Transcultural Psychiatry

Ethnography and hermeneutics help us think of the clinical encounter as a meeting of cultures. In this paper, we examine Ernesto De Martino’s concept of critical ethnocentrism and its relevance for psychiatry, arguing for the necessity of a cultural self-assessment on the part of the clinician as a means of optimizing analyses of the patient’s culture. Conceptualizing the clinician as an “ethnologist,” we argue that clinicians should be able to describe and acknowledge patients’ cultural backgrounds, while remaining aware of their own culturally rooted prejudices. Focusing on the case of persons affected by schizophrenia, we suggest that De Martino’s work invites an openness to hermeneutic dialogue that aims for the coconstruction of shared narratives by clinician and patient.

The psychological consequences of sexual abuse are generally serious and enduring, particularly when the perpetrator is known and trusted by the survivor. This paper explores the experiences of five contemplative nuns who were sexually abused by priests and the spiritual journeys that followed. In the context of an ethnographic study of contemplative practice, participant observation and in-depth interviews were used to examine the ways that the nuns sought to make sense of their experiences through a long process of solitary introspection. The pursuit of meaning was shaped by religious beliefs relating to forgiveness, sacrifice, and salvation. Thus, trauma was transformed into a symbolic religious narrative that shaped their sense of identity. They were able to restructure core beliefs and to manage their current relationships with priests more securely. They described regaining their spiritual well-being in ways that suggest a form of posttraumatic spiritual growth. We conclude by discussing the findings in the light of the existing literature on the interaction of trauma and spirituality.

The Israeli government’s decision to evacuate Jewish settlers from the Gaza Strip and the West Bank introduced a new category of at-risk individuals to Israeli mental health discourse, namely victims of what has come to be termed the “trauma of the Disengagement.” This category refers to Jewish settlers who are motivated by a religious-Zionist ideology and who define their role as fulfilling the divine command of “redeeming the Land of Israel.” Based on an analysis of the professional activities of the Mahout Center, a mental health service that aimed to mitigate the “trauma of the Disengagement,” this article examines how the Disengagement experience was constructed in the rhetoric and practices of mental health practitioners identified with the religious-Zionist enterprise. It explores the specific notion of trauma and the characteristics of the resilient self, as fashioned according to the distinctive “culture of trauma” that has been developed in the Mahout Center in the context of the Disengagement. This “culture of trauma” is based on a unique alliance between the Western therapeutic model of trauma and the ideological and theological imperatives of religious Zionism.

The illness behavior of patients with medically unexplained physical symptoms (MUS) depends largely on what the patient believes to be the cause of the symptoms. Little data are available on the illness attributions of patients with MUS in China. This cross-sectional study investigated the illness attributions of 96 patients with MUS in the outpatient departments of Psychosomatic Medicine, biomedicine (Neurology, Gynecology), and Traditional Chinese Medicine in Shanghai. Patients completed the Illness Perception Questionnaire (IPQ) for illness attribution, the Screening Questionnaire for Somatoform Symptoms, the Hospital Anxiety and Depression Scale for emotional distress, and questionnaires on clinical and sociodemographic data. The physicians also filled out a questionnaire regarding the cause of the illness (IPQ). In contrast to previous research, both physicians and patients from all three areas of medicine most frequently reported “psychological attributions.” The concordance between the physicians’ and the patients’ illness attributions was low. Emotional distress was an important predictor of psychological attributions. Further research should include large-scale studies among patients from different regions of China and qualitative studies to deepen our understanding of cultural influences on illness attribution.

We compared service outcomes of dedicated language and cultural competency services in adequacy of care, ER, and inpatient care among Portuguese-speaking patients in ethnic- and non-ethnic-specific behavioral health clinics. We assessed adequacy of mental health care, and use of inpatient emergency department among Portuguese-speaking patients, comparing individuals receiving care from a culturally and linguistically competent mental health care setting (the Portuguese Mental Health Program [PMHP]) with usual mental health care in a community health care system in the USA. Propensity score matching was used to balance patients in treatment and control groups on gender, marital status, age, diagnosis of mental disorder, and insurance status. We used de-identified, longitudinal, administrative data of 854 Portuguese-speaking patients receiving care from the PMHP and 541 Portuguese-speaking patients receiving usual care from 2005–2008. Adequate treatment was defined as receipt of at least eight outpatient psychotherapy visits, or at least four outpatient visits of which one was a psychopharmacological visit. PMHP patients were more likely to receive adequate care. No differences were found in rates of ER use or inpatient mental health care. The present study suggests increased quality of care for patients that have contact with a clinic that dedicates resources specifically to a minority/immigrant group. Advantages of this setting include greater linguistic and cultural concordance among providers and patients. Further research is warranted to better understand the mechanisms by which culturally appropriate mental health care settings benefit minority/immigrant patients.

This study examined the prevalence of mental distress among groups in Afghanistan considered to be at risk. Data were drawn from a representative cross-sectional disability survey carried out in Afghanistan including 5,130 households in 171 clusters throughout the 34 provinces of the country. The sample included 838 nondisabled control participants aged above 14, and 675 disabled participants. Results showed that various vulnerable groups (disabled people, the unemployed, the elderly, minority ethnic groups, as well as widowed, divorced or separated women) were at higher risk of experiencing mild to severe mental health problems. The adjusted odds ratio for war-related disability compared to nondisabled was 4.09 (95% confidence interval 2.09 to 7.99) for mild mental distress disorders, and 7.10 (3.45–14.5) and 14.14 (3.38–59.00) for moderate or severe mental distress disorders, respectively. Women with disabilities (whatever the cause of impairment) when compared with nondisabled men, as well as poorer segments of society compared to the richest, had a higher prevalence of mental health problems. Women with non-war-related disabilities compared with nondisabled men were respectively 3.35 (1.27–8.81) and 8.57 (3.03–24.1) times more likely to experience mild or moderate mental distress disorders. People who experience multiple vulnerabilities are more at risk of deteriorating mental health in conflict zones. The study shows that mental health, in times of war, is influenced by a combination of demographic and socioeconomic characteristics linked to social exclusion mechanisms that were in place before the conflict began and that are redefined in relation to the changing social, cultural, and economic contexts. Mental health policies and programmes must prioritise the most vulnerable segments of Afghan society.

Borderline personality disorder (BPD) is a common and severe clinical problem. While cross-cultural research suggests that this condition can be identified in different societies, indirect evidence suggests that BPD and some of its associated symptoms (suicidality and self-harm) have a higher prevalence in developed countries. If so, sociocultural and historical mechanisms may have influenced the development of the disorder. While the vulnerabilities underlying BPD are broad and nonspecific, specific symptoms can be shaped by culture. The mechanisms involve the influence of a “symptom bank,” as well as the role of social contagion. These trends may be related to a decrease in social cohesion and social capital in modern societies.