a cultural psychiatry and its implication.pptx

cultural psychiatry

1. Cultural Psychiatry Presenter: Dr Prabidhi Adhikari Moderator: Dr Md Ainuddin Bagban

2. Contents Introduction Culture and psychiatric diagnosis Culture and clinical practice Culture and mental illness Culture and treatment Immigration and mental illness

3. Introduction Culture is defined as a set of meanings, norms, beliefs, values, and behavior patterns shared by a group of people. These values include social relationships, language, nonverbal expression of thoughts and emotions, moral and religious beliefs, rituals, technology, and economic beliefs and practices, among other items. CTP

4. Introduction

5. Introduction Race: Is a concept that entails people being grouped primarily by physiognomy. Its impact on individuals/groups is intense, due to its reference to physical, biological, and genetic underpinnings, and because of the intensely emotional meanings and responses it generates. Ethnicity: Refers to the subjective sense of belonging to a group of people with a common national or regional origin and shared beliefs, values, and practices, including religion. It is part of every person’s identity and self-image.

6. Introduction Culture brings together race , ethnicity and other ways of life under one rubric to examine its impact. Culture, race, and ethnicity are concepts of crucial importance in the clinical assessment of every patient.

7. Introduction cultural psychiatry is  a branch of psychiatry that focuses on the cultural factors influencing mental health(manifestation, treatment and the delivery of mental health services ) Prof. Murphy, defines the discipline as: “ the study of the relations between mental disorders and the psychological characteristics which differentiate nations, peoples or cultures. Its main goals are to identify, verify and explain the links between mental disorders and these broad psychosocial characteristics ” (1982). This field recognizes the importance of considering cultural context in understanding, diagnosing, and treating mental health issues.  Transcultural psychiatry, ethno - psychiatry, cross-cultural psychiatry

8. History of cultural psychiatry

9. History of cultural psychiatry 1964 APA Committee on transcultural psychiatry by APA 1982 1955 Eric Wittkower & Jacob Fried Established a programme in transcultural psychiatry, McGill University, Canada 1957 Eric Wittkower International conference in Zurich, attended by psychiatrists from twenty different countries The term ‘transcultural’ was adopted by Wittkower implying moving through and beyond cultural barriers Murphy defined the principal objectives of the discipline ; to identify, verify, and explain the links between mental disorders and the broad psychosocial characteristics which differentiates nation, people and cultures 1970 H.B.M. Murphy Founded APA section on Transcultural psychiatry

10. Importance

11. Importance

12. Cultural competence Ability of mental health professionals to provide person-centric care by considering individual cultural identity. Components: Cultural sensitivity : recognition that groups of people may tend to experience different types of stress in living and utilize different coping patterns Cultural knowledge : basic knowledge about the habits, customs, beliefs, value systems and illness behaviour of different cultures Cultural empathy : ability to feel and understand on an emotional level about patient’s own cultural perspective Cultural guidance : specific treatment models suited for particular ethnic groups ( Tseng el al., 2003)

13. Three levels Clinical level: to promote culturally competent mental health care for patients with diverse ethnic and cultural backgrounds Research level: exploration of how ethnic and cultural factors influence behavior and psychopathology as well the treatment process Theoretical level: expansion of knowledge about human behavior and mental problems transculturally to facilitate the development of more universally applicable and cross culturally valid theories of psychopathology

14. Culture and psychiatric diagnosis Impacts of culture on psychopathology

15. Culture and psychiatric diagnosis Culture influences what is viewed as a social, moral, spiritual, or specifically a mental health problem. The distinction between mind and body varies across cultures. Hence, the conceptualization and the experiencing of a mental disorder depend on cultural modes of perception, explanation, and causal attributions. Ideas that appear to be delusional in one culture may be commonly held in other.eg witchcraft In some cultures, visual and auditory hallucinations with religious content ( eg hearing gods voice ) are normal part of religious experiences . Eg in church In certain culture distress may take the form of hallucination, pseudo hallucination or overvalued ideas that may be clinically similar to psychosis but are normative to patients' subgroup.

