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Culture and Mental Health Final Project

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Forrest Wells

on 13 March 2013

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Transcript of Culture and Mental Health Final Project

Preface 1) For mental health workers to adopt culturally-sensitive viewpoints, they must first accept that the Western model of mental illness is not the only valid paradigm
2) Promoting open-mindedness in Western mental health workers can occur independently of the culture they work in, so I have elected not to choose a specific culture
a) people indigenous to other cultures are better qualified to explain conceptions of mental health in their societies than I am
b) this presentation can be generalized for mental health workers serving in a variety of cultures
3) People generally respond more positively to lessons that fit within their pre-established worldview
a) I believe that the psychiatric staff will be most likely to accept lessons that fit within the Western model of scientific empiricism
b) other viewpoints have merit, but mental health workers will be more willing to change their opinions and practice if given convincing reasons that they are predispositioned to accept
c) powerful arguments for culturally sensitive mental healthcare can be made within the scientific paradigm Culturally Competent Psychiatry:
Observations, Outcomes, and Health Forrest Wells
March 11, 2013 Introduction •Many among the audience have heard psychiatry condemned for a variety of reasons, and although I will touch upon many of the criticisms here, it is not my intention to malign the field or to claim you should forget everything you have been taught

•Rather, I would like to place psychiatry in a broader context and suggest actions and viewpoints that you can adopt within your current practice to increase the quality of the care you provide and to improve your patients’ outcomes Outline 1) Conceptions of Psychopathology
2) Idioms of Distress
3) Culture and Clinical Reality
4) Pitfalls of Psychiatric Diagnosis
5) Alternative Approaches
6) Success Stories Conceptions of Psychopathology (Maddux, Gosselin, & Winstead, 2005) Statistical Deviance Maladaptive Behavior Distress and Disability Social Deviance Harmful Dysfunction Diagnostic and Statistical Manual Social Constructionism Idioms of Distress Culture and Clinical Reality Pitfalls of Psychiatric Diagnosis Summary So Far Alternative Approaches Success Stories Questions? (Watters, 2010) 1) People from different cultures express distress differently
a) they may use different terms to describe the same subjective feelings
b) they may experience distress in fundamentally different ways
c) example: Japanese students describe their equivalent of depression very differently than American students describe depression
2) Acceptable and recognizable ways of expressing psychological suffering are culturally determined and known as idioms of distress
3) Individuals generally express psychopathology with idioms of distress appropriate for their culture, suggesting the concept of a symptom pool:
a) an unconscious collection of symptoms that individuals experience because the symptoms are culturally accepted idioms of distress
b) largely influenced by medical professionals/healers within a culture
c) varies across cultures and over time
d) can change rapidly, and changes will be accompanied by rapid changes in the way patients experience and describe psychological distress
4) Research findings and cross-cultural dissemination of mental illness paradigms can add to the symptom pool
5) Effective psychiatry requires patient and provider to come to consensus on acceptable idioms of distress; psychiatrists shouldn't use their symptom pool to describe a patient's psychopathology (P. Birrell, personal communication, 2013) 1) Culture-based subjective experience
•individuals internalize cultural expectations of how they should react to life events, how their experience should shape their emotions, and so on (tied to concept of symptom pool)
2) Culture-based idioms of distress
•individuals describe suffering in culturally-accepted ways
3) Culture-based diagnoses
•providers describe psychopathology according to their culture of healing
4) Culture-based treatments
•providers propose (and patients accept) culturally-accepted treatments
5) Culture-based outcomes
•patients and providers may view particular outcomes as likely, desirable, and stable depending on what they have been told by their society
•outcomes for similar psychopathologies differ from one culture to the next (Mehl-Madrona, 2010) There are many effective alternative approaches, I choose to focus on three key factors outlined by Mehl-Madrona that I think will be particularly easy to integrate into a traditional psychiatric model:

1) deep listening to the patient's story
a) importance of bracketing/non-judgemental open listening
b) provides patients a sense of validation that may decrease subjective distress
c) gives provider a deeper understanding of the patient's psychopathology
2) facilitating patient empowerment
a) patients more likely to improve if they take an active role in their own treatment
b) "patient as subject" paradigm may cause learned helplessness and social defeat
3) acknowledging the importance of social relationships
a) mental illness stigma can cause social isolation, which in turn decreases quality of life and worsens the mental illness prognosis
b) different types of social relationships often lead to different outcomes
c) interventions that take the patient's social context into account (and utilize close friends and family in treatment) may be particularly effective Concept: psychopathology is statistically significant deviance from normal psychology

