17 - 10. Culture and mental health

10. Culture and mental health

© SPMM Course 10. Culture and mental health

Comparative psychiatry refers to the study of mental illness in different sociocultural settings; Kraepelin traveled to Southeast Asia and developed the concept of comparative psychiatry. This is now referred to as transcultural psychiatry. Two perspectives of cultural studies often discussed:  Emic perspective (emic view): Used to refer to the perspective of an individual from a specific cultural group about his own group.  Etic perspective (etic view): Refers to the perspective of an individual outside a specific cultural group about the studied group. The etic approach, for instance, involves applying Western psychiatric concepts en bloc into a different culture and uses it for diagnosis. This approach assumes

1. Universality of illnesses
2. Invariance of core symptoms
3. Validity of diagnostic constructs

Different views in etic / emic approaches:

ETIC approach EMIC approach Diagnosis of mental illness Similar core symptoms in all cultures Linguistic and cultural variations acknowledged Classification system Common classificatory systems endorsed Locally derived systems endorsed Preferred measurement method Identical rating scales and measures across nations

Preferred research method Quantitative methods emphasizing reliability are preferred Qualitative methods emphasizing cultural validity Treatment methods Biomedically driven Local belief driven Help seeking behaviour Provision of services most important Individual health belief and explanatory models most important

Ethnicity is often defined by a set of cultural patterns (values, beliefs, roles, affective and cognitive styles, and norms), heritage, or ancestry shared by a social group of common national or geographic origin.

© SPMM Course Term Characters Determined by Perceived as Race Physical appearance Genetic Permanent Culture Behaviour & attitudes Upbringing (enculturation) and choice Changeable (see acculturation) Ethnicity Group identity Social; pressures, psychological need for identification Partially changeable (From Seminars in Gen Adult Psych 1e. Pg. 783) Acculturation refers to the process of cultural change that takes place when an individual or a group comes in continuous contact with a culturally distinct group. Acculturation can result from immigration and can occur in either direction – hosts can get accultured; as evident in certain places in times of Colonial rule. Four types are described according to the degree of retention and adoption of the two cultures at ethnocultural group level: Berry’s model of acculturation High degree of retention of culture of origin Low degree of retention of culture of origin High degree of adoption of new culture INTEGRATION ASSIMILATION Low degree of adoption of new culture SEPARATION MARGINALISATION

 Assimilation: This refers to partial adaptation of a new culture (seen in migrants or refugees) without retaining or giving up all of one’s culture of origin completely.  Integration refers to both high retention of one’s own cultural values and high adoption of the practices of the new culture.  Separation refers to high retention of one’s own cultural values and low adoption of the practices of the new culture.  Marginalisation refers to both low retention of one’s own cultural values and low adoption of the practices of the new culture. These individuals get marginalized by members of both culture of origin and culture of adoption. When someone loses the identity of one’s culture of origin voluntarily e.g. upon immigration but does not assimilate or integrate, then the risk of loss of cultural identity and subsequent increase in mental illness are noted.

© SPMM Course Enculturation refers to culture being learnt through contact with family, friends, teachers and the media. This happens to everyone irrespective of migration. At a larger societal (as opposed to small group) level, Berry’s model is often mapped using the terms given below: Berry’s model of acculturation High degree of retention of individual culture identities Low degree of retention of individual culture identities High degree of relationship among various cultures MULTICULTURALISM MELTING POT Low degree of relationship among various cultures in the society SEGREGATION EXCLUSION

Cultural bereavement refers to a self-limited grieving response developed by an individual on leaving his own culture. Cultural diffusion or syncretism refers to the spread of cultural traits (including psychiatric syndromes, treatment methods) through contacts across societies. This leads to creating innovations that are distinct from both groups. Sojourning refers to voluntary but brief exposure to different culture e.g. tourists, Peace Corps volunteers. Nostalgia or homesickness is common in sojourners and can be reduced by shortening length of stay, keeping in touch with family and friends at home and learning about a new culture before arrival. Segregation: This refers to removal of people from communities and placing them in an artificial community, which is more or less an institution. Goffman described 5 types of segregation:

1. Incapable harmless – orphanages and old age homes
2. Ill but threat to society – mental hospitals
3. Not ill, threat to society with malice – prisons
4. Occupation related – military barracks, boarding schools
5. Retreat from the world – monasteries, convents.

What happens when a family emigrates?

© SPMM Course 1. The elderly often find difficult to adapt and change – rejection of new culture happens 2. Complete assimilation is seen in young children 3. A bicultural pattern is seen among young adults in working age – at work they adapt to new culture, but at home they remain attached to the culture of origin.

Function of culture in psychiatric practice The five elements of cultural formulation (American Psychiatric Association, 2002)

1. The cultural identity of the individual
2. Cultural explanations of the individual’s illness
3. The influence of the patient’s psychosocial environment and level of functioning within it
4. Cultural elements in the patient–professional relationship (this requires the psychiatrist to be knowledgeable of her own cultural values and beliefs)
5. The use of cultural assessment in deciding diagnosis and care. The concept of explanatory models  Patients’ explanatory models are not fixed and are influenced by the circumstances of their symptoms, age, gender, educational attainment, time point and context of assessment and importantly their cultural beliefs.  Explanatory models themselves can influence a physician’s assessments.  The process of exploring patient’s identity and explanatory model ensures improved understanding and informs the successful negotiation of different worldviews. This exploration does not require psychiatrists to enter into another culture as a participant observer. Idioms of distress Culture as an explanatory tool: This allows description of non-pathological behaviours in the context of one’s culture. Culture as a pathoplastic agent: This allows description of psychopathology that result from cultural practices. Culture as a diagnostic factor: This allows culture-specific, unique diagnostic framework e.g. culture-bound disorders Culture as a service instrument: This allows utilization of cultural knowledge in service delivery and resource distribution.

© SPMM Course Idioms are well-structured and codified way expressing thoughts via language. Idioms in one language cannot be translated as such to another – they lose their meaning out of context. In cultural psychiatry, idioms of distress refer to somatic symptoms that serve as a code for expressing one’s mental distress in some cultures. Models of care in cultural psychiatry: Culturally sensitive care could be delivered using various models. Some of these include 1. Ethnic minority services: Separate services are set up for the growing minority population, but there is a risk of organizational marginalization in such models. 2. Cultural consultation model: This has been tested in Canada. It consists of a specialized multidisciplinary team which provides consultations to other clinical teams, sometimes to the families directly. They do not provide direct patient care. 3. Melting pot model: In this model, institutional factors promoting inequalities are addressed. Culture is not perceived as a problem area that needs special resources. Instead, mainstream services are commonly enriched by responding to all cultural groups’ needs. This guarantees equality of access in care. (Melting pot refers to regions or countries that accommodate other cultures in huge numbers, eventually paving way for a high degree of admixture and cultural mosaicism, e.g., United States). 4. A hedge-your-bets approach: Following both prescribed medication and ethnic, spiritual therapy may be the best hope for securing adherence. This encourages honest discussion with family and maintaining religious affiliations.