Industrial Psychiatry Journal

: 2008  |  Volume : 17  |  Issue : 1  |  Page : 4--20

Transcultural psychiatry

R Vikash1, S Chaudhury2, S Sukumaran1, AR Singh3, DK Giri4, K Srivastava5, J Prakash6, K Sanger7,  
1 PhD Scholar (Clinical Psychology)
2 Prof & Head, Dept of Psychiatry
3 Prof & Head, Dept of Clinical Psychology
4 Asst. Prof., Dept of Psychiatry
5 Scientist E, Dept of Psychiatry, AFMC
6 Assoc. Prof., Dept of Clinical Psychology
7 Asst. Prof., Dept of Clinical Psychology

Correspondence Address:
R Vikash
PhD Scholar (Clinical Psychology)


During the last half of the century the researchers have placed a great deal of importance on brain behavior relations. This has brought upon a huge body of knowledge but unfortunately at the cost of culture - the true roots of much of our behaviour. This general disregard of cultural factors has not only led to false generalizations but has also blocked the understanding of the real forces that motivate and shape our perceptions, attitudes, and actions. This paper is therefore an attempt to highlight the trajectory of transcultural psychiatry, right from the conceptions of its idea, through flaws in methodology, assessment, treatment and to its future and its limitations.

How to cite this article:
Vikash R, Chaudhury S, Sukumaran S, Singh A R, Giri D K, Srivastava K, Prakash J, Sanger K. Transcultural psychiatry.Ind Psychiatry J 2008;17:4-20

How to cite this URL:
Vikash R, Chaudhury S, Sukumaran S, Singh A R, Giri D K, Srivastava K, Prakash J, Sanger K. Transcultural psychiatry. Ind Psychiatry J [serial online] 2008 [cited 2019 Dec 14 ];17:4-20
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Full Text

The earliest serious links between culture and mental health were pointed out by Ibn Khaldun, an Arab social historian, in the 14th century. Nicolo Conti, a Venetian traveler, gave the first description of a culture bound syndrome i.e. amok in Java. By the sixteenth and seventeenth centuries European writers started hypothesizing not that mental illness might be due to culture, but that cultural change might be due to mental illness (Edgerton, R. 1992).

Emil Kraepelin-Comparative Psychiatry

In the early years of the twentieth century, Emil Kraepelin (1904), the father of modern Western psychiatry, journeyed from his home in Germany to Asia and North America as part of a worldwide lecture tour. During the course of his travels, Kraepelin experienced difficulties diagnosing some patients. He noted that the patients in these lands failed to express their illness with the prototypical symptoms characteristic of his patients in Germany and Northern Europe. Puzzled by this situation, Kraepelin suggested a new specialty within psychiatry be created-'Vergleichende Psychaitrie' or Comparative Psychiatry-to study cultural differences in psychopathology:

In the interim between Kraepelin's early remarks and present times, the study of cultural differences in psychopathology has progressed under a number of names within psychiatry (e.g., transcultural psychiatry, cultural psychiatry, ethnopsychiatry, cross-cultural psychiatry) and related social sciences (e.g., psychiatric anthropology, culture and psychopathology, culture and mental health) (Marsella, 1993).

Within the last few decades, psychiatry and the other mental health professions and sciences (i.e., anthropology, psychology, sociology, public health, and social work) increasingly have acknowledged the critical importance of cultural factors in mental illness. This had led to new conceptual and methodological frameworks that position cultural factors as a major determinant of the onset, expression, course, and outcome of mental disorders. Indeed it was often assumed by those in positions of power and influence that mental disorders were universal in their onset, expression, course, and outcome, and that any variations (e.g., culture-specific disorders such as koro, latah, susto) were simply minor deviations within a prototypic universal disorder (e.g., Marsella, in press, b) even some non-Western psychiatric pioneers accepted this perspective owing, in large part, to their training in Western medical schools and residency programs (Yap, 1951; Leighton et al., 1963).

The "New" culture and mental health

Voices that were long silenced because of their powerlessness within the professional and scientific culture are now speaking out with force and energy. A perfect example of this is the inclusion of the section on culture-bound disorders in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV) (American Psychiatric Association, 1994). This section of DSM-IV came to be included only after some ethnic minority psychiatrists (e.g., Glorisa Canino, Juan Mezzich, Frances Lu, Horacio Fabrega) and a new generation of White transcultural psychiatrists (e.g., Laurence Kirmayer, Arthur Kleinman, Ronald Wintrob) expressed the importance of culture for diagnosis, assessment, and treatment. Using knowledge from the social sciences and the "new" transcultural psychiatry (e.g., Mezzich, Kleinman, Fabrega, & Parron, 1996), changes were made in the DSM-IV, even as those in power continued to resist some recommendations (e.g., Jenkins, 1998).

People with power who rejected evidence of cultural variations for the past few decades, psychiatry has sought to extricate itself from its Freudian heritage and to re-establish itself as a medical specialty. Klerman (1978), a staunch supporter of the efforts to establish psychiatry as a medical profession and science (i.e., Neo-Kraepelinian viewpoint) wrote the credo for the new orientation. Some key points in Klerman's credo include the following: (a) psychiatry is a branch of medicine, (b) there is a boundary between the normal and the sick, (c) There are many discrete types of mental illness, (d) the focus of psychiatric physicians should be particularly (directed toward) the biological aspects of mental illness.

They were doing so because they believed that psychiatry was moving away from its medical roots toward a social science conception of mental illness. Their struggle for identity, purpose, and professional direction was real. Ultimately, those favoring al biomedical orientation for psychiatry won the power positions.