16. Culture and psychiatric diagnosis The boundaries between normality and pathology vary across cultures for specific types of symptoms and behaviors. Thresholds of tolerance for specific symptoms or behaviors differ also across cultures and social settings. Hence, the level at which an experience becomes problematic or pathological will differ. Judgment that a symptom or behavior is abnormal and requires clinical attention depends on cultural norms.

17. Culture and psychiatric diagnosis Culture influences the process of diagnosis in many ways: Experience/expression of symptoms, signs, and behaviors; Configuration of symptoms into culturally distinctive syndromes; Stigma attached may prevent their clinical reporting As a result, cultural context and differences between the clinician and patient have implications for the accuracy of diagnosis as well as treatment decisions, prognostic considerations, treatment compliance, and clinical outcomes. Diagnostic assessment must consider: social and cultural contexts of the patient’s life and of the clinician The degree to which the patient’s experience and behavior differ from relevant social and cultural norms and generate conflict or difficulties in adaptation within his/her culture of origin and the current social context.

18. Psychopathology - transcultural differences Social and cultural factors may be partly or wholly responsible for the causation of disease and modify its nature and course Dependence vs autonomy Linguistic competence Cognitive style Social support system Material culture Psychological sophistication Nature of guilt vs shame ( Varma et al., 1986 )

19. Psychopathology - transcultural differences psychodynamic factors leading to psycopathology ; 1. Dependence versus Autonomy An autonomous individual resist mental breakdown to larger extent. But such a breakdown results in greater psychopathology and less favorable course and outcome in him. 2. Linguistic Competence The more competence, the more elaborate symptomatology may develop. high level of linguistic competence leads to binding of intense anxiety found in initial stages of schizophrenia leading to elaborate delusions that are less amenable to treatment. A low level of competence leaves the anxiety unbound and results in catatonic and somatic symptoms Varma (1981)

20. Psychopathology - transcultural differences 3. Cognitive style It represents ways on which mind perceives the environment, interprets and draws conclusions about it. can be and synthetic or analytical Western mind is classically analytical and hence suits science and technology well. However it fails to suffice in human behavior. Indian mind is synthetic which is conducive to the development of unitary and holistic concepts. 4. Material Culture E.g. there is possession of ghost, evil spirit in developing culture, technologically advanced society, the same is attributed to UFO, Martians.

21. Psychopathology - transcultural differences 5. Social support and Expressed Emotions Traditional societies are richer in social networks - better course and outcome. Patients living in homes characterized by high levels of expressed emotion are significantly more likely to relapse. (Vaughn C, leff J 1976; karno et al 1987) 6. Psychological Sophistication Can be perceived as ability to see conflicts in the intra-psychic terms as required in psychotherapy. It involves introspection and ability to translate one’s emotions into words. These factors are more important in psychotherapy and have to be taken into account.

22. Impacts of culture on psychopathology Patho- genic effects Patho- selective effects Patho- plastic effect Patho- elaborative effects Patho- facilitative effects Patho- reactive effects

23. Pathogenic effects Culture is a direct causative factor in forming or ‘generating’ psychopathology Cultural ideas and beliefs contribute to stress, which in turn produces psychopathology, not of disease per se Dhat syndrome Koropanic Culture STRESS PSYCHO PATHOLOGY

24. Patho selective effects Through enculturation & socialization some individual members of a given society select culturally influenced reaction patterns, which may be pathological. amok, family suicide. In Japan, cultural influences leads a family to choose, from among many alternative solutions, to commit suicide together, forming the unique psychopathology Culture STRESS PSYCHO PATHOLOGY * ******* * * ***** * * * ** ** * ** Selected people in society

25. Patho plastic effect the ways in which culture contributes to the modeling or ‘ plastering ’ of the manifestations of psychopathology The content of delusions, auditory hallucinations, obsessions, or phobias are subject to the cultural context in which the pathology is manifested CULTURE content DELUSION ADUITORY HALLUCINATION OBSESSION PHOBIAS President of US is more popular Delusion of grandiosity I am President of US

26. Patho elaborating effects Situations where the cultural context exaggerates behaviours which otherwise are normal through cultural reinforcement e.g., latah. Phenomenon of “ Trance and possession state ” This could be described to the religious elaboration of association with ‘Atman’ and ‘Deities’ CULTURE Behavior Reinforcement Behavior Response to Startle Cultural acceptance

