Curbside Consult

Editors’ Note: Curbside Consult is an occasional column aimed at helping psychiatrists think through family and cultural considerations when treating patients. It examines case vignettes and is written by two Group for the Advancement of Psychiatry (GAP) committees – the Committee on Family Psychiatry and the Committee on Cultural Psychiatry. The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements.

Case vignette

Bill is a 25-year-old man of Chinese descent who sought psychiatric evaluation of his psychosis risk. His parents emigrated from China to Canada more than 30 years ago; Bill was born in Canada, and moved to the United States with his parents and two siblings at age 7.

His family has a strong history of mental illness. His older sister was diagnosed with schizophrenia; she frequently got into verbal altercations with her parents. When Bill was 15, she walked out of the house after a fight with the family and never returned. Bill’s family thinks his father has had paranoid delusions. In the past, he attempted to call the police multiple times because he suspected the neighbors had planted a listening device in his front yard. The family stopped him from making the actual calls. However, the family never brought him to psychiatric evaluation because of perceived stigma and social discrimination in their community. He also was emotionally and physically abusive to Bill during his childhood by calling him names and hitting him with a belt. As an adult, Bill still has posttraumatic stress disorder symptoms including flashbacks, nightmares, and avoidance when thinking about his father.

Bill identifies himself as Chinese American and speaks English only. He often perceives himself as a newcomer to U.S. society, making comments such as: “I guess I should live my life like this to fulfill the American dream.” Bill’s parents placed a strong emphasis on academic success, often at the expense of their children’s social interaction and playtime activities. Bill describes himself as a “loner” with few friends. He maintained high academic achievement during high school and was accepted by a prestigious college. Although he was interested in music composition, Bill was “forced” by his parents to major in courses deemed good preparation for law school.

During college, he suffered severe depression with insomnia, low energy, hopelessness, anhedonia, social withdrawal, poor appetite with weight loss, and ruminative thoughts but without delusional thoughts or perceptual disturbances. He had one near-lethal suicide attempt, during which he impulsively took the contents of an entire bottle of Tylenol in the context of family conflicts, resulting in psychiatric hospitalization. Bill recalled with animosity the inpatient psychiatrists who put him on psychotropic medications during a 3-day hospitalization. He was not adherent to the medication and did not follow up with postdischarge outpatient care. He did not remember the medication trial he had during the hospitalization, nor did he give consent to obtain medical records from there. Bill withdrew from college in sophomore year, because of his declining academic performance secondary to his mental illness. He currently works at a gas station.

Over the last year, Bill’s interpersonal communication has become disorganized in both work and social settings, and he has developed thought blocking, causing him substantial distress. He intermittently hears voices of strangers in the background; these have gradually become more frequent, now occurring 3-4 times a week. Bill also is more depressed, with frequent crying episodes and worsening social isolation. He often thinks that life is not worth living, but he has no active suicidal plans or intent.

Bill’s supervisor and coworkers strongly suggested that he seek medical evaluation. As an outpatient, Bill started weekly cognitive-behavioral therapy (CBT) and biweekly medication sessions for early psychosis symptoms, receiving low-dose risperidone (1 mg b.i.d.) and fluoxetine (20 mg daily). Despite initial improvement, he was very skeptical about continuing the medications because of concern that they will cause a “change in his identity” by altering his body chemistry. His parents have been reluctant to join family meetings, because they were ambivalent about Bill’s ongoing psychiatric treatment.
 

Treatment team’s impressions

Clinical high risk (CHR) syndrome refers to the prodromal phase before a full psychotic disorder. As one of the three subcategories of CHR, genetic risk and deterioration (GRD) prodromal syndrome is defined by having a genetic risk for psychosis (first-degree relative with a psychotic disorder or meeting criteria for schizotypal personality disorder) and a recent decline in daily functioning equivalent to a 30% drop in Global Assessment of Functioning rating.¹ Due to Bill’s family history of psychosis, new difficulties in self-care, psychotic-spectrum symptoms, and declining social/executive function, he meets criteria for GRD prodromal syndrome. In addition, major depressive disorder should be considered on his differential diagnosis.

Bill has not received a diagnosis of acute psychosis, and instead is judged to be in the CHR spectrum for psychosis, because of his level of insight that the occasional perceptual disturbance and abnormal thought content are in his own mind. Since 26% of individuals with CHR in mainland China² and 35% in the general U.S. population develop fully psychotic symptoms within 2-3 years, Bill’s current presentation warrants secondary preventive care (early intervention) to promote improved clinical outcomes. Given the high rates of comorbid depressive and anxiety disorders among individuals with CHR, Bill’s mood symptoms and passive suicidality also require psychiatric intervention. The treatment team raised three questions, which are answered below.
 

