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Cultural and Social Context of Clinical Assessment
Introduction
The mental health disparities suffered by the English-speaking Afro-Caribbean diaspora living with psychosis in North America and the United Kingdom have been well described for decades, but the root causes of these disparities remain poorly understood. Part of the problem may be that the attitudes and beliefs of Caribbean communities regarding psychosis have never been systematically assessed. Such an inquiry could lay the foundation for changes to how psychiatric services for psychosis are implemented with migrant Caribbean communities. The ideal would be a re-design of services, or cultural adaptation of care, based on input from community members, patients, and their families, with the hope that disparities of care would be reduced or eliminated as clinicians co-create interventions that are more appropriate and acceptable to Caribbean people. To lay the groundwork of such an important endeavor, we investigated the shared attitudes, beliefs, experiences, practices, and traditions of English-speaking Afro-Caribbean people in relation to psychosis and psychiatric care.
Methods
We conducted a scoping review by searching Medline, PsychINFO and Scopus, reviewing 764 articles, and selecting 220 for thematic content analysis.
Results
We highlighted the heterogeneity in the Caribbean diaspora living in North America and the UK. Five principal themes emerged: (1) The enduring effects of colonialism on the psychiatric care of Afro-Caribbean migrants; (2) The effects of adaptation to migration on the experience of psychosis; (3) Pervasive cultural mistrust of psychiatry and mental health institutions; (4) A collective approach to life; and (5) The role of religion and spirituality in the understanding of psychosis.
Conclusion
Historical, sociocultural, and geopolitical themes characterize the English Afro-Caribbean experience of psychosis and inform culturally adapted clinical interventions for patients with psychosis and their families. Careful attention to these adaptations will reduce clinical bias and misdiagnosis, optimize adherence to treatment, engage patients and families in recovery, and ultimately, reduce treatment disparities while empowering Afro-Caribbean people and their communities. By bringing forward the themes in this chapter, individual clinicians will be given tools to change how they work with Caribbean people with psychosis in addition to laying the foundation for higher order changes in the mental health professions and society as a whole.
Refining the cultural safety concept to include an acknowledgement of both the discomfort inherent in training and care and the time needed to overcome multiple layers of oppression may partially buffer the feelings of failure or fraud that often arise from unrealistic expectations regarding equity, diversity and inclusion policies.
Objective:
Using a retrospective sample, the authors sought to determine whether Black patients with first-episode psychosis (FEP) in Canada were at a higher risk for coercive referral and coercive intervention than non-Black patients with FEP.
Methods:
Retrospective data from patients referred to an FEP program in 2008-2018 were collected via chart review (N=208). The authors used chi-square and logistic regression analyses to explore the relationships among race-ethnicity, diagnosis of psychosis, and coercive referral and intervention.
Results:
Results showed that Black persons of Caribbean or African descent with FEP were significantly more likely to be coercively referred (χ2=9.24, df=2, p=0.010) and coercively treated (χ2=9.21, df=2, p=0.010) than were non-Black individuals with FEP. Age and violent or threatening behavior were predictors of coercive referral. Ethnoracial status, age, and violent or threatening behavior were predictors of coercive intervention.
Conclusions:
This study contributes to the dearth of research on Black Canadians and offers insight into factors that may place patients with FEP at risk for coercive treatment. More research is needed to explore the role that ethnoracial status may play in hospital admissions and to uncover the role of racial prejudices in the assessment of danger.
Background:
In Europe, the incidence of psychotic disorder is high in certain migrant and minority ethnic groups (hence: 'minorities'). However, it is unknown how the incidence pattern for these groups varies within this continent. Our objective was to compare, across sites in France, Italy, Spain, the UK and the Netherlands, the incidence rates for minorities and the incidence rate ratios (IRRs, minorities v. the local reference population).
Methods:
The European Network of National Schizophrenia Networks Studying Gene-Environment Interactions (EU-GEI) study was conducted between 2010 and 2015. We analyzed data on incident cases of non-organic psychosis (International Classification of Diseases, 10th edition, codes F20-F33) from 13 sites.
Results:
The standardized incidence rates for minorities, combined into one category, varied from 12.2 in Valencia to 82.5 per 100 000 in Paris. These rates were generally high at sites with high rates for the reference population, and low at sites with low rates for the reference population. IRRs for minorities (combined into one category) varied from 0.70 (95% CI 0.32-1.53) in Valencia to 2.47 (95% CI 1.66-3.69) in Paris (test for interaction: p = 0.031). At most sites, IRRs were higher for persons from non-Western countries than for those from Western countries, with the highest IRRs for individuals from sub-Saharan Africa (adjusted IRR = 3.23, 95% CI 2.66-3.93).
Conclusions:
Incidence rates vary by region of origin, region of destination and their combination. This suggests that they are strongly influenced by the social context.
The Cultural Formulation Interview (CFI) developed for DSM-5 provides a way to collect information on patients’ illness experience, social and cultural context, help-seeking, and treatment expectations relevant to psychiatric diagnosis and assessment. This thematic issue of Transcultural Psychiatry brings together articles examining the implementation and impact of the CFI in diverse settings. In this editorial introduction we discuss key areas raised by these and other studies, including: (1) the potential of the CFI for transforming current psychiatric assessment models; (2) training and implementation strategies for wider application and scale-up; and (3) refining the CFI by developing new modules and alternative protocols based on further research and clinical experience.