27. Patho elaborating effects In western countries there is increasing concern with body weight Culture-shaped body image belief that “slim is beautiful" may cause “body weight anxiety” Common reason for eating disorders in developed countries

28. Patho facilitative effects Facilitating effects of culture makes it easier for certain psychopathologies to develop and increase their frequency in certain cultures e.g., AUD, anorexia. #$%^&*@+- $#@%^*+$ ^&*U#@*+% Cultural facilitation for ‘+’ Global prevalence #$%^&*@ + - $#@%^* + $ ^&*U#@* + % +++++++++ +++++++++ +++++++++ Prevalence in facilitated society Media facilitation

29. Patho reactive effects Culture influences: How people perceive pathologies and label disorders How they react to them emotionally Guides them in expressing their suffering Better prognosis of schizophrenia in developing countries like India Family, social and cultural factors have Pathoreactive effects on schizophrenia resulting in different prognosis (Sartorius et al., 1978 ) Culture Psychopathology Course & Outcome

30. CULTURE & CLINICAL PRACTICE Culture bound syndromes (CBS) and Cultural formulation interview (CFI)

31. Culture in DSM-5 To give the context of culture a more prominent position, the following additions were made in DSM 5 Description of basic cultural concepts and culture-related diagnostic issues for each diagnostic category. specific diagnostic criteria were changed to better apply across diverse cultures. For example, the criteria for social anxiety disorder now include the fear of “offending others” to reflect the Japanese concept in which avoiding harm to others is emphasized rather than harm to oneself.) DSM-5 (2013)

32. Culture in DSM-5 Data in DSM-5 criteria includes information on cultural variations in prevalence, symptomatology, associated cultural concepts and other clinical aspects Revision of the Outline for Cultural Formulation and Culture Formulation Interview (Section III) Clinical conceptualizations of distress (Section III and appendix) provides examples of well-studied cultural concepts of distress DSM-5 (2013)

33. Outline for culture formulation (OFC) Outline for Cultural Formulation introduced in DSM-IV was revised in DSM-5 Calls for assessment of following categories Cultural identity of the individual Cultural explanation of individual’s distress Interpretation of cultural factors related to psychosocial vulnerabilities and resilience (e.g. social support, environmental stressors) Cultural aspects of relationship between individuals and clinician Overall assessment of how cultural context influences the diagnosis and management plan DSM-5 (2013)

34. Culture formulation interview (CFI) To explore the significance of culture in psychiatric assessments in an individualized, non-stereotyping way Developed and field tested in 6 countries including India (>300 patients) Brief, semi-structured interview addressing: Identity and background Stressors and coping strategies Patient’s own conceptualization of problem Earlier experiences of help seeking and barriers Communication with patient’s network about illness Experience of relation with clinician and current expectations of care DSM-5 (2013)

35. CFI Consists of 16 questions divided into 4 sections: DSM-5 (2013)

36. CFI Recommended for all patients irrespective of cultural backgroud 12 supplementary modules for in depth exploration of initial 16 questions and for use in other groups (children, elders, migrants, refugees) Supplementary modules for informants, social network and caregivers on how patients interact with family, friends or other community members and how they provide support E mphasizes shared decision regarding diagnosis and treatment between patients, families, community members, and clinicians DSM-5 (2013)

37. Cultural concepts of distress represent ways in which the individual patient “experiences, understands, and communicates his or her symptoms to others.” The cultural explanations of illness also may help define the sick role or behavior the patient assumes. The explanatory model of illness includes the patient’s beliefs about their prognosis and the treatment options they would regard as being helpful.(moral model, religious model, the magical or supernatural explanatory model, the medical model, and the psychosocial stress model) Difficulties may arise when there are conceptual differences in the explanatory model of illness between clinician, patient, family, and community.