Postmodern views

The emergence of postmodernism and related changes in intellectual thought have taught us in recent years that our realities, including our scientific realities, are all culturally constructed. Knowledge in psychiatry and the social sciences is cultural relative, and as such, it is ethnocentric and biased. What passes for truth is, in fact, a function of who holds the power. Those who are in power (e.g., Western psychiatry) have the "privilege" of determining what is acceptable, and those who are not, are marginalized in their opinion and influence. Similarly, Misra (1996), an Asian Indian psychologist, writes:

The current Western thinking of the science of psychology in its prototypical form, despite being local and indigenous, assumes a global relevance and is treated as a universal mode of generating knowledge. Its dominant voice subscribes to a decontextualized vision with an extraordinary emphasis on individualism, mechanism, and objective. This peculiarly Western mode of thinking is fabricated, projected, and institutionalized though representation technologies and scientific rituals and transported on a large scale to the non-Western societies under political-economic domination. As a result, Western psychology tends to maintain an independent stance at cost of ignoring other substantive possibilities from disparate cultural traditions. Mapping reality through Western constructs has offered a pseudounder-standing of the people of alien cultures and has had debilitating effects in terms of misconstruing the special realities of other people and exoticizing or disregarding psychologies that are non-Western. Consequently, when people from other cultures are exposed to Western psychology, they find their identities placed in question and their conceptual repertoires rendered obsolete.

American Psychological Association Guidelines

It is noteworthy that the study of culture and mental health has greatly matured in recent years, and many new publications provide a substantial theoretical, methodological, and clinical basis for the field. There are a score of readily available general texts (e.g., Al-Issa, 1995; Castillo, 1997; Gaw, 1993; Leff, 1988), and a growing number of specialized research and clinical journals (e.g., Transcultural Psychiatry; Culture, Medicine, and Psychiatry, Cultural Diversity and Ethnic Minority Psychology) that publish rigorous and scholarly articles reflecting the new orientation.

The "new" culture and mental health professional and researcher believes individual and societal mental health are inextricably linked-that we must understand the ecology of mental health. Thus, mental health is not only about biology and psychology, but also about education, economics, social structure, religion, and politics. There can be no mental health where there is powerlessness, because powerlessness breeds despair. There can be no mental health where there is poverty, because poverty breeds hoplessness. There can be no mental health where their is inequality, because inequality breeds anger and resentment. There can be no mental health where there is racism, because racism breeds low self-esteem and self-denigration; and lastly, there can be no mental health where there is cultural disintegration and destruction, because cultural disinegration and destruction breed confusion and conflict.

In brief, the roots of despair, hoplessness, anger, low self-esteem, and confusion reside in the ecological relationships among human biology, psychology, and sociocultural and environment milieus and contexts. This does not mean our biological (e.g., genetics, neurotransmitters) nature is unimportant. Rather, this view repositions biology as one of many interactive determinants of mental health, and it acknowledges the importance of socioenvironmental demands. The "new" culture and mental health professional and researcher must be skilled and adept at diagnosing and treating individual and sociocultural problems within an ecological framework. This will often require him or her to initiate economic, political, and community actions.

The following characteristics are offered as a foundation for the "new" culture and mental health:

It is a worldview.It is committed to diversity.It is committed to social justice and activism.It is concerned with optimizing communication.It is concerned with empowering individuals, groups, and nations.It is concerned with offering hope, optimism, and opportunity.It is multicultural, multidisciplinary, and multisectoral.It is ecological, historical, interactional, and contextual.It is biopsychosocial.It is revolutionary and progressive.

 Overview of Culture and Mental Health Questions, Concepts, and Issues

Some important concepts

1. Ethnocentrism

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, behaviours, 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, in press, a).

2. Culture

An older effort at compiling the different definitions of culture (Kluckhohn & Kroeber, 1952) listed more than 150 different definitions. For current purposes a psycho-behavioural definition of culture used by the senior author for a number of years will be used:

"Shared learned meanings and behaviours that are transmitted from within a social activity context for purposes of promoting individual/societal adjustment, growth, and development." Culture has both external (i.e. artifacts, roles, activity contexts, institutions) and internal (i.e., values, beliefs, attitudes, activity contexts, patterns of consciousness, personality styles, epistemology) representations. The shared meanings and behaviour are subject to continuous change and modification in response to changing internal and external circumstances.

3. Ethnocultural identity

Ethnocultural identity refers to the extent to which an individual endorses and manifests the cultural traditions and practices of a particular group. Clearly, what is important is not a person's ethnicity, but rather, the extent to which they actually are identified with and practice the lifestyle of that group. In groups undergoing acculturation, there can be considerable variation in the extent of ethnocultural identity with a particular cultural tradition. Thus, it is important to determine both a person's ethnicity and their degree of identification with their ethnocultural heritage.

 Cultures as Causative of Psychiatric Disorders

Cultural factors may play an important role in causing psychiatric disorders, via their roles as a stressor, resource/support system, definition and standard of normality/abnormality, and the concepts of self and personhood.

1. Stress and stressors

A cultural context can be a major stressor by confronting individuals and/or groups with demands that exceed their abilities and resources to cope. A typical example of this is the rapid social change that characterizes contemporary life and the serious problems associated with urbanization and urban life styles (Marsella, 1998b) or modernization and change (Sloan, 1996). Other culture related stressors that may play a role in the etiology of mental disorders include racism, acculturation, social change, cultural abuse, and cultural disintegration.

Acculturation is a good example of the kind of stress that may be imposed on an individual or group of people. Acculturation refers to the process that occurs when an individual or group from a given culture in required to adapt and adjust to the cultural worldviews, customs, and traditions of another group. In many instances, the latter culture is a dominant culture in the interaction. Under pressures to conform, comply, and accommodate to the dominant culture's way life, the acculturating individual group may find their own cultural worldviews, customs, and traditions are denigrated, devalued, or denied. Thus, the acculturating individual or group may be left without the cultural anchors that defined their identity and meanings. Sometimes, the acculturation pressures are so great that they provoke burdensome and oppressive patterns of uncertainty, anger, resentment, and despair. The ways of life that had guided people for centuries are now devalued or destroyed. Languages and customs are lost, and children caught in the turmoil of change are often caught between the new and old worlds with resulting anomie and alienation.