The high prevalence and psychological impact of childhood exposure to potentially traumatic events (PTE) is a major public health concern in the United States. Considerable evidence has demonstrated the significant racial disparities that exist with respect to PTE exposure, indicating that Black youth are particularly burdened by these harmful experiences. Racism may serve a unique role in explaining why Black youth are disproportionately exposed to PTEs, and why mental health disparities are more likely to occur following such experiences. Despite clear evidence acknowledging racism as a major life stressor for Black youth, theoretical models of early childhood adversity have largely neglected the multifaceted influence of racism on mental health outcomes. Inspired by bourgeoning literature highlighting the potentially traumatic nature of racism-related experiences for Black youth, we present a culturally-informed Adverse Childhood Experiences (ACEs) model, or “C-ACE”, to understand the pervasive and deleterious mental health impact of racism on Black youth. This model extends the ACE framework by noting the significance of racism as an ACE exposure risk factor, a distinct ACE category, and a determinant of post-ACE mental health outcomes among Black youth. The model acknowledges and supports the advancement of ACEs research that takes a culturally informed approach to understanding the intergenerational and multilevel impact of racism on the mental health of Black youth. Future research utilizing the proposed C-ACE model is essential for informing clinical and public health initiatives centered on reducing the mental health impact of racism-related experiences and health disparities in the United States.
Background:
Eliminating indigenous and ethnic health inequities requires addressing the determinants of health inequities which includes institutionalised racism, and ensuring a health care system that delivers appropriate and equitable care. There is growing recognition of the importance of cultural competency and cultural safety at both individual health practitioner and organisational levels to achieve equitable health care. Some jurisdictions have included cultural competency in health professional licensing legislation, health professional accreditation standards, and pre-service and in-service training programmes. However, there are mixed definitions and understandings of cultural competency and cultural safety, and how best to achieve them.
Methods:
A literature review of 59 international articles on the definitions of cultural competency and cultural safety was undertaken. Findings were contextualised to the cultural competency legislation, statements and initiatives present within Aotearoa New Zealand, a national Symposium on Cultural Competence and Māori Health, convened by the Medical Council of New Zealand and Te Ohu Rata o Aotearoa - Māori Medical Practitioners Association (Te ORA) and consultation with Māori medical practitioners via Te ORA.
Results:
Health practitioners, healthcare organisations and health systems need to be engaged in working towards cultural safety and critical consciousness. To do this, they must be prepared to critique the 'taken for granted' power structures and be prepared to challenge their own culture and cultural systems rather than prioritise becoming 'competent' in the cultures of others. The objective of cultural safety activities also needs to be clearly linked to achieving health equity. Healthcare organisations and authorities need to be held accountable for providing culturally safe care, as defined by patients and their communities, and as measured through progress towards achieving health equity.
Conclusions:
A move to cultural safety rather than cultural competency is recommended. We propose a definition for cultural safety that we believe to be more fit for purpose in achieving health equity, and clarify the essential principles and practical steps to operationalise this approach in healthcare organisations and workforce development. The unintended consequences of a narrow or limited understanding of cultural competency are discussed, along with recommendations for how a broader conceptualisation of these terms is important.
The objective of this research was to use intersectionality to explore Asian men’s experiences of stigma and mental illness to tease out the ways in which stigma of mental illness among Asian men is mediated by age, immigration experiences, sexual and gender identities, racism and racialization processes, normative expectations about masculinity, and material inequality. The data for this research are based on a 4-year, multi-site (Calgary, Vancouver, and Toronto) mixed-methods intervention study that evaluated the effectiveness of interventions in reducing self and social mental health stigma among Asian men (Livingston et al. International Journal of Social Psychiatry 64, 679-689, 2018; Guruge et al. Contemporary Clinical Trials 71, 133–139, 2018). Participants were Asian men living with or affected by mental illness and community leaders interested in stigma reduction and advocacy. Quantitative survey data captured participants’ self-reports of stigma, psychological flexibility, valued life domains, mindfulness, and empowerment readiness. Qualitative data included focus group transcripts, field notes, and participants’ logs about anti-stigma activities in their communities. The data analyzed here are from ten pre-intervention and seven post-intervention focus groups conducted at the Vancouver site. The data collected pre- and post-interventions revealed that men understand and experience stigma as inextricably linked to social location, specifically age, race, masculinity, ethnicity, and time of migration. Our analysis also revealed that mental health stigma cannot be understood in isolation of other social and structural barriers. The application of intersectional frameworks must figure prominently in psychological research and in public health policies that seek to reduce mental health stigma in racialized communities.
Background
The aims of this meta-analysis are (i) to estimate the pooled relative risk (RR) of developing non-affective psychotic disorder (NAPD) and affective psychotic disorder (APD) among migrants and their children; (ii) to adjust these results for socioeconomic status (SES); (iii) to examine the sources of heterogeneity that underlie the risk of NAPD.
Methods
We included population-based incidence studies that reported an age-adjusted RR with 95% confidence interval (CI) published 1 January 1977–12 October 2017 and used a random-effects model.
Results
We retrieved studies performed in Europe ( n = 43), Israel ( n = 3), Canada ( n = 2) and Australia ( n = 1). The meta-analysis yielded a RR, adjusted for age and sex, of 2.13 (95% CI 1.99–2.27) for NAPD and 2.94 (95% CI 2.28–3.79) for APD. The RRs diminished, but persisted after adjustment for SES. With reference to NAPD: a personal or parental history of migration to Europe from countries outside Europe was associated with a higher RR (RR = 2.94, 95% CI 2.63–3.29) than migration within Europe (RR = 1.88, 95% 1.62–2.18). The corresponding RR was lower in Israel (RR = 1.22; 0.99–1.50) and Canada (RR = 1.21; 0.85–1.74). The RR was highest among individuals with a black skin colour (RR = 4.19, 95% CI 3.42–5.14). The evidence of a difference in risk between first and second generation was insufficient.