38. Cultural concepts of distress Formulation of a collaborative model that is acceptable to both the clinician and the patient is the sought-for, which would include an agreed upon set of symptoms to be treated and an outline of treatment procedures to be used Culture affects the patient’s expectations of treatment, such as whether the clinician should assume an authoritarian, paternalistic, egalitarian, or nondirective demeanor in the treatment process. Conflicts between explanatory models Results Between the patient’s and the clinician’s Diminished rapport or treatment noncompliance Between the patient’s and the family’s Lack of support from the family and family discord Patient’s and the community’s Lead to social isolation and stigmatization of the patient.

39. Cultural concepts of distress The moral model implies that the patient’s illness is caused by a moral defect such as selfishness or moral weakness. The religious model suggests that the patient is being punished for a religious failing or transgression. The magical or supernatural explanatory model may involve attributions of sorcery or witchcraft as being the cause of the symptoms. The medical model attributes the patient’s illness primarily to a biological etiology. The psychosocial model infers that overwhelming psychosocial stressors cause or are primary contributors to the illness. Culture has both direct and indirect effects on help-seeking behavior. In many cultural groups an individual and his or her family may minimize symptoms due to stigma associated with seeking assistance for mental disorders. Culture affects the patient’s expectations of treatment, such as whether the clinician should assume an authoritarian, paternalistic, egalitarian, or nondirective demeanor in the treatment process.

40. Cultural concepts of distress Cultural syndromes Cultural idioms of distress Causal attribution Defined as a cluster/group of cooccurring symptoms found in a specific cultural group, community, or context. The syndrome may or may not be recognized as an illness within the culture but may nevertheless occur and be recognized by an outside observer. Eg : Ataque de nervios , dhat , syndrome, khyâl cap, kufungisisa , maladi moun , nervios , shenjing shuairuo , susto and tajin kyofusho Is a linguistic term, phrase or way of talking about suffering, shared with other people from the same culture and used to express, communicate, or comment on distress in general. It need not be associated with specific symptoms, syndromes, It may be used to convey a wide range of uncomfortable, emotional pain or social shakiness including subclinical conditions or everyday experiences that do not necessarily constitute mental disorders. Eg : physical symptoms (somatization) Causal attribution is a label, an attempt at explaining or ascertaining the causes of the symptoms, illness, or distress. Causal explanations may be part of folk classifications of disease used by laypeople or healers, which may provide temporary relief.

41. Culture bound syndromes Yap (1962) first gave the term ‘Atypical Culture-Bound Psychogenic Psychosis’ currently known as, Culture bound syndromes (CBS) Defined as production of atypical forms of psychopathology due to implicit values, social structures and shared beliefs that are confined to special areas CBS are considered atypical with reference to conventional psychiatric nomenclatures Called culture bound due to the overriding influence of specific cultural traits in the formation of these conditions CBS occur with much greater frequency in some societies than in others They may occur in a variety of dissimilar cultures including separated by considerable distances (Current understanding)

42. Ataque de nervios Ataque de nervios ("attack of nerves") is a syndrome among individuals of Latino descent, characterized by symptoms of Intense emotional upset, including acute anxiety, anger, or grief Screaming and shouting uncontrollably, attack of crying, trembling, becoming verbally and physically aggressive C/o heat in the chest rising into the head Dissociative experiences (depersonalization, derealization, amnesia), seizure-like or fainting episodes, and suicidal gestures (infrequent)

43. Ataque de nervios Related conditions in other cultural contexts : Indisposition in Haiti Blacking out in the Southern United States Falling out in the West Indies Related conditions in DSM-5 : Panic attack/ panic disorder Other anxiety disorders Dissociative disorder Conversion (functional neurological symptom) disorder Intermittent explosive disorder Trauma and stressor-related disorder DSM-5 (2013)

44. Dhat syndrome Seen in young male patients who attributed their various symptoms to semen loss: Anxiety, depression Fatigue, weakness, c/o weight loss Impotence Multiple somatic complaints The cardinal feature is anxiety and distress about the loss of dhat / semen in the absence of any identifiable physiological dysfunction

45. Dhat syndrome Related conditions in other cultural contexts : Koro in Southeast Asia, particularly Singapore Shen- k'uei ("kidney deficiency") in China Related conditions in DSM-5 : Major depressive disorder/ persistent depressive disorder (dysthymia) Generalized anxiety disorder Somatic symptom disorder Illness anxiety disorder Erectile disorder/ early (premature) ejaculation/ other sexual dysfunctions DSM-5 (2013)

