Cultural Factors in Mental Health

1. Cultural Factors in Mental Health Dinesh Bhugra Professor of Mental Health and Cultural Diversity Institute of Psychiatry, London

2. What the lecture deals with: Overview of culture/cultural competence Culture/beliefs/attitudes of patients Culture/beliefs/attitudes of staff Review of research findings on ethnic disparities Culture and its influences

3. Defining Culture "learned, shared and transmitted values, beliefs, norms and life ways of a particular group that guides their thinking, decisions, and actions in patterned ways." Leininger (1991)

4. Culture Is dynamic Changes subtly over time Can change acutely Culture is integrated People acquire culture. Culture ensures generational continuity. Influences cognitive and social development

5. Culture and mental health Culture affects all aspects of the illness: Generation of symptoms Expression of symptoms Experience of symptoms and coping Help seeking Management of symptoms Some syndromes are unique to some cultures?

6. How does culture influence? Pathogenic (causes symptoms) Pathoselective (affects groups of people in specific ways) Pathoplastic (modifies symptom presentation)

7. How does culture influence? Pathoelaborating (reinforced by culture) Pathofacilitative (some cultures are prone to some disorders) Pathodiscriminating (culture defines deviance)

8. Idioms of distress? Ways in which different cultures express, experience, and cope with feelings of distress. Emotional or psychological Physical symptoms Metaphors Idioms are in keeping with cultural beliefs and traditions and shared within the culture May not match ‘diagnostic criteria’ Example: Somatisation

9. Defining some terms: Ethnicity: Self or social description of belonging to a group – common geographical origins, race, religion Social group: Characterised by distinctive tradition, common history and maintained across generations

10. Defining some terms: Race: Biological inheritance, via genetic material, of a physical characteristic or a physical potential or predisposition. Not useful as a social category. Racism Using race as a variable to indicate superiority-with additional elements of power. Ideology/belief. Superior race “deserves” privileges e.g. health and education.

11. Cultural competence “The ability of individuals to see beyond the boundaries of their own cultural interpretations, to be able to maintain objectivity when faced with individuals from cultures different to their own and to be able to interpret and understand behaviours and intentions of people from other cultures non judgementally and without bias” Walker (1991)

12. Cultural competence Understand the concept of culture and how it can influence: Human behaviour Interpretations of that behaviour Evaluations of that behaviour

13. Cultural competence Demonstrate an openness/willingness to identify and explore one’s own: Cultural base (values, beliefs and attitudes) Emotions and thoughts generated by intercultural interactions

14. Cultural competence Demonstrate an openness/willingness to explore the same things from the perspective of people from diverse cultures Demonstrate the ability to identify useful and culturally appropriate strategies for working with people from diverse cultural backgrounds

15. Cultural competence requires Cultural Sensitivity Cultural Knowledge Cultural Empathy Culturally appropriate Interactions Cultural Awareness (own)

16. Pointers in assessments Place of assessment Mode of presentation of problems Style of assessment Verbal interactions Non verbal interactions Using interpreters Examination and diagnostic methods

17. Cultural formulation: Cultural identity of the individual Beliefs and values Symptoms in cultural context Relationship with the environment Reinforcing factors Distress due to the problems Explanations for the distress Shared understanding of the problems Shared plan for addressing the problems The nature of the interaction

18. Broad typology of cultures! Sociocentric Extended/Joint Family Status Predetermined Strong Social Links Little or no Choice Interdependent Group Advance Tradition Egocentric Nuclear Family Status Oriented Weak Social Links Choice of Partner Independent Individual Advance Newness “Modern”

19. Individual Vs Social role Culture exerts a profound role on human behaviour Personality is essentially a social construct Deviance from normal behaviour Degree of tolerance to deviance Collectivist cultures: interdependent self-identity Individualistic cultures: Emphasis on individual behaviour. More psychopathy?

20. Why? We have an era of increased awareness, globalisation and information? So why is there still a need to improve cultural competency?

21. Reviewing research findings… Psychosis Depression Expressed emotion Family burden Pathways Service use and service satisfaction Health beliefs Coercive treatments Interventions

22. Research into psychosis Major cross-cultural/multi-national studies International Pilot study of Schizophrenia Form of symptoms are similar Better outcomes in less-developed countries for schizophrenia Role of the family? Lack of services?

23. Research into psychosis UK-700 study African Caribbean patients: Have more affective symptoms? Less likely to have continuous disorder Higher suicide rates in younger patients

24. Depression Under diagnosed and under treated worldwide Difficult to classify Differences across cultures Correlates with length of time in UK for migrant populations

25. Expressed Emotion (EE) Strong predictor of relapse in schizophrenia Can be measured using the Camberwell Family Interview (CFI) Also with shorter interview schedules Components include: hostility, critical comments, emotional over involvement, warmth, and positive remarks Differences across cultures?