1. How can we understand Bill’s and his family’s resistance to mental health treatment?

Chinese Americans tend to access mental health services at a lower rate than that of the general U.S. population.³ They also tend to exhibit elevated discontinuation from mental health care, compared with non-Latino whites.⁴ Since first- and second-generation Chinese Americans have similar use rates, it is likely the barriers to care are not immigration specific but also related to factors that endure across generations, including culture-related aspects. These include cultural concepts of illness and how to interpret prodromal symptoms such as Bill’s, stigma and interpersonal shame regarding mental illness and psychiatric treatment, and value orientations such as self-reliance, avoidance of direct expressions of interpersonal conflict, and family privacy.

Exploring cultural concepts of distress common among Chinese American families might help clinicians address barriers to mental health service use and persistence. For example, Chinese Americans tend to emphasize the physical-symptom components of psychiatric problems, partly because of mind-body holism – which combines physical and psychological symptoms into cultural syndromes and idioms of distress – and partly because of concerns about stigma and shame regarding mental health symptoms. Hence, they are more likely to seek help from primary care clinicians for psychological distress before any mental health provider. Many Chinese Americans interpret mild to moderate psychological distress as “mental weakness” or “excessive thinking” (xiang tai duo), which does not require clinical evaluation. In this view, only alarmingly bizarre or disruptive behaviors warrant formal psychiatric treatment.

2. How does Bill’s cultural and social context affect his prognosis?

Individuals with psychosis and their close relatives are generally vulnerable to stigma and discrimination. Mental health stigma has a substantial effect on the lives of patients with psychosis and their family members. The magnitude of the perceived stigma tends to be greater if the patient has more severe positive symptoms, is more educated, or resides in a highly urbanized area.

Acutely ill patients usually face more negative community responses than do milder cases, since their close relatives are blamed for failing to uphold the moral and legal responsibility of ensuring that the patients control their behavior. The effect of stigma in Chinese society also is greater among male patients with early-onset illness, because of the expectation that men marry and become the family breadwinner to attain higher social status. Hence, young males who are unable to achieve these socially determined adult milestones can be considered socially inferior, and suffer more community discrimination and exclusion, which are risk factors for clinical deterioration and functional impairment.

Social stigma can intensify relationship conflicts within the family and magnify expressed emotion (EE), which is defined as caregivers’ attitude toward a person with mental illness as reflected by their comments and interaction patterns. “High EE” comprises three behavioral patterns: criticism, hostility, and emotional overinvolvement. High EE is associated with psychiatric symptom relapse among individuals with schizophrenia and other disorders.⁹

Currently, most of the literature on EE is limited to white samples in Western countries. Some researchers have studied the relationship between the EE index of emotional overinvolvement and schizophrenia relapse among Hispanic populations.¹⁰ However, there are limited data on cultural congruence of EE research in Asian populations. Therefore, clinicians should carefully evaluate the contribution of high EE to Bill’s family’s situation during his course of treatment.

Higher education often is associated with greater levels of EE and can result in anxious and fearful responses to the person’s illness.¹¹ This may be attributable to more negative reactions to actual or feared stigma and discrimination, possibly because relatives feel they have more to lose regarding the family’s social status, especially in densely populated urban areas where it might be harder to keep the patient’s mental illness as a “family secret.”

On the other hand, certain explanatory models of psychosis can modulate Chinese community members’ perceptions and allow ill individuals to remain socially integrated. Cultural idioms such as “excessive thinking” (xiang tai duo), “taking things too hard” (xiang bu kai), and “narrow-mindedness” (xiao xin yan) promote socially accommodating behaviors that facilitate acceptance of mildly to moderately ill individuals as full-status community members.¹²

Another important contributor to psychosis risk is Bill’s acculturative stress about his cultural identity. Linguistic challenges, limited social support, perceived discrimination, and an acculturation gap between parents and children are major sources of acculturative stress among Chinese American college students.¹³ Greater acculturative stress elevates the risk of mental illness and symptom deterioration. However, highly acculturated Chinese Americans with above-average bicultural self-efficacy tend to express more positive attitudes toward mental health services.
 

3. Are there culturally appropriate interventions that can help Bill and his family?

A major predictor among Chinese Americans of the intent to use services is the perceived credibility of the treatment and the provider. Ethnic-specific services staffed by bicultural/bilingual mental health clinicians delivering culturally responsive interventions are increasingly available in many metropolitan areas with major Asian communities. These programs have shown clinical efficacy in encouraging service use and promoting treatment persistence. Bill and his family may benefit from referral to ethnic-specific services, where they can obtain culturally sensitive psychoeducation about his mental illness and treatment plan.