46. CULTURE BOUND SYNDROMES Name Geographical localization/populations AMOK MALAYSIA ,  INDONESIA ,  PHILIPPINES ,  BRUNEI ,  SINGAPORE ATAQUE DE NERVIOS LATINOS BILIS, CÓLERA LATINOS BOUFFÉE DÉLIRANTE WEST AFRICA  ,  HAITI BRAIN FAG WEST AFRICAN   DHAT INDIA FALLING-OUT ,  BLACKING OUT SOUTHERN UNITED STATES GHOST SICKNESS AMERICAN INDIAN HWA-BYUNG ,  WOOL-HWA-BYUNG KOREAN KORO CHINESE  ,  MALAYSIAN    SOUTHEAST ASIA ;  ASSAM LATAH MALAYSIA  ,  INDONESIA

47. CULTURE AND SPECIFIC MENTAL ILLNESSES

48. Effect of culture on mental illness Determine the pattern of certain specific disorders May give rise to basic personality types, some of which are especially vulnerable to psychiatric disorders May give rise to psychiatric disorders through certain childrearing practices Have selective influences on a particular gender based to culturally designated roles Precipitate disorder by rewarding it in prestigious roles such as holy man, witch doctor ( Leighton et al., 1963)

49. Effect of culture on mental illness Precipitate disorder by changing more rapidly than personality systems are able to tolerate Produce disorder through inculcation of sentiments damaging to the mind such as fears, jealousies, and unrealistic aspirations Influencing the amount and distribution of disorder through patterns of poor hygiene and nutrition Contribute to large disparity in global mental health distribution ( Leighton et al., 1963)

50. Impact of culture on schizophrenia Landmark research projects by the Mental Health Division of WHO: International Pilot Study of Schizophrenia (IPSS) Study of the Determinants of Outcome of Severe Mental Disorders (DOSMED) These studies confirmed that: The syndrome originally described by Emil Kraepelin and Eugen Bleuler exists in very diverse ethnic and cultural groups Pathoplastic effects of socio-cultural factors shape the symptom profiles differently in developed and developing countries

51. Impact of culture on schizophrenia Western developed countries showed a higher frequency of: Depressive symptoms Primary delusions Thought insertion Thought broadcasting Non-Western developing countries showed a higher frequency of: Visual hallucination Auditory hallucinations [SARTORIUS et al. 1986; JABLENSKY et al 1992]

52. Impact of culture on schizophrenia According to IPSS Study: India had highest percentage with best outcome (66%) Nigeria had the lowest percentage with worst outcome (10%) The major limitation of the study was that the sample was not an epidemiological sample Schizophrenic psychoses have a better prognosis in Asian and African than in comparable British patient populations Two‑thirds of schizophrenia patients in India have partial to full remission of symptoms Demonstrated by: The Madras longitudinal study The study of factors associated with course and outcome of schizophrenia (SOFACOS) [JABLENSKY et al 1992, OGAWA et al. 1987; LEE et al. l991; TSOI & WONG l991]

53. Impact of culture on schizophrenia The DOSMED study used an epidemiological sample from 12 centers in 10 countries Conclusions: The content of psychotic symptoms tends to identify critical problems existing in a particular culture Persecutory delusions and auditory hallucinations are not necessarily indicative of schizophrenia in persons of African cultural background Influence of ethnicity and culture on psychopathology weighs more than geographic proximity, historical relations and racial similarity Ethnic and cultural differences are reflected in the schizophrenic symptom profiles even if the populations adhere to the same religion Studies in Japan, Hong Kong and Singapore demonstrated a more favourable course and outcome than in Europe and North America [KATZ et al. 1988] [NDETEI & VADHER1984; NDETEI 1988]

54. Culture and acute transient psychosis Acute transient psychotic reactions are known to be more common than schizophrenia in developing countries French term bouffée délirante introduced by Magnan in 1886 Bouffée délirante is reminiscent of the transient psychotic reactions occuring in the early phases of industrialization and mass-urbanization in 19th century Europe [MOREL 1860; MEYNERT 1889]

