The Culture of Emotions

[00:00:13.00] A variegated tapestry composed of race, ethnicity, and culture permeates each life domain, including those of suffering and health, diagnosis, and the healing arts of medicine and psychotherapy. However they are conceptualized, in art, philosophy, or science neither personality nor human nature, mental health, or mental illness exists apart from culture.

[00:00:58.48] There are two questions which are fundamental to any experience of illness which most physicians do not ask about and most people don't offer an explanation of. The two questions are, why has this happened to me? And the second, why now? If one is going to understand the experience of illness for different people from different backgrounds, one needs an answer to those two questions. The beliefs about why one gets sick when one does, and what are the social circumstances that have contributed to the illness, are the reason for having a cultural formulation.

[00:01:42.30] Culture and locality often influence the way that an individual expresses his or her distress. It often is responsible for a pattern which we refer to as an idiom of distress. This does not always correspond directly to the categories of disorder within the DSM-IV. Therefore, we have to be extremely careful of how we interpret these symptoms in calling them pathological versus understanding what is normal within the context of a particular culture.

[00:02:28.10] Patients of all kinds of cultural backgrounds, every kind of patient, often has some experience of spiritual matters, which comes into play when they get sick. Illness is such an important existential aspect of life.

[00:02:44.58] If you look at the history of research in American psychiatry, the first studies, as related to African Americans and other ethnic groups, show that we were inferior. And there was study after study after study. Then in the '70s, civil rights came along, and all of a sudden you saw no mention of race or ethnicity. It just dropped out, because no one wanted to be un-politically correct.

[00:03:10.77] Now, when you're beginning to get things around psycho-pharmacology and ethnopharmacology, which shows that there are ethnic differences. And so we're back to having the discussion about race and ethnicity as a factor to be considered. But it's brand new as a field of legitimate science. And there's still a lot of concerns about its being used in a negative, destructive manner by people of color.

[00:03:40.15] We're talking about the importance of interaction between culture and biology. And one reason for the interaction is genetics. But in addition to that, now we know that the development of the brain is very much influenced by what's going on in the environment. As a dramatic example of how the brain is influenced by the environment, recent research show very clearly that if somebody experiences early childhood trauma, then later on in their adult life, the brain structure is clearly very different, and that increases the person's risk of developing psychiatric problems, including major depression, chronic depression.

[00:04:37.01] We tend to see seasonal changes with increasingly northern latitudes, so that, for example, in Washington, DC area, about 28% of the population experiences some sort of seasonal change, perhaps not depression, but fatigue or carbohydrate craving or sleepiness. When you go up to Boston, this percentage of the population goes up to 43%, and in Anchorage, Alaska, it's nearly 2/3 of the population.

[00:05:09.26] Personality results from a concurrence of different factors. To begin with, we all must accept that there is a what we may call genetic neurobiological background that creates sort of a model or a template on which environmental factors accommodate themselves, play a role, and create personality. Those environmental factors include what we call social and cultural, particularly cultural ways of influencing the formation of personality.

[00:05:57.48] Many people of color, in particular African Americans, have experienced oppression, discrimination, and racism. Those kinds of environments actually have a direct impact on behavior. It is, in fact, the case-- and it has been documented-- that people who feel oppressed often have feelings of powerlessness, often withdraw, sometimes have angry outbursts targeted at their oppressors and sometimes targeted at themselves.

[00:06:30.07] If one goes back to the 1930s, anthropologists often believed that every society had its own unique constellation of mental illnesses. Over against that developed a notion that there are universal biological diseases. What's really become increasingly clear is that every disease, every psychiatric condition, is both biological to the core and cultural to the core.

[00:06:57.40] The need to pay attention to cultural issues in diagnostic systems basically comes from the fact that culture informs life, health, the emerging of health problems, and how we deal with them. But more specifically, one could say that the growing multiculturality of American cities and population in general, as well as the maturity of anthropological research in the past decade, has made possible to develop the tools that would be pertinent to this endeavor.