Other services that might be useful for Bill and his family include family psychoeducation programs and supportive groups specifically designed for Chinese American families; these can improve the entire family’s psychosocial health, promote medication adherence, and reduce the risk of symptom relapse through family-centered intervention models.¹⁴ Connecting with local National Alliance on Mental Illness (NAMI) programs might help Bill’s parents obtain social support from Chinese American families with similar caregiver experiences.

However, services that are not designed specifically for Chinese-origin patients also can provide excellent care for these patients, and be perceived as credible and effective. A thorough cultural assessment is necessary, as well as inclusion of the information obtained in the treatment plan. As described in the DSM-5 Outline for Cultural Formulation and operationalized in the Cultural Formulation Interview, clinicians should assess possible cultural differences among Bill, his family, his community, and his clinicians regarding their cultural concepts of distress and illness and expectations of care in order to formulate a treatment plan acceptable to patient and family. Practical cultural barriers should be addressed, such as Bill’s parents’ limited English proficiency, in which case a bilingual clinician or trained interpreter should be included in the treatment team.

With Bill’s consent, the treatment team also should consider reaching out to his parents, especially his mother, to understand and empathize with their cultural concepts of distress and illness as well as expectations for care. In addition to providing psychoeducation, the clinicians should validate the parents’ experience of shame, fear, and worry about their son. Bill’s brother, for example, might be a useful bridge in communicating with the parents given his higher acculturation and potentially greater acceptance of psychiatric care. He might help alleviate the tension between Bill and his parents and encourage them to seek family-based help.
 

Take-home points

• Clinical training programs should offer cultural competency training about underserved populations, including communities of color.
• Certain key concepts, such as traditional idioms of distress and explanatory models, social stigma, and acculturative stress, should be included in these trainings and evaluated in a comprehensive psychosocial assessment.
• High expressed emotion among family caregivers is associated with higher rates of psychiatric symptom relapse, whereas families with above-average bicultural self-efficacy have more positive attitudes toward mental health services.
• Clinicians should incorporate culturally appropriate educational materials (for example, CHR warning signs) and interventions to engage underserved patients and their families in mental health treatment.

Contributors

Emily Wu, MD – Harvard Medical School, Boston

Francis Lu, MD – University of California, Davis

John Sargent, MD – Tufts Medical Center, Boston

Roberto Lewis-Fernández, MD – Columbia College of Physicians & Surgeons, New York



If you would like to a submit case in which your understanding and treatment are affected by challenging cultural and family values, send it to [email protected]. We will then write back with our best answers about how one might proceed in such a case. Your case and our response will then be published at mdedge.com/psychiatry. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they are employed by or affiliated with or the Group for the Advancement of Psychiatry.

References

1. J Nerv Ment Dis. 2013 Jun;20(6);484-9.

2. Schizophr Res. 2014 Feb;152(2-3):391-9.

3. Perspect Psychiatr Care. 2013;49(4):288-92.

4. Ment Health Serv Res. 2001 Dec;3(4):201-14.

5. Br J Psychiatry. 2000 Jul;177;20-5.

6. Cultr Divers Ethnic Minor Psychol. 2008 Jan;14(1):10-8.

7. Couns Psychol. 2003 May1;31:343-61.

8. Emotion. 2002 Dec;2(4):341-60.

9. Am J Psychiatry. 1986 Nov;143(11):1361-73.

10. J Nerv Ment Dis. 2013 Oct;201(10):833-40.

11. Schizophr Bull. 1981;7(1):43-4.

12. Schizophr Bull. 2010 Jul;36(4):836-45.

13. Am J Orthopsychiatry. 2011 Oct;81(4):489-97.

14. Patient Educ Couns. 2009 Apr;75(1):67-76.

Editors’ Note: Curbside Consult is an occasional column aimed at helping psychiatrists think through family and cultural considerations when treating patients. It examines case vignettes and is written by two Group for the Advancement of Psychiatry (GAP) committees – the Committee on Family Psychiatry and the Committee on Cultural Psychiatry. The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements.

Case vignette

Bill is a 25-year-old man of Chinese descent who sought psychiatric evaluation of his psychosis risk. His parents emigrated from China to Canada more than 30 years ago; Bill was born in Canada, and moved to the United States with his parents and two siblings at age 7.

