By , On 4th November 2018 Comments Off on The interaction of culture, diagnosis and treatment

What does my culture mean about my therapy?
Sometimes, we might not realize how our social system directly influences our sense of identity and, subsequently, our own internal dialogue.
Ethan Watters wrote a book called Crazy Like Us: The Globalization of the American Psyche. We will reference it throughout this blog. If you find the topics of this blog interesting, you may find this book interesting as well…

A World Health Organization study on Schizophrenia compared low and high income contexts (1967). An individual who experiences symptoms of Schizophrenia may have delusions, hallucinations disorganized speech, disorganized or catatonic behavior and diminished emotional expression or avolition. The results of this study found a better prognosis hypothesis of participants in low income countries. This means that one is likely to be better off living with symptoms of Schizophrenia in a low- or middle- income country than in a high-income country! The authors concluded that social-cultural conditions should be used to modify long-term course of symptoms of Schizophrenia.
The researchers found that after a five-year follow-up, India had the most success with 42% of Schizophrenia cases reporting “best” outcomes. This was followed by Nigeria with 33% of cases. By contrast, the rich countries performed poorly: “best” outcomes were seen in only 17% of cases in the USA and in fewer than 10% in the other developed nations.

These findings have been subsequently supported with further WHO research with rates of complete clinical remission of 37% in low income countries and 15.3% in high income countries (Leff, Sartorious, Jablensky, Korten and Ernberg, 1992). However, it seems that when one leaves individuals out who are not on antipsychotics, the best prognosis hypothesis vanished (Karagianis et al., 2009). This means that the solution is not only medication or only social support, but an individualized intervention (or treatment plan) with a unique balance of the two which diminishes distress.

Some hypotheses in Ethan Watter’s book illustrates these differences. In Western culture the solicitous nature of the carer leads someone who is experiencing the symptoms of Schizophrenia to feel guilt or shame for acting inappropriately leading to increased stress and illness exacerbation. Ostracism also leads to a sense of rejection in this case. In Zanzibar, which is a Tanzanian culture the symptoms of Schizophrenia are not perceived as a physical or mental issue, but a spiritual one (with which one can identify). If someone who experiences the symptoms of Schizophrenia is having a bad day, they are encouraged to rest. In the case of good days, they contribute to the community engaging in normal activity. This contributes to increased self worth and maintenance of symptoms.

Marsella (2010) also published a study on the ethnocultural aspects of posttaumatic stress (PTSD). Posttraumatic stress can take place when one is exposed to actual or threatened death, injury or sexual violence and can lead to distressing images, avoidance behavior, alterations in mood or cognitive ability and distress which may effect social, occupational or other important areas of function. Marsella wrote that “The concept of culture, its definition, and its developmental socialization process are foundations for understanding the many influences cultural variables have on the perception, experience, clinical expression and treatment responses to trauma.” He names this the “trauma-event-person” ecology model and identifies different factors that shape the outcome of trauma within and across cultures.

When considering posttraumatic stress, although the potential psychic damage of war or natural disaster is indisputable, the process by which that damage becomes an outward symptom is a reflection of the cultural beliefs in a particular time and place. In many aid situations, practitioners import their own culture’s explanatory and treatment models which may disrupt the very real effects of local models of resilience and healing (Watters, 2010).

In a literature review called “Voices of Trauma: Treating Psychological Trauma Across Cultures”  Drozdek & Wilson (2007) found that re-experiencing, hyperarousal and depressive symptoms are similar across cultures however emotional numbing, social withdrawal and other avoidance symptoms are culture specific.

This means that the presentation of mental health symptoms is not consistent across cultures or systems. This means that interventions, or treatment plans, need to be sensitive to this and developed according to an individual’s unique context and needs.

James, Noel, Favorite & Jean (2012) found that individuals participating in an intervention in a post-disaster setting can benefit from evidence-informed Western psychological and local explanatory models of coping mechanisms simultaneously, even if the content is contradictory.

This may, also, be implicated in not only treating, but creating a system for healthy physiological and psychological growth and developent for our children. Conditions for child development may be lacking in relation to the regulation of social behaviors, empathy, and social responsibility. Please see the videos below of Dr. Gabor Mate.

Whether using Cognitive Behavioral or Emotion Focussed Therapy techniques, at TOP Clinic we will look at your internal working model with you while considering your socio-cultural and contextual realities. This allows us to build a new day-to-day dynamic, with you, which aims to decrease your distress and increase your ability to harness your skills.

Please get in touch to schedule a session!

Written by
Lauren Deimling Johns
D.Couns.Psy., C. Couns. Psychol. PsSI.

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