[00:07:39.10] Of importance to citizens is the fact that when they go to a hospital or a clinic that is supported by public funds-- when I say public funds, I mean funds that come from the federal government, not necessarily state government-- that there is a requirement that that facility provide, if necessary, translation services, interpreters, so that the individuals who come for care within that setting have it available to them in a way that they can understand it and comprehend what's going on.

[00:08:44.62] The DSM-IV Outline for Cultural Formulation appears in the Diagnostic and Statistical Manual, Fourth Edition, published by the American Psychiatric Association in 1994. It provides a concise clinical tool for clinicians and mental health professionals to help them use the DSM-IV diagnostic system in a culturally competent way with culturally diverse individuals.

[00:09:16.66] The outline for cultural formulation contains five sections involving, first of all, the cultural identity of the individual, secondly, the cultural expressions and explanations of illness. Third are the cultural elements of stressors and supports in the person's environment. Fourth are the cultural elements of the relationship between the individual and the clinician, and lastly, the overall assessment for diagnosis and care.

[00:09:59.08] The first part of the outline asks the clinician to assess the cultural identity of the individual. Now in the DSM-IV outline itself, there's specific reference to ethnicity, biculturality, involving acculturation, and language. However, we must include other elements related to cultural identity such as age, gender, sexual orientation, religious and spiritual beliefs, disabilities, class, amongst other factors.

[00:10:38.74] In ethnic identity we find that people have a group consciousness, which is historically rooted. So the notion of affiliation of membership is derived from historical circumstances, not contemporary ones. So a labor union is not an ethnic group. But a group that believes it descended from a particular population that came down from the mountains 5,000 years ago, that's an ethnic group. So there is this historical orientation that separates ethnic identity from other group identities that is very, very salient.

[00:11:12.83] As an African American woman professional in this country, I think the issue of race and ethnicity is an important one for African Americans. The complexity of finding a level of comfort with one's racial identity is one that can certainly be challenged along the whole life spectrum. Certainly as a child, even in elementary school, children will come home and notice that there are differences, and how valuable are those differences? Because they're not the same, does it mean that they're less intelligent? Does it mean that they can't play with certain children because they're different? These are issues that come up with children all the time.

[00:12:06.73] If you look at African American people in the States, for example, in New Orleans, there is a French flavor there. If you go to New England, you'll find African Americans who have family histories where there was never any slavery, for example. If you go to Oklahoma, you'll find African Americans are very intermarried with Native American and Euro-American. If you go to places like Chicago and Detroit, you'll find urbanized African Americans who don't-- who are sort of middle of the road in everything.

[00:12:44.80] So there are a lot of differences. If you go to Georgia, you'll find African Americans who are very much tied into west coast Nigerian culture, and in fact, their burying rituals are just like west coast Africa, as is their language.

[00:13:02.05] The term Hispanic or Latino in the US has important political as well as cultural meaning. Latinos do share a significant number of cultural factors in common. But they also have tremendous differences between them. It's not the same to be an Argentinian from Buenos Aires than it is to be an agricultural worker from Central Dominican Republic.

[00:13:33.65] There's two primary groups of elderly that we have to consider. One are the American-born elderly, and the other is a group of immigrant elderly. In Asian and Hispanic populations in particular, it's been clear that the children usually immigrate first, form a life here, and then bring their parents over. And there's special problems that exist with the immigration of parents who are already in their '60s and '70s, have no skills, no English competency, and no knowledge of American culture. And one sees the culture-bound syndromes, and one sees the kind of intergenerational problems that are often written about most.

[00:14:16.35] I understand religion to be like a big umbrella. People huddle under it, saving themselves from the elements, the uncertainties and vagaries of life. And it also defines a certain kind of solidarity between people who are huddling together under this protective umbrella. Religion actually means something that binds people together. And it is in this sense that religion provides a sense of solidarity, sense of kinship, brotherhood, and enhances a sense of a group as a group.

[00:14:58.46] Another kind of social identity that people have has to do with gender identity. So in the United States we have racial identity, ethnic identity, and gender identity. Gender identities are those identities that are, again, culturally created. We distinguish in social science between sex and gender. Sex is the sheer reality of the biological difference. Gender is what cultures make of it.