His family has a strong history of mental illness. His older sister was diagnosed with schizophrenia; she frequently got into verbal altercations with her parents. When Bill was 15, she walked out of the house after a fight with the family and never returned. Bill’s family thinks his father has had paranoid delusions. In the past, he attempted to call the police multiple times because he suspected the neighbors had planted a listening device in his front yard. The family stopped him from making the actual calls. However, the family never brought him to psychiatric evaluation because of perceived stigma and social discrimination in their community. He also was emotionally and physically abusive to Bill during his childhood by calling him names and hitting him with a belt. As an adult, Bill still has posttraumatic stress disorder symptoms including flashbacks, nightmares, and avoidance when thinking about his father.

Bill identifies himself as Chinese American and speaks English only. He often perceives himself as a newcomer to U.S. society, making comments such as: “I guess I should live my life like this to fulfill the American dream.” Bill’s parents placed a strong emphasis on academic success, often at the expense of their children’s social interaction and playtime activities. Bill describes himself as a “loner” with few friends. He maintained high academic achievement during high school and was accepted by a prestigious college. Although he was interested in music composition, Bill was “forced” by his parents to major in courses deemed good preparation for law school.

During college, he suffered severe depression with insomnia, low energy, hopelessness, anhedonia, social withdrawal, poor appetite with weight loss, and ruminative thoughts but without delusional thoughts or perceptual disturbances. He had one near-lethal suicide attempt, during which he impulsively took the contents of an entire bottle of Tylenol in the context of family conflicts, resulting in psychiatric hospitalization. Bill recalled with animosity the inpatient psychiatrists who put him on psychotropic medications during a 3-day hospitalization. He was not adherent to the medication and did not follow up with postdischarge outpatient care. He did not remember the medication trial he had during the hospitalization, nor did he give consent to obtain medical records from there. Bill withdrew from college in sophomore year, because of his declining academic performance secondary to his mental illness. He currently works at a gas station.

Over the last year, Bill’s interpersonal communication has become disorganized in both work and social settings, and he has developed thought blocking, causing him substantial distress. He intermittently hears voices of strangers in the background; these have gradually become more frequent, now occurring 3-4 times a week. Bill also is more depressed, with frequent crying episodes and worsening social isolation. He often thinks that life is not worth living, but he has no active suicidal plans or intent.

Bill’s supervisor and coworkers strongly suggested that he seek medical evaluation. As an outpatient, Bill started weekly cognitive-behavioral therapy (CBT) and biweekly medication sessions for early psychosis symptoms, receiving low-dose risperidone (1 mg b.i.d.) and fluoxetine (20 mg daily). Despite initial improvement, he was very skeptical about continuing the medications because of concern that they will cause a “change in his identity” by altering his body chemistry. His parents have been reluctant to join family meetings, because they were ambivalent about Bill’s ongoing psychiatric treatment.
 

Treatment team’s impressions

Clinical high risk (CHR) syndrome refers to the prodromal phase before a full psychotic disorder. As one of the three subcategories of CHR, genetic risk and deterioration (GRD) prodromal syndrome is defined by having a genetic risk for psychosis (first-degree relative with a psychotic disorder or meeting criteria for schizotypal personality disorder) and a recent decline in daily functioning equivalent to a 30% drop in Global Assessment of Functioning rating.¹ Due to Bill’s family history of psychosis, new difficulties in self-care, psychotic-spectrum symptoms, and declining social/executive function, he meets criteria for GRD prodromal syndrome. In addition, major depressive disorder should be considered on his differential diagnosis.

Bill has not received a diagnosis of acute psychosis, and instead is judged to be in the CHR spectrum for psychosis, because of his level of insight that the occasional perceptual disturbance and abnormal thought content are in his own mind. Since 26% of individuals with CHR in mainland China² and 35% in the general U.S. population develop fully psychotic symptoms within 2-3 years, Bill’s current presentation warrants secondary preventive care (early intervention) to promote improved clinical outcomes. Given the high rates of comorbid depressive and anxiety disorders among individuals with CHR, Bill’s mood symptoms and passive suicidality also require psychiatric intervention. The treatment team raised three questions, which are answered below.
 

1. How can we understand Bill’s and his family’s resistance to mental health treatment?

Chinese Americans tend to access mental health services at a lower rate than that of the general U.S. population.³ They also tend to exhibit elevated discontinuation from mental health care, compared with non-Latino whites.⁴ Since first- and second-generation Chinese Americans have similar use rates, it is likely the barriers to care are not immigration specific but also related to factors that endure across generations, including culture-related aspects. These include cultural concepts of illness and how to interpret prodromal symptoms such as Bill’s, stigma and interpersonal shame regarding mental illness and psychiatric treatment, and value orientations such as self-reliance, avoidance of direct expressions of interpersonal conflict, and family privacy.

