Handbook of Multicultural Mental Health

Assessment and Treatment of Diverse Populations

Freddy A. Paniagua, Ann-Marie Yamada

• Publisher: Academic Press
• Year: 2013
• eBook ISBN: 9780123978127
• Edition: 2
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

The Handbook of Multicultural Mental Health, Second Edition, discusses the impact of cultural, ethnic, and racial variables for the assessment, diagnosis, treatment, service delivery, and development of skills for working with culturally diverse populations. Intended for the mental health practitioner, the book translates research findings into information to be applied in practice.The new edition contains more than 50% new material and includes contributions from established leaders in the field as well as voices from rising stars in the area. It recognizes diversity as extending beyond race and ethnicity to reflect characteristics or experiences related to gender, age, religion, disability, and socioeconomic status. Individuals are viewed as complex and shaped by different intersections and saliencies of multiple elements of diversity.Chapters have been wholly revised and updated, and new coverage includes indigenous approaches to assessment, diagnosis, and treatment of mental and physical disorders; spirituality; the therapeutic needs of culturally diverse clients with intellectual, developmental, and physical disabilities; suicide among racial and ethnic groups; multicultural considerations for treatment of military personnel and multicultural curriculum and training.- Foundations-overview of theory and models- Specialized assessment in a multicultural context- Assessing and treating four major culturally diverse groups in clinical settings- Assessing and treating other culturally diverse groups in clinical settings- Specific conditions/presenting problems in a cultural context- Multicultural competence in clinical settings

Domain I

Foundations-Overview of Theory and Models

Chapter 1 The Study of Culture and Psychopathology

Chapter 2 Culture-Bound Syndromes, Cultural Variations, and Psychopathology

Chapter 3 Cultural Models of Health and Illness

Chapter 4 Indigenous Approaches to Assessment, Diagnosis, and Treatment of Mental Disorders

Chapter 5 Race, Ethnicity, and the Epidemiology of Mental Disorders in Adults

Chapter 6 The Role of the Social Class Worldview Model in the Assessment, Diagnosis, and Treatment of Mental and Physical Health

Chapter 7 Gender Role Conflict and Intersecting Identities in the Assessment and Treatment of Culturally Diverse Populations

Chapter 8 Spirituality and Culture

Chapter 9 Nativity and Migration

Chapter 1

The Study of Culture and Psychopathology

Fundamental Concepts and Historic Forces

Ann-Marie Yamada, School of Social Work, University of Southern California, Los Angeles, CA, USA

Anthony J. Marsella, Department of Psychology, University of Hawaii, Honolulu, HI

I Introduction

Psychological research is assumed to be unbiased as the scientific methods are held to be universal and generalizable across cultures. Psychopathology, however, cannot be studied in a culture-free vacuum, because the “realities” of normal versus abnormal behavior are culturally constructed (Marsella, 1999). When interpreting research findings, it is necessary to have a firm understanding of the standards of normality and abnormality for participants and their culture and especially their particular models of health and illness (Alarcon et al., 2002; Mezzich & Fabrega, 2001; Paniagua, 2001).

This chapter begins by highlighting key terms and concepts central to understanding the role of culture in the expression, course, and manifestation of psychopathology. Next, historic foundations and forces that have advanced research on culture and psychopathology are presented. This review ends with discussion of promising directions for advancing the consideration of culture in research on psychopathology.

II Key Concepts in the Study of Culture and Psychopathology

A Operationalizing Culture and Proxy Variables Representing Culture

1 Culture

If we are to understand the relationship of culture to psychopathology, it is critical that we first understand the concept of culture. Definitions of culture are numerous and varied. More than a half-century ago, Kluckholm and Kroeber (1952) summarized over 125 definitions and more recently their work has been extended through an interdisciplinary review and analysis of 300 definitions of culture (Baldwin, Faulkner, & Hecht, 2006). In the study of psychopathology, a widely used definition of culture by Betancourt and Lopez (1993) refers, not to groups of people, but to the beliefs, values, and rituals that are held within a given ethnocultural group. Lopez and Guarnaccia (2000) offered a definition of culture that is more dynamic and includes “other social forces such as class, poverty, and marginality that work in conjunction with culture to shape people’s everyday lives” (p. 590). Expanding the definition of culture to include these social elements has led to an increase in use of the term “sociocultural” in lieu of using the term “culture.”