[00:15:22.33] With African Americans, there still is a belief that it is unacceptable be gay, homosexual, lesbian, or bisexual. Oftentimes individuals who have these issues, and particularly adolescents who may be struggling with issues around sexual orientation, do not feel the freedom to discuss these issues because of the fear of cultural responses.

[00:15:56.50] There is such a thing as a homosexual culture. But just like if you were to say, what is American culture, you would get a million answers, the same would be true of homosexual cultures. So that, for example, in New York City, in certain neighborhoods, you will see that most of the restaurants are places where homosexual men go. There's a particular way of dressing, of socializing.

[00:16:22.81] Also, if you go into a different part of my city, New York City, and let's say you go into a Latino homosexual area, what you will find is that Latino homosexual men have very different attitudes about even their self-perception, even how they define whether they are homosexual or not. And I use that term in the sort of mainstream homosexual way, meaning that a man who engages in sex with another man.

[00:16:54.00] The Latino may not consider himself homosexual if he is not the recipient. And this is a very dramatic difference, and it's something that's been very important to address, especially as we try to do more education about AIDS, for example.

[00:17:09.64] Growing up African American in a dominant white society such as here in this country presents certain challenges. The issue of being able to hold onto and develop better understandings and appreciations of your own culture, and the kind of identification that needs to go along with that, gets challenged by the dominant society, by the dominant culture. How much do you buy into the dominant culture? How much do you try to hold onto your own culture? How do you take those and put them together in some meaningful whole?

[00:17:50.55] For adolescents, particularly adolescent African American males, or adolescent minority males, there's a problem because they have to fit in within their own group, which means they need to look a certain way, they need to act a certain way. And that the larger society, and the larger culture, doesn't understand that, and perceives that, to a large degree, as a threat.

[00:18:14.54] It becomes a different situation with people who were born in the United States. And again, you have to make differentiations between the ones who were excluded from the dominant population by prejudice or various socioeconomic barriers versus the ones who were able to assimilate. Usually the ones who have been barred from any kind of access to the dominant culture have a lot more problems with self-esteem quite often, and just tend to have a higher rate of problems in thinking they have a right to services. They frequently have a lot more problems with relationships to authority figures, and a lot more fears of even accepting help.

[00:18:58.05] Marginalization is the idea of people who have felt, through the process of culture change, that the values they started with, what represented to them their ethnic background, is no longer valued by their group, by themselves, or by the majority culture. And they have seen that to give it up will be much more advantageous to them. It's a very unfortunate choice. No one can deny their background. And they suffer greatly as a consequence.

[00:19:41.28] The second part of the outline is entitled Cultural Explanations of the Individual's Illness. I would include also in the title cultural expressions and explanations of illness, because there are five parts to this section. First of all, it asks clinicians to understand the idioms of distress that the person might use, such as nerves or somatic complaints.

[00:20:10.60] Secondly is the meaning and severity of these symptoms in reference to the culture reference group. This is a very important section because it asks us to understand what the norms are, and we must know-- if we know those norms or don't know the norms, we then must seek a cultural consultant.

[00:20:35.56] The third part involves any local illness categories, which is an anthropological term for, essentially, the culture-bound syndromes. There is a glossary of culture-bound syndromes in Appendix I of 25 syndromes which are distressing experiences, experienced in different cultures, which may or may not be seen as psychopathological.

[00:21:04.41] The fourth part asks us to understand the explanatory model that the person or the family group may utilize to explain what is happening. And the last part involves an understanding of the sources of professional and popular sources of care and the treatment pathway. And oftentimes the explanatory model and the treatment pathway are related.

[00:21:33.78] I think it's very important for us not to come up with our assessment and diagnosis based on DSM-IV and not a professional degree or professional experience. We have to really center on the clients and ask them, number one, what do each family member's cultural perspective of the symptom? That in the whole country, how do they label the symptom? Then, where did they get help? What kind of traditional help, or what kind of help they get. And then assess a little bit about what is the exposure to western psychiatry or mental health system? And the most important thing is to really try to give them the kind of trust to tell you that they may not believe in western approach of treatment.