Exploring cultural concepts of distress common among Chinese American families might help clinicians address barriers to mental health service use and persistence. For example, Chinese Americans tend to emphasize the physical-symptom components of psychiatric problems, partly because of mind-body holism – which combines physical and psychological symptoms into cultural syndromes and idioms of distress – and partly because of concerns about stigma and shame regarding mental health symptoms. Hence, they are more likely to seek help from primary care clinicians for psychological distress before any mental health provider. Many Chinese Americans interpret mild to moderate psychological distress as “mental weakness” or “excessive thinking” (xiang tai duo), which does not require clinical evaluation. In this view, only alarmingly bizarre or disruptive behaviors warrant formal psychiatric treatment.

2. How does Bill’s cultural and social context affect his prognosis?

Individuals with psychosis and their close relatives are generally vulnerable to stigma and discrimination. Mental health stigma has a substantial effect on the lives of patients with psychosis and their family members. The magnitude of the perceived stigma tends to be greater if the patient has more severe positive symptoms, is more educated, or resides in a highly urbanized area.

Acutely ill patients usually face more negative community responses than do milder cases, since their close relatives are blamed for failing to uphold the moral and legal responsibility of ensuring that the patients control their behavior. The effect of stigma in Chinese society also is greater among male patients with early-onset illness, because of the expectation that men marry and become the family breadwinner to attain higher social status. Hence, young males who are unable to achieve these socially determined adult milestones can be considered socially inferior, and suffer more community discrimination and exclusion, which are risk factors for clinical deterioration and functional impairment.

Social stigma can intensify relationship conflicts within the family and magnify expressed emotion (EE), which is defined as caregivers’ attitude toward a person with mental illness as reflected by their comments and interaction patterns. “High EE” comprises three behavioral patterns: criticism, hostility, and emotional overinvolvement. High EE is associated with psychiatric symptom relapse among individuals with schizophrenia and other disorders.⁹

Currently, most of the literature on EE is limited to white samples in Western countries. Some researchers have studied the relationship between the EE index of emotional overinvolvement and schizophrenia relapse among Hispanic populations.¹⁰ However, there are limited data on cultural congruence of EE research in Asian populations. Therefore, clinicians should carefully evaluate the contribution of high EE to Bill’s family’s situation during his course of treatment.

Higher education often is associated with greater levels of EE and can result in anxious and fearful responses to the person’s illness.¹¹ This may be attributable to more negative reactions to actual or feared stigma and discrimination, possibly because relatives feel they have more to lose regarding the family’s social status, especially in densely populated urban areas where it might be harder to keep the patient’s mental illness as a “family secret.”

On the other hand, certain explanatory models of psychosis can modulate Chinese community members’ perceptions and allow ill individuals to remain socially integrated. Cultural idioms such as “excessive thinking” (xiang tai duo), “taking things too hard” (xiang bu kai), and “narrow-mindedness” (xiao xin yan) promote socially accommodating behaviors that facilitate acceptance of mildly to moderately ill individuals as full-status community members.¹²

Another important contributor to psychosis risk is Bill’s acculturative stress about his cultural identity. Linguistic challenges, limited social support, perceived discrimination, and an acculturation gap between parents and children are major sources of acculturative stress among Chinese American college students.¹³ Greater acculturative stress elevates the risk of mental illness and symptom deterioration. However, highly acculturated Chinese Americans with above-average bicultural self-efficacy tend to express more positive attitudes toward mental health services.
 

3. Are there culturally appropriate interventions that can help Bill and his family?

A major predictor among Chinese Americans of the intent to use services is the perceived credibility of the treatment and the provider. Ethnic-specific services staffed by bicultural/bilingual mental health clinicians delivering culturally responsive interventions are increasingly available in many metropolitan areas with major Asian communities. These programs have shown clinical efficacy in encouraging service use and promoting treatment persistence. Bill and his family may benefit from referral to ethnic-specific services, where they can obtain culturally sensitive psychoeducation about his mental illness and treatment plan.

Other services that might be useful for Bill and his family include family psychoeducation programs and supportive groups specifically designed for Chinese American families; these can improve the entire family’s psychosocial health, promote medication adherence, and reduce the risk of symptom relapse through family-centered intervention models.¹⁴ Connecting with local National Alliance on Mental Illness (NAMI) programs might help Bill’s parents obtain social support from Chinese American families with similar caregiver experiences.

However, services that are not designed specifically for Chinese-origin patients also can provide excellent care for these patients, and be perceived as credible and effective. A thorough cultural assessment is necessary, as well as inclusion of the information obtained in the treatment plan. As described in the DSM-5 Outline for Cultural Formulation and operationalized in the Cultural Formulation Interview, clinicians should assess possible cultural differences among Bill, his family, his community, and his clinicians regarding their cultural concepts of distress and illness and expectations of care in order to formulate a treatment plan acceptable to patient and family. Practical cultural barriers should be addressed, such as Bill’s parents’ limited English proficiency, in which case a bilingual clinician or trained interpreter should be included in the treatment team.

