

What is universal about What is universal about different forms of different forms of

therapy and healing? therapy and healing?

(C) AJM-1/1/2001

(C) AJM-1/1/2001

The PSYCHOTHERAPY The PSYCHOTHERAPY EQUATION:EQUATION:

Outcome = Function of:Outcome = Function of:

DisorderDisorder

TherapyTherapy

TherapistTherapist

Client/PatientClient/Patient

TimeTime

PaymentPayment

(C) AJM-1/1/2001

COMMON ELEMENTS OF ALL COMMON ELEMENTS OF ALL THERAPY/HEALING SYSTEMSTHERAPY/HEALING SYSTEMS

1.1. Assumptions about the nature Assumptions about the nature and and causes of problems;causes of problems;

2.2. Assumptions about healing Assumptions about healing context/setting context/setting

requirements;requirements;

3.3. Require elicitation of Require elicitation of particular particular expectations, expectations, emotions, behaviors; emotions, behaviors;

(C) AJM-1/1/2001

COMMON ELEMENTS OF THERAPYCOMMON ELEMENTS OF THERAPY(CONTINUED)(CONTINUED)

4.4. Requirements for activity level Requirements for activity level and and participation levels and/or participation levels and/or roles for roles for patient, family, and patient, family, and therapist;therapist;

5.5. Specific requirements for training Specific requirements for training and and skill expertise of therapist.skill expertise of therapist.

Issue #2Issue #2

What is cultural about What is cultural about therapy/healing?therapy/healing?

(C) AJM-1/1/2001

(C) AJM-1/1/2001

What is Cultural About Therapy?What is Cultural About Therapy?

(Patient Perspective)(Patient Perspective)

1.1. Patient’s conception of health and Patient’s conception of health and

illness;illness;

2.2. Patient’s expectations about what will Patient’s expectations about what will

or or should occur in therapy; should occur in therapy;

3.3. Patient’s definition of the patient or Patient’s definition of the patient or

illness illness role;role;

4.4. Patient’s perception of therapist;Patient’s perception of therapist;

5.5. Patient’s motivation to comply;Patient’s motivation to comply;

6.6. Patient’s language and communication Patient’s language and communication

mode mode preferences; preferences;

7.7. Patient’s resources. Patient’s resources.

What is Cultural About Therapy?What is Cultural About Therapy?Therapist PerspectiveTherapist Perspective

1.1. Therapist conceptions of illness Therapist conceptions of illness

and and health;health;

2.2. Therapist’s therapy systemTherapist’s therapy system

3.3. Therapist’s perception of patientTherapist’s perception of patient

4.4. Therapist’s language and Therapist’s language and

communication stylecommunication style

5.5. Therapist’s training Therapist’s training

Examples of Non-Western Therapy Examples of Non-Western Therapy and Healing Systems and Healing Systems (Marsella, 1982)(Marsella, 1982)

1.1. Naikan Therapy Naikan Therapy (Japanese)(Japanese)

2.2. Morita Therapy Morita Therapy (Japanese)(Japanese)

3.3. I-Ching I-Ching (Chinese)(Chinese)

4.4. Ho’oponopono Ho’oponopono (Hawaiian)(Hawaiian)

5.5. Voodou Voodou (Caribbean)(Caribbean)

6.6. Sweat Lodge/Vision Quest Sweat Lodge/Vision Quest (American (American

Indian)Indian)

7.7. Expressive TherapiesExpressive Therapies (Art, Dance, (Art, Dance,

Singing) Singing)

8.8. YogaYoga (Hindu)(Hindu)

Examples of Examples of Healers/TherapistsHealers/Therapists

1.1. Mudangs (Korea)Mudangs (Korea)

2.2. Herbolarios (Philippines)Herbolarios (Philippines)

3.3. Kahunas (Hawaii)Kahunas (Hawaii)

4.4. Dukhuns (Indonesia)Dukhuns (Indonesia)

5.5. Santerias (Latino)Santerias (Latino)

6.6. Curanderos (Latino)Curanderos (Latino)

7.7. Shamans (Widespread)Shamans (Widespread)

8.8. Temple Masters and Priests Temple Masters and Priests

(Buddhism, (Buddhism, Taoism)Taoism)