[00:22:27.90] In the African American culture, women in particular grow up with the sense of obligation to be caretakers. They therefore may not acknowledge or respond to their depression or their distress as compared to men, or as compared to women of other cultures.

[00:22:54.63] Black women might experience premenstrual mood swings or changes, but they may not seek treatment for that. That doesn't means that the illness doesn't exist in that community, but it's a different expectation, cultural expectation of what's an illness versus what's not an illness.

[00:23:13.38] It's important to be careful not to overgeneralize or to perpetuate stereotypes. But at the same time, being knowledgeable about patterns or potential issues or areas of vulnerability that may be related to historical experience of particular cultures is very important. For example, the African American man is very concerned about his manhood, is very concerned about respect, does not want to feel vulnerable, and therefore may hesitate to seek help when he is under stress.

[00:24:04.24] Of course there is stigma attached to psychiatric illness, probably in all cultures, and my culture is no exception to it. It means to people that they are somehow weak, unable to care for themselves, somehow not able to derive strength from their relatives, friends, religion, or their thinking is muddled. And therefore they see themselves as somehow stigmatized in going to see a psychiatrist for professional care.

[00:24:36.59] Stigma regarding mental illness is a big concern in the African American community. If you are poor, if you are discriminated against, and you are mentally ill, that's three strikes against you. If in addition to that, you happen to be a woman, then that's four strikes. And people don't like being stigmatized. And so there is a huge avoidance of being crazy, to be colloquial about it.

[00:25:09.81] Cultures have narrative structures. Stories are specific to particular cultures. Sometimes a clinician is simply not able to understand what story a person is trying to tell. Bringing in a cultural consultant is often useful, precisely to help understand, what's the story that someone is in the middle of? What is the story that someone is in the middle of that they themselves may not exactly understand?

[00:25:45.84] The reasons different cultural populations express different symptoms, or express different interpretations of the same symptoms, these reasons are complex. And often they have to do not only with biological and genetic differences, but also, because of the different historical backgrounds of the different symptoms and syndromes that they are expressing, and their importance to other key aspects of the culture.

[00:26:21.82] I work on a syndrome known as ataque de nervios, attack of nerves. And there, a key element of an attack-- which is a fit of loss of control, an intense emotion after something, typically bad, has happened, often in the family setting-- one of the key parts of that syndrome of the attack is this feeling of losing control.

[00:26:46.87] And the importance of that is that in Puerto Rican culture, which is the culture where I've studied the ataque, and where most ataque research has happened, there's a great importance given to the concept of being at peace, or being calm. Even in the face of bad circumstances, one is supposed to retain a certain experience of tranquility. This is highly prized. And so when bad things happen to such a degree that it's impossible to keep calm, one way that people cope with it is by having bursts of loss of control, which are then contained pretty quickly.

[00:27:34.19] There's a culture-bound syndrome in the African American community known as the witch is riding you. And what it really is, is it's a case of isolated sleep paralysis, which is where you're falling asleep or waking up, and you find yourself completely paralyzed, can't move. You're aware of your surroundings, but it's scary. And you might even have what's known as a sleep hallucination, you might hear or see something, and you wake up terrified.

[00:28:06.24] But if you do the cultural formulation, and you ask about the factors that might go into causing this, they will tell you that someone has hexed them and the witch is riding them. And then rather than putting them on antipsychotic medication, you can assure them that it's just isolated sleep paralysis and they're not going to die, although they are a little more likely to have panic disorder if they have a lot of it.

[00:28:31.39] Panic disorder is a condition in which people experience sudden floods of anxiety, panic, terror. One of the questions is, what provokes that? Apparently people monitor their own bodies. They experience sensations in their body as frightening, and in some cases that leads to a cascade of anxiety and a panic attack.

[00:28:56.56] Turns out that in different cultures, different cultural groups, people monitor their bodies for different kinds of sensations. People may experience in one society a sense of dizziness as something that is a signal of great danger. In another society, heart palpitations may a signal of danger. And all of these signals are related to ideas of ethnophysiology, local ideas, local ideas about the biology of the body.