1) Definitions of psychological constructs (e.g. impulsivity) are inherently subjective
2) No definitive demarcation between "normal" and "abnormal" for any psychological construct
--or, if a demarcation is made, it will invariably be subjective or arbitrary
3) A certain trait (e.g. extreme intelligence) may be abnormal but beneficial Concept: psychopathology is maladaptive behavior that is ineffective in accomplishing personal goals

1) No clear demarcation between adaptivity and maladaptivity
2) Adaptivity is often situationally dependent
3) No clear connection between maladaptivity and statistical infrequency (e.g. shyness is "maladaptive" yet not rare)
4) acceptable "personal goals" are culturally determined
--i.e., a person's behavior may be very effective at accomplishing personal goals such as mass shootings or bombings, but this person would still be considered mentally ill Concept: psychopathology is subjective distress (undesirable emotions) and disability (inability to accomplish personal goals)

1) Inherently subjective definition
2) No clear demarcation of how much distress/disability is psychopathological
3) Does not account for people who engage in socially unacceptable behaviors without feeling distressed or disabled Conception: psychopathlogy is behavior that deviates from social or cultural norms

1) Social norms are inherently subjective standards
2) No clear demarcation of how much deviation from norms is required to constitute psychopathology
3) Certain traits (e.g. extreme altruism) may deviate from social or cultural norms but still be beneficial and respected
4) Social and cultural norms vary over time and across cultures Concept: psychopathology is a harmful dysfunction
•harmful: culturally-determined value term
•dysfunction: scientifically-determined failure of mental mechanism to fulfill its evolutionary role

1) Difficult or impossible to observe mental mechanisms
2) Cannot determine evolutionary function of many mental mechanisms
3) At best useful for describing scientific consensus on the definition of a mental disorder, but this does not prove the inherent existence of said mental disorder (Wakefield, 1992, 1993, 1997 1999) Conception: psychopathology is a clinically significant syndrome that is associated with distress, disability, or increased risk of negative outcomes; the syndrome must not be a culturally normal response and must contain elements of psychological dysfunction rather than elective deviation from cultural norms

1) Composed of many of the prior definitions, and so contains all of their problems!
2) Categorical rather than dimensional (APA, 2000) "The solution, instead, is to accept that the problem has no solution." (p. 11) Concept: science cannot develop objective definitions of mental illness because psychopathology is a socially-determined construct: each culture collectively decides what is and is not psychopathological

Problem: Some disease processes have psychological symptoms (e.g. Down Syndrome, AMS) and well-understood etiologies; however, most diseases that are considered psychological in nature have poorly understood etiologies and are delineated into arbitrary and subjective categories

Bottom Line: Maybe science will someday be able to definitively categorize mental disorders, but it probably won't be anytime soon 1) Assumes that mental illnesses are discrete, inherently-existing phenomena that can be understood with science, despite the fact that there is little scientific evidence to suggest that this is true
2) Is often associated with social stigma
3) May become a self-fulfilling prophecy: patients may express the symptoms they are expected to express, remain symptomatic if they are expected to have a "chronic" psychiatric disorder
4) May not accurately describe patient's subjective experience, can blind providers to key insights about psychological distress
5) DSM-IV-TR diagnoses are culture-bound! While some categories may apply across cultures, we cannot assume that criteria used to diagnose disorders (or even the disorders themselves) are universal across cultures
--ties back into idea of symptom pool/idioms of distress 1) People from different cultures experience and describe psychological distress differently
2) Current scientific research is inadequate to prove the inherent existence of many mental disorders
3) Psychiatric diagnoses may not represent actual phenomena and can have negative effects

Throw it all away? Not necessarily. Extensive education in Western psychiatry is a double-edged sword: it provides useful insights into psychopathology, but risks blinding providers (and the world!) to the value of alternative paradigms for mental health and the importance of the patient's subjective experience 1) Soteria House
a) nonprofessionally staffed, medication-free treatment for psychosis in a residential context
b) emphasis on building non-intrusive, non-controlling, actively empathetic relationships with clients
c) developed as part of a scientific study to examine its own effectiveness, findings indicate remarkably positive improvements for patients
2) Crossing Place/McAuliffe House
a) similar to Soteria House but with more chronically ill patients and a shorter time-frame
b) more organized, structured, and economically practical than Soteria House
3) The Finnish Psychosis Project
a) fosters a sense of agency in patients struggling with psychosis
b) sees psychotic episodes as inherently valuable as long as they don't cause problems
c) integrates different treatment modalities in a relationship-oriented context

Studies examining these and other alternatives to psychiatric hospitalization and medication have found that the alternative treatments were at least as effective and significantly less expensive than traditional approaches

Bottom Line:
If mental health workers are to provide the highest possible level of care to their patients, they must sometimes break from traditional psychiatric approaches in favor of relationship-based, patient-oriented techniques supported by scientific outcome studies (Mehl-Madrona, 2010)
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