Archive for the 'transcultural psychology' Category

Publication: Review of posttraumatic cultural concepts of distress

Although not every human culture would recognize psychological terms as we use them in North America and Europe, every culture has ways of talking about how individuals feel, and every culture has terms that describe extreme and abnormal versions of these feelings. Cultural concepts of distress are those culturally-specific ways that people from within a given group express their psychological distress. For example, Cambodians talk about a khyal attack” as an experience whereby “wind” that flows naturally through the body (akin to chi in Chinese medicine) is blocked from exiting, causing problems that Western psychologists would call symptoms of panic attack (if you’re at all curious, you really should visit the website dedicated to explaining khyal attack).

A couple of colleagues and I recently published a review in Social Science and Medicine of the symptoms that are included in the various ways that different cultures think about the emotional distress following trauma. Our review included 55 studies and identified 116 different cultural concepts of distress. We categorized these concepts based on their symptoms (using hierarchical cluster analysis), and found that the 116 concepts could be described in four basic categories: (1) somatic dysphoria, which largely concerned bodily complaints; (2) behavioral disturbances, “odd” behavior (relative to cultural norms), (3) anxious dysphoria, which as its name implies included lots of anxiety; and (4) depression, which was surprisingly similar to depression as it appears in North American and European medicine. Notably, none of these groups of concepts looked like the psychological disorder that most mental health professionals in North America and Europe think of when they think about trauma — posttraumatic stress disorder, or PTSD.

Of course there are all sorts of limitations to our review, and some would argue that the way we categorized cultural concepts of distress using symptoms alone misses the point of the diversity of these concepts globally (which is broader concerning explanations for distress than it is concerning symptoms). Others would argue that PTSD is actually somewhere in the mix of concepts we reviewed. I’d like to think our review is a starting point for discussion of these issues, rather than a definitive answer to any of these questions.

You can find a link to the publication in Social Science and Medicine here.

Global Mental Health Capacity Building at the 2012 ISTSS Annual Meeting







Looking for graduate school applicants for research in forced migration, trauma and stress at Fordham University

Fall is graduate school application time, as many programs have application deadlines in October, November and December. I have recently moved to Fordham University’s Department of Psychology, and will be looking for graduate student applicants to the Clinical Psychology Division for the 2013 cohort. If you read this blog you know my experience and general research interests, so you know what kind of student researchers I am looking for. Current research projects include comparing the social networks of forced and voluntary immigrants and the health and mental health implications of network differences, measuring trauma and stress in different culturally-defined subgroups, and community-based participatory research with immigrant populations in general. If those are topics that interest you (and you want to get a PhD in Clinical Psychology), follow the links on the Clinical Psychology website and apply.

Deadline for 2013 applicants is Wednesday, December 5, 2012.

If you are not sure you want to commit to a PhD, but know that you are generally interested in psychology, program evaluation and related skills, please visit Fordham University’s MS in Applied Psychological Methods page. Fordham’s APM program is a relatively new course of study that draws heavily on it’s well-respected Psychometrics and Applied Developmental Psychology divisions within the Department of Psychology. Admissions are “rolling,” meaning that you can apply at any time and start the following semester. Students can be full- or part-time.

Proposed DSM-5 Cultural Formulation guidelines: A report from the SSPC

Last week saw the annual meeting of the Society for the Study of Psychiatry and Culture (SSPC) in New York City. SSPC’s mission includes “furthering research, clinical care and education in cultural aspects of mental health and illness,” and although somewhat small includes some of the most prominent thinkers in the world of psychiatry and culture. These are the people who go beyond simplistic cultural diatheses (e.g., individualism versus collectivism), incorporating multidimensional frameworks that include political factors as well as ethnicity and race.