2. Resource and support system

Culture may be implicated in the etiology of mental disorders because of the presence of absence of different resources or supports. Resources and supports include such factors as social support systems, effective communication networks, effective leaders, flexible belief systems, and the socialization of effective personality dispositions (e.g., hardiness, ego strength, sense of coherence) (Marsella & Scheuer, 1993). Consider the power of belief. In Islamic cultures, the phrase "Inshallah" If Allah will it" or "It is the will of Allah." This belief is invoked to help explain and accept many life circumstances and difficulties. This, rather than accepting personal or individual responsibility for faiture, a person can instead say "It is the will of Allah." Within the Hindu and Buddhist cultural traditions, the belief in Kharma, or cosmic destiny serves a similar function. Although some in the West may consider this fatalism, the positive functions these beliefs serve suggest it should be called "optimistic fatalism".

3. Standards of Normality/Abnormality

Culture also may influence the etiology of mental disorders by its 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 here is often the balance between tolerance and suppression. Certain cultures insist on absolute conformity while others tolerate high levels of deviancy (Edgerton, 1992). It is essential the mental health professional be alert to cultural variations in normality.

Clearly, a mental health professional must be alert to cultural variations in normality and abnormality; however, they must be able to negotiate the controversial demands that dominant cultural norms place on minority culture members. Killing a young daughter for losing her virginity before marriage in culture A does not mean it must be accepted in culture B. As the Western nations become home to more and more immigrants and refugees from Asian, Middle-Eastern and Latino nations, there are a growing number of problems that are arising regarding value differences such as polygamy, rituals such as clitorectomy, impulse control behaviours, drug and alcohol use, cult memberships, religious rituals promoting particular kinds of altered states of experience, and various indigenous healing methods that conflict with conventional practices.

4. Definition of Selfhood and Personhood

Culture helps shape the etiology of mental disorders by socializing particular patterns of selfhood and personhood (Marsella, 1985; Shweder, 1991). These patterns not only define what is acceptable behaviour, but also influence the types of symptoms that may define an illness (isolation, loneliness, narcissism, dependency, delusions) because of the view of self and person that is promulgated.

 Culture and Methodology in Personality Assessment

Bias in research

Sources of Bias:

In assumptions made for conventional statistical tests interpretation in research designs, in selection and sampling of research participants (Dana, 1998; Okazake & Suo, 1995)Standard Psychological Test

1. Eurocentric Bias

Research bias begins in eurocentric. Eurocentric is a culture specific construction of reality that seeks to provide societal cohesion, solidarity, and survival by developing standards for acquisition of knowledge and establishment of universal or etic laws governing human behaviour. A eurocentric reality assumes that human similarities are greater than human behaviours as primary desiderata for science. This science is motivated by a genuine desire to reduce differences among persons in order to facilitate the development of etic constructs that can be applied worldwide.

A.Sources of research bias

1. Selection and sampling of research participants

The selection and sampling of research participants is dependent upon people definitions that do not degrade samples by over inclusion of non representative participants and/or underinclusion of representative participants. For this, the manner in which the ethinicity of participations is identified is critical. Identification is accomplished b using self reports, or surname without confirmation as well as inclusion of persons with mixed racial and ethic identities.

Also the participants are recruited forcefully or by providing incentives, as such they constitute capturing and non representative population.

2. The matching of groups

When groups are matched, conventional wisdom is used to select a small number of variables instead of a representative away of presumably relevant variables. This identification of these relevant variables was decided historically by fiat. Without adequate matching comparative group research is to unethical by definition because to many groups will be misrepresented or pathologized.

B. Bias is standard psychological tests

MMPI Minnesota Multiphasic Personality Inventory

The MMPI was developed to measure psychopathology constructs as defined in the United States using psychometric technology available during the 1930's (Flelnus, 1993). The nature and specific definitions of these constructs have changed several times over a 60 year period (Castillo, 1996). As a consequence, MMPI interpretation relied or established empirical correlates that made the original diagnostic systems and caueasisn normative sample far less relevant to the clinical application of the instrument" (Hardel, 1999).

Although the test originated as Anglo-American emic, the constructs have been accepted as universal dimensions of psychopathology is spite of research demonstrated cultural differences (Chung, 1996).

To combat this problem, items were translated but no adequate field testing of translations has occurred (Wichols et al. 1999).

Matched cultural group were subsequently were used for comparison of scale scores with test acceptance of less than a five point T- score difference to demonstrate equivalence. However, T-score differences of this magnitude to not necessarily constitute evidence for no differences between groups.

Rorschach Comprehensive System

Exner (1993) described stages in the Rorschach response process that recognize the origins of perceptual styles and their impact upon the response process. These stages are inextricable from cultural elements in personality. First, the initial visual imput and encoding of the inkblot stimulus is culturally determined. Second, the potential response repertoire always has relevance to daily life within a cultural context. Third, implicit norms and values provide selectivity among possible responses as well as censorship or expression of particular responses. Fourth, the language and learned modes of expression contribute to the manner in which responses are articulated.

Rorschachers generally believe that the ink blot determinants have universal meanings, although only the Erlebnistypus, or extraversion-introversion system constructs as defined by movement and colour have received validation from a variety of research approaches (Dana, 1993).