[00:29:28.49] First one needs to elicit from the patient what other approaches they may have used to solve their problem. And one of the things that is critical for the physician, or the mental health care provider, to take into account is that patients know that doctors, nurses, social workers don't really believe in shamanism or in healers or spiritists. So they're not going to be all that comfortable telling you about it unless you let on that you have a clue about it, and that you'll be receptive to it, because they don't want you to think that they're kooky or that they're doing something that is stupid.

[00:30:13.82] The physician's role, the caretaker's role, is absolutely critical in helping the patient feel comfortable revealing this type of information, which the patient understands, generally, might be construed as something that is not the right approach.

[00:30:29.98] A housekeeper of mine started to become ill, but the presentation happened more at home so that I did notice, and others around us didn't notice it. She was beginning to hear things, or feel that things in her house was moved around and put into different places. She went to a medium in her community who actually took a sizable amount of money to help to get the evil spirits out of her house.

[00:31:07.31] Of course, there was no change, because she actually was beginning to experience a psychotic episode. When it came to my attention that this was actually what was happening, I ended up getting her medical care, and we ended up actually hospitalizing her. I was very aggravated at the fact that this man had taken her money and didn't recognize-- or didn't care-- that this was actually an illness.

[00:31:41.89] The third part of the outline asks the clinician to understand and assess the psychosocial factors in the environment which relate to stressors and supports. Let's look at stressors. A very nice way to think about stressors is to look at Axis Four in the DSM-IV multiaxial classification. There's a number of stressors which clinicians should review. And things such as acculturation and discrimination are actually in that list. And there may be other factors-- economic factors, amongst others-- that should be looked at there. In terms of supports, in the outline there's specific reference to religion and kin networks as possible sources of support.

[00:32:38.23] In a general sense, African Americans seek help primarily and first from family and/or extended family. If the resources are not available there, then they often go to the church next. The church historically has been a place where African Americans have found the opportunity for political support, economic support, social engagement. It's very possible for an economically deprived individual in the community to have social status as a deacon or deaconess in a church.

[00:33:17.22] Person may change religious affiliations during their lifetime. Or illness may cause them to change religious affiliations. For example, everybody is aware of the importance of the Catholic church in Latin America. But in addition to the Catholic church, there are other indigenous, or mixtures of indigenous and European healing aspects, healing practices that are important, like spiritism, like Santeria, which originally came from Cuba, which has become a big part of Puerto Rican experience as well, as well as the growing rise of evangelical and fundamentalist Protestant groups, which are also extremely important in determining how people interpret and deal with illness.

[00:34:05.11] The three major differences between immigrant and refugee groups are, number one, the degree of choice. Many refugees did not have the freedom of choice to come. But most of the immigrants, they do have choices to decide whether they want to come to United States or not. The second difference is degree of trauma and losses. I do believe the refugee population suffers more losses and trauma because of the war.

[00:34:42.27] And other thing between them is the whole thing about community support. If you're Chinese, move to Chinatown, you have already a very established community to help you, to give you kind of security blanket, a cushion for you, while if you belong to a very minority refugee group, then you have to start over again and reestablish your community.

[00:35:10.86] One of the things I like to point out about gang activity, especially in urban environments, is that I believe that they provide a purpose, especially to disenfranchised youth. Gangs actually take on features of families in lots of ways. Youth able to belong to a group, they're able to have companionship, develop relationships. They're designed to bring wealth to those individuals and wealth to their families and friends. If we took those same behaviors, those same practices, and put them in the entrepreneur world, we would actually identify those as features that are positive.

[00:35:55.17] Intergenerational stress is very crucial in assessment and treatment of immigrant and refugee families. Family in transition implies that not just physical relocation, but also implies the change of family dynamics in a new country. Number one is a acculturation rate difference among family members.

