2023 Lecture 5 Culture and Psychopathology Lecture Notes PDF

Culture and Stigma Dr Chris Groot Melbourne School of Psychological Sciences University of Melbourne Learning Outcomes • Culture – Describe important cultural considerations as regards psychopathology and clinical practice? – Understand what are cultural syndromes, idioms and explanations, and...

Culture and Stigma Dr Chris Groot Melbourne School of Psychological Sciences University of Melbourne Learning Outcomes • Culture – Describe important cultural considerations as regards psychopathology and clinical practice? – Understand what are cultural syndromes, idioms and explanations, and describe examples – Describe how culture affects psychopathology • Stigma – Describe what stigma is – Identify various stigma processes – Understand the significance of stigma for individuals with lived experience – Describe methods to understand and reduce stigma Culture Culture and psychopathology Social context Ethnicity & Culture Gender Sexuality Culture & Psychopathology Culture and Age (time) Migration Globalisation Politics Culture and psychopathology • When psychiatric assessment fails to take into account sociocultural factors it risks misdiagnosis and the perpetuation of clinical stereotypes based on race, ethnicity, gender, religion or sexual orientation (among other factors). Cultural considerations in clinical practice • Cultural identity of the individual. • Cultural explanations of the individual's illness. • Cultural factors related to psychosocial environment and levels of functioning. • Cultural elements of the relationship between the individual and the clinician. Cultural syndrome • A cluster or group of co-occurring, relatively invariant symptoms found in a specific cultural group, community, or context. • The syndrome may or may not be recognized as an illness within the culture (e.g., it might be labelled in various ways), but such cultural patterns of distress and features of illness may nevertheless be recognizable by an outside observer. Cultural syndrome: Ataque de nervios • A syndrome among individuals of Latino descent. • Characterized by symptoms of intense emotional upset, including acute anxiety, anger, or grief; screaming and shouting uncontrollably; attacks of crying; trembling; heat in the chest rising into the head; and becoming verbally and physically aggressive. • Sometimes, but not always, dissociative experiences (e.g., depersonalization, derealization, amnesia), seizure-like or fainting episodes, and suicidal gestures are prominent. Cultural syndrome: Khyâl cap • A syndrome found among Cambodian people both in Cambodia and internationally; • Common symptoms include those of panic attacks, such as dizziness, palpitations, shortness of breath, and cold extremities, as well as other symptoms of anxiety and autonomic arousal (e.g., tinnitus and neck soreness). • Khy'l attacks include catastrophic cognitions centered on the concern that khy'l (a windlike substance) may rise in the body—along with blood—and cause a range of serious effects (e.g., compressing the lungs to cause shortness of breath and asphyxia; entering the cranium to cause tinnitus, dizziness, blurry vision, and a fatal syncope). Aboriginal Australian Culturally-Bound Syndromes (Pilbara and Perth Regions) Westerman, 2021 Aboriginal Australian Culturally-Bound Syndromes (Pilbara and Perth Regions) Westerman, 2021 Longing for country Problems associated with spiritual disconnection Aboriginal people experience when removed from traditional lands. 1. Physical ill health, including weakness, nausea, general “sickness” and somatic complaints; 2. Spiritual ill health; 3. Cognitive disorientation, dissociative fugue; 4. Cultural “ill health” including identity confusion, disorientation, acculturative stress. Westerman, 2021 Longing for country Appropriate intervention included returning to country to reconnect with land, culture, and spirit. Participants spoke of knowing when they needed to return home and this was often precipitated by feelings of sadness, despondency, moodiness, frequent crying, wanting to be alone and arguing with loved ones for no apparent reason. Participants described going home as feeling like “a rejuvenation”. Westerman, 2021 Cultural idiom of distress • A linguistic term, phrase, or way of talking about suffering among individuals of a cultural group (e.g., similar ethnicity and religion) referring to shared concepts of pathology and ways of expressing, communicating, or naming essential features of distress; Cultural idiom of distress: Kufungisisa • ‘thinking too much’ in Shona (Zimbabwe) • As an explanation, it is considered to be causative of anxiety, depression, and somatic problems (e.g., “my heart is painful because I think too much”). • As an idiom of psychosocial distress, it is indicative of interpersonal and social difficulties (e.g., marital problems, having no money to take care of children) Cultural explanation or perceived cause • A label, attribution, or feature of an explanatory model that provides a culturally conceived etiology or cause for symptoms, illness, or distress (e.g., ‘maladi moun’ – Haiti; or being sung/pointing the bone – Australian Aboriginal culture). • Causal explanations may be salient features of folk classifications of disease used by laypersons or healers. Cultural explanation: Maladi moun • Literally “humanly-caused