Culture and Mental Health

• A lecture on culturally reflective mental health, obsessive-compulsive and other related disorders, and anxiety-related disorders.
• Learning outcomes include discussion of general concepts, and identifying different perspectives and experiences that can impact mental health outcomes.

Culture

• Culture is an intergenerational, transmitted system of meanings encompassing values, beliefs, and expectations shared by a group.
• Thoughts, beliefs, and experiences shape human emotions and behaviors.
• Culture serves as a broader organizing principle for thoughts, beliefs, and ideas and influences interaction with systems like healthcare and justice.
• Collective and individual experiences affect understanding, client work, and addressing barriers of care like stigma in East Asian cultures.
• Culture influences assumptions, expectations, and participation, for example, caretaking behaviors, disclosure, and sick role behaviors.
• Culture promotes equitable access to services, treatments, and a right to cultural safety, including legal and ethical considerations.

Culture Myths

• One common myth is the belief that only "other people" have culture or that one's own culture is boring.
• This belief typically comes from people belonging to a dominant culture, where assumptions have not been examined through minority stress.
• Culturally reflective practice does not entail memorizing how to work with people from different backgrounds.
• The correct framework includes the collective experience and the individual one.

Culture Awareness vs. Cultural Assumptions

• Achieve culture awareness by asking, listening, and knowing a bit about their culture; avoiding assumptions.
• Psychologists have an ethical obligation for cultural safety, cultural sensitivity, person-centered care, and trauma-informed care.

Australia's Migrant Context

• Nearly 50% of Australians were born overseas (28%) or had at least one parent born overseas (20%) according to the ABS (2021).
• 21% of Australians speak a language other than English at home.
• CALD (Culturally and Linguistically Diverse) refers to residents born in a non-English speaking country or with parents from such countries.

Mental Health and Illness Context

• Many mental health models in psychology and psychiatry are developed from a Western viewpoint.
• The "depression is a chemical imbalance in the brain" medical model stems from a Western perspective and may not apply to other cultures.
• While monoculture understandings are powerful, they are problematic when applied to non-Western cultures due to a lack of consideration for the complexities involved.
• CALD individuals are more likely to need psychological services but less likely to access them, facing a double burden.
• CALD children and families more often face risks of psychological distress from psychosocial stressors like discrimination and isolation.

Barriers to Mental Health Access in CALD Groups

• Stigma and shame, such as "saving face" in high-context cultures, act as barriers.
• Oppression and disenfranchisement lead to lower trust in healthcare and government.
• Racism and discrimination leads to stereotyping in cultural groups' health care needs, like over-diagnosis in schizophrenia in African American women.
• Models of coping, such as resilience and parental love, may vary across cultures.
• The therapeutic relationship may be negatively impacted if a patient feels "othered" due to a therapist's negative or incorrect cultural views.

Framework For Culturally Responsive Practice

• "If we don’t ask, we don’t know" is based on cultural reflection, not assumption
• Diagnose patients while using the DSM, by applying it through a lens based on the the patient's cultural understanding.
• Symptoms of mental illness may differ based on a patient's culture, so assessment needs to always be in the context of their culture.
• The Cultural Formulation Interview is at the back of the DSM-5.
• Deliver mental health care in a language the client understands with access to interpreters
• Culturally adapted interventions have a moderate strong benefit, with targeted interventions being 4x time more effective.
• Interventions conducted in the client's native language are said to be twice as effective.
• Building trust and rapport is important, as well as providing a wrap around supporters for individuals.

Refugees and Asylum Seekers

• A refugee is someone outside their country due to a well-founded fear of persecution, unable or unwilling to seek protection there. Has access to a refugee visa.
• An asylum seeker is someone whose request for sanctuary is pending processing. They do not have a visa.
• Their visa status is a major determinant of mental health, well-being, and available services.

Refugee Experience

• Pre-flight experiences include war and civil disruption, sexual violence leading to racism, losses, arrests, and uncertainty.
• Flight experiences include lack of necessities, survivor guilt, and multiple resettlements, averaging 17 years.
• Post-migration experiences include acculturation stress, loss of status, family separation, and social marginalization.
• Dose response - The more trauma experienced in "pre-flight", the more PTSD you will develop in "post-migration".

Case Study - Asha

• Asha is a 7-year-old South Asian child diagnosed with intellectual disability, ASD, and ADHD, exhibiting challenging behaviours.
• Her refugee status makes her ineligible for NDSI and Medicare.
• An effective treatment plan includes goals, such as establishing boundaries, emotional vocabulary, and safe sensory stimulation.
• It also includes interventions like sensory assessment and time-out.
• When working with interpreters, consistency is key, and briefing + debriefing are important.
• With linguistically diverse clients, it is key that there is curiosity and a multidisciplinary team.

Key Takeaways

• Culture is connected to mental health and illness.
• Double and triple burden describes challenges that racial and ethnic minorities can experience. Culturally reflective practice focuses on individual needs with awareness and sensitivity, assessing treatment at every level.
• Experiences as refugee and asylum seekers can have a severe impact on mental health.

