Through a Cultural Lens: a different way to understand (and diagnose) our clients

1. Through a Cultural Lens: a different way to understand (and diagnose) our clients Alison Solomon, LCSW

2. “Culture is the collective programming of the mind which distinguishes the members of one group or category of people from another.” Hofstede “We learn about culture primarily not by learning the fact of another’s culture but rather by changing our attitude.” McGoldrick

3. Because the analytic categories of professional psychiatry so fundamentally share assumptions with popular Western cultures… the complaints of patients are viewed as reflecting an underlying pathological phenomenon. From this perspective, culture appears epiphenomenal: cultural differences may exist, but they are not considered essential to the phenomenon itself. However, when culture is treated as a significant variable, for example, when the researcher seriously confronts the world of meaning and experience of members of non-Western societies, many of our assumptions about the nature of emotions and illness are cast in sharp relief. (Kleinman and Good, 1985.)

4. Two Men at the Beach: a story of culture

5. The core of culture is formed by values • Values shape how we feel about things; they have a plus and a • minus side. • Values are among the first things children learn - not consciously, • but implicitly. • Development psychologists believe that by the age of 10, most • children have their basic value system firmly inplace. • Because they were acquired so early in our lives, many values • remain unconscious to those who hold them. • Therefore they cannot be discussed, nor can they be directly • observed by outsiders. They can only be inferred from the way • people act under various circumstances.

6. Hofstedes’ five dimensions of culture Power distance (from small to large ): does my culture say, everyone is important and can influence those in power or, we all have our place in society and most of us can’t effect any kind of change? Collectivism versus individualism: does my culture say, you look out for yourself first, or does it say, first you take care of the group? Femininity versus masculinity: does my culture encourage me to treat people everywhere as equals or does it encourage me to be the best and the strongest? Uncertainty avoidance (from weak to strong): does my culture encourage or tolerate difference and non-conformity, or does it say our culture is the best and things work better when we all conform to it? 5. Short-term versus long-term orientation: which does my culture value more – what I’m doing now, or what I’m going to achieve in the future? Does my culture value saving face over telling the truth?

7. Power Distance • Small power distance: expect and accept power relations that are more consultative or democratic. • Small power distance: People relate to one another more as equals regardless of formal positions. Subordinates are more comfortable with and demand the right to contribute to and critique the decision making of those in power. • Large power distance: those with less power accept power relations that are autocratic and paternalistic. Subordinates acknowledge the power of others simply based on where they are situated in certain formal, hierarchical positions. • Large power distance: no-one thinks all people are equal or should be.

8. Collectivism versus individualism • Individualism: • Ties between individuals are loose. • Everyone is expected to look after him/herself and his/her immediatefamily. • Collectivism: • Ties within extended family are very strong. People from birth onwards are integrated into strong, cohesive groups. • Groups protect the individual in exchange for unquestioning loyalty.

9. Masculinity vs. femininity (also called Quantity vs. Quality of Life) Refers to the value placed on traditionally male or female values (as understood in most Western cultures). Masculine cultures • Value competitiveness, assertiveness, ambition, and accumulation of • wealth. • Differences between gender roles are more dramatic and less fluid. • Unequal role distribution coincides with tougher society. Feminine cultures • Place more value on relationships and quality of life. • Caring for others and being modest are important. • Small is beautiful, better than achieving something big. • No difference between education for girls and boys. No gender roles. • More emphasis on caring and compromise than competition.

10. Uncertainty Avoidance Weak: • One group's truth should not be imposed on others • If rules cannot be respected, they should be changed • Innovative ideas are welcomed or at least tolerated • Loose rules on what is dirty or taboo • Strong: • There is only one truth, and we have it. • If you can’t follow the rules, there’s something wrong with you. • Deviant or innovative ideas are repressed. • Strong rules about what is dirty or taboo

11. Short-term vs. Long-Term Orientation Long Term Orientation values: • Thrift and perseverance; • Hard work and persistence • Children are taught to sacrifice the pleasures of today for the • benefit of their future. Short Term Orientation values: • Respect for tradition, • Fulfilling social obligations • Protecting one's 'face'.

12. Small Group Discussion Understanding where you are on the five dimensions Understanding how you react to those whose way of viewing the world is different than yours

13. What happens to the dimensions in multi-cultural societies like the USA? • There tends to be one dominant culture • Some folks are part of the dominant culture and others aren’t. • Those who are part of the dominant culture have access to power while others don’t. • They are the ones who decide on values – what’s good, what’s not. • This applies to all aspects of society, including the field of psychiatry.