Researchers in many countries were initially puzzled by the impact of norms developed in the United States upon their normal children and adults. Persons believed to have good psychological adjustment were described by RCS variables as unstable and psychopathological. Only Finland (Mattlar and Fried, 1993) and Portugal (Pires, 1999) have developed national norms comparable to U.S. norms. The Portuguese national norms as well as the diverse samples of Rorschach records collected in many countries were all markedly dissimilar from the Exner norms. These dissimilarities included fewer movement and color responses in contexts of equivalent numbers of total responses, more form responses (and particularly many move poor from responses), and an absence of texture responses. These alternations in RCS responses markedly affected a number of ratios and indices of which they were components. RCS studies from many countries strongly suggested that the use of the RCS with multicultural populations in the United States also may be pathologizing. The major discrepancies between Exner norms and norms/ samples collected throughout Latin America, Portugal and Spain, and Northern Europe will be examined for (a) culture-specific meanings of the test situation and interaction with an examiner, (b) the settings used for RCS administration, and (c) sample differences. The very high-inference statements tendered in this chapter should be viewed in the context of these RCS samples and their earlier culture-specific interpretations. The Rorschach inkblots are relatively will known, particularly among middle-class persons who recognize the implicit social expectations for accommodating their responses to the inkblots. In Latin America, by contrast, the test is more novel, anxiety-producing, and lacking specific rules that could lead to an anticipation of what may constitute acceptable responses. All samples collected outside of the United States had less M and less C. Lambda (L) summarizes F responses relative to all other responses and yields approximately 60 for adults in the United States while Lambda is 1.21 in Portugal. X+%, Xu%, and X-% are .50, .12, and .37 in Portugal as contrasted with .79, .07, and .14 in the United States, whereas P responses average 2 less in Portugal in records with equivalent numbers of responses.

Finally, texture (T) is conventionally interpreted in the United States as signifying need for emotional contact with other persons, and no T suggests absence or scarcity of interpersonal resources in childhood. Sum T in Exner norms is 1.03, whereas in Portugal it is .68, and even closer to zero in Latin America. Southern Europe and Latin American have been described as "contact cultures" in which physical contact and interpersonal warmth and shared feelings are characteristic throughout life. No T is these records would be expected without a major disruption in the person's effectual life and frustration of needs for affection.

 Culture-Bound Syndromes, Cultural Variations, and Psychopathology

The term culture-bound syndrome denotes recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category. Many of these patterns are indigenously considered to be "illnesses," or at least afflictions, and most have local names . . . . culture-bound syndromes are generally limited to specific societies or culture areas and are localized, folk, diagnostic categories that frame coherent meanings for certain repetitive, patterned, and troubling sets of experiences and observations. Inaccuracies in the assessment and diagnosis of psychopathological conditions with culturally diverse groups (i.e. overdiagnosis, underdiagnosis, and misdiagnosis) might result from a lack of understanding of the presence of cultural variants leading to symptoms resembling psychopathology. These variables have generally been described in the case of culture specific disorders known as "culture bound syndromes" (Castillo, 1997; Dana, 1993; Dana, 1995; Ivey, Ivey, & Simek-Morgan, 1996; Paniagua, 1998; Pedersen, 1997; Pedersen, Draguns, Lonner & Timble, 1996; Ponterotto, Casas Suzuki, & Alexander, 1995; Smart & Smart, 1997). Smart and Smart (1997), for example, pointed out that the glossary (Appendix 1) of culture bound syndromes included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) "are description of 25 forms of aberrant behavior that are referred to as locality specific troubling experiences that are limited to certain societies or cultural areas" (p. 294). These "locality-specific aberrant experiences," have been given specific names in the cross cultural literature. It was Pow Meng Yap who introduced the term "Culture Bound Syndrome" in 1967 (Levine and Gaw, 1995). The United States National Institute of Mental Health Culture and Diagnosis Group defines it as "recurrent, locally specific patterns of aberrant behaviour and troubling experiences that appear to fall outside conventional Western psychiatric categories" (Mezzich et al., 2000).

However, it should be noted that in case of several disorders, DSM-IV suggest that the particular disorder may resemble one of the culture board syndromes in Appendix-I. But the 'resemble' suggest that in the DSM-IV that disorder is not a culture board syndrome per se.

 Disorders that Resemble DSM-IV Categories (In Alphabetical Order)

I. Anxiety Disorders

1.Panic disorder

Ataques de neruios (hispanics). Association of most ataques with a precipitating event and the frequent absence of the hallmark symptoms of acute fear or apprehension distinguish it from panic attack.

Ode-Qri (Nigeria)


Participation of women in public life is sometimes restricted in some ethnic and cultural group (Arabic countries).

3. Specific phobia

Hisparic culture share fear of spirits, ghosts and witches.

4. Social phobia

In some cultures, social demands may lead to symptoms of social phobia. e.g.

Taijir kyofusho (Japan and Korea)

5. Obsessive-compulsive disorder

Compulsive praying i.e. praying five times a day (Moslems).

Repetition of some words many times during day (India, Israel etc.).

6. Post traumatic stress disorder and acute stress disorder

Ataques de nervios


7. Generalized anxiety disorder Ode-Ori (Nigeria)

II.Attention deficit- Disruptive disorders.


Cultural tempo leads to increase in environmental stimulation leading to significant increase in impulsivity, inattention, and overactivity among individuals exposed to the cultural tempo.

2. Conduct disorder

This disorder might be misapplied to individuals residing in settings (high crime etc) when undesirable behaviours could be considered as protective of immigrant youth.

III. Delusional disorders

Contact of delusion varies. e.g. In hispanic couple, acculturation of the wife of new styles of dressing and the husband's refusal to accept the assimilation of styles by his wife may be misdiagnosed as delusional disorder (Jealous type).

IV. Dissociative disorder

1.Dissociative fugue


V.Mental retardation

Individual's ethnic and cultural behavioural should be taken into consideration during intellectual testing procedures.

VI. Mood disorders

1.Major depressive disorder (Brain fag and Susto)

In some cultures, symptoms of depression are not considered as a case of mental disorder (Castillo, 1997).