Conclusions
Positive selection may explain the low risk in Canada, while the change from exclusion to inclusion may do the same in Israel. Given the high risks among migrants from developing countries in Europe, social exclusion may have a pathogenic role.
Purpose of Review
The present review synthesizes recent literature on social determinants and mental health outcomes and provides recommendations for how to advance the field. We summarize current studies related to changes in the conceptualization of social determinants, how social determinants impact mental health, what we have learned from social determinant interventions, and new methods to collect, use, and analyze social determinant data.
Recent Findings
Recent research has increasingly focused on interactions between multiple social determinants, interventions to address upstream causes of mental health challenges, and use of simulation models to represent complex systems. However, methodological challenges and inconsistent findings prevent a definitive understanding of which social determinants should be addressed to improve mental health, and within what populations these interventions may be most effective.
Summary
Recent advances in strategies to collect, evaluate, and analyze social determinants suggest the potential to better appraise their impact and to implement relevant interventions.
Therapists and mental health professionals strive to provide competent treatment to increasingly diverse populations, but can struggle to effectively engage with clients from different cultural backgrounds. Cultural humility is an approach and process that can help facilitate strong working alliances between therapists and diverse clients, leading to better therapy outcomes. In this article, we first consolidate definitions of cultural humility and work to better operationalize the construct. Next, we provide a brief review of empirical studies examining the role of cultural humility in therapy. Then, we offer a 4-part framework for applying cultural humility in therapy by (a) engaging in critical self-examination and self-awareness, (b) building the therapeutic alliance, (c) repairing cultural ruptures, and (d) navigating value differences. Finally, we illustrate what cultural humility looks like in the therapy room with two case studies.
This study investigates bi- and multilingual clients’ self-reported language practices in counselling and psychotherapy. Quantitative and qualitative data were collected through an international web survey inviting adults who had experienced one-to-one therapy to describe their experiences. Analysis of responses by 109 multilingual clients revealed that clients did not always have an opportunity to discuss their multilingualism with therapists, and for some this inhibited their language switching. Others were assertive in their language choices, or benefited from working with a therapist who was either bilingual or skilled at creating an inclusive linguistic environment. Very few reported two main therapy languages, while nearly two thirds of participants reported short code-switches. These happened occasionally within sessions and were typically linked to difficulties in translation, expressing emotion, accessing memories or quotation. Over a third of respondents used a second or additional language as their main therapy language, with nearly half of this group reporting that they never switched to their first language in sessions, despite some using it daily for inner speech. The implications for therapy and further research are discussed, including the role of the therapist in inviting the client's multiple languages into the therapeutic frame.
Depression is now recognized as a global health problem, with estimates that it accounts for up to 10% of years lost to disability in developing countries (Desjarlais et al. 1995; Murray and Lopez 1997). Global disability due to depression has increased over the last two decades, especially for women (GBD 2017 DALYs and HALE Collaborators 2018). Given this widespread prevalence and social impact, there is a pressing need to examine cross-cultural differences in the causes, course and treatment of depression (Scott and Dickey 2003). At the same time, responding to the health disparities associated with cultural diversity is increasingly recognized as an important issue in high income countries, creating new challenges for mental health care (US Surgeon General 2002; Napier et al. 2014).
Cultural psychiatry is concerned with the impact of variations in ways of life on psychiatric disorders and their treatment (Kleinman 1988). Among the questions it seeks to address are: How does culture shape the experience and expression of human suffering? What are the most effective methods of interpreting and responding to suffering in a given social or clinical context? Are the forms of distress identified in current psychiatric nosology similar around the globe? More specifically, can mood disorders be recognized across diverse cultures and do they have similar symptoms, course, treatment response and outcome? These questions raise complex epistemological and methodological problems for psychiatric research and practice (Kirmayer and Ban 2013). The answers are crucial to the advance of research, the design of health care systems and the delivery of clinical care in societies facing increasing cultural diversity (Kirmayer and Jarvis 2019).
Much of what we know about the role of culture in psychopathology comes from qualitative ethnographic research in clinical settings and in the community (Kleinman 1988; Kirmayer 1989). Conventional psychiatric research is ill suited to explore the cultural meaning of distress because it tends to reduce the complexity of illness narratives to checklists of symptoms and signs of disorder. However, there is a growing body of epidemiological research informed by ethnography that goes beyond parochial assumptions to identify clinically important cultural variation. In this chapter, we review some of what is known about cultural variations in the prevalence, clinical presentation, mechanisms and treatment of depressive disorders and address some of the broader conceptual issues that are central to meaningful research and effective clinical intervention.
