>> So now we're going to talk about culture and mental illness. And this brings us firmly into North America again because we're going to be talking about it in the context of the Diagnostic and Statistical Manual. When they developed the, the DSM IV culture was definitely on the agenda. The teams working on it at the time asserted that culture is a key concept in assessment and treatment of mental illness. And if you have examined a copy of the DSM, you will see that there is always a recommendation to consider individual cultural setting when trying to make decisions about diagnosis, diagnosis in treatment. Although culture was identified as key in the introduction, there was a lot of kerfuffle about the fact that it only ends up being addressed in the appendices of the manual. That section was divided into two sections, the culture bound syndromes and the cultural formulation. I'm going to start with the cultural formulation. A formulation is a summary of the information gathered in an assessment process. And the cultural formulation was specific to the gathering of information about cultural background. The cultural formulation lists areas that must be taken into consideration when assessing a client that represents, sorry, that presents from a different culture. Now, different, meaning, well we'll talk about what that means. Essentially, the placement of cultural formulation in an appendix with culture bound syndromes communicated that it was something that was not part of typical practice, but for some, something for use when you were dealing with someone with some kind of exotic difference. That's my word, exotic. It's as if there was a large group of people who had no culture and therefore they could be assessed using the bulk of the manual and a smaller group of people who had culture and you could flip to the appendix when one of them showed up. So you can imagine then not everyone was happy with the way that this was approached. The categories of assessment that were included in the cultural formulation were cultural identity of the individual, which is how this person identifies and with whom they would say that they were affiliated, who they would describe as their cultural group. Second, cultural explanations of illness. Any description that they might provide of the problems that they were having, maybe using culturally based idioms of distressed. Cultural levels of psychosocial support which is an indication of what kind of support network this person had within their cultural group. Cultural elements of the patient-physician relationship, which is information about how the patient might respond to a cultural dif, difference between him or her and the clinician. It also could be information about what expectations the patient might have of the clinician based on his or her cultural background. And finally, a catch-all category to capture any other cultural information that might affect diagnosis and treatment. Now these are all important things to consider in the context of mental health care. Some of them speak to the importance of the social context and understanding why someone is ill or how they can get better. Some of them point to recognition of the fact that other cultures have different ways of talking about mental disorder, and we need to understand them in order to communicate effectively. When I say other cultures, I'm talking about cultures outside of North America. And I want to make special note of the inclusion of a category about the client-clinician relationship, because we know that the relationship between a patient and a practitioner is an important part of the healing process. And it's important to understand how that will work best for the patient. However, the problem that many people had with this cultural formulation has already been stated. It was only something that got used to understand the exotic circumstances of exotic patients. The culture bound syndromes were another version of this problem. Culture bound syndromes are disorders that are only seen or, more specifically, only recognized in specific cultural contexts. For the most part, they are presentations that people within the cultural context have seen before, but they are usually not seen anywhere else. A lot of writing about culture bound syndromes locates them within what they call folk medicine. And you'll see that I have not left that with folk, because I am not entirely happy with that word. It's another way of downplaying the importance and sophistication of indigenous methods, in my opinion. It's also worth noting that before culture bound syndromes were included in the DSM, they were mostly known in medical anthropology through their, through the reports of doctors and psychiatrists that were working in colonial outposts. Then, and in the contemporary context, culture bound syndromes come across as reports of the exotic problems of exotic peoples. Here are a few examples. Amok, or running amok, is associated with Southeast Asia, especially Malaysia. And it describes a man erupting into a sudden homicidal rage and going on a killing spree. Ataque de nervios is associated with Latin America and the Care, Caribbean, and it covers a group of behaviors in which a person demonstrates high stress and uncontrolled behavior. And Dhat, which seems to be one of the most commonly discussed cultural bound syndromes from what I can tell, describes an anxiety about semen loss that is seen in India. So I have to admit, I worked on a general psychiatry unit in Toronto, Canada, for ten years. I saw almost everything that's been described in the DSM, but I never saw any of these. But there are many people who think the culture bound syndrome description is unfairly associated with only non-Western populations. There have been many nominations for North American culture bound syndromes, some of which are seen here. For example, until fairly recently, eating disorders were mostly seen only in North America, and