Also, the manifestation differs, e.g. Latin American express it as nerves'; headaches'.

Asians and weakness, tiredness, or imbalance. Severity may also be evaluated differently e.g. sadness may lead to less concern than irritability in some culture.

2.Bipolar I and II and cylothynic disorders.

As noted by Castillo (1997) symptoms of hypomania may be culturally accepted e.g. in Hindu culture, engagement in mediatative trances to achieve permanent hypomanic state is sanctioned.

VIII.Personality disorders

1.Paranoid personality disorders

Behaviours influenced by sociocultural contexts or specific life circumstances may be erroneously labeled paranoid e.g. males in swat Pukhtn society (tribal people living in the mountains of northern Pakistan trust no one and distrust the sexual loyalty of all women to the extent of keeping them confined in their homes and are therefore constantly or guard and suspicious of everyone. For this reason, diagnosis of Paranoid personality disorder is not recommended here.

2.Schizoid and schizotypal personality disorder

Defensive, detached from social activities and restricted range of emotions displayed by individuals from different cultural background may be erroneously considered schizoid. E.g. in Hindu culture to be detached and unmoved by good or bad events is considered to be saintly. Cognitive and perceptual distortions associated with religious believes can appear to be schizotypal e.g. Voodoo ceremories, belief in life beyond death, mind reading, evil eye etc. (Campinha Bacote, 1992).

3.Antisocial personality disorder

One should consider the social and economic contact as antisocial behaviour may functions as a protective survival strategy.

4.Borderline personality disorder

Does not represent a culture specific disorder because behaviours as associated with it is found in cultures around the world.

Histrionic personality disorder, norms for personal appearance, emotional expressiveness, and interpersonal behaviour vary widely across cultures. Therefore it is important to determine whether these symptoms cause clinically significant impairment or distress to the individual in comparison to what is culturally expected.

Narcissistic Personality Disorder are common in cultures like swat Pukhtur tripe and Hispanic males for their excessive administration and belief having unlimited power is pervasive.

5. Avoidant and dependent personality disorders

Avoidant personality disorder different culture and ethnic group regard avoidance as appropriate.

Also, symptoms of this disorder may result from acculturation problems associated with immigration.

Dependent personality disorder Appropriateness of dependent behaviour vary across cultures. In addition some cultures may differentially foster these behaviour in females (Paneager, 1998). e.g. Hispanic, Islam, Hinduism.

VII. Pica- Eating seemingly non nutritive substance is considered of value in some cultures (DSM-IV, 1994, pg, 95).

VII. Selective mutism- Immigrant children might refuse to talk to strategies because of unfamiliarity and uncomfort with the new language (DSM-IV, pg, 114).

9. Schizophrenia and other psychotic disorder

Delusional ideas (e.g. Witchcraft), auditory hallucination (e.g. seeing / hearing God's voice) may be abnormal in one culture and normal in other (Castillo, 1997; Kirmayex et al. 1995). This resembles Ode-Ori. Also brief psychotic disorder should be distinguished from culturally sanctioned response patterns and it resembles boufee deliranate.

XI. Sexual Dysfunctions

Certain cultures emphasize male dominance and control or female sexuality whereas some reward the opposite and these variations may affect sexual desire, expectations and attitude about performance.

XII Sleep disorder

1.Nightmare disorder- the importance attached to nightmare differ. Some culture see it as having spiritual/ supernatural influence whereas some view it as indicators of mental or physical disturbance.

2. Sleep disorders related to other mental disorder

Sleep complaints are seen as least stigmatizing in some cultures (Asia) therefore these people, readily come up with it as manifestation for depression.

The history, Current Status, and Future of Multicultural Psychotherapy

At the start of the 1990s, Pedersen (1991) asserted multiculturalisma as the fourth force in psychology. This bold statement positioned multiculturalism for the first time beside the traditional schools of psychoanalysis, behaviorism, and person-centered humanism in the field of counseling and psychotherapy. It also served to legitimize a movement that began in the 1960s and early 1970s when psychologists started to examine the role of culture in the therapy hour (Jackson, 1995). The development and refinement of multicultural psychotherapy has evolved since from the recognition to serve culturally different populations to specific counseling models for these populations. Multicultural psychotherapy is now applicable to all groups of people because individual and cultural differences are integrated into the basic therapeutic philosophy and approach.

I. Cultural considerations in traditional theories

Traditional theories of psychotherapy (e.g., psychoanalysis, cognitive-behaviorism, humanistic-existentialism) historically have received criticism for their lack of sensitivity to cultural diversity. The criticism has centered justifiably on the fact that these theories were developed according to Euro-American and middle and upper-class assumptions of human behavior and well-being (D. Sue & Sue, 1999). The very notion of a talking cure for psychological problem is an excellent example of a Eurocentric value. Other culture-bound behaviours and values that pervade traditional theories of psychotherapy include the intrapsychic etiology for psychological problems sharing intimate feelings and thoughts with a nonfamily member (e.g., therapist), and separation and autonomy from the family. These assumptions mistakenly have been thought to apply to all groups of people, regardless of gender, race, sexual orientation, religion, and physical abilities (Atkinson, Morten, and Sue, 1998). Cultural deviations from these norms of behavior and well-being consequently have been viewed as abnormal or pathological (Szasz, 1970) and not simply a reflection of cultural differences or variations (D. Sue & Sue, 1999). Likewise clients who have not responded to Western-based interventions oftentimes have been viewed as resistance or not amendable to treatment (Draguns, 1989). The theories and models of traditional psychotherapy, however, rarely have been viewed as Eurocentric or insufficient for use across cultural groups (Jackson, 1995).