While the lack of a standard, widely accepted definition does pose challenges for amassing a coherent body of research, an emphasis has been placed on clearly conceptualizing culture as used in each study, rather than on building consensus for one approach. For current purposes, a psychobehavioral definition of culture used by the authors for a number of years will be used. “Culture is shared learned behavior and meanings that are socially transmitted in various life-activity settings for purposes of individual and collective adjustment and adaptation” (Marsella, 2006, p. 353).

This definition recognizes that culture has shared external (e.g., roles, institutions) and internal (e.g., beliefs, attitudes, values) features that are modified as the situation warrants (Marsella, 2006). In essence, this depiction acknowledges that the meanings and behaviors shaped by culture, in both its external and internal representations, are dynamic and subject to continuous modification and change (Marsella, 2003). Although the impulse is generally toward adaptation and adjustment, it should be noted that cultures can frequently become pathogenic (e.g., Edgerton, 1992) because of the values and the cultural constructions of reality they impart. This definition conceptualizes culture as a lens or filter that influences how a group of individuals interprets and experiences reality (Marsella, 2003). Mental disorders therefore cannot be separated from cultural experience; “…if we define the very nature of what is real, and what is acceptable, and even what is right and wrong, how can we then expect similarities in something as complex as madness?” (Marsella, 1982, p. 363).

2 Ethnocultural Identity

Ethnocultural identity refers to the extent to which an individual endorses and manifests the cultural traditions and practices of a particular group (Marsella & Kameoka, 1989). Clearly, what is important to determining one’s relevant cultural group affiliation is not a person’s race or ethnicity, but rather, the extent to which they actually are identified with and practice the lifestyle of a group or groups. In cultural groups undergoing acculturation, there can be considerable variation in the extent of ethnocultural identity with a particular cultural tradition. Although some individuals may be bicultural, others may be fully acculturated, and still others may maintain a traditional identification. For example, despite a resurgence of ethnic pride and affiliation, some Native Hawaiians consider themselves Hawaiian, some as multiethnic/multiracial reflecting high rates of interracial marriages, and others as “local,” a pan ethnic label referring to persons born in Hawai’i (McCubbin & Marsella, 2009). Thus, it is important to determine both a person’s ethnicity and their degree of identification with their ethnocultural heritage in studying cultural aspects of symptoms and signs of mental disorders.

3 Migration/Immigration

Migration/immigration has long been considered a major influence upon the onset of psychopathology (e.g., Marsella & Ring, 2003). Researchers have speculated about the possibility that migrants may actually be selected for particular forms of disorder or social deviancy and this is reflected in the actual choice to migrate. Yet others have argued that the very best and strongest stock often migrates and that is the stress of the process and of acculturation that is the source of psychopathology. The answer remains in debate. Certainly, if the pressures of migration and acculturation exceed the resources available for coping, then maladaptation and maladjustment may occur.

B Conceptualizing Abnormality and Normality

Diagnosis of psychopathology relies on the ability of the mental health professional to determine that the symptoms and experiences of a patient are considered to be abnormal within their cultural group (American Psychiatric Association, 2000). Culture thus is central to the etiology of mental disorders by providing standards for normality and abnormality. Problems in defining the limits in these areas can lead to serious problems regarding deviancy and conformity. The main issue is often the balance between tolerance and suppression. Certain cultures insist on absolute conformity while others tolerate high levels of deviancy (e.g., Edgerton, 1992). These standards both define what is acceptable, and also set tolerance limits that may promote or discourage eccentricity and deviancy. It is essential the mental health professional be alert to cultural variations in normality. More than a half-century ago, Hallowell (1934) wrote that the cross-cultural investigator must have:

an intimate knowledge of the culture as a whole, he must also be aware of the normal range of individual behavior within the cultural pattern and likewise understand what the people themselves consider to be extreme deviations from this norm. In short, he must develop a standard of normality with reference to the culture itself, as a means of controlling an uncritical application of the criteria he brings with him from our civilization. (p. 2)

Hallowell’s words have contemporary relevance. Determining the abnormality of behaviors, beliefs, and values, however, has grown more challenging, in part given the culturally pluralistic context of our modern world, changes in the manifestation of ethnocentrism, and recognition of the importance of cultural identity in determination of relevant cultural contexts.