9.9. Faith Healers (Fundamentalist Faith Healers (Fundamentalist

Christianity)Christianity)

(C) AJM-1/1/2001

Non-Western Medical Health SystemsNon-Western Medical Health Systems

1.1. AyurvedaAyurveda

2.2. Chinese Medicine (Korean, Japanese)Chinese Medicine (Korean, Japanese)

3.3. Tibetan MedicineTibetan Medicine 4.4. Unani (Arabic)Unani (Arabic)

5.5. Indigenous (Australian Aboriginal, Indigenous (Australian Aboriginal, American American Indian, Native Hawaiian )Indian, Native Hawaiian )

6.6. Shamanistic MedicineShamanistic Medicine

(C) AJM-1/1/2001

The Codification ofThe Codification of

Human ExperienceHuman Experience

• CognitionCognition

• ImageryImagery

• AffectiveAffective

• VisceralVisceral

• ProprioceptiveProprioceptive

Issue # 3Issue # 3

Are there different Are there different therapy/healing therapy/healing

principles in various principles in various cultural therapies?cultural therapies?

(C) AJM-1/1/2001

(C) AJM-1/1/2001

Principles of Healing in Different Principles of Healing in Different Therapies Therapies (Marsella, 1982) (Marsella, 1982)

1.1. InsightInsight

2.2. InformationInformation

3.3. CatharsisCatharsis

4.4. FaithFaith

5.5. Reduction of uncertainty, anxiety, Reduction of uncertainty, anxiety, fearfear

6.6. Relocation of locus of Relocation of locus of control/attributioncontrol/attribution

(C) AJM-1/1/2001

Principles (Continued)Principles (Continued)

7.7. Reconstruction of “reality”Reconstruction of “reality”

8.8. Guilt reduction/release and Guilt reduction/release and penancepenance

9.9. Cultural re-embeddedness and Cultural re-embeddedness and identificationidentification

10.10. SuggestionSuggestion

11.11. Instill hope and meaning makingInstill hope and meaning making

12.12. Specific behavioral activities and Specific behavioral activities and skillskill

(C) AJM-1/1/2001

Principles (Continued)Principles (Continued)

13.13. InterpretationInterpretation

14.14. PersuasionPersuasion

15.15. Social SupportSocial Support

16.16. Mobilization of immune system Mobilization of immune system and and endorphin systemendorphin system

17.17. Understanding & EmpathyUnderstanding & Empathy

18.18. ExpressionExpression

Shou-JingShou-Jing Versus Talk Therapy Versus Talk TherapyAnn Shu-Ping Lin (2000). Why counseling and not shou-jing?Ann Shu-Ping Lin (2000). Why counseling and not shou-jing?

Cross-cultural Psychology Bulletin, 10-15. Cross-cultural Psychology Bulletin, 10-15.

““I do not know how to communicate with the I do not know how to communicate with the experts. He told me that I have some kind of experts. He told me that I have some kind of disease in my mind but I think I am okay. He disease in my mind but I think I am okay. He kept asking me to express my feelings toward kept asking me to express my feelings toward the earthquake, but I feel embarrassed if I tell the earthquake, but I feel embarrassed if I tell people my own feelings. . . . I went to a Master people my own feelings. . . . I went to a Master in the temporary temple and she taught me in the temporary temple and she taught me how to deal with the situation. How to calm how to deal with the situation. How to calm my anxieties through worship and helping my anxieties through worship and helping others. How to accept grief as an others. How to accept grief as an arrangement of the gods. You know that our arrangement of the gods. You know that our people have done so many wrong things.” people have done so many wrong things.” (p.10-11)(p.10-11) (C) AJM-

1/1/2001

IX. MENTAL IX. MENTAL HEALTH HEALTH SERVICE SERVICE

DELIVERYDELIVERY

Barriers to Mental Health Service Barriers to Mental Health Service Utilization by Ethnocultural MinoritiesUtilization by Ethnocultural Minorities