they really only emerged in the 1980s, or at least they only started to be recognized in the 1980s. These other things like Type A personality, adolescent rebellion, midlife crisis, PMS, and chronic fatigue syndromes are all things that have been nominated as possibly being bound within the North America, Western cultural context. However, they are becoming more global all the time. So with eating disorders, for example, we are finding those in many other contexts now, some would say because the exportation of North American culture has resulted in the exportation of these and other Western culture bound syndromes to other populations. I am not sure how useful the culture bound syndrome idea is and whether it will make it into DSM V, but I know that something I have found more useful and intriguing is Ian Hacking's idea that there are ecological niches for mental illness. He wrote a book called The Mad Traveler. You have the reference for that in your, in your resource list. So he wrote a book called The Mad Traveler that explores the emergence and then disappearance of fugue states in nineteenth-century Europe. A fugue state is a type of dissociative state in which a person has amnesia for the details of their personal life and wanders or travels to another place and starts a new life that often resembles the old one. Often this fugue state was triggered by some kind of trauma. Now a fugue state still exists as a diagnosis, but they are extremely rare. This is in contrast with a sort of ecide sorry, a sort of epidemic of it in the nineteenth century. This speaks to the point Hacking is making about ecological niches. Using this biological metaphor, he attempts to explain how things come together in a particular time, place, and space to make certain mental disorders appear and be recognized. And when those circumstances are no longer in place, the mental disorders disappear for the most part. So what makes an illness become possible? Well, we have to create a language that gives us a way to describe whatever is happening, and there needs to be some kind of response available once that language is in place and attached to a diagnosis. There also need to be technologies available and social developments in place that make it possible. So let me give you an example that might give you some idea of how this could work. This example comes from the pages of Psychology Today. You also have the reference for this in your list. In this age of worldwide, 24-hour media, we hear all the time about spree killers. In North America, it's becoming alarmingly common to hear about another man who has gone into a public space and killed strangers, often killing themselves afterwards. The Psychology Today article asks, why are virtually all spree killers men? Honestly, the question I would have asked is, why do we have so many spree killers all of a sudden? But yes, it's interesting that they are usually men. Now, if you've been following the recent media surrounding gun control in the U.S., and the law being there has been to bring guns under tighter control, you may have noticed that there is often an argument that the problem is not the guns, the problem is untreated mental illness. But that argument doesn't ring true for me, because there are many people with mental illness and most of them are not spree killers. And not all spree killers have a history of any kind of mental illness. So, why are so many spree killers men? And why does it suddenly seem that we have so many of them? Well, the ecological niche theory would suggest that there is a convergence of circumstances that makes this possible right at this moment. The Psychology Today article spends most of its time talking about one circumstance that may be the contemporary culture of masculinity. It suggests that we currently have a way of thinking about men and manhood that makes things like the loss of face, a rejection, loss of job, all of these things, trigger a homicidal rage. I would add that an econogal, ecological niche is being created for spree killing. It includes having deadly weapons available to a person who has these feelings, and it also includes a worldwide media that sensationalizes these incidents and makes spree killing a way of gaining instant fame. Put that together with this kind of dangerous masculinity that the Psychology Today article is, is talking about, and you create the potential, or the niche, for this type of disordered behavior. And the ecological niche theory would suggest that it won't stop until we do something to destroy the niche. As I've said, I don't know what's going to become of culture bound syndromes in the DSM V, but the cultural formulation is going to have an appearance in some form. The American Psychiatric Association circulated a version of a cultural formulation interview last year that covers many of the same categories that were in the DSM IV formulation. But it actually gives people questions to ask in order to get this information. Part of what is different about this iteration of the cultural formulation is that it's not presented as something that is only used when you think you've got some kind of exotic situation in front of you. There's been, they have been very deliberate in suggesting that this is an interview that is relevant to anyone and applicable to all kinds of culture, not just culture associated with ethnicity or nationality. It is, however, described as a type of deviation from the main diagnostic interview. So it's not certain that this cultural interview is actually integrated part of the diagnostic process they are recommending. Next we're going to take a look at how these issues of culture and mental health and culture and mental illness play out in trying to deal with mental disorder and distress in the global context. We'll be discussing one of the papers that was assigned as a reading this week, social determinants of health among internally displaced persons in Northern Uganda.