1 Culturally Pluralistic World

It is time for Western mental health professionals and scientists to reconsider their assumptions within the culturally pluralistic context of our world. The current world population now exceeds six billion people. Only a small proportion of the world population is of European and North American ancestry, and there has been increasing recognition of the need for cultural relativism in place of universal notions of normality. As Western nations have become home to more immigrants and refugees from Asian, Middle-Eastern, and Latino nations, there have been a growing number of ethical conundrums and legal battles (Foblets & Renteln, 2009) regarding value differences in determining the “abnormality” of such things as polygamy, impulse control behaviors, drug and alcohol use, cult membership, religious rituals promoting particular kinds of altered states of experience, and various indigenous healing methods that conflict with conventional practices (e.g., Edman & Koon, 2000). At the extreme, strong beliefs associated with political and religious fundamentalism may lead to ethnic and religious cleansing, genocide, and torture being perceived as acceptable (Marsella, 2005); clearly these are not considered “normal” by international standards and invoke strong emotions that could challenge the objectivity of any mental health professional. While sometimes related to less dramatic cases, debate over proper use of the “cultural defense” to explain how a defendant was acting “normal” in accordance with his or her view of culturally accepted behavior captures the complexity of colliding cultural views within legal systems worldwide (Dundes Renteln, 2004).

2 Ethnocentrism

Mental health professionals must be alert to cultural variations in normality and abnormality; however, they must also be able to negotiate the controversial demands that dominant cultural norms place on “minority” culture members. Because certain Western nations are the dominant economic and political powers, their cultural tradition—their worldview—exercises a disproportionate influence on views of what is normal and abnormal. Ethnocentrism refers to the natural tendency or inclination among all people to view reality from their own cultural experience and perspective. In the course of doing so, the traditions, behaviors, and practices of people from other cultures are often considered inferior, strange, abnormal, and/or deviant. Ethnocentrism becomes a problem in the field of mental health when certain realities regarding the nature and treatment of mental health are imposed on people by those in power without concern for possible bias (Marsella, 2000a). For example, the dominant culture’s degree of tolerance for activity level in young children may influence mental health professionals’ perception of problem behaviors. Great heterogeneity in rates of ADHD diagnosis and treatment worldwide illustrate the serious consequences of ethnocentric views of illness (Hinshaw et al., 2011). Furthermore, there is great need for mental health professionals and researchers to continue to explore the role of mental health defenses in those cases where a defendant’s behavior meets conventional diagnostic standards of mental illness, except for the determination of cultural acceptance of the actions as within standards of normalcy for the reference cultural group (Hiday & Wales, 2013).

3 Ethnocultural Context

Diagnosing a patient’s manifestation of illness experience as pathological requires knowledge of which particular ethnocultural context is applicable. The DSM-IV-TR (American Psychiatric Association, 2000) guidelines for the cultural formulation of a case list the cultural identity of the individual as the first criteria to be assessed. The DSM-5 cultural formulation has been improved by development of questions to facilitate the cultural assessment (Mezzich, Caracci, Fabrega, & Kirmayer, 2009). Providers may also use available measures of ethnocultural identity that reflect a variety of methods, including...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Dedication
• In Memoriam
• List of Contributors
• Preface
• Domain I: Foundations-Overview of Theory and Models
• Domain II: Specialized Assessment in a Multicultural Context
• Domain III: Assessing and Treating Four Major Culturally Diverse Groups in Clinical Settings
• Domain IV: Assessing and Treating Other Culturally Diverse Groups in Clinical Settings
• Domain V: Specific Conditions/Presenting Problems in a Cultural Context
• Domain VI: Multicultural Competence in Clinical Settings
• Index