[00:36:19.71] Another definitely important issue is the complication of dialects in each family. The grandparents speak tradition village tongue, like Toisanese. The parents come from Hong Kong, they speak Cantonese. And the children, they do not understand Chinese, or they only understand what I call the kitchen Chinese. So there's not enough language, common dialect, to express their emotion.

[00:36:49.88] Dr. Chester Pierce, who's a professor of public health, education, and psychiatry, wrote about microinsults and microaggressions. In fact, I recall once I walked into a dermatologist's office, and the receptionist, because I was black, assumed I was on public aid instead of assuming that I run a $16 million mental health center. And so when I walked in, she said, do you have your Medicaid card with you? And of course I was insulted because she stereotyped me and made an assumption about me. And it destroyed our possibility of ever having a good relationship.

[00:37:31.91] The problem is that when you, as a black person, are the recipient of that stereotype and you react to it, you're told that you're sensitive or touchy.

[00:37:43.71] One of the things I talk about is functional paranoia. It is, in fact, the case that in this society, if there are African Americans who have come to a place where they totally trust police, they totally trust institutions, they totally trust aspects of the society that's contrary to their historical existence in that society, I would tend to worry more about those African Americans than I would those that are hypersensitive at times, that are guarded, that are cautious, that question authority, and often question whether or not institutions are designed to provide the things that would benefit them.

[00:38:32.18] The fourth part of the outline involves the cultural elements of the relationship between the individual and the clinician. This is an extremely important section of the outline, which is quite complex. It speaks about the differences in cultural identity between the individual and the clinician, and then secondly, to understand how these differences may cause problems in the therapeutic relationship.

[00:39:07.37] Some examples given involve negotiating an appropriate level of intimacy, issues of rapport and respect, and how is that to be established cross-culturally, as well as communication, both verbal and nonverbal. The use of interpreters can be very important in interacting with patients. That's an obvious difference that can occur between individual and a clinician. Staff must be trained in the use of interpreters. Interpreters must be trained in the process of interpretation involving mental health concepts. That's an example of issues that get surfaced by applying this section of the outline in our clinical work, that it identifies problems that we need to look at and address in the fifth section of the outline.

[00:40:07.29] A lot of times people don't understand the issue of how different cultures interface and meet. But if you consider a Catholic who is having bad and negative thoughts, and you consider a psychiatrist who is practicing standard psychiatry, the psychiatrist would say to the Catholic, well, you know, Freud said that the thought is not the act. And so, so what? You're having bad thoughts. Who cares as long as you're not acting on them?

[00:40:43.81] Of course, the problem is that if you're Catholic, the thought is the act. And so that's a real clear example of where the culture of psychoanalysis, psychiatry, bumps at loggerheads with the culture, religion of Catholicism.

[00:41:06.60] Establishing intimacy is a basic part of any psychotherapeutic process, including doing assessment and diagnosis. And often it's not examined and not thought of as a cultural process. But intimacy is something that is very, very rich culturally.

[00:41:35.14] Asian clients that we have tend to use a lot of indirect communication style, where maybe more acculturated western style is more direct. Also, there's many different subjects that, according to Asian culture, that you don't talk about before they trust you. You have to ignore the sense of shame and guilt are coming in. Focus on more problem-focused kind of approach, and I think it's very important for us, what I call, be the Tiger Balm oil at the first interview.

[00:42:13.55] Most of what the possess as culture is out of our conscious awareness. Our beliefs, our values, our attitudes are things that we don't question. And as we try to understand and be sensitive to other people's beliefs and cultural attributes, we have to be able to disconnect from our own cultural assumptions so that we can hear them.

[00:42:43.10] When we talk about culture, we tend to focus on patients. But in fact, the culture inferences among clinicians and researchers may be even more important. Clinicians are not culture-free. We all have our beliefs and our cultural backgrounds. And at the same time, we are also very much influenced by our environments, such as your colleagues' ideas, professional ideologies, even the advertisement of drug companies and reimbursement patterns.

[00:43:17.81] Oftentimes women come to see me because I am a woman, because they feel that a woman can better understand their trials and tribulations. Of lot of it has to do with the ability to form an empathic connection, and women often feel better understood by other women who share a life experience with them, who know what it's like to struggle with, for example, juggling family and work, or the vicissitudes of trying to succeed in a competitive environment where competitiveness is not considered OK for women.