illness,” also referred to as “sent sickness”; • An explanatory model, interpersonal envy and malice cause people to harm their enemies by sending illnesses such as psychosis, depression, social or academic failure, and so on. Culture and symptom expression example Psychosis – Visual hallucinations more common in developed than developing cultures; – Paranoid delusions more common now whilst delusions of wealth and grandeur more documented during 1930’s in US; Culture and Hearing Voices • Auditory verbal hallucinations – phenomenology and cultural responses vary considerably. • USA vs Africa/Asia: – Explanations of voices. • USA vs India/Ghana: – Distress – Command-Order AVH phenomenology • Kenya – Masai – Culturally sanctioned AVH vs not. Stigma Origin of the term ‘stigma’. ‘Stigma’ originated with the ancient Greeks, who physically branded criminals, slaves or traitors in order that they may be identified as undesirable and avoided (Goffman, 1963). Mental Illness Stigma Framework (Fox et al., 2017) Perspective of the Stigmatiser Public Stigma (plural of personal stigma) refers to stigma exhibited by the public towards those with a mental disorder. Public Stigma : •Manifests in three ways: 1. Stereotyped attitudes and beliefs. e.g. someone is ‘less than’ – manifest through devaluing language. 2. Prejudicial affective responses. e.g. fear. 3. Discriminatory behaviours. e.g. avoidance of interaction or social exclusion. •Is thought to be particularly harmful, and the driving force behind other aspects of stigma Perspective of the Stigmatiser Groot, C. (2021). Understanding How to Address Public Stigma about Mental Ill-Health. National Mental Health Commission. Perspective of the Stigmatiser Structural Stigma refers to ingrained stigma manifest at the societal level. Structural Stigma: • is maintained by societal institutions (both government, religious, and private) through policy, law, and prescribed ideologies that restrict opportunities for particular groups. • varies considerably across societies, time, and topics. • applies to mental illness but also extends beyond it to other issues. For example, HIV-AIDS in the 1980’s. Perspective of the stigmatized. Multiple stigmas affect persons living with mental ill-health • Individuals living with mental ill-health are affected by numerous mechanisms of stigma. • These mechanisms are invariably outcomes of public stigma about mental ill-health. • The Mental Illness Stigma Framework (Fox et al, 2017) outlines that they include perceived stigma, experienced stigma, anticipated stigma, and selfstigma. Perceived stigma Perceived stigma • is experienced by members of the public living either with or without mental ill-health. • The term refers to individuals’ awareness and perception of public stigmatised stereotypes, prejudicial emotions, discriminatory behaviour or practices, and/or stigmatised structural practices. • Distinct from one’s own beliefs. • Individuals living with mental ill-health are reported to show higher levels of perceived stigma than those unaffected by mental health problems. • Shares a positive relationship with symptom severity for those living with mental ill-health (Fox et al., 2017; Freidl et al., 2008). • a fundamental substrate of the anticipation and internalisation of public and structural stigma. Experienced stigma Experienced stigma • refers to the experience of having been the target of expressed negative stereotypes, prejudices and manifest discrimination related to one’s mental ill-health. • may occur in subtle and insidious terms such as chronic exposure to commonplace stigmatising representations of people with mental ill-health in mass media, or in more acute ways such as the experience of being denied of significant housing or employment because of one’s mental ill-health (Fox et al., 2017; Groot et al., 2020). • can contribute to withdrawal from future opportunities and shares a relationship with the anticipation of stigma (Fox et al., 2017; Groot et al., 2020; Link, 1987). Anticipated Stigma Anticipated stigma • is defined as the extent to which individuals living with mental ill-health expect to experience stereotyping, prejudice, and discrimination in the future because of their mental health status. • Central to the experience of anticipated stigma is an awareness of public and structural stigma, and how this affects people living with mental ill-health in contexts that are relevant to the self (Fox et al., 2017). • commonly results in withdrawal from opportunities for people living with mental ill-health (Groot et al., 2020; Link et al., 1997). Self-stigma Corrigan’s model Awareness: “I am aware of the stereotype that people with schizophrenia are dangerous.” Agreement: “I agree! People with schizophrenia are dangerous!” Application to the self: “I have schizophrenia, therefore I am likely to be dangerous.” Damage to self: self-esteem (”I don’t deserve help”) and selfefficacy (‘I am unable to meet the demands of opportunity’), exacerbation of mental health problems. Examining the experiences of people living with mental health issues • – Our Turn to Speak and the National Stigma Report Card About Our Turn to Speak Our Turn to Speak was a national survey that sought to understand the life experiences – whether positive or negative – of people living with severe and complex mental health issues in Australia. We wanted to understand if and how a