14. A multicultural perspective for clinician diagnosis Four basic reasons for misdiagnosis: • Cultural expression of symptomatology • Unreliable research instruments and evaluation inventories • Clinician bias and prejudice • Institutional racism • *See Solomon, Alison: "Clinical Diagnosis Among Diverse Populations: A Multicultural Perspective." Families in Society, Vol. 73, No. 6, 1992 • Reprinted in: Chapter 25, Assessment, A Sourcebook for Social Work Practice. Milwaukee: Families in Society Press, 1993 • Reprinted in: Questions of Gender: Perspectives and Paradoxes. Ed. Anselmi, Dina and Anne Law. Boston: McGraw-Hill, 1998

15. Because the analytic categories of professional psychiatry so fundamentally share assumptions with popular Western cultures… the complaints of patients are viewed as reflecting an underlying pathological phenomenon. From this perspective, culture appears epiphenomenal: cultural differences may exist, but they are not considered essential to the phenomenon itself. However, when culture is treated as a significant variable, for example, when the researcher seriously confronts the world of meaning and experience of members of non-Western societies, many of our assumptions about the nature of emotions and illness are cast in sharp relief. (Kleinman and Good, 1985.)

16. The kinds of diagnoses that may be affected by cultural symptoms: • Mood Disorders • Anxiety Disorders • Substance-Related Disorders • Psychotic Disorders • Sexual and Gender Identity Disorders • Personality Disorders • Dementia, Amnestic and Cognitive Disorders • Somatoform Disorders… • In other words, most diagnoses actually have cultural components to them!

17. Cultural Expressions of Symptomatology • Depression looks different in different cultures • What’s considered psychosis in Western culture, may not be in another culture • What’s considered “normal” for women is “abnormal” for men and vice-versa • Same symptoms that are considered affective for one group (Caucasians) are sometimes diagnosed as psychotic disorders for another (African-Americans.) • Pathology is missed if it’s a cultural trait (depressed Asian- American child) • Pathology is ascribed when it’s a cultural trait (bouncy ADD African-American child)

18. Unreliable instruments and evaluation inventories: • MSE: Do you ever hear voices that others don’t hear? • Eye contact, blunted affect – can be cultural • BHA: one brief question about culture • Gender bias in psychiatric evaluations • Generalization within ethnic groups: research done on “Hispanics.” • Generalized research done on one population only.

19. Clinician bias and prejudice • Which clients/patients do we prefer? • Language of blame: how does this affect the diagnosis we give clients/patients? • Why are certain patients discharged sooner than others? • Do we understand the effect of language barriers? • Personal bias in diagnosis

20. Institutional Racism • DSMIV – what made it in, what didn’t? • The historical connection between political oppression and mental illness is real. It distorts and disfigures. It limits hopes and futures. • Psychiatry focuses on individual pathology rather than on social, cultural or political realities i.e. diagnosis doesn’t have a social context. • What if Axis IV were Axis I and reimbursable? • What if domestic violence were considered a mental illness? • Who decided that alcohol and substance abuse is a mental illness?

21. Cultural Assumptions, a few examples • Alcohol – Pathology and Criminality in US vs. other cultures. • Open bottle – why is it a crime and who does this discriminate against? • Drinking age – how many other cultures say you’re old enough to go to war and kill someone but not to drink a beer? • Domestic Violence –what if we said that someone who beats up his wife is insane and needs to be hospitalized until he can prove his sanity? • Homelessness – What is society’s obligation to the homeless?

22. What we can do? • Find out about client’s cultural background and how it influences them: • Immigrant-generation status of client • Level of cultural assimilation (monocultural, bicultural, unicultural) • Level of integration within cultural assimilation – isolated, marginal, acculturated • Religious beliefs • Social Class • Reactions to racial oppression • Influence of majority culture • Influence of own culture • Pay constant attention to our own reactions. • Learn as much as we can about various cultures, but never make assumptions that what we know is what is relevant. • Speak up when we see biases (treatment teams, diagnosis, etc.)

23. Eight rules for avoiding racism and humanizing others • The rule of expediency • The rule of humanity • We do it too. • They hate it too. • Go to the Source • Don’t overdo self-abasement • Avoid polarizing • Remember Non-homogeneity