1.1. Availability, accessibility, Availability, accessibility, acceptability;acceptability;2.2. Cultural incongruity (e.g., Cultural incongruity (e.g., language, language, communication, health communication, health beliefs);beliefs);3.3. Coordination with other services;Coordination with other services;4.4. Presence of staff from similar Presence of staff from similar

backgrounds (Also opposite of backgrounds (Also opposite of this);this);5.5. Financing and costsFinancing and costs6.6. Absence of outreach and follow-upAbsence of outreach and follow-up7.7. Iatrogenic problemsIatrogenic problems

Multicultural Accommodation in Multicultural Accommodation in Mental Health Service DeliveryMental Health Service Delivery

1.1. Availability, accessibility, and Availability, accessibility, and acceptability of services;acceptability of services;

2.2. Language resources;Language resources;

3.3. Knowledge of idioms of distress, Knowledge of idioms of distress, alternative diagnostic alternative diagnostic

systems, systems, therapy systems;therapy systems;

4.4. Knowledge of outcome criteria for Knowledge of outcome criteria for disorder (e.g., distress, disorder (e.g., distress,

disorder, disorder, deviancy -- health, deviancy -- health, problem problem solving, coping, solving, coping, competence); competence);

Cultural Accommodation Service Cultural Accommodation Service Delivery (Continued)Delivery (Continued)

5.5. Emphasis on problem-solving Emphasis on problem-solving rather rather than diagnostic labelsthan diagnostic labels

6.6. Broad range of services Broad range of services (continuity of (continuity of care, outreach, follow-care, outreach, follow-up, up, indigenous indigenous healers, family);healers, family);

7.7. Assessment equivalence;Assessment equivalence;

8.8. Continual cultural sensitivity Continual cultural sensitivity training, training, evaluation and evaluation and accountability;accountability;

Cultural Accommodation Service Cultural Accommodation Service Delivery (Continued)Delivery (Continued)

9.9. Adjustable payment optionsAdjustable payment options

10.10. Knowledge and practice of Knowledge and practice of ethnopsychopharmacologyethnopsychopharmacology

11.11. Design of physical Design of physical environment of environment of building and building and groundsgrounds

12.12. Use of indigenous healers and Use of indigenous healers and therapiestherapies

Training for Cultural Training for Cultural CompetencyCompetency

(Some Ideas from Hansen, Pepitone-Arreloa-Rockwell,(Some Ideas from Hansen, Pepitone-Arreloa-Rockwell, & Greene, 2000) & Greene, 2000)

1.1. Cultural SensitivityCultural Sensitivity

A.A. Write cultural biographyWrite cultural biography

B.B. Identify Agents (Power Identify Agents (Power and and Privilege)Privilege)

C.C. Targets (Those Without)Targets (Those Without)(ADDRESSING Acronym)(ADDRESSING Acronym)

Cultural Competence Cultural Competence (Continued)(Continued)

2.2. Learn about culturesLearn about cultures

A.A. ReadRead

B.B. TravelTravel

C.C. Workshops/CoursesWorkshops/Courses

Cultural Competence Continuum Cultural Competence Continuum Assessment (Assessment (Miguel Tirado (2000)- Others)Miguel Tirado (2000)- Others)

Culturally ResistanceCulturally Resistance (Condone race (Condone race discrimination, discourage cultural discrimination, discourage cultural

variation)variation)

Culturally UnawareCulturally Unaware (Ignore cultural (Ignore cultural considerations)considerations)

Culturally ConsciousCulturally Conscious (Tokenism, selective (Tokenism, selective policies)policies)

Culturally InsightfulCulturally Insightful (Ad Hoc hiring in crisis (Ad Hoc hiring in crisis track track according to ethnicity)according to ethnicity)

Cultural VersatileCultural Versatile (Anticipatory, incentives, (Anticipatory, incentives, policies, monitor)policies, monitor)

MH Professional Cultural MH Professional Cultural Competence Continuum (Tirado, Competence Continuum (Tirado,

2000)2000)

CRCR CU CU CCCC CI CI CVCV (Res)(Res) (Unaw) (Consc) (Insig)(Unaw) (Consc) (Insig)

(Versat)(Versat)

