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Related Topics
Cultural Assessment in Clinical PsychiatryReview - Cultural Assessment in Clinical Psychiatry
by Committee on Cultural Psychiatry The Group for the Advancement of Psychiatry
American Psychiatric Press, 2002
Review by Deborah L. Scuglik, M.D.
May 13th 2003 (Volume 7, Issue 20)

Culture, as a ubiquitous aspect of life, allows us to construct our own unique view of the world as individuals and as a part of the larger human drama. Knowledge of this "cultural concept" is especially important in the medical field as a key component of a successful physician-patient relationship. In this book, the authors have all demonstrated expertise in cultural psychiatry as is shown by their impressively researched presentation of how culture intertwines with and affects mental health and illness. In addition, clinical values are well illustrated through consideration of specific cultural variables along with application of DSM-IV-TR guidelines as they are used for cultural formulation of a series of clinical case examples.

The book begins with a historical review of cultural psychiatry and its evolution over the last several decades including the views of Kraepelin in 1904 and followed by the contributions of psychoanalysis described by Freud (1913/1955), dissidents such as Jung and Adler, neo-Freudians such as Horney (1937) and Fromm (1978), and Engel's (1980) biopsychosocial approach to medicine. Modern approaches emphasize ethnographic research regarding cultural variables (Kleinman 1979; Littlewood 1990) with the work of experts in this field leading to a delineation of transcultural psychiatry as a specialized field of study. This chapter reviews essential definitions of culture along with concepts such as race, ethnicity, disease, and illness (Alarcon and Ruiz 1995; Cohen 1961; Kleinman 1988). The authors then move on to describe the model of cultural psychiatry and the five functions of culture developed by Alarcon et al. in 1999 as a frame of reference for this topic, and how these five functions are related to clinical psychopathology. These five factors include an interpretive and explanatory tool of behaviors that may or may not constitute clinical entities, a pathogenic and pathoplastic agent, a diagnostic and nosological factor, a protective and therapeutic instrument, and an element in the management and structuring of clinical services. This is, to me, the most valuable and useful concept of this chapter.

The second chapter not only contains a wealth of invaluable information for those new to cultural studies, but also provides fresh insight and advantageous reorganization of material for those who have already attained expertise in this area. Cultural variables such as ethnicity, gender, sexual identity, age, religion, socioeconomic status, education, and language are examined along with their positive and negative effects on cultural identity. These variables are then viewed within the context of the previously described model of cultural psychiatry including their conceptual relationship with the five functions of culture that influence mental health and illness behaviors.

This chapter also highlights the important concept of heterogeneity within cultural labels or the "cultures within cultures" that can affect clinical perceptions and diagnosis. For example, the cultural label "American Indian" really refers to people from 260 different language groups and various descendants from North Asia to Siberia and Alaska. Although many of these subgroups do have some common characteristics and beliefs, there are also many important differences that need to be recognized to really understand the cultural experience of each person. Another, more global example is illustrated by gender differences of behavior associated with acknowledgment, presentation, or denial of symptoms such as sadness, anger, or pain.

The authors provide a helpful discussion of the acculturation process with the attainment of bicultural competence through a mediation of two cultures. The importance of this concept has been shown by evidence of less acculturation stress associated with attainment of bicultural competence. People can feel comfortable and function effectively in two distinct cultural contexts with integration of elements of both cultures. Understanding of this process and its various maladaptive variants is an essential component of clinical assessment and treatment when addressing mental health issues of immigrant and refuge populations. Evaluating language and working effectively through a translator, ethnocultural dietary influences on behavior and mental illness, and culturally determined variations at the genetic level that may affect medication response and metabolism are also addressed.

The focus of the third chapter is the use of the DSM-IV-TR as a tool for cultural assessment and formulation. This formulation assimilates the patient's cultural identity, cultural explanation of illness, cultural factors in the psychosocial environment, and cultural elements of the relationship between the patient and clinician into a framework that allows the clinician to understand and address the cultural uniqueness of the patient in the treatment plan.

Of course, the most enjoyable section of this book is the presentation of five case studies describing individual patients from various clinical situations. The excellent formulation of these case studies follows the American Psychiatric Association Practice Guidelines for Psychiatric Evaluation of Adults with special emphasis on cultural factors in their lives. Culture is a primary and central piece of the human drama. Case studies are used in this chapter as a wonderful learning tool that allow visualization of a person's life story as a puzzle, with the cultural piece being centrally located and in contact with all other pieces as the puzzle spreads out to a complete picture. If we look at the puzzle with a center piece missing, the picture is incomplete and the puzzle pieces themselves may not fit together as they should. This is the chapter that really brings together the essence of this book and spotlights the expertise of the authors.

The last and final chapter provides an excellent but brief summary of the book content and conclusions.

Academically, I would recommend this book as an excellent resource for psychiatrists and other mental health care professionals. If a reader should so desire, it is not too cumbersome to read as a whole, and it is also organized in a manner that would allow students and professionals to just "dip" into the information more specifically. As an individual actively involved in ethnographic and clinical psychiatric research of immigrant Somali populations, I found the information and organizational style of this book to be validating of my own findings. The authors definitely met their group goal of providing for the advancement of psychiatry with this work.

 

2003 Deborah L. Scuglik

 

Deborah L. Scuglik, M.D., Department of Psychiatry and Psychology, Addiction Psychiatry, Child and Adolescent Psychiatry, Mayo Clinic


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