Gender-based violence (GBV) among female refugees/asylum seekers is a major underreported/understudied psychosocial issue. The aims of this study were: to describe the proportion of GBV-related experiences among female refugees/asylum seekers referred to a Cultural Consultation Service (CCS) in Montreal; to describe their sociodemographic and clinical characteristics; and to compare these characteristics among women who make GBV their principal refugee claim (Group A), those who did not but had suffered GBV (Group B1), and those who had never reported GBV (Group B2). Data on sociodemographic and clinical variables and GBV were gathered by chart review. Data were analyzed using chi-square for categorical and ANOVA for continuous comparisons. A total of 91 female refugees/asylum seekers were evaluated from 2000 to 2013; 80% (73/91) having reported GBV, with 38.5% (35/91) using GBV as the principal reason for seeking asylum in Canada (Group A), mainly due to intimate partner violence (IPV). Fully 66.6% (38/56) of women who sought asylum for reasons other than GBV reported having experienced GBV (Group B1). When compared to the other groups, Group A women exhibited a number of statistically significant differences: they tended to migrate alone ( p < .001), be divorced/single ( p = .02), have more suicidal thoughts/behaviors ( p < .001), and report a history of IPV ( p < .001). Women from Group B1 were more likely to be diagnosed with Affective Disorders ( p = .045), and to have suffered sexual violence ( p < .001). Results suggest that GBV is frequently experienced by refugee/asylum seeker women in this small, tertiary care clinical sample. When assessing refugee women such as these, differences in the kind of violence suffered, migration process, family/social support, and clinical related features should be taken into account and explored by clinicians in a culturally appropriate and safe manner.
Patients and families each present unique microcultures, mixing and blending numerous broadly conceptualized cultural identity groups. Within individuals and families, cultural identities are experienced and enacted as complex matrices of intersecting identities that, to varying degrees, complement, assimilate, accommodate, or clash. In these patterns, individuals' relationships to cultures are not necessarily categorically distinct ("multicultural"). Instead, they are often "polycultural," defined as partial and plural; rather than interpreting different cultural traditions as separate and independent, they are, within the lives of individuals and families, better understood as systems that interact with and influence one another.Cultural identity groups extend beyond those traditionally considered by transcultural psychiatry-that is, beyond ethnic, racial, and language groups. They encompass (in alphabetical order) educational, ethnic, extended family, gender-oriented, generational, geographic, language and dialect, organizational, physical or psychiatric disability, political, professional, racial, religious, sect, social class, and vocational identity groups, among others. Simplistic assumptions and generalities about identity groups risk cultural stereotyping that may negatively bias clinical assessments. Therefore, practitioners striving for cultural sensitivity need to adopt nuanced strategies for approaching broad polycultural identity questions in clinical practice. Accordingly, this article suggests frameworks and strategies for (1) assessing and confronting one's own cultural preconceptions and prejudices, and (2) developing etic (objective quantitative data) and emic (insiders' experiential worldviews) perspectives pertinent to clinical anthropathology. Both etic and emic perspectives are necessary for polyculturally nuanced, respectful, comprehensive inquiries pertinent to patients' and family's health beliefs, psychiatric difficulties, and health practices. Supplementary material from the DSM-5 section on cultural formulation is adapted and discussed, along with the implications of polycultural psychiatry for education and training in psychiatry.
While social science research has demonstrated the importance of culture in shaping psychiatric illness, clinical methods for assessing the cultural dimensions of illness have not been adopted as part of routine care. Reasons for limited integration include the impression that attention to culture requires specialized skills, is only relevant to a subset of patients from unfamiliar backgrounds, and takes too much time to be useful. The DSM-5 Cultural Formulation Interview (CFI), published in 2013, was developed to provide a simplified approach to collecting information needed for cultural assessment. It offers a 16-question interview protocol that has been field tested at sites around the world. However, little is known about how CFI implementation has affected training, health services, and clinical outcomes. This article offers a comprehensive narrative review that synthesizes peer-reviewed, published studies on CFI use. A total of 25 studies were identified, with sample sizes ranging from 1 to 460 participants. In all pilot CFI studies 960 unique subjects were enrolled, and in final CFI studies 739 were enrolled. Studies focused on how the CFI affects clinical practice; explored the CFI through research paradigms in medical communication, implementation science, and family psychiatry; and examined clinician training. In most studies, patients and clinicians reported that using the CFI improved clinical rapport. This evidence base offers an opportunity to consider implications for training, research, and clinical practice and to identify crucial areas for further research.
(Copyright © 2009, American Psychiatric Association. Published with permission).
The guidelines of an anti-racist care and treatment plan are summarised in the panel. These guidelines address the needs of professionals (eg, psychiatrists and psychologists) and students in terms of training to provide anti-racist mental health care. They integrate the results of research from the past 30 years on the racist experiences of Black communities, and the effectiveness of treatment and care approaches for different psychiatric disorders. These guidelines address ways of caring for Black communities in western countries by taking into account issues of individual, institutional, and systemic racism. They include four main axes: an awareness of racial issues, an assessment adapted to the real needs of Black individuals, a humanistic approach to medication, and a treatment approach that addresses the real needs and issues related to the racism experienced by Black individuals. These guidelines also specify what needs to be addressed at each stage to provide anti-racist care. They are cross-cultural and reflect the complexity of racial issues and the variations that might exist within Black communities in western countries, although the problems are experienced in similar ways.
The guidelines of an anti-racist care and treatment plan are summarised in the panel. These guidelines address the needs of professionals (eg, psychiatrists and psychologists) and students in terms of training to provide anti-racist mental health care. They integrate the results of research from the past 30 years on the racist experiences of Black communities, and the effectiveness of treatment and care approaches for different psychiatric disorders. These guidelines address ways of caring for Black communities in western countries by taking into account issues of individual, institutional, and systemic racism. They include four main axes: an awareness of racial issues, an assessment adapted to the real needs of Black individuals, a humanistic approach to medication, and a treatment approach that addresses the real needs and issues related to the racism experienced by Black individuals. These guidelines also specify what needs to be addressed at each stage to provide anti-racist care. They are cross-cultural and reflect the complexity of racial issues and the variations that might exist within Black communities in western countries, although the problems are experienced in similar ways.