Among the livelier presentations was a report by Roberto Lewis-Fernandez, Neil Aggarwal (both at Columbia), Laurence Kirmayer (McGill), and Renato Alarcón (Mayo Clinic and Universidad Peruana Cayetano Heredia) on much needed updates to the Cultural Formulation guidelines in the upcoming DSM-5. The DSM — Diagnostic and Statistical Manual — is the American Psychiatric Association’s official guidebook to human psychopathology, and the current version, DSM-IV-TR, is largely accepted as the last word on mental health problems in psychiatry, psychology, social work, and related disciplines. Cultural Formulation guidelines are suggestions for how clinicians should conceptualize the role of culture in patients’ mental health problems. The guidelines appeared first in the pages of the DSM-IV (1994), but, along with a short and messy list of “Culture-Bound Syndromes,” were placed in the back of the book where few practitioners would ever find them.

This time around there is a widespread effort to place the Cultural Formulation front and center in the DSM-5. Drs. Lewis-Fernandez and Aggarwal reported on a tool designed to make cultural formulation quicker and easier, the Cultural Formulation Interview, or CFI. The CFI is meant to be administered during patients’ initial assessment, and consists of 14 questions. Many of these questions are just good clinical practice. For instance, the first question is, “What problems or concerns bring you to the clinic?” Although there are hints at what might be considered culture by question three (“People often understand their problems in their own way, which may be similar or different from how doctors explain the problem. How would you describe your problem to someone else?”), it’s not until the seventh question that culture is explicitly mentioned: “Is there anything about your background, for example your culture, race, ethnicity, religion or geographical origin that is causing problems for you in your current life situation?”

The point of framing the questions this way  is to not make a big deal of culture while at the same time getting a good person-centered assessment that considers culture as important to how patients view their problems. This is meant to avoid the stereotyping that considering culture often leads to in situations in which clinician and patient differ on some cultural dimension. The CFI seems to provide space for individuals to define their problems as they see fit — i.e., to make explicit their own explanatory models — and then relate this to how others within their social networks (including family members and those that don’t share their culture) may see their problems.

My favorite exchange came after one audience member looked over the CFI and asked, “For whom would these questions not be relevant?”

Dr. Lewis-Fernandez replied: “Yes, exactly.”

The CFI is currently undergoing field trials. Read more about the proposed DSM-5 Cultural Formulation and the CFI, and express your opinion as to whether it should be emphasized (or not, I suppose), by following this link to the DSM-5 commentary website. Common sense needs advocates.

On a related note: If you haven’t read it yet, Allen Frances’ Op-Ed in Saturday’s New York Times, provocatively titled Diagnosing the DSM, is worth it. In it Dr. Frances, one of the architects of the DSM-IV, argues strongly that the DSM-5 development process should be untethered from professional psychiatry in order to build a better product. A teaser:

Until now, the American Psychiatric Association seemed the entity best equipped to monitor the diagnostic system. Unfortunately, this is no longer true. D.S.M.-5 promises to be a disaster — even after the changes approved this week, it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription. The association has been largely deaf to the widespread criticism of D.S.M.-5, stubbornly refusing to subject the proposals to independent scientific review.

Article supplement: Posttraumatic idioms of distress among Darfur refugees










More from McGill’s Summer Program: The Affliction Film Series

McGill University’s Summer Program in Social and Cultural Psychiatry is not just about the differences between Swedes and Irish. As part of the summer program’s keynote course, Cultural Psychiatry, McGill luminary Laurence Kirmayer includes a number of film clips in the syllabus to give students a chance to observe some of the phenomena that gets diagnosed by psychiatrists using Western psychiatric categories, but may perhaps make more sense by examining the patient’s cultural and historical context.

One of the most striking films shown (so far) comes from Robert Lemelson’s psychiatric anthropology series, Afflictions: Culture and Mental Illness in Indonesia. In “Shadows and Illuminations,” a man presents with visual and auditory hallucinations of Balinese spirits, disorganized behavior and inappropriate dress. His family and neighbors regard him as odd, so it’s not the case that he is just odd to our foreign eyes. Our psychiatric practice tells us to look for schizophrenia. He reports the symptoms began with the death of his daughter, and we think perhaps it is a posttraumatic stress reaction of some sort. He is examined by two traditional healers and a psychiatrist, all of which have their own treatments, but none of which seem to help. Accommodations are made for the man’s behavior in his own home, and he seems to get a little better. Improvement had nothing to do with our diagnosis, or lack thereof.