55. Culture and acute transient psychosis Transient psychotic reactions are of particular interest to comparative cultural psychiatry because: They are interwoven with culturally validated beliefs in sorcery and witchcraft These beliefs persist even after the traditional resources of protection or assumed persecution by magical or supernatural powers are no longer valid as a consequence of Westernization and urbanization Number of individuals experiencing the pressures of rapid social change is steadily increasing Many feel unprotected against magical forces in which they still firmly believe The individual reacts with an acute psychotic episode to react to emotional trauma and to severe social stress

56. Affective disorders- depression Culture greatly influences the way in which depressive symptoms are expressed In the WHO collaborative study assessed depressive disorder in 583 patients at five centers (Basel, Montreal, Tehran, Nagasaki, and Tokyo) Most of them had common features of sadness, anhedonia, lack of interest and energy, impaired concentration, and ideas of worthlessness Feelings of guilt and suicidal ideations were least common in Tehran

57. Depression Indian studies have found guilt to be less common among Indian patients than those in the West Indian patients reported guilt of an impersonal nature The present suffering is attributed to possible bad deeds of previous life (consequence of “Karma”) rather than due to self‑failure as in the West Physical symptoms are common presenting symptoms in depression

58. Anxiety disorders Results of a study assessing the prevalence rates of anxiety disorders in U.S population: Asian Americans had symptoms of all four major anxiety disorders less frequently than other racial groups White Americans reported symptoms of social anxiety disorder, generalized anxiety disorder and panic disorder more frequently than other racial groups African Americans more frequently met criteria for post-traumatic stress disorder (PTSD) as compared to other racial groups

59. Transcultural aspects of dissociative and somatoform disorders Concept of somatization may have arisen from the Cartesian dualism prevalent in Western societies Cartesian Dichotomy may have led to the cleavage of mental health care from "medical care" Transformation of personal or social distress into somatic complaints is a norm in most cultures Patients tend to develop symptoms that are "medically correct “ Somatic symptoms tend to be less stigmatizing than psychological symptoms ( Fabrega , 1991) ( Kleinman , 1987)

60. Transcultural aspects of dissociative and somatoform disorders Worldwide most common medically unexplained symptoms are Gastrointestinal complaints Abnormal skin sensations (World Health Organization, 1992) Most common medically unexplained somatic symptoms in the United States were gynecological complaints, followed by gastrointestinal and cardiovascular symptoms (Epidemiologic Catchment Area study ,Escobar et al., 1987)

61. Transcultural aspects of dissociative and somatoform disorders Nigeria and India common somatic symptoms are: Feeling of heat Peppery and crawling sensations Numbness Burning hands and feet Hot, peppery sensations in head These symptoms are extremely rare in Western countries Indian study observed that most patients with dissociation presented with a "brief dissociative stupor" that coexisted with anxiety and panic symptoms Multiple Personality Disorder (MPD) is an iatrogenic disorder largely confined to North America MPD is rare or nonexistent in other western and non western countries

62. Need of Cultural standard to assess insight If a person acknowledges some kind of non-visible change in his or her body or mind that affects the ability to function socially and If he or she feels the need for restitution/ restoration then Irrespective of the attribution and the pathways of care that the person seeks We could call this as presence of “insight” The awareness of changes in body or mind has to have a non-delusional explanation Diagnosing the non-delusional nature of the explanation requires an understanding of the local culture Need to use local and cultural standards rather than universal yardsticks to assess insight in people with psychosis

63. Factors influencing the outcome (Murphy et. al) 1.Social rejection More a society rejects, fears the schizophrenic, greater the difficulty the patient must overcome in regaining normal roles. 2. Rigidity of role ideals The more a society defines what it considers qualities of a true person are the more liable schizophrenics to relapse, after they find themselves deviated from these ideals. 3. Assignment of responsibility The more patient are expected to be accountable for there for there own disturbed behavior in the past more likely they are to relapse when faced with the task of rationally accounting for that behavior. 4. Sick role typing The more a society believes that insanity is chronic the less it will facilitate the patients efforts to break out of the sick once he has entered it, even though there may be great tolerance and support for the sick role. 5 . Acceptance of dependency The more a culture tolerates the idea of dependency, the longer patients are content to remain in the sick role, when the caring agency is seen as benevolent and the external realities are considered harsher. 6 . Social networks The more interconnected people in the society, the more aid a patient is likely to find in resisting relapse, assuming that he has retained a place in society.