[This position paper has been substantially revised by the Canadian Psychiatric Association (CPA)’s Section on Transcultural Psychiatry and the Standing Committee on Education and approved for republication by the CPA’s Board of Directors on February 8, 2019. The original position paper was first approved by the CPA Board on September 28, 2011]
Canada is a highly diverse society and, through policies of multiculturalism and a vigorous academic and research tradition of transcultural psychiatry, Canadian scholars and clinicians have been world leaders in efforts to understand the impact of culture on mental health. In response to the need for national guidelines for the integration of culture in psychiatric education and practice, an earlier version of this position paper was prepared by the Section of Transcultural Psychiatry of the Canadian Psychiatric Association (CPA) for the Standing Committee on Education. This revision updates the paper with new material reflecting advances in psychiatric education and cultural psychiatry, including competence-oriented training methods, recent research on cultural and social structural determinants of mental health and the introduction of cultural formulation interview (CFI) in DSM-5. The guidelines are based on a review of literature, experiences with existing training programs and expert consensus. This paper addresses issues relevant to general psychiatry as well as specific populations including immigrants, refugees, racialized and ethnocultural groups, as well as First Nations, Inuit and Métis.
Models of cultural competence highlight the importance of the sociocultural world that is inhabited by patients, and the question of how best to integrate sociocultural factors into clinical assessment and intervention. However, one significant limitation of such approaches is that they leave unclear what type of in-session therapist behaviors actually reflect cultural competence. We draw on the Shifting Cultural Lenses model to operationalize culturally competent in-session behaviors. We argue that a key component of cultural competence is the collaborative relationship between therapists and patients, in which therapists shift between their own cultural lenses and those of their clients, as they co-construct shared narratives together. Accordingly, we propose that culturally competent therapist behaviors include accessing the client’s views, explicitly presenting their own views as mental health care professionals, and working towards a shared understanding. We further specify the latter set of behaviors as including the practitioner’s integration of the patient’s view, their encouragement of the patient to consider their professional view, and the negotiation of a shared view. We developed a coding system to identify these therapist behaviors and examined the reliability of raters across 11 couple and 4 individual therapy sessions. We assessed whether the behavioral codes varied in expected ways over the first 3 sessions of 2 therapists’ couple therapy as well. Operationalizing the behavioral indicators of the Shifting Cultural Lenses model opens the door to the integration of both process- and content-oriented approaches to cultural competence.
(Reprinted from Focus 2015; 13:426-431).
This article reviews the clinical and research literature on the Cultural Formulation Interview (CFI) since its publication in DSM-5. The CFI is an interview protocol designed to be used by clinicians in any setting to gather essential data to produce a cultural formulation. The CFI aims to improve culturally sensitive diagnosis and treatment by focusing clinical attention on the patient's perspective and social context. Preliminary evidence indicates that the CFI can improve clinical communication by enhancing clinician-patient rapport, allowing the clinician to obtain new, cultural data in a relatively short period, eliciting patients' perspectives on what caused their symptoms, and helping patients to become aware of their problems in more insightful ways. With practice, the CFI takes approximately 20 minutes to complete. The CFI has been evaluated internationally in the United States, Canada, Kenya, Peru, the Netherlands, India, and Mexico and generally has been found to be clinically acceptable and useful in these varied settings. Clinicians receiving as little as one hour of training on the CFI improved their ability to work with culturally diverse patients. The CFI may be more difficult to conduct with patients who have severe symptoms, including acute psychosis, suicidal behavior, aggression, and cognitive impairment. The CFI provides a simple way to begin the process of cultural assessment, and its systematic use can foster a reflective stance and promote systemic thinking in routine clinical practice about the patient's life and experience.
Indigenous peoples, immigrants and refugees and racialized groups, as well as some long-established ethnic, linguistic, cultural and religious communities, experience inequities in mental health in Canadian society. These inequities result from social structural determinants of health that are embedded in the cultural knowledge, values and attitudes of the specific group as well as those of the larger society. Culture shapes the experience and expression of mental health problems, modes of coping, pathways to care and the effectiveness of treatment and prevention, as well as the processes of resilience and recovery. Systematic attention to culture in the provision of mental health services can improve access, utilization and health outcomes. We review models to address diversity in mental healthcare and identify key areas in which we believe policy innovation is urgently needed:
For more than 50 years, biological anthropology has argued against the use of the biological race concept. Despite such efforts, aspects of the concept remain in circulation within society and within the discipline itself. As commonly articulated, anthropology's rejection of the biological race concept lacks an evolutionarily based explanatory grounding. Biological patterns of variation in living humans do not map onto commonly utilized categorizations of race, but this knowledge does not explain why human evolution has not produced such structures. This article attempts to offer one such explanation by constructing a biocultural framing of race around ancestry. By examining ancestry through two related lenses, genealogical and genetic, it is shown that the coherence of race as a biological concept has been disrupted by demographic changes in our recent evolutionary past. The biological construction of race is invalid not because it is impossible but because evolutionary forces have actively worked against such patterns in our evolutionary past.
Expected final online publication date for the Annual Review of Anthropology Volume 48 is October 23, 2019. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
The contributions to this issue of Transcultural Psychiatry on cultural concepts of distress show how much work on this topic has evolved and equally what remains to be done. In this Commentary, we take stock of the current state of the field and outline some future directions for research and clinical application.
