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Course[1].Cross Cultural_Aspects_of_Health_and_Illness.abdo.pptx

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Cross-Cultural Aspects of Health and Illness

Biological ModelThe Biological ContextEvery thought, mood, and urge is a biological eventEvolutionary PerspectiveAdaptation and reproductive successLife-Course PerspectiveAge-related aspects of health and illnessNew Technology

The Biopsychosocial Model

PsychologyPersonalitySelf-EfficacyPersonal ControlOptimismSocial SupportCopingStressHealth BehaviorsBiologyGeneticsPhysiologyGenderAgePredispositionImmune SystemMedicationsCulture/SocialSESEthnicityCultural BeliefsRacism and DiscriminationLiving with Chronic illnessHealth Disease

Definition of CultureEnduring behaviors, ideas, attitudes, and traditions shared by a large group of people and transmitted from one generation to the nextThe lens through which a person sees their world. Culture is an integrated pattern of human behaviorwhich includes: thought, communication, languages, beliefs, values, practices, customs, courtesies, rituals, manners of interacting, roles, relationships, and expected behaviors of a racial, ethnic, religious, social or political group;The ability to transmit the above to succeeding generations; dynamic in nature

Definition of CultureEnduring behaviors, ideas, attitudes, and traditions shared by a large group of people and transmitted from one generation to the nextThe lens through which a person sees their world. Culture is an integrated pattern of human behaviorwhich includes: thought, communication, languages, beliefs, values, practices, customs, courtesies, rituals, manners of interacting, roles, relationships, and expected behaviors of a racial, ethnic, religious, social or political group;The ability to transmit the above to succeeding generations; dynamic in nature

Definition of CultureEnduring behaviors, ideas, attitudes, and traditions shared by a large group of people and transmitted from one generation to the nextThe lens through which a person sees their world. Culture is an integrated pattern of human behaviorwhich includes: thought, communication, languages, beliefs, values, practices, customs, courtesies, rituals, manners of interacting, roles, relationships, and expected behaviors of a racial, ethnic, religious, social or political group;The ability to transmit the above to succeeding generations; dynamic in nature

Definition of CultureWhat is completely healthy and normal in one culture may readily be defined as deviant in another.  Culture and psycho-pathology are inseparable—abnormal behaviors can only be understood within the cultural context in which they occur.This perspective is called CULTURAL RELATIVISMCR postulates that there are cultures so different from the West that they are incomprehensible to outsiders, who therefore cannot translate them into their own terms.

Emic – Etic DistinctionEmic:Refers to approach that deals with the insider’s (intrinsic) view of the culture. It emphasizes differences between cultures . Emicist concentrates on describing the indigenous values of a particular society. Etic: Refers to approach that deals with the outsider’s (extrinsic) view who is not the part of that culture. It emphasizes similarities between culturesEticist applies broader theoretical models across a number of societies.

An Iceberg Concept of CultureDress - agerace/ethnicitygender - languageeye behavior - facial expressionbody language - sense of self concept of justice - value individual vs. group notions of modesty - concept of cleanlinessemotional response patterns rules for social interaction child rearing practicesApproach to decision-making - problem solvingperceptions of mental health, health, illness, disabilitypatterns of superior and subordinate roles in relation to status by age, gender class etc.

Definition of Related TermsRace: Refers to human groupings biologically determined (skin color)Ethnic group: A social group within a large cultural and social system claiming certain behavioral characteristic set them off from mainstream cultureEthnocentric: tendency to judge others by the standards and values of one’s ownIndividualism vs. collective cultureAcculturation Affiliation

Humanistic ApproachNeurosis: Neurotics are those who had been prevented or preventing themselves from attaining their basic needs

Cross-Cultural PsychiatryA branch of psychiatry concerned with the cultural and ethnic context of mental disorder and psychiatric services.Emerged from surveys of the prevalence and form of disorders in different cultures or countries; the study of migrant populations and ethnic diversity within countries; The early literature was associated with colonialism and with either sidelining or denigrating different cultures or ethnic groups.

Objectives of Cross-Cultural Psychiatry Help psychiatrists become aware of the hidden assumptions and limitations of current psychiatric theory and practice.Identify new approaches to classifications of disorders appropriate to different cultures or ethnic groups. Psychiatric illnesses represent social constructs as well as genuine medical conditionsPsychiatric classifications in different cultures, whether: 1) Informal (e.g category terms used in different languages), Or 2)formal (for example the ICD, the APA's DSM, or the Chinese Society of Psychiatry’s CCMD

Outline for cultural assessment The cultural identity of the patient, including ethnicity, involvement with original and host cultures, and language abilitiesThe cultural explanations and idioms of distress used by patients and their community concerning their illness or situationThe cultural factors impacting patients’ social situations, including work, religion, and kin networksThe cultural and social status differences between the patient and clinician that may affect assessment and treatment, including problems with communicating, negotiating a patient-clinician relationship, and distinguishing between normal and pathological behaviorsThe formulation of an overall cultural assessment for diagnosis and care

Outline for cultural assessment (cont.)Traditional tools are based on a standard definition of abnormality and standard set classification.Have little meaning in cultures with varying definitions.The American Indian Depression Schedule Developed to assess depressive illness.Includes items not found in the Diagnostic Interview Schedule and the Schedule for Affective Disorders and Schizophrenia.Researchers have offered guidelines for developing measures.Examine socio-cultural norms of healthy adjustment and culturally based definitions of abnormality.