Each story in the series situates behavior and concepts of illness within the families and societies in which they occur. Not satisfied with biological explanations of these patients’ problems, Lemelson’s films remind us that psychiatric practices have non-psychiatric implications, specifically around family relations, historical meaning-making, and even implications related to the freedom of the individuals with mental health problems.

NIMH, LMICs, & CHIRMH: Funding for global mental health research

Back in March of this year I wrote about Vikram Patel’s call for more international mental health research:


Since then the National Institutes for Mental Health (NIMH) has come up with more than just ominous blog titles. As I was trolling program announcements (“PAs” — the mechanism by which the National Institutes of Health says to researchers what they are really interested in paying for) earlier today I stumbled across several intended to fund research outside of the global North (that’s North America and Europe), or in the language used in these PAs, “LMICs” — “low- to middle-income countries.” Most of these were offered in a variety of funding amounts, from $50,000 to $250,000 (US dollars) per year over 2-5 years.

Here a a few. There’s the basic public health PAR-10-278: Global Research Initiative Program, Basic/Biomedical Sciences, intended to


For neurologists there’s PAR-11-031: Brain Disorders in the Developing World: Research Across the Lifespan, which


There’s even an ethics PA: PAR-10-174: International Research Ethics Education and Curriculum Development Award,


(Not a bad idea for folks in the North involved in international research either, I might add.)

By far the biggest news among these titles is the new RFA-MH-11-070: Collaborative Hubs for International Research on Mental Health (U19). “U series” grants (look at the “U19″ in parentheses at the end of the title) are meant to pay for academic infrastructure — scholarly institutes and centers that produce a lot of research and are thought to be indicators of universities’ general research prowess. Here’s the full “purpose” section:

The National Institute of Mental Health invites applications to establish Collaborative Hubs for International Research on Mental Health (CHIRMH).  This program aims to establish three regional hubs to increase the research base for mental health interventions in World Bank designated low- and middle-income countries (LMICs) through integration of findings from translational, clinical, epidemiological and/or policy research.  Each regional hub is to conduct research and provide capacity-building opportunities in one of six geographical regions (i.e., East Asia and the Pacific; Europe and Central Asia; Latin America and the Caribbean; Middle East and North Africa; South Asia; Sub-Saharan Africa).  The purpose of the CHIRMH program is to expand research activities in LMICs with the goal of providing the necessary knowledge, tools, and sustainable research-based strategies for use by government agencies, non-governmental organizations, and health care institutions to reduce the mental health treatment gap.  The mental health treatment gap refers to the proportion of persons who need, but do not receive care.  As a group, awardees will constitute a collaborative network of regional hubs for mental health research in LMICs with capabilities for answering research questions (within and across regions) aimed at improving mental health outcomes for men, women, and children.

The treatment gap for mental disorders across the world is large and leads to chronic disability and increased mortality for those affected.  Research is needed to identify effective treatment and prevention strategies to close this gap. Mental health research that ultimately enables effective services to preempt, prevent, and treat mental disorders requires both infrastructure and partnerships.  Tackling the urgent challenges of the treatment gap demands effective collaborations among researchers, mental health service users, mental health service providers, and government agencies that will implement and sustain services.  Therefore, a goal of this FOA is to support research partnerships and activities in LMIC settings that will stimulate research to address the prevention and treatment of mental disorders and ultimately increase the evidence base for mental health interventions.

Notably, the PA states that “This program is not intended to support research that can be conducted primarily in and/or by United States or other high income country institutions.” This has the potential to be the start of something big, a US-funded development effort for global mental health. The NIMH is committing $2 million to this effort in 2011, and applicants are eligible for awards up to $500,000 per year for up to 5 years. (Letters of intent are due December 21 and applications due January 21, 2011, for those of you thinking about applying.)

August 2014
« Apr    


Get every new post delivered to your Inbox.