Minority groups within the United States continuously endure stress placed upon them by the dominant culture. The ongoing stresses of racism, prejudice, and discrimination have lasting and deleterious effects on minorities’ physical and emotional well-being. In this chapter, we provide an overview of the concept of minority stress theory and describe the various sociological and psychological constructs contributing to its development. We then examine the various elements of internalized prejudice, review validated measurement scales used to quantify internalized prejudice in minority populations, and present evidence on the role of internalized prejudice in a number of psychiatric conditions. We discuss the concept of intersectionality and its implications for mental health. At the end of this chapter, we provide clinical recommendations to address the complexities of minority stress theory and internalized prejudice in psychiatric illness.
This book documents the ways that clinical practitioners and trainees have used the “structural competency” framework to reduce inequalities in health. The essays describe on-the-ground ways that clinicians, educators, and activists craft structural interventions to enhance health outcomes, student learning, and community organizing around issues of social justice in health and healthcare. Each chapter of the book begins with a case study that illuminates a competency in reorienting clinical and public health practice toward community, institutional and policy level intervention based on alliances with social agencies, community organizations and policy makers. Written by authors who are trained in both clinical and social sciences, the chapters cover pedagogy in classrooms and clinics, community collaboration, innovative health promotion approaches in non-health sectors and in public policies, offering a view of effective care as structural intervention and a road map toward its implementation.
Structural Competency in Mental Health and Medicine is a cutting-edge resource for psychiatrists, primary care physicians, addiction medicine specialists, emergency medicine specialists, nurses, social workers, public health practitioners, and other clinicians working toward equality in health.
Cultural clinical psychology and psychiatry aim to address the mental health needs of diverse communities by integrating attention to cultural differences in knowledge, social institutions, iden- tities, and practices. These differences affect mental health by influencing the causes and mech- anisms of psychopathology, shaping illness experience and expression, and guiding processes of coping, adaptation, healing, and recovery. Various theoretical models, borrowed from the social sciences, have been used to understand the interaction of culture and mental health and the nature of psychiatric disorders. These models reflect the cultural assumptions of psychiatry itself, and becoming aware of some of these tacit assumptions is essential to open up a space for intercultural work. In this chapter, we will advance an ecosocial approach to culture in mental health in terms of culturally responsive care. This aims to identify crucial dimensions of culture and social context relevant to the lived experience of those with mental health problems and apply that understanding to clinical assessment and interventions.
The DSM-IV Outline for Cultural Formulation (OCF) was a framework for assessment based on principles of cultural psychiatry. The Cultural Formulation Interview (CFI) for DSM-5 provided a tool enabling wider use of cultural formulation in clinical cultural assessment. Validation to justify the inclusion of the CFI in DSM-5 involved quantitative analysis of debriefing interviews of patients and clinicians for feasibility, acceptability and clinical utility. We now further examine qualitative field trial data from the CFI interviews and the debriefing interviews in Pune, India. Administration of the CFI was followed by routine diagnostic assessment of 36 psychiatric outpatients—11 found to have severe mental disorders (SMD) and 25 with common mental disorders (CMD). Domain-wise thematic analyses of the CFI and debriefing interviews identified recurrent themes based on cultural identity, illness explanatory models, stressful and supportive social relationships, and the impact of political, economic, and cultural contexts. A tendency to elaborate accounts, rather than simply name their problem, and more diverse past help-seeking distinguished CMD from SMD groups. Patients valued the CFI more than clinicians did, and most patients did not consider cultural background differences of clinician-patient relationships to be relevant. Qualitative analysis of CFI data and critical analysis of domain mapping of CFI content to the structure of OCF domains indicated the value of revising the dimensional structure of the OCF. A proposed revision (OCF-R) is expected to better facilitate clinical use and research on cultural formulation and use of the CFI.
This book addresses the unique sociocultural and historical systems of oppression that have alienated African-American and other racial minority patients within the mental healthcare system. This text aims to build a novel didactic curriculum addressing racism, justice, and community mental health as these issues intersect clinical practice. Unlike any other resource, this guide moves beyond an exploration of the problem of racism and its detrimental effects, to a practical, solution-oriented discussion of how to understand and approach the mental health consequences with a lens and sensitivity for contemporary justice issues. After establishing the historical context of racism within organized medicine and psychiatry, the text boldly examines contemporary issues, including clinical biases in diagnosis and treatment, addiction and incarceration, and perspectives on providing psychotherapy to racial minorities. The text concludes with chapters covering training and medical education within this sphere, approaches to supporting patients coping with racism and discrimination, and strategies for changing institutional practices in mental healthcare.
Written by thought leaders in the field, Racism and Psychiatry is the only current tool for psychiatrists, psychologists, administrators, educators, medical students, social workers, and all clinicians working to treat patients dealing with issues of racism at the point of mental healthcare.
Trust is a crucial element in the provider–patient relationship. However, trust is eroded when specific racial and ethnic groups systematically experience substandard levels of health care as a consequence of racism, leading to cultural mistrust. This chapter aims to outline potential cultural barriers to mental health utilization among racial and ethnic minorities as a result of cultural mistrust. Strategies are suggested for building a strong therapeutic alliance in spite of differences in provider–patient backgrounds.