[00:43:58.51] Transference, in this case, in common parlance, really refers to the patient's overt reaction and thoughts and behaviors toward the therapist. Counter-transference refers to the therapist's responses-- they might even be immediate-- to the particular patient that they have in front of them. This becomes particularly important issue in cross-cultural work, in terms of the positive as well as the negative.

[00:44:35.54] Patients' transference to a therapist-- if the therapist, for example, is from a culture other than the patient, or a social class other than the patient-- carries with it natural responses. For example, if the therapist is well-bred from an elite social group and the patient recognizes that there is a major class or status difference, the patient is unlikely to fully trust, is going to be somewhat wary, perhaps somewhat either deferential or a little antagonistic. These might be quite overt reactions, and this could be based on social class, it could be based on racial differences, could be based on false assumptions regarding cultural values, for example, even religious differences, differences in political parties, differences in neighborhoods.

[00:45:47.87] This can go both ways. Likewise, the therapist might have certain attitudes that one could call counter-transference based on these same differences. If they are from an elite social class, they may not find much in common with a patient who's from a peasant community. There may be false assumptions that the therapist might hold because of their own cultural and religious backgrounds.

[00:46:26.42] If the patient and therapist are different, it does not necessarily preclude the establishment of a therapeutic alliance. A therapist has to always be aware and ready to acknowledge what differences do exist in order to give the patient the opportunity to bring those issues out, and to discuss them and to clarify any misperceptions.

[00:46:56.74] What is most important is not whether or not it is a crossed match between patient and therapist, or whether it's a match dyad, where patient and therapist are from the same culture. What's important is to understand the patient's degree of trust or mistrust, the patient's degree of consolidation of his or her own sense of self and cultural identity.

[00:47:25.59] My first premise is that anybody who does not speak English as their first language deserves to have an interpreter. It doesn't matter that they are competent, to some extent, in English. They deserve to be able to express themselves in their first language so that their complexity of meaning, and the feelings connected to the thoughts, can be expressed clearly.

[00:47:55.00] The fifth part of the outline asks the clinician to provide an overall cultural assessment for diagnosis and care, to take all of the previous four sections, and to bring that together into an assessment that affects our differential diagnosis and our treatment planning.

[00:48:22.54] The differential diagnosis is a process that should include our appreciation of culture-bound syndromes, the age, gender, and culture considerations in the narrative sections of 79 of the diagnostic categories, differences in phenomenology, prevalence, and outcomes as seen in these sections.

[00:48:52.16] The last section of the outline also asks us to look at how the cultural assessment affects our treatment planning, including biological, psychological, sociocultural, and spiritual elements. Also, how the attitudes towards medications may vary across cultures.

[00:49:17.70] In the area of psychotherapy, the question there is how our understanding of the cultural assessment can affect our psychotherapeutic work with patients. To what extent should we include indigenous therapies, cultural strategies? To what extent do we need to modify our cognitive, supportive, psychodynamic therapies? In the realm of sociocultural therapies, how do we modify our family therapy work with patients and involve other activities such as community work?

[00:50:02.15] In the United States, many behaviors that are quite normal among African Americans are abnormalized in psychiatry. There are behaviors of particular ethnic groups, Eastern European Mediterranean, which are also abnormalized by psychiatry, having to do with the different concepts of person. In the Northern European Protestant tradition, the individual is an autonomous, bounded, discrete self, a center of motivation, action, interpretation.

[00:50:33.34] In many cultures in the world, including from Western Europe, for instance, the Mediterranean groups, Spain and Italy and the Eastern European groups, individuals are not so distinct and autonomous and bound, and as a consequence maintain very close relationships, familial relationships, which, to American psychiatry, appear to be dependent relationships that are pathological, children living with their parents into their 30s and so forth.