With Bill’s consent, the treatment team also should consider reaching out to his parents, especially his mother, to understand and empathize with their cultural concepts of distress and illness as well as expectations for care. In addition to providing psychoeducation, the clinicians should validate the parents’ experience of shame, fear, and worry about their son. Bill’s brother, for example, might be a useful bridge in communicating with the parents given his higher acculturation and potentially greater acceptance of psychiatric care. He might help alleviate the tension between Bill and his parents and encourage them to seek family-based help.
 

Take-home points

• Clinical training programs should offer cultural competency training about underserved populations, including communities of color.
• Certain key concepts, such as traditional idioms of distress and explanatory models, social stigma, and acculturative stress, should be included in these trainings and evaluated in a comprehensive psychosocial assessment.
• High expressed emotion among family caregivers is associated with higher rates of psychiatric symptom relapse, whereas families with above-average bicultural self-efficacy have more positive attitudes toward mental health services.
• Clinicians should incorporate culturally appropriate educational materials (for example, CHR warning signs) and interventions to engage underserved patients and their families in mental health treatment.

Contributors

Emily Wu, MD – Harvard Medical School, Boston

Francis Lu, MD – University of California, Davis

John Sargent, MD – Tufts Medical Center, Boston

Roberto Lewis-Fernández, MD – Columbia College of Physicians & Surgeons, New York



If you would like to a submit case in which your understanding and treatment are affected by challenging cultural and family values, send it to [email protected]. We will then write back with our best answers about how one might proceed in such a case. Your case and our response will then be published at mdedge.com/psychiatry. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they are employed by or affiliated with or the Group for the Advancement of Psychiatry.

References

1. J Nerv Ment Dis. 2013 Jun;20(6);484-9.

2. Schizophr Res. 2014 Feb;152(2-3):391-9.

3. Perspect Psychiatr Care. 2013;49(4):288-92.

4. Ment Health Serv Res. 2001 Dec;3(4):201-14.

5. Br J Psychiatry. 2000 Jul;177;20-5.

6. Cultr Divers Ethnic Minor Psychol. 2008 Jan;14(1):10-8.

7. Couns Psychol. 2003 May1;31:343-61.

8. Emotion. 2002 Dec;2(4):341-60.

9. Am J Psychiatry. 1986 Nov;143(11):1361-73.

10. J Nerv Ment Dis. 2013 Oct;201(10):833-40.

11. Schizophr Bull. 1981;7(1):43-4.

12. Schizophr Bull. 2010 Jul;36(4):836-45.

13. Am J Orthopsychiatry. 2011 Oct;81(4):489-97.

14. Patient Educ Couns. 2009 Apr;75(1):67-76.

Editors’ Note: Curbside Consult is an occasional column aimed at helping psychiatrists think through family and cultural considerations when treating patients. It examines case vignettes and is written by two Group for the Advancement of Psychiatry (GAP) committees – the Committee on Family Psychiatry and the Committee on Cultural Psychiatry. The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements.

Case vignette

Bill is a 25-year-old man of Chinese descent who sought psychiatric evaluation of his psychosis risk. His parents emigrated from China to Canada more than 30 years ago; Bill was born in Canada, and moved to the United States with his parents and two siblings at age 7.

His family has a strong history of mental illness. His older sister was diagnosed with schizophrenia; she frequently got into verbal altercations with her parents. When Bill was 15, she walked out of the house after a fight with the family and never returned. Bill’s family thinks his father has had paranoid delusions. In the past, he attempted to call the police multiple times because he suspected the neighbors had planted a listening device in his front yard. The family stopped him from making the actual calls. However, the family never brought him to psychiatric evaluation because of perceived stigma and social discrimination in their community. He also was emotionally and physically abusive to Bill during his childhood by calling him names and hitting him with a belt. As an adult, Bill still has posttraumatic stress disorder symptoms including flashbacks, nightmares, and avoidance when thinking about his father.

Bill identifies himself as Chinese American and speaks English only. He often perceives himself as a newcomer to U.S. society, making comments such as: “I guess I should live my life like this to fulfill the American dream.” Bill’s parents placed a strong emphasis on academic success, often at the expense of their children’s social interaction and playtime activities. Bill describes himself as a “loner” with few friends. He maintained high academic achievement during high school and was accepted by a prestigious college. Although he was interested in music composition, Bill was “forced” by his parents to major in courses deemed good preparation for law school.