The comprehensive lived experiences of lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals of color remain invisible in neurobiological studies of LGBTQ populations. Models of minority stress posit that LGBTQ and Latinx individuals experience and internalize sexual, ethnic, racial, and gender discrimination, which may adversely impact mental and physical health. However, the current minority stress models predominantly focus on single categorical social identities and do not account for interlocking systems and processes of oppression based on features of sexuality, race, ethnicity, sex, and gender , as explained by an intersectionality framework in feminist theory. Thus, it remains unclear how LGBTQ people of color internalize and navigate multiple cultural, institutional, and societal stressors, and, furthermore, how these sources of stress may affect health and well-being. A potential mechanism for this adverse internalization process is through the effects of stress on neurobio-logical regulation. This review will apply an intersectionality framework to the examination of how heterosexism, racism, and cissexism, as systems of oppression , create LGBTQ and Latinx lived experiences, and the differential impacts of these inequalities on neurobiological stress regulation. The overarching goal of this manuscript is to advocate for the application of intersectionality theory to advance the ecological validity of biopsychosocial models of multiple-minority stress.
This article examines the concept of “structural violence.” Originating in the work of Johan Galtung in 1969 and popularized by Paul Farmer, structural violence is increasingly invoked in health literature. It is a complex concept – rich in its explanatory potential but vague in its operational definition and arguably limited in its theoretical precision. Its potential lies in the focus it gives to the deep structural roots of health inequities; in contrast to the more passive term “social determinants of health,” structural violence explicitly identifies social, economic, and political systems as the causes of the causes of poor health. It is also evocative in its framing of health inequities as an act of violence. Yet the formulation of structure used in this literature is largely atheoretical and, by extension, apolitical. Development of the concept hinges on clarifying the precise aspects of structure it points to (perhaps through using the concept in conjunction with larger theoretical frameworks) as well as improving operational definitions to enable its use in quantitative social epidemiology. We argue that the concept of structural violence can provide a useful lens for understanding health inequities, but its full potential is only realized when combined with larger theoretical frameworks.
The comprehensive lived experiences of lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals of color remain invisible in neurobiological studies of LGBTQ populations. Models of minority stress posit that LGBTQ and Latinx individuals experience and internalize sexual, ethnic, racial, and gender discrimination, which may adversely impact mental and physical health. However, the current minority stress models predominantly focus on single categorical social identities and do not account for interlocking systems and processes of oppression based on features of sexuality, race, ethnicity, sex, and gender, as explained by an intersectionality framework in feminist theory. Thus, it remains unclear how LGBTQ people of color internalize and navigate multiple cultural, institutional, and societal stressors, and, furthermore, how these sources of stress may affect health and well‐being. A potential mechanism for this adverse internalization process is through the effects of stress on neurobiological regulation. This review will apply an intersectionality framework to the examination of how heterosexism, racism, and cissexism, as systems of oppression, create LGBTQ and Latinx lived experiences, and the differential impacts of these inequalities on neurobiological stress regulation. The overarching goal of this manuscript is to advocate for the application of intersectionality theory to advance the ecological validity of biopsychosocial models of multiple‐minority stress.
This title is part of American Studies Now and available as an e-book first. Visit ucpress.edu/go/americanstudiesnow to learn more. In the last decade, public discussions of transgender issues have increased exponentially. However, with this increased visibility has come not just power, but regulation, both in favor of and against trans people. What was once regarded as an unusual or even unfortunate disorder has become an accepted articulation of gendered embodiment as well as a new site for political activism and political recognition. What happened in the last few decades to prompt such an extensive rethinking of our understanding of gendered embodiment? How did a stigmatized identity become so central to U.S. and European articulations of self? And how have people responded to the new definitions and understanding of sex and the gendered body? In Trans*, Jack Halberstam explores these recent shifts in the meaning of the gendered body and representation, and explores the possibilities of a nongendered, gender-optional, or gender-queer future.
People with mental illness are often members of multiple stigmatized social groups. Therefore, experienced disadvantage might not be determined solely by mental illness stigma. Nevertheless, most available research does not consider the effects and implications of membership in multiple stigmatized social groups among people with mental illness. Reflecting on intersectionality theory, the authors discuss two intersectional effects determining disadvantage among people with mental illness who are members of multiple stigmatized social groups, namely double disadvantage and prominence. To be effective, interventions to reduce disadvantage experienced by people with mental illness need to be flexible and targeted rather than universal in order to address the implications of intersectionality. Whereas education-based approaches usually assume homogeneity and use universal strategies, contact-based interventions consider diversity among people with mental illness.
Psychiatrists in training launch their careers in a time of inequalities and structural barriers to their patients’ health. Many believe that the uncertain funding and regulation of the US health care system and a frayed social safety net have led to a crisis in mental health care. The United States has fewer mental hospital beds per capita than almost all peer countries, while US suicide rates are at a historic high.¹ Prisons and jails have become the largest provider of “care” of those with severe mental illness. Systemic violence and discrimination based on race, ethnicity, religion, sex, and sexual orientation have increased.² These broader forces not only likely contribute to psychiatric disorders but also make living with these disorders significantly more difficult.
Revisioning Psychiatry explores new theories and models from cultural psychiatry and psychology, philosophy, neuroscience, and anthropology that clarify how mental health problems emerge in specific contexts and points toward future integration of these perspectives. Taken together, the contributions point to the need for fundamental shifts in psychiatric theory and practice: • Restoring phenomenology to its rightful place in research and practice; • Advancing the social and cultural neuroscience of brain-person-environment systems over time and across social contexts; • Understanding how self-awareness, interpersonal interactions, and larger social processes give rise to vicious circles that constitute mental health problems; • Locating efforts to help and heal within the local and global social, economic, and political contexts that influence how we frame problems and imagine solutions. In advancing ecosystemic models of mental disorders, contributors challenge reductionistic models and culture-bound perspectives and highlight possibilities for a more transdisciplinary, integrated approach to research, mental health policy, and clinical practice.