KnowledgeKnowledge of Patientsof Patients

Practice-Practice-Related BehRelated Beh

AttitudesAttitudestoward toward DiversityDiversity

PracticePracticePatternsPatterns

MH Professional Cultural MH Professional Cultural Competence Continuum (Tirado, Competence Continuum (Tirado, 2000)2000)

CRCR CU CU CCCC CI CI CVCV (Res) (Unaw) (Consc) (Insig)(Res) (Unaw) (Consc) (Insig) (Versat)(Versat)

HumanHumanResourceResourceCapacityCapacity

Policies and Policies and ProceduresProcedures

MonitoringMonitoring

X. X. MULTICULTURAL MULTICULTURAL COMPETENCIESCOMPETENCIES

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 CompetenciesEighteen Multicultural Competencies(Continued)(Continued)

3.3. Knowledge of how cultural variables Knowledge of how cultural variables influence the etiology and influence the etiology and

manifestation of manifestation of mental illness.mental illness.

4.4. Knowledge of normative values illness, Knowledge of normative values illness, help-seeking, world views of help-seeking, world views of

groups to be groups to be treated.treated.

5.5. Ability to evaluate emic and etic Ability to evaluate emic and etic hypotheses.hypotheses.

6.6. Ability to design and implement non-Ability to design and implement non-biasedbiased

treatment plans.treatment plans.

Eighteen Multicultural CompetenciesEighteen Multicultural Competencies(Continued)(Continued)

7.7. Ability to initiate and explore Ability to initiate and explore differences between the therapist differences between the therapist

and and client, and to incorporate these client, and to incorporate these into into treatment.treatment.

8.8. Knowledge of culture-specific Knowledge of culture-specific disorders and dx categories.disorders and dx categories.

9.9. Knowledge of culture specific Knowledge of culture specific assessment assessment procedures and tools.procedures and tools.

10.10. Ability to establish rapport and convey Ability to establish rapport and convey empathy .empathy .

Eighteen Multicultural CompetenciesEighteen Multicultural Competencies(Continued)(Continued)

11.11. Knowledge of how to assess variables Knowledge of how to assess variables of of special relevance to identified groups special relevance to identified groups (e.g., (e.g., culture orientation, acculturation, culture orientation, acculturation, culture culture shock, discrimination).shock, discrimination).

12.12. Ability to ascertain effects of therapist-Ability to ascertain effects of therapist-client client language differences on language differences on assessment and assessment and treatment.treatment.

13.13. Ability to modify assessment tools for Ability to modify assessment tools for use use with specified groups.with specified groups.

Eighteen Multicultural CompetenciesEighteen Multicultural Competencies(Continued)(Continued)

14.14. Ability to explain results in a Ability to explain results in a culturally-culturally- sensitive and contextual sensitive and contextual way.way.

15.15. Ability to assess one’s own Ability to assess one’s own multicultural competence.multicultural competence.

16.16. Ability to critique epistemologies, Ability to critique epistemologies, concepts, methods, concepts, methods,

instruments, and instruments, and results based on results based on assumptions related assumptions related to a group and to a group and to propose alternatives. to propose alternatives.

Eighteen Multicultural CompetenciesEighteen Multicultural Competencies(Continued)(Continued)

17.17. Knowledge of how psychological Knowledge of how psychological theory, methods of inquiry, theory, methods of inquiry,

and and professional practices are professional practices are culturally culturally embedded. embedded.

18.18. Ability to thoughtfully critique Ability to thoughtfully critique multicultural approaches in multicultural approaches in

mental health.mental health.

XI. CLOSINGXI. CLOSING THOUGHTSTHOUGHTS

The Brighter Future . . .For the real question is whether the For the real question is whether the “brighter future”“brighter future” is really always so is really always so distant. What if, on the contrary, it has distant. What if, on the contrary, it has been there for a long time already, and been there for a long time already, and only our blindness and weakness has only our blindness and weakness has prevented us from seeing it around us prevented us from seeing it around us and within us, and kept us from and within us, and kept us from developing it.developing it.

(Vaclav Havel, 1994)(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 . . . THE END . . .