During college, he suffered severe depression with insomnia, low energy, hopelessness, anhedonia, social withdrawal, poor appetite with weight loss, and ruminative thoughts but without delusional thoughts or perceptual disturbances. He had one near-lethal suicide attempt, during which he impulsively took the contents of an entire bottle of Tylenol in the context of family conflicts, resulting in psychiatric hospitalization. Bill recalled with animosity the inpatient psychiatrists who put him on psychotropic medications during a 3-day hospitalization. He was not adherent to the medication and did not follow up with postdischarge outpatient care. He did not remember the medication trial he had during the hospitalization, nor did he give consent to obtain medical records from there. Bill withdrew from college in sophomore year, because of his declining academic performance secondary to his mental illness. He currently works at a gas station.

Over the last year, Bill’s interpersonal communication has become disorganized in both work and social settings, and he has developed thought blocking, causing him substantial distress. He intermittently hears voices of strangers in the background; these have gradually become more frequent, now occurring 3-4 times a week. Bill also is more depressed, with frequent crying episodes and worsening social isolation. He often thinks that life is not worth living, but he has no active suicidal plans or intent.

Bill’s supervisor and coworkers strongly suggested that he seek medical evaluation. As an outpatient, Bill started weekly cognitive-behavioral therapy (CBT) and biweekly medication sessions for early psychosis symptoms, receiving low-dose risperidone (1 mg b.i.d.) and fluoxetine (20 mg daily). Despite initial improvement, he was very skeptical about continuing the medications because of concern that they will cause a “change in his identity” by altering his body chemistry. His parents have been reluctant to join family meetings, because they were ambivalent about Bill’s ongoing psychiatric treatment.
 

Treatment team’s impressions

Clinical high risk (CHR) syndrome refers to the prodromal phase before a full psychotic disorder. As one of the three subcategories of CHR, genetic risk and deterioration (GRD) prodromal syndrome is defined by having a genetic risk for psychosis (first-degree relative with a psychotic disorder or meeting criteria for schizotypal personality disorder) and a recent decline in daily functioning equivalent to a 30% drop in Global Assessment of Functioning rating.¹ Due to Bill’s family history of psychosis, new difficulties in self-care, psychotic-spectrum symptoms, and declining social/executive function, he meets criteria for GRD prodromal syndrome. In addition, major depressive disorder should be considered on his differential diagnosis.

Bill has not received a diagnosis of acute psychosis, and instead is judged to be in the CHR spectrum for psychosis, because of his level of insight that the occasional perceptual disturbance and abnormal thought content are in his own mind. Since 26% of individuals with CHR in mainland China² and 35% in the general U.S. population develop fully psychotic symptoms within 2-3 years, Bill’s current presentation warrants secondary preventive care (early intervention) to promote improved clinical outcomes. Given the high rates of comorbid depressive and anxiety disorders among individuals with CHR, Bill’s mood symptoms and passive suicidality also require psychiatric intervention. The treatment team raised three questions, which are answered below.
 

1. How can we understand Bill’s and his family’s resistance to mental health treatment?

Chinese Americans tend to access mental health services at a lower rate than that of the general U.S. population.³ They also tend to exhibit elevated discontinuation from mental health care, compared with non-Latino whites.⁴ Since first- and second-generation Chinese Americans have similar use rates, it is likely the barriers to care are not immigration specific but also related to factors that endure across generations, including culture-related aspects. These include cultural concepts of illness and how to interpret prodromal symptoms such as Bill’s, stigma and interpersonal shame regarding mental illness and psychiatric treatment, and value orientations such as self-reliance, avoidance of direct expressions of interpersonal conflict, and family privacy.

Exploring cultural concepts of distress common among Chinese American families might help clinicians address barriers to mental health service use and persistence. For example, Chinese Americans tend to emphasize the physical-symptom components of psychiatric problems, partly because of mind-body holism – which combines physical and psychological symptoms into cultural syndromes and idioms of distress – and partly because of concerns about stigma and shame regarding mental health symptoms. Hence, they are more likely to seek help from primary care clinicians for psychological distress before any mental health provider. Many Chinese Americans interpret mild to moderate psychological distress as “mental weakness” or “excessive thinking” (xiang tai duo), which does not require clinical evaluation. In this view, only alarmingly bizarre or disruptive behaviors warrant formal psychiatric treatment.

2. How does Bill’s cultural and social context affect his prognosis?

Individuals with psychosis and their close relatives are generally vulnerable to stigma and discrimination. Mental health stigma has a substantial effect on the lives of patients with psychosis and their family members. The magnitude of the perceived stigma tends to be greater if the patient has more severe positive symptoms, is more educated, or resides in a highly urbanized area.