As the multicultural movement in the field of psychology gained momentum in the United States of America of the 1960s and 1970s, considerations of cultural differences were developed ironically in the context of these existing theories of psychotherapy. Culture for the most part was viewed as a nuisance variable or ancillary to the basic psychotherapy process. Culturally different clients were seen as lacking the appropriate education and cultural sophistication to benefit from psychotherapy. This mistakenly led some therapists who worked with culturally diverse populations to assume a benevolent role as if they were helping the less fortunate. Other therapists recognized the salience of culture in the psychotherapy process, but refused to abandon the traditional psychotherapy paradigm. The responsibility remained with the culturally different clients to adjust to the psychotherapy process, rather than therapists adjusting the models to the needs of the clients.

As the multicultural movement continued to develop and mature in psychology, there was a shift fro the client-as-problem to the therapist-as-problem (Helms, 1990). This perspective recognized that another reason for the lack of success in treating culturally different people was the therapist's own cultural insensitivity and possible racial biases and prejudices. The therapist as a perceived barrier to working with culturally diverse clients remains a salient issue today. D.W. Sue and Sue (1999) state that therapists trained in traditional or mainstream Euro-American models of psychotherapy often hold certain values and assumptions that are distinct from those held by culturally different people. Some therapists may be aware of their own biases and prejudices, but they use this awareness to excuse their inability to work effectively with culturally different clients. Other therapists may recognize cultural differences with clients, but they nonetheless insist that clients maintain a certain degree of psychological mindedness, which is itself a culture-bound characteristic. If clients did not adequately understand the meaning and process of psychotherapy, therapists might educate them about traditional Western-based psychotherapy goals, strategies, and techniques. This education about psychotherapy was and remains a common approach to working with culturally different clients. Yet similar to blaming the victim, it shifts the responsibility from the therapists to the clients. It forces clients to conform to the worldviews of the therapists.

Fortunately, cultural considerations in traditional theories of psychotherapy are increasing without necessarily viewing the client-as-problem or therapist-as-problem. This transition to more culturally responsive forms of traditional psychotherapies remains a work in progress.

A serious consequence of the persistent lack of appropriate cultural considerations in traditional psychotherapy, however, has been the underutilization of mentalhealth services by ethnic/racial minority populations.

Sue et al. (1991) have suggested that a major reason for the underutilization of mental health services is the limited availability of culturally competent psychotherapists and culturally responsive services. Akutsu, Snowden, and Organista (1996), for example, found higher referral and usage rates by ethnic minorities at agencies that were more culturally responsive. This need to better serve culturally different populations have slowly been addressed by scholars, practitioners, and professional governing bodies (American Psychological Associaiton (APA, 1993).

II. Multicultural counseling and supervision competencies

The lack of cultural consideration in traditional psychotherapy and the rising need for culturally responsive services for all people led to a call to the psycholocial professiona in 1982 by D.W. Sue et al. (1982). They argued for a more comprehensive effort to incorporate cultural differences into the field of counseling and psychotherapy. They particularly advocated for the development of multicultural conseling competencies for psychotherapists, since the responsibility to best serve culturally diverse clients rests with the therapist and not the client. Similarly, Cross, Bazron, Dennis, and Issac (1989) advocated that all human service providers need to be culturally competent and, more specifically, share the positive value of cultural diversity, be responsive to the cultural needs of clients, and deliver services in a way that empowers the client.

The multiculturally competent therapist and mental health service provide is characterized by (a) an awareness of one's own assumptions, values, and biases and how they might impact work with culturally different clients, (b) an understanding and respect of the worldviews of clients, and (c) the development of culturally appropriate interventions, strategies, and techniques (D.W. Sue et al., 1982).

D. Multicultural Techniques and Interventions

As this review of multicultural psychotherapy has shown, most approaches rely upon an assortment of techniques and interventions drawn from different theoretical orientations when working with culturally different clients. This eclectic practice has made it more difficult to validate empirically any given multicultural psychotherapy mode. Furthermore, research on the value and effectivness of universal and culture-specific therapeutic strategies is limited and mixed at best. Atkinson and Lowe's (1995) review of multicultural therapy, for example, found moderate support for the use of a directive style of counseling when working with Hispanic/Latino and Asian American populations. They did not find compelling evidence, however, for the use of therapist self-disclosure with culturally diverse populations. Among American Indians, LaFormboise (1992) found moderate support for the use of self-disclosure and chairfication techniques, but found negative reactions to therapist guidance and advice giving. Perhaps most exciting is the potential for incorporating cultural-specific healing models into multicultural psychotherapy. Constantino et al.'s (986) study using Cuento therapy, for example, suggests that use of Puerto Rican Folktales can reduce anxiety, decrease aggression, and increase reading comprehension compared to traditional therapy and no therapy.

Difficulties in Distinguishing Psychopathology from culture related conditions

Time factor - In all mental health science, the overall expectancy is that the first session (45 mins. to 1 hours) would be devoted to the assessment of the case and diagnosis of symptoms whereas the majority of the sessions would be used to treat the disorder. But this is not always feasible Eg. Asians believe that emotional problems being shame and guilt to the family preventing the clients to open up (Pariagua, 1998). It would be difficult to conclude that extreme anxiety of this Asian is 'Koeo' (Chowdhury, 1996).The cultural variable are not emphasized by the practicenours. This is because the current standard clinical ratings and the diagnostic instrument do not require assessment of cultural variable leading to Culture bound syndromes.Reimbursement

 Guidelines to Distinguish psychopathology from Culture Related Conditions

Paniagua (1998) suggests four guidelines

Consultation with family, peers and folk healers within multicultural group.An examination of practiceners over biases and prejudice before engaging in the evaluation of clients who do not share the practiceners race and ethniticity.Preventing the use of the term racism as an explanation of psychopathologyClinicians ability to ask culturally appropriate questions.Therefore clinicians are encouraged to use four V codes when assessing and treating multicultural groups.