This book examines the deep roots of racism in the mental health system. Suman Fernando weaves the histories of racial discourse and clinical practice into a narrative of power, knowledge, and black suffering in an ostensibly progressive and scientifically grounded system. Drawing on a lifetime of experience as a practicing psychiatrist, he examines how the system has shifted in response to new forms of racism which have emerged since the 1960s, highlighting the widespread pathologization of black people, the impact of Islamophobia on clinical practice after 9/11, and various struggles to reform. Engaging and accessible, this book makes a compelling case for the entrenchment of racism across all aspects of psychiatry and clinical psychology, and calls for a paradigm shift in both theory and practice.
Purpose
This study investigates factors underlying recall of autobiographical memories by considering multiple dimensions of bilingualism (e.g., proficiency, frequency of use), rather than treating it as a monolithic construct. Specifically, we investigated what factors predicted recall of memories in which the language of encoding did not match the language of the task, a recall phenomenon that, by definition, only occurs with bilingual individuals.
Design
Spanish/English heritage bilinguals viewed cue words in English to prompt recall of autobiographical memories and narrated those memories out loud, then stated in what language the original events had occurred.
Data and Analysis
The dataset consists of 18 narratives from each of 37 participants. Mixed-effects models determined which aspects of the heritage bilingual experience predicted recall of memories in which language of encoding and task did not match.
Findings/Conclusions
More frequent use of Spanish and having been born outside the USA predicted more Spanish-language memories retrieved in an English-language task. Interestingly, Spanish proficiency, English age of acquisition, and the type of cue word (object, action, or emotion) did not have effects. Results are discussed in terms of language use and language skill, as well as the importance of considering the specific nature of the bilingual experience.
Originality
This study follows calls to take a multifaceted approach to empirical studies of bilingualism and is innovative in its use of mixed-level models to do so.
Significance/Implications
By analyzing multiple factors that contribute to bilingual experiences, we are able to better state what exactly it is about bilinguals that affects – or does not affect – cognition, including autobiographical memory. The results will allow us to be more precise in advising policy and practice, such as in bilingual education.
Cultural awareness, knowledge, and responsiveness are essential components of person-centered psychiatry. The construct of culture refers to the systems of knowledge, values, institutions, and practices that constitute social systems, including families, communities, and societies. Culture and social context influence the causes of psychiatric disorders by creating identities and social positions that may differentially expose individuals to social stressors including racism, discrimination, and forms of structural violence, as well as to positive social support and resources that promote health, resilience, and well-being. Culture shapes symptom experience, and expression as well as modes of coping and the social response of others in ways that affect the recognition, diagnosis, and treatment of mental health problems. The course and outcome of psychiatric disorders depend on the interplay between culturally mediated processes of individual psychology, family and community dynamics, and relationships with the larger society. In this chapter, we outline current thinking about the role of culture in mental health and illness and review approaches to integrating attention to culture and social context in person-centered care. We discuss some specific tools and strategies for culturally informed assessment and treatment and outline some issues for culturally responsive mental health services, health care policy, and mental health promotion.
Subjective experience is central to person-centered psychiatry for ethical, conceptual, and pragmatic reasons. Experience is central to what is of greatest concern to patients and drives help-seeking, coping, and treatment response. In the case of psychiatric disorders, alterations of experience may be crucial signs and symptoms of illness, indicating the nature of the problem and providing targets for intervention. In this chapter, we consider some of what is known about the nature of the processes of embodiment, interpretation, and enactment that contribute to subjectivity. We discuss phenomenological, cognitive-interpretive, and sociocultural approaches to illness experience. Both the experience and expression of health and illness depend on bodily, psychological, and interpersonal processes of perception, attention, interpretation, coping, and communication. We outline an approach to clinical assessment that gives explicit attention to patients’ experience and values through understanding the meanings of symptoms and suffering in social and cultural context.
Objective: While some studies suggest that men and women report different symptoms associated with depression, no published systematic review or meta-analysis has analyzed the relevant research literature. This article aims to review the evidence of gender differences in symptoms associated with depression.
Methods: PubMed, Cochrane, and PsycINFO databases, along with further identified references lists, were searched. Thirty-two studies met the inclusion criteria. They included 108,260 participants from clinical and community samples with a primary presentation of unipolar depression. All 32 studies were rated for quality and were tested for publication bias. Meta-analyses were conducted on the 26 symptoms identified across the 32 studies to assess for the effect of gender.
Results: The studies indicate a small, significant association of gender with some symptoms. Depressed men reported alcohol/drug misuse (Hedges’s g = 0.26 [95% confidence interval (CI), 0.11–0.42]) and risk taking/poor impulse control (g = 0.58 [95% CI, 0.47–0.69]) at a greater frequency and intensity than depressed women. Depressed women reported symptoms at a higher frequency and intensity that are included as diagnostic criteria for depression such as depressed mood (g = −0.20 [95% CI, −0.33 to −0.08]), appetite disturbance/weight change (g = −0.20 [95% CI, −0.28 to −0.11]), and sleep disturbance (g = −0.11 [95% CI, −0.19 to −0.03]).
Conclusions: Results are consistent with existing research on gender differences in the prevalence of substance use and mood disorders, and of their co-occurrence. They highlight the potential utility of screening for substance misuse, risk taking, and poor impulse control when assessing depression in men. Future research is warranted to clarify gender-specific presentations of depression and co-occurring symptoms.