[00:51:01.75] Among Hispanics, the Hispanic way of behaving sometimes is loud, expressive, very close in terms of physical closeness to the other person. They speak with a lot of enthusiasm and a lot of expressiveness. That behavior may be, if we do not know that it is culturally determined, can be easily labeled as histrionic, hysterical, disorganized, et cetera. And those are terms, by the way, that are labels used in the clinical classification of personality disorders.

[00:51:51.14] African Americans are also subject to a phenomenon of misdiagnosis. What happens is, if you are poor and if you're African American, the health care system you get services from is likely to be public, which is not as well resourced. There's not as much time to interview people to gather history. So that contributes to the misdiagnosis.

[00:52:13.68] Misdiagnosis leads to difficulties in the treatment process. If you don't diagnose accurately, than the medications that you give might be wrong, and most often are, so that you have problems with regard to treating someone for schizophrenia who, in effect, is manic depressive, and there are different medications that they should be on.

[00:52:36.15] The information that the clinician obtains as a result of using the cultural formulation must be used in the treatment by definition. By knowing, for instance, what the patient thinks is the origin of his condition, we are going to respectfully deal with that type of explanation. But at the same time, in the spirit of cooperation with the patient, we are going to offer him or her our clinical knowledge about what the condition may be.

[00:53:15.16] Finally, in knowing how the patient relates to the authority figure represented by the clinician or the therapist, we are going to adjust, as professionals, our behavior to the way this individual deals with authority so that we will not hurt the values, the beliefs, and the cultural principles that guide his behaving the way he does in front of the doctor.

[00:53:45.66] The support systems that are a part of an individual's culture can influence compliance with treatment or the lack of compliance.

[00:53:56.35] The different ethnic or racial groups may have very different metabolism patterns of medications, and also patients from different groups may be taking other kinds of over the counter medications, and may also have a different usage of medication in their culture of origin.

[00:54:20.48] An important general implication of the cultural formulation for future diagnostic systems is to have made it very difficult to plan any new diagnostic system, be this the DSM-V of the American Psychiatric Association or the ICV-11 of the World Health Organization, without paying pointed attention to culture as a fundamental concept for the framework of the system.

[00:55:00.39] Who am I? Not an easily answered question. If you are American Indian, I would reply that I'm Anishnabe, eminent Chippewa from the Turtle Mountain Reservation in North Dakota. But if you were a health professional, I'd reply that I'm a medical anthropologist, indeed a professor of psychiatry, at the University of Colorado Health Sciences Center.

[00:55:20.41] And in fact, knowing both of those elements about me is important because the nature of my work bridges both. That work is focused on trying to understand the relationship between the cultural experience of American Indian Alaska native people and what it holds for our understanding about the health and well-being of native people, all the way from the process of risk and assessment for those kinds of problems on through treatment and prevention.

[00:55:48.57] The question of emotional an problems among American Indians, particularly such illnesses as major depression, are not easily understood without a deep understanding of the context in which such illnesses arise. There is a long history-- generations, in fact-- of something we call historical trauma and grief that brings with it a legacy of deep sadness, both at the level of the individual as well as the collective community. How, then, do we begin to understand the nature of individual depression apart from that broader social and cultural context?

[00:56:28.27] In my work among the Hopi, specifically combat Vietnam veterans, their experience, often, is one that has many parallels to those among non-native Vietnam combat veterans. But there are some unique aspects. The importance of the family, the understanding of the extent to which the actual experience of combat itself introduces into their lives a deep sense of pollution, of disjunction, between who they are and the ways in which they've been raised to believe that they are connected to the world.

[00:57:05.30] Spirituality is an important part of our patients' experience, and in fact can prove to be a critical lever in terms of the therapeutic process. From the view of most people, particularly native people who have had experiences in psychiatry and counseling, that process is largely concerned with the acute experience, the signs and symptoms of the immediate emotional and psychological problem. It's the traditional healing approaches-- the sweat lodge, the enemy way, the variety of different kinds of techniques that have been centuries proven in native communities-- that are designed to address ultimate cause.

[00:57:53.30] So when we're able to bring those two together, we're able to address more powerfully than either might alone the particular problems that bring our patients to us for help.

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