Partner Relational ProblemReligious ProblemsAcculturation ProblemParent Child Relational Problem DSM-IV outline for Cultural formulation

A clinician using the DSM-IV would first make a diagnosis of mental disorder and then would consider each category in that formulation to rule out cultural variables that could explain symptoms suggesting psychopathology.

The outline for Cultural Formulation includes the following five categories.

A. Cultural Identity of the Individual

This would include (a) the client's cultural or ethnic preference group, (b) in the case of immigrants, the degree of involvement with the culture of origin versus the host culture, and (c) language use and preference.

B. Cultural Explanation of the Individual's Illness

To be included her are (a) idioms of distress used by the individual to communicate symptoms (e.g., "nerves," "spirits"), (b) the meaning of the severity of the symptoms as perceived by the client in relation to the cultural reference groups, (c) the client's perception of the cause of the problem, (d) and names applied to symptoms within the client's culture.

C.Cultural Factors Related to the Psychosocial Environment and Level of Functioning

Example include (a) interpretation of social stressors in cultural terms and (b) social supports.

D.Cultural elements of the Relationship Between the Individual and the Clinician

Included her are (a) ethnic and racial differences between the client and the clinician, and (b) the negative impact of these differences on the diagnosis and treatment of the client.

E.Overall Cultural Assessment for Diagnosis and Care

In this category, clinicians are advised to conclude with a formulation, including a discussion of how cultural variables influence the diagnosis of the case and care.

Conducting the Cross- Cultural clinical interview using Dana's assessment modal (Dana, 1993)

Cultural competence in conducting a clinical interview is a developmental process. The fundamental basis of developing this competency lies in the respect for others, their ways of life, their religions practices, their worldviews, and their individual autonomy.

Warming up and screening

1.Language: Language should be selected which the patient speaks best, feels most comfortable with, and that can also be understood and spoken by the clinician. This is most notable for minority and for elderly minority patient.

2. Asking culturally appropriate questions:

3. Symptoms Presentation: Manifestation of causal sources may be more common is cross cultural settings because of the recognized tendency among some groups to somatize their distress. Careful attempts need to be made to elicit greater subjective elaboration, for this collateral observation may be needed.

4. Follow-up or Preliminary Impressions: As in all clinical interview perhaps more in cross cultural settings, the clinicians need to attend to their inner mental state. Clinicians should examine themselves for tensions, biases, worries, because these have the potential to interfere with clear clinical thinking. Also certain culture groups tend to stimulate these distracting biases and reaction.

5. Value Differences Impinging the Interview: Patients may belong to communities where traditions have strong influence like their greater emphasis on family ties, strictly defined gender roles, of beliefs in folk explanation for natural phenomenon. It is for the clinicians to not to consider dependency as pathologic to be careful not to impose one's culturally determine notions about self autonomy upon others. This might else push the patient into a more acute and perhaps irresoluble conflict or worsen still may not have a solution at all.

6. Clinicians should handle the religious concerns sensitively

Using the Mental Status Examination in Cultural Context

1.Appearance / Behaviour

Eye contact (Sue and Sue, 2003)Dress/Grroming

2. Speech and language

When assessment of the client's speech is not conducted in the client's first language, the client may speak very softly and exhibit delays in answering questions or suddenly stop talking, not because he or she is experiencing fear, intellectual deficiency, changes in affect/mood, or hallucinations, but because of a language barrier. In addition, the client may not feel comfortable communicating with a clinician whose racial or ethnic background is different from the client's (Sue and Sue, 2003).

3. Thought process

The assessment of thought process is a crucial component of the mental status exam. Clinician should be aware that clients whoa are not fluent in English or Hindi might exhibit thought blocking (a sudden cessation of thought or speech that may be suggestive of schizophrenia, depression, and anxiety; Mueller et al., 1993).

4. General knowledge

The assessment of general knowledge can reveal poor educational back ground, severe deterioration in intellectual functioning, and the ability to access remote memory.

5. Concentration and vigilance/attention

Many researchers have questioned the validity of the test of subtracting 7 from 100 and then continuo subtracting 7 from each answer (Hughes, 1993) many members of the cultural groups. Would fail the task because they are not versed in the skill of counting, whether forward or backward. A culturally sensitive alternative to this task would be for the clinician to determine the client's arithmetic skill level and then ask the client to select two numbers and subtract the smaller number from the larger several times.

6. Orientation / awareness

If the client is asked the name of the current month and he or she does not know the name in Standard English, or is asked where he or she does not know the name in Standard English, or is asked where he or she is at that moment but is not familiar with the name of the hospital or clinic, the practitioner might mistakenly assume that the client is exhibiting negativism, hearing impairment, or receptive language disorders.

Responding to the challenge: mental health professionals for the now

Cultural proficiency is a continuum rather than a dichotomous "all-or-nothing" professional skill or personal quality. One important consideration in training is that course work must be designed to meet the level of competence from which the students or trainees are starting. There are two very useful paradigms in the literature for conceptualizing the levels of cultural competence: (a) the cultural competence continuum, and (b) the three domains of multicultural competence.

A. The Cultural Competence Continuum

Among the most useful tools developed to help one understand and assess cultural proficiency is the cultural competence continuum by Terry Cross (Cross, Bazron, Dennis, & Issacs, 1989), which can be applied to institutions as well as individuals. This paradigm defines six positions along a continuum, ranging from cultural destructiveness on the negative end, to cultural incapacity, cultural blindness, cultural precompetence, cultural competence, and finally cultural proficiency on the positive end. It should be noted that these six levels are not discrete steps.