Obsessive-Compulsive and Related Disorders

• This class of disorders share the central feature of repetitive behaviors or mental acts that the individual feels driven to perform. This is commonly comorbid, and likely found in first-degree relatives.

Hoarding Disorder

• Persistent difficulty discarding possessions, due to a perceived need and distress when discarding.
• This leads to accumulation that congests living areas and compromises intended use.
• Clinically significant distress/impairment in social/occupational or areas of functioning, including maintaining a safe environment.

Trichotillomania: Hair-Pulling Disorder

• Recurring hair pulling leads to hair loss.
• Repeated efforts to stop hair pulling (ego-dystonic).
• The hair pulling causes clinically significant distress.
• The disorder is not attributable to another symptom.
• Rituals will occur, triggered by an unpleasant emotion, but results in a pleasant one.

Excoriation Disorder

• Characterized by recurrent skin picking resulting in lesions.
• Includes repeated attempts to stop skin picking (ego-dystonic).
• Causes clinically significant distress or impairment.
• Not attributable to another medical condition.
• The skin picking is not better explained by symptoms of another mental disorder (schizophrenia).

Obsessive Compulsive Disorder (OCD)

• Characterized by obsessions, compulsions, or both, which are time-consuming and cause significant distress.
• Not attributable to substance use or a medical condition (ex: PANDAS).
• It is not better explained by other mental conditions.
• Obsessions include persistent thoughts, urges, or images experienced as intrusive and unwanted that cause anxiety or distress.
• Compulsions are repetitive behaviors/mental acts performed in response to an obsession in order to reduce distress.

Dimensions Of OCD

• The core features and thoughts in OCD will vary widely
• The four dimensions of obessions include: Contamination, Symmetry/Order, Doubt/Harm, Forbidden/Taboo.
• The most common compulsions include Washing/cleaning, Checking, Repeating ("just right" feeling), Ordering and arranging and Mental compulsions

The Cognitive Model

• Likelihood TAF: Believing a thought about an event makes that event more likely.
• Moral TAF: Equating thinking about an action with performing it.
• It's about identifying and challenging the cognitive distortions.
• It is important to take into account the impact that negative/early experiences and dysfunctional beliefs may have.

Intrusions of the Mind

• Intrusions that disturb mood when interpreted negatively causing a pre-existing dysfunctional schema.
• Those with OCD commonly have an inflated responsibility.

Treatment of OCD

• Cognitive behavioral therapy is the best course of action.
• It is important to conduct thought monitoring and change cognitive behaviors by testing their beliefs.
• SSRI's are typically the common antidepressant treatment, and alter the patients brain by creating a relative perception change.

Illness Anxiety Disorder (IAD)

• Health Anxiety is individuals with elevated levels of worry about health.
• With IAD, a person's bodily sensation has a high likelihood of an adverse cost or burdened.
• For someone to be characterized, their behaviors are excessive.

Illness Anxiety Disorder Maintenance

• A person's stimuli and sensations then results in threat interpretations in the terms of illness.
• Maintainence factors may derive from health information, catastrophic event and bodily functions.
• Holden et al. describes that those with IAD are instructed to imagine bodily sensations and generate possible explanations for it. Healthy individuals are less likely to generate normal/somatic information, and IAD is the opposite.

Cognitive Processes

1. attentional biases to health-related information
2. catostraphic about symptoms, with an inflated cost of cost & probability estimates

Behaviour Process

1. excessive checking and researching
2. avoidance - (not going to a doctor)
3. reassurance seeking - (loved ones and doctors)

Anxiety Disorders

• Anxiety "disorders" are marked by excessive or inappropriate occurrences with an overestimation of likelihood of threat.
• Frequency and intensity of anxiety affects a person, and avoidance can worsen anxiety.

Panic Attacks

• A panic attack defined as an abrupt surge of intense fear that will peak over minutes, with four or more key symptoms.
• There are 10 physiological and 3 cognitive symptoms as core indicators of a panic attack.
• Panic attacks are not in themselves a disorder, but a physiological process.
• Attacks that are triggered are called "cued" panic attacks.
• When there is an identified trigger, its considered Expected Panic attack.
• When there is no trigger or cause, its considered Unexpected Panic attack.

Clark's (1986) Cognitive Model of Panic

• Individuals will misinterpret physical sensation in a catastrophic manner which has a flight response.

Models for Managaging Discomfort

• Individuals must recognize when sensations occur.
• Identify Apprehension.
• Interpretations can vary between threatening, or non-threatening.
• Discomfort can be caused by heightned anxiety.

Triple Vulnerability Model

• Generalized Biological Vulnerability: Inherited traits that result in increased reactivity to everyday stressors. Generalized Psychological Vulnerability: Increased sensitivity and reaction to false alarms, potentially leading to a panic disorder.
• Specific Psychological vulnerability: Individuals may catastrophically misinterpret physical sensations which lead to more anxiety.

How is Panic Disorder Maintained

• Focused on internal Sensations or when people thinking highly of a panic and it's likely. Safety Seeking: Avoiding things that will trigger panic.

Goal For Therapy

• To improve interpersonal functioning, and decrease disruption of routines.
• Focus on identifying and challenging the negative automatic thoughts.
• To enhance caregivers illness management and self-care.