person’s experience of mental health issues impacts the way they are treated by others in different areas of their lives. Now replicated internationally. Who participated? Participants were Australian residents, aged 18 and over, and living with at least one of the following severe and complex mental health issues over the 12 months prior to taking part: • Schizophrenia spectrum disorders • Post-traumatic stress disorder • Bipolar and related disorders • Dissociative disorders • Personality disorders • Eating disorders • Obsessive-compulsive and related disorders • Severe and treatmentresistant depression and anxiety requiring multiagency support Our To to Speak Participants • Our Turn to Speak sample retained for analysis comprised N = 1912 participants • Participants were aged 39.21 years on average (SD = 12.82, range = 18-86 years) Experiences of stigma & discrimination Life domain Relationships with friends and family Social media Healthcare services Employment Mass media Mental healthcare services Education and training Welfare and social services Public spaces and recreation Financial and insurance services Sports, community groups and volunteering Housing Cultural, faith, spiritual practices and communities Legal and justice services Most frequent stigma and discrimination Most affected by Any experience stigma and of stigma and discrimination discrimination 46.4% 69.1% 95.6% 40.0% 31.7% 31.2% 40.8% 22.1% 14.0% 19.7% 10.1% 25.3% 26.3% 43.0% 22.1% 23.6% 10.5% 12.5% 5.1% 84.6% 83.9% 78.1% 76.8% 71.8% 60.0% 58.9% 55.0% 16.4% 7.3% 50.9% 8.7% 5.2% 50.7% 9.7% 6.3% 39.4% 10.2% 5.3% 39.4% 10.3% 4.8% 37.3% Experiences of Stigma and Discrimination in Relationships I have been treated unfairly in my role as a parent or caregiver to my child(ren) Strongly Agree Agree Slightly Agree Slightly Disagree Disagree Strongly Disagree I have been treated unfairly by my family I have been treated unfairly by my intimate partner(s) I have been rejected by or estranged from my friends 0% 50% 100% Anticipation of Stigma and Discrimination in Relationships I expect to be treated unfairly when starting a family or having a child/children Strongly Agree Agree Slightly Agree Slightly Disagree Disagree Strongly Disagree I expect to be treated unfairly by my family I expect to be treated unfairly when dating or in intimate relationships I expect that people will not want to be friends with me 0% 50% 100% Withdrawal from Opportunity in Relationships I have stopped myself from starting a family or having a child/children Strongly Agree Agree Slightly Agree Slightly Disagree Disagree Strongly Disagree I have withdrawn from my relationships with family I have withdrawn from my relationships with intimate partners I have stopped myself from making or keeping friends 0% 50% 100% Effective approaches to stigma reduction. Approaches to stigma reduction that are wellestablished to be effective include: • Contact: being in contact with someone with mental illness. Positive for both parties and particularly effective for addressing stigma in adulthood. • Education: being educated about mental illness. This makes sense as familiarity with mental illness is well-established to be associated with decreased stigmatized attitudes and beliefs. Education and Mental Health Literacy Education about mental illness influences stigma reduction by: • Increasing knowledge and understanding. For example, mental disorder, biological contributions, and blame attributions. • Dispelling myth? For example, the violence myth – fear and dangerousness. • Opening societal discourse decreases self-stigma. Observing that it is okay to experience and talk about mental illness. This in turn increases the likelihood of helpseeking, and in turn, recovery. BUT! What is the right balance? BUT! The wrong type of education can increase stigma. The key is how mental illness is explained. Psychosocial explanation: leads to increased blame. Biomedical explanation: leads to increased perception of uncontrollability and immutability. For more on Public and Self-Stigma What is happening in MSPS right now with this research? MSPS Mental Ill-Health Stigma Lab Projects: - National Stigma Report Card V2.0 Symptoms stream Teleweb Service BPD Stigma News reporting and stigma Hearing Voices project Motivations to stigmatise Podcast intervention Psychosis + alcohol and other drugs Messaging strategy intervention trials BPD in mental health system BPD in relationships Previous PSYC30014/now MISTLab students: Kelton Hardingham - Capstone 2016, Honours 2017, PhD 2021; Beth Hobern – Honours 2018, RA 2019, PhD current; Jessica Westfold, Honours 2018, Clinical Masters 2019; Ellen Rankin, Honours 2019; Emma Waldron, Honours 2018, Mengie Cai, Honours 2020, Alsa Wu, Honours 2021, Elise Carrote, PhD current; and 2022 Masters students Ernest Wang, Ashley Milosevska, Kayla Matisi and Robyn Young. 2023 Masters students x 5. Learning Outcomes • Culture – Describe important cultural considerations as regards psychopathology and clinical practice? – Understand what are cultural syndromes, idioms and explanations, and describe examples – Describe how culture affects psychopathology • Stigma – Describe what stigma is – Identify various stigma processes – Understand the significance of stigma for individuals with lived experience – Describe methods to understand and reduce stigma © Copyright The University of Melbourne 2011