In sum, the cultural competence continuum is a useful framework for training programs to gauge the needs of their students and trainees and to define realistic learning goals, guiding and encouraging students and trainees to move forward onto the more advanced levels. A training program can also apply this framework for self-evaluation to determine to what extent it is culturally responsive on the institutional level. Finally, we also want to encourage students and trainees to utilize this model as a means to self-exploration and development. It is important to remember that cultural proficiency does not stop with graduation from a training program or with the attainment of professional licensure. It is a life ling learning process that a responsible mental health professional will pursue.

B. Three Domains of Multicultural Competence

The second useful paradigm for cultural competence is presented by a number of authors in the field or multicultural counseling and psychotherapy (Arredondo et al., 1996; Pedersen, 1988; Sue, Arredondo, & McDavis, 1992; Sue et al., 1982), often referred to as "Pedersen's Model of Training." This approach identifies three domains in cultural competence: awareness, knowledge, and skills, These three domains or dimensions can be conceptualized as developmental levels with trainees progressing from one stage to another.

1. Awareness Level

The first stage or domain is awareness, which is also called the beliefs and attitudes dimension. Here, students and trainees develop awareness of their own cultural heritage and values, as well as their negative emotional reactions, preconceived notions, biases, and stereotypes about other ethnic groups. They also learn to respect their clinets' belief, values, and culturally based helping practices (Arredondo et al., 1996; Sue et al., 1992).

One useful activity for the development of awareness it to have students examine themselves via the cultural competence continuum (Cross et al., 1989). This can be done privately and anonymously so that an individual will not feel embarrassed or defensive in exploring and identifying one's position on the scale. Continuum very helpful in identifying their blind spots and helping them set new goals for their cultural competency development.

In addition to reading the literature, direct exposure to minority cultures and communities is also a crucial part of training on the knowledge level. This can be done by organizing visits to community agencies, especially mental health clinics.

Skills Level

The third stage or dimension is skills. Here, students and trainees develop specific clinical skills for assessment, counseling, and psychotherapy with clients from minority cultures. Students find appropriate resources for consultation and referrals for their clients. They also learn to provide intervention at the institutional level (Arredondo et al., 1996; Sue et al., 1992).

The student are ready for 'hands-on" experience. Community agencies are ideal placement sites, as students will have the opportunity to acquire clinical experience while having further exposure to the community (Hong & Ham, 1994). For students and trainees who have difficulty mainstream institutions, such as public schools and college counseling centers, can be an alternative. However, we do encourage students, regardless of their ethnicities, to develop the language skills required for serving the client population they are to work with, as this is one of the competencies at the skills level (Sue et al., 1992).

At the skills level, reflective thinking is a crucial component of the training experience. This is a process that requires deliberate and focused attention on one's thoughts, words, and behaviors as well as their effects in the clinical setting. A number of activities can help students develop skills in reflective thinking, including journal writing, group discussion, case studies, and coaching.

Multicultural issues in treating with HIV/AIDS

Multicultural issues are often classified into two areas: (a) general issues shared by all racial minority clients with HIV/AIDS (Hoffman 1996; Jue & Kain, 1989) and (b) issues specific to the particular racial group (Medrano & Klopner, 1992).

Specific multicultural issues comparison of Hispanic and Asian community

A. Hispanic

Folk Beliefs and FatalismoMachismo and MarianismoPersonalismo As noted above, clinicians with lack of understanding of the significance of machismo and marianismo in the Hispanic culture might just be on the wrong track when suggesting therapeutic interventions from standard textbooks. For example, the general goal of social skill training interventions (Lang & Jakubowski, 1976) is to teach the client to be assertive in his or her expression of feelings, emotions, and behavior. Hispanic women who believe in marianismo and machismo as culturally appropriate values in her community would probably drop out from therapy in those cases when they are told that they will be trained to be "self-assertive" and to "negotiate" safe-sex practices with the assistance of these interventions (Paniagua, 1998).

B. Asians

Shame and Guilt - It may prevent families from reporting or admitting to their problems and might cause to choose between dying in isolation or suffering the rejection of family. This minimizes the role of family and other social supportsSomatic terms for psychological problems

This situation may be problematic in those cases when a clinician suspects that an Asian client is experiencing a severe depression (including suicidal ideation and/or attempts) because of his or her knowledge of having HIV (not AIDS), but the client elects to talk about physical conditions (unrelated to this disease) rather than the depression resulting from having that knowledge. Two approaches have been recommended to handle the expression of mental disorders in somatic terms among many Asians. First, the clinician should acknowledge these somatic complaints and inform the client that medical consultations will be arranged to assess physical disorders reported by the client. Second, the clinician should gradually introduce statements that allow the client to move from verbalizations of somatic complaints to verbalizations involving mental problems. In the case of clients with HIP (but not AIDS), this second recommendation could be enhanced with a brief summary of symptoms suggesting AIDS (e.g., Kaposi's sarcoma, pneumocystis pneumonia, AIDS wasting syndrome; see Kotler & Grunfeld, 1996, and Hoffman, 1996) versus symptoms commonly reported in the general population not infected with HIP (e.g., fever, fatigue, loss of appetite).

3. Confidentiality

Indian client would not answer questions dealing with his or her private life if he or she knows that relatives and friends are working in the clinic or hospital.


The "new" culture and mental health professional and researcher believes individual and societal mental health are inextricably linked that we must understand the ecology of mental health. Thus, mental health is not only about biology and psychology, but also about education, economics, social structure, religion, and politics.

In brief, the roots of despair, hoplessness, anger, low self-esteem, and confusion reside in the ecological relationships among human biology, psychology, and sociocultural and environment milieus and contexts. This does not mean our biological (e.g., genetics, neurotransmitters) nature is unimportant. Rather, this view repositions biology as one of many interactive determinants of mental health, and it acknowledges the importance of socioenvironmental demands. The "new" culture and mental health professional and researcher must be skilled and adept at diagnosing and treating individual and sociocultural problems within an ecological framework.[67][Table 1]


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