26. Family burden Cultural differences Under-researched Linked to coping mechanisms/support Differences between nuclear and joint families Several family burden scales available Important to recognize and support carers

27. Pathways to health care More compulsory admissions for black patients in the UK Asian and especially black patients more complex pathways and had higher levels of both involvement with the police and compulsory detention than their white counterparts

28. Health care utilisation Consensus view: minority ethnic groups use less of mental health services Worsens with contact over time Perhaps linked to more adverse contacts? Are the services meeting their needs? More research needed in this area

29. Service satisfaction Second generation Black Caribbean patients, are significantly less satisfied with almost every aspect of the services that they received than either older Black Caribbean patients born in the Caribbean or White patients. More adverse contacts later in the course of illness for black patients

30. Health beliefs Vary in different cultures Locus of control (Internal Vs External) Beliefs in supernatural Health beliefs influence: The types of treatment sought Congruence of models of illness between the patient and the doctor

31. Beliefs about illness causation Supernatural Natural Medical/biological Psychological Social Mixture Is it an evolutionary process?

32. Contacts Poor case recognition by GP (Raine et al, 2000) More complex pathways into care More adverse contacts Less likely to be offered follow up (Virnig et al, 2004) Less case management (Carr et al, 2003) Fewer psychological treatments

33. (Bhui et al, 2003) Meta-analysis of 12 papers on compulsory admission

34. Secure care 3 times more for black patients in Medium secure units (Maden et al, 1999) Compulsory admissions 5.6 times more for Black patients (Coid et al, 2000) 6-8 times more in high secure units (Thornicroft et al, 2005, unpublished)

35. Migration and Acculturation Migration: different types Economic Political Refugees Migrants have higher rates of mental illness Differences in rates of illness across generations The effect of Acculturation and assimilation

36. Pharmacological interventions Low adherence to medication in ethnic minority groups Higher blood levels of anti-psychotics in Asians Lower response rates to treatment Differences in diet, nutrition, body mass and link to substances Differences in use of complementary and alternative medicine

37. Psychological interventions, Most western psychotherapies- ego based Cognitive behaviour therapies: adaptable across cultures Ethnically matching therapists & patients Use of indigenous therapies and their adaptation

38. Culture Bound Syndromes “Recurrent and locality specific patterns of abnormal behaviour and troubling experience that may not be linked to a particular diagnostic category. They are indigenously considered to be ‘illnesses’ or at least afflictions.. and have local names. They are localised, folk, diagnostic categories that frame coherent meaning for certain repetitive, patterned and troubling sets of experiences and observations” DSM IV (American Psychiatric Association)

39. Culture Bound Syndromes Many well described syndromes e.g., Koro, Pikbloto, Amok, Dhat syndrome Increasing globalisation changes patterns Anorexia Nervosa: a CBS? More research into illness characteristics than symptoms needed

40. Interaction settings Outpatient Community/home based Inpatient (open wards) Inpatient (locked wards) Detained under Mental Health Act Forensic situations Psychotherapy settings Other?

41. Therapist qualities Aware of own likes, dislikes, beliefs stereotypes Aware of own identity Ability to be neutral and open-minded Ability to learn about other cultures Awareness that there are differences Tendency to idealise one or other cultures Strengths and weaknesses of own/other cultures

42. Some assumptions: Colour Blindness Assumes minority patient is same. Colour Consciousness All problems are due to minority status. Cultural Transference Patients feelings to do with therapists race. Cultural Counter-transference Therapist feelings to do with patients race. Cultural Identification Minority therapists may over identify. Identification with Oppressor Minority therapists deny their status.

43. Self examination: Do you know your ethnic heritage? Monocultural? Bicultural? Multicultural? What messages do you receive from each cultural group? How do these influence your therapeutic work? How well do you recognise your abilities, strengths and weaknesses? Are you aware of your worldview? discrepancy with the client?

44. The Explanatory Model (Kleinman) How an individual accounts for the distress Some questions: What do you call your problem? What do you think caused your problem? Why do you think it started when it did? What does your illness do to you? How severe is it? How long do you think it will last? What do you fear most about your illness? What treatments do you think you should receive?

45. Non verbal communication Eye contact Facial expressions Gestures Styles of speaking Pronunciation Rate and volume of speech Use (choice) of words Emotional tone of voice

46. Confrontational styles Some cultures openly express anger while some avoid it. May feel threatened by expressed anger May feel confused about lack of reaction May feel unable to deal with the emotion

47. Religion Explains both natural and supernatural Some consider separate part of peoples lives, others Explains attitudes to illness Explains help seeking, folk healing etc. Integral part of many cultures

48. Stereotyping Rigid preconceptions that we hold about all people who are members of a particular group. Passed from generation to generation Impervious to logic and experience Constantly reinforced! Barrier to communication

49. Conclusions Culture and idioms of distress are linked Sensitivity to cultural and spiritual matters is important in engagement There are no universal models of psychotherapy or pharmacotherapy Patients’ and carers’ explanatory models are helpful in engagement

50. Thank you