64. Culture & psychopharmacology Ethnopharmacology - Use of substances medicinally by different ethnic or cultural groups (e.g. folk remedies) Example - St John Wart - used traditionally in Germany and North western Europe Pharmacogenetics - differences in response to or handing of drugs based on ethnicity Example - Asian patients require lower dose of dopamine receptor antagonist, tricyclic antidepressants, benzodiazepines and lithium to achieve same clinical response compared to white population with more predisposition to side effects at higher doses ( Potkin et al., 1984)

65. Culture & psychopharmacology Other role of culture in psychopharmacology: Affect levels of expectation for optimum treatment response Affect expected rate of treatment recovery Affect threshold and tolerance for side effects Influence the target symptoms

66. Culture & psychotherapy Ethnopsychology - study of how individuals within a cultural group conceptualize the self, emotions, human nature, motivation, personality, and the interpretation of experience ( Kirmayer , 1989) There is a lack of of perceived cultural relevance of Western psychotherapeutic techniques Need to modify the existing psychotherapeutic techniques according to culture and to integrate existing traditional forms of support Example - In Indian population there is need to involve family members during therapy sessions, involving religious concepts, introduce the concept of “mind control” or Sattvavajaya(Trance therapy)

67. IMMIGRATION & MENTAL ILLNESS Migration and accultration

68. Immigration and mental illness When a person shifts his residence from one political or administrative boundary to another, it is known a migration Three principal hypothesis explain the relationship between immigration and mental illness: Certain mental disorders incite their victims to migrate The process of migration creates mental stress, which may precipitate mental illness in susceptible individuals There is a non-essential association between migration and other variables, such as age, social class and culture conflict ( Murphy et el., 1973)

69. Culture shock Normal psychological adjustment to an abrupt transition from one culture to another Consists of 4 phases: Phase 1/ Honeymoon phase - new environment is regarded as exciting and new opportunities for work, pleasure and social activities are welcomed Phase 2/ Disenchantment phase - fatigue of not understanding gestures, signs and language sets in; and miscommunications may happen frequently Phase 3/ Beginning resolution phase - the individual seeks patterns of behaviour appropriate to the new setting leads directly to the Phase 4/ Effective function phase - the individual has worked through his loss and re-established his self-esteem, and may experience reverse culture shock on returning home (Brink and Saunders,1976)

70. Acculturation Enculturation : the process by which a person learns the requirements of his/her culture and acquires values and behaviour that are necessary or appropriate in that culture Acculturation : the process by which members of one cultural group adopts the cultural traits and social patterns of another cultural group Acculturative stress : refers to the psychological, somatic and social difficulties that may accompany acculturation Assimilation : the process by which a minority group gradually adapts to the customs and values of the prevailing culture Diaspora : it is the movement, migration or scattering of people from established or ancestral homeland

71. Acculturation Integration Assimilation Marginalization Separation Host countries felt that immigrants should acculturate to the normative behaviors and values of the majority or mainstream culture of the host population. Most immigrants had the same wish to assimilate, to become part of the melting pot. The intensity of acculturative stress experienced by immigrant and other minority groups, and the individuals comprising those groups, has been directly proportional to the openness of the host government and population. The acceptance position encourages the cultural integration of immigrants, whereas the rejection position encourages either cultural exclusion or cultural assimilation.

72. Psychiatric assessment of immigrants and refugees Mental illness among immigrants and refugees may have been present before migration, may have developed during the immigration process, such as during months or years living in refugee camps, or presented for the first time in the country of immigration. The immigration process and premigration trauma may precipitate the manifestation of underlying symptoms or result in exacerbation of a preexisting disorder. Obtaining a thorough migration history will assist in understanding background and precipitating stressors and help guide development of an appropriate treatment plan.

73. References