Outline for cultural assessment (cont.)Cultural backgrounds of therapist and client contribute to perception and assessment of mental health.2 types of errors in making assessments (Lopez, 1989)Overpathologizing: clinician incorrectly judges the client’s behavior as pathological when in fact they are normal in that individual’s culture.Underpathologizing: a clinician explains the client’s behavior as cultural when in fact it is an abnormal symptom.Gender: Diagnosis of Depression

Cultural overgeneralization (CO):Hall (1997) points out that the effectiveness of therapy is limited by ‘cultural overgeneralization’CO occurs when a therapist assumes that client’s presenting problems are related to his or her culture rather than other factorsThis contributed to (racial and ethnic group): - Premature drop out - Underutilization of services

Outline for cultural assessment (cont.)Healthy Cultural paranoiaRefers to the normal (nonpathological) response of African-Americans and other ethnic/racial minorities to oppression and racism. Symptoms:Distrust; suspicion of whites; feeling of being cautious to avoid harmTreatment: Therapist should help patient to bring his/her feelings about whites into conscious awarenessHira Kiri (honorable suicidality)

Developing Diagnostic Systems Across CulturesDiagnostic and Statistical Manual of Mental Disorders (DSM – IV-TR)Adjustments were made to most recent version to include:Incorporating information on how manifestations of symptoms can vary across culturesIncluding 24 culture bound syndromes in the appendixAdding in depth guidelines for including cultural backgroundsHowever, does not require an assessment of cultural elements.

Developing Diagnostic Systems Across Cultures (cont.) …International Classification of Diseases100 major diagnostic categories encompassing 329 individual clinical classifications.Fails to incorporate culture.Chinese Classification of Mental DisordersHas culture specific features that do not exist in international systemsConsidered homosexuality as mental illness till 1998

Cross-Cultural ResearchSomatizationBodily symptoms/complaints as expression of psychological distress.Some studies indicate, certain cultural groups (Hispanics, Japanese, Arabs) somaticize more than Europeans or Americans.However recent studies, indicate that there is not much support that somatization varies across cultures (Kirmayer, 2001).Although previously considered culture specific, it is a universal phenomenon with culture specific meanings and expressions.Conversion Disorder (Sudan vs. United States) Prevalence of CD in rural, low SES, less knowledge about medical and psychological concepts, Executive Functions

Mental health of Ethnic MinoritiesAfrican AmericansReiger et al (1993)Studied over 18,000 adults from five US cities on the prevalence of a variety of disorders.Found that prevalence of mental illness was higher among African American than European AmericanLindsey and Paul (1989)African American more often diagnosed with schizophrenia than European Americans.Differences may be due to SES disparitiesWhen Regier controlled for SES, the prevalence difference disappeared.Differences in misdiagnosis may be due to biases

Mental health of Ethnic Minorities(cont..) Native AmericansFew studies have included this group, but those that have suggest that Depression is a significant problem.Alcohol abuse, and rates of suicide significantly higher than US nationals.MigrantsExperiencing stresses associated with acculturation may lead to poorer mental health (Berry and Sam, 1997)Findings are inconsistentRefugeesMigrants forced to flee from their countries because of political violence, social unrest, war, etc.They report higher rates of PTSD, depression and anxiety.

Mental health of Ethnic Minorities(cont..)Asian AmericansSome studies indicate a higher prevalence of mental disorders than European AmericansHowever, other studies indicate a variation within Asian Americans depending on Ethnic Background, Generational Status, and Immigrant or Refugee StatusI.e. Kuo’s study (1984) found that Korean Americans had higher rates of depression followed by Fillipino Americans, Japanese Americans, and Chinese Americans.

Mental health of Ethnic Minorities(cont..)Latino AmericansFewer differences have been found between Latino Americans and European Americans in rates of psychiatric disorders.Canino et al. (1987) study of Puerto RicansReported similar lifetime and 6-month prevalence rates of disorders compared with there US communities.

Cross-cultural perspectives on abnormal behaviorSocial-cultural perspective. Abnormal behavior is learned within a social context ranging from the family, to the community, to the culture. Cultural variables, acquired through learning and cognitive processes, are believed to be important in producing abnormal behavior.

Culture - bound Syndrome Definition:Culturally Specific SyndromesForm of abnormal behavior found only in certain cultures that may or may not linked to a particular DSM-IV diagnostic category. Indigenously considered to be “illnesses” or afflictions, and most have local names

Examples of Culture – bound Syndrome AMOK – sudden rage and homicidal aggression directed at persons and objects - Found: Parts of Asia (Malaysia, Philippines, Thailand)Precipitated by a perceived slight or insult and seems to be prevalent only among menAccompanied by persecutory idea, automatism, amnesia, exhaustion, and returns to premorbid state Differential diagnosis: Brief psychotic reaction

Examples of Culture – bound Syndrome SUSTO Found in Mexico, Central and Southern America.Related to frightening events that “soul leaves the body and results in unhappiness and sickness”Symptoms:Appetite disturbances; inadequate or excessive sleep; feeling of sadness; lack of motivation to do anythingFeeling of low self-worth or dirtinessSomatic symptoms: muscle aches; headache and stomachache; diarrhea Treatment: ritual healings focus on calling soul back to the body to restore bodily and spiritual balanceDifferential experiences: MDD; PTSD; Somatization

Examples of Culture – bound Syndrome (cont..)BRAIN FAG (brain tiredness) Found in West AfricaUsed by high school and university students in response to the challenges of schooling. Symptoms: difficulty concentrating, remembering and thinkingSomatic symptoms: head and neck pain; pressure or tightness; blurring of vision; heating or burning

Examples of Culture – bound Syndrome (cont.)DHAT:Found in IndiaRefers to severe anxiety and hypochondriacal concerns Symptoms: Discharge of semen, whitish discoloration of urine, feeling of weakness and exhaustion

Examples of Culture – bound Syndrome (cont..)ZARFound in Somalia, Egypt, Sudan, Iran, and other North African and Middle Eastern societiesRefers to the experience of spirits possessing an individualSymptomsDissociative episodes: shouting, laughing, singing, dancing, hitting the head against a wall, weeping, refusing to eat, or involving in excessive drinking of alcoholNot considered pathological locallyDifferential Diagnosis: Histrionic PD

Mal de ojo: Culture specific syndrome and Spanish term for "the evil eye.“ Evil eye occurs as a common metaphor for disease, misfortune, or social disruption throughout the Mediterranean, Latin American, and Muslim world 

Examples of Culture – bound Syndrome (cont..)ANOREXIA NERVOSA and DISSOCIATIVE IDENTITY DISORDER (formerly multiple personality disorder)Found in Western CountriesDID is characterized by:Presence of 2 or more distinct identities or personality states that take control of the behaviorInability to recall important personal informationEach personality is different and has distinct nameIn conflict with each other (name, age, hostility, controlling, self-destructive, etcAsymmetrical amnesia: more passive ID tend to have constricted memories whereas the more hostile, controlling and protector tend to have more complete memory

FATNESS and Thinness: Considered attractiveness in some cultures. Symbol of wealth in the old timeDisease in the present time

Culture and Treatment

Sociocultural Approach to TreatmentExplores how behavior is shaped by history, society, and cultureIt focuses on assessment of the following:Ethnicity: A social and political construct used by individuals and communities to define themselves and others. Ethnicity tends to be based on a common culture, language, or nationhood.Gender issues Lifestyles Income The influence of culture on behavior and the mental process  

Potential solutions Exploring cultural beliefs Building trust: “Some people find it hard to trust clinicians who are not from their culture Addressing communication barriers Addressing religion and spirituality Involving the family Understanding and accommodating differences in treatment preferences

Christina Puchalski MDUS Schools Teaching Courses on Spirituality and Health199220007247

psychotherapyCognitive Behavior TherapyCognitive: examining the rationality or validity of one’s beliefsWhat a person believes is more important than what the person thinks or sees.Cognitive behavioral: the development of strategies for teaching cognitive skills.

Culturally Competent TherapyFor instance, psychoanalytic approaches indicate that problems are derived from unconscious conflicts, Whereas other cultures may view the problem as stemming from physical problems or being out of harmony with the environment

Culturally Based Therapies(cont.)MalaysiaPrayer and religion has been incorporatedChinaUsing Taoist and Confucian principles, which are embedded in psychotherapy (restricting self desires, learning how to be content, etc.)EuropeGroup therapy has been incorporated

Culturally Competent Therapy(cont.)Blending Traditional and Non-TraditionalA patient may need individual counseling but also involve a culturally sanctioned treatment For example: a Religious Healer or Shiekh may be more beneficial (from text) for spiritual treatmentShaman for treating a Native Indian patient