Acutely ill patients usually face more negative community responses than do milder cases, since their close relatives are blamed for failing to uphold the moral and legal responsibility of ensuring that the patients control their behavior. The effect of stigma in Chinese society also is greater among male patients with early-onset illness, because of the expectation that men marry and become the family breadwinner to attain higher social status. Hence, young males who are unable to achieve these socially determined adult milestones can be considered socially inferior, and suffer more community discrimination and exclusion, which are risk factors for clinical deterioration and functional impairment.

Social stigma can intensify relationship conflicts within the family and magnify expressed emotion (EE), which is defined as caregivers’ attitude toward a person with mental illness as reflected by their comments and interaction patterns. “High EE” comprises three behavioral patterns: criticism, hostility, and emotional overinvolvement. High EE is associated with psychiatric symptom relapse among individuals with schizophrenia and other disorders.⁹

Currently, most of the literature on EE is limited to white samples in Western countries. Some researchers have studied the relationship between the EE index of emotional overinvolvement and schizophrenia relapse among Hispanic populations.¹⁰ However, there are limited data on cultural congruence of EE research in Asian populations. Therefore, clinicians should carefully evaluate the contribution of high EE to Bill’s family’s situation during his course of treatment.

Higher education often is associated with greater levels of EE and can result in anxious and fearful responses to the person’s illness.¹¹ This may be attributable to more negative reactions to actual or feared stigma and discrimination, possibly because relatives feel they have more to lose regarding the family’s social status, especially in densely populated urban areas where it might be harder to keep the patient’s mental illness as a “family secret.”

On the other hand, certain explanatory models of psychosis can modulate Chinese community members’ perceptions and allow ill individuals to remain socially integrated. Cultural idioms such as “excessive thinking” (xiang tai duo), “taking things too hard” (xiang bu kai), and “narrow-mindedness” (xiao xin yan) promote socially accommodating behaviors that facilitate acceptance of mildly to moderately ill individuals as full-status community members.¹²

Another important contributor to psychosis risk is Bill’s acculturative stress about his cultural identity. Linguistic challenges, limited social support, perceived discrimination, and an acculturation gap between parents and children are major sources of acculturative stress among Chinese American college students.¹³ Greater acculturative stress elevates the risk of mental illness and symptom deterioration. However, highly acculturated Chinese Americans with above-average bicultural self-efficacy tend to express more positive attitudes toward mental health services.
 

3. Are there culturally appropriate interventions that can help Bill and his family?

A major predictor among Chinese Americans of the intent to use services is the perceived credibility of the treatment and the provider. Ethnic-specific services staffed by bicultural/bilingual mental health clinicians delivering culturally responsive interventions are increasingly available in many metropolitan areas with major Asian communities. These programs have shown clinical efficacy in encouraging service use and promoting treatment persistence. Bill and his family may benefit from referral to ethnic-specific services, where they can obtain culturally sensitive psychoeducation about his mental illness and treatment plan.

Other services that might be useful for Bill and his family include family psychoeducation programs and supportive groups specifically designed for Chinese American families; these can improve the entire family’s psychosocial health, promote medication adherence, and reduce the risk of symptom relapse through family-centered intervention models.¹⁴ Connecting with local National Alliance on Mental Illness (NAMI) programs might help Bill’s parents obtain social support from Chinese American families with similar caregiver experiences.

However, services that are not designed specifically for Chinese-origin patients also can provide excellent care for these patients, and be perceived as credible and effective. A thorough cultural assessment is necessary, as well as inclusion of the information obtained in the treatment plan. As described in the DSM-5 Outline for Cultural Formulation and operationalized in the Cultural Formulation Interview, clinicians should assess possible cultural differences among Bill, his family, his community, and his clinicians regarding their cultural concepts of distress and illness and expectations of care in order to formulate a treatment plan acceptable to patient and family. Practical cultural barriers should be addressed, such as Bill’s parents’ limited English proficiency, in which case a bilingual clinician or trained interpreter should be included in the treatment team.

With Bill’s consent, the treatment team also should consider reaching out to his parents, especially his mother, to understand and empathize with their cultural concepts of distress and illness as well as expectations for care. In addition to providing psychoeducation, the clinicians should validate the parents’ experience of shame, fear, and worry about their son. Bill’s brother, for example, might be a useful bridge in communicating with the parents given his higher acculturation and potentially greater acceptance of psychiatric care. He might help alleviate the tension between Bill and his parents and encourage them to seek family-based help.
 

Take-home points

• Clinical training programs should offer cultural competency training about underserved populations, including communities of color.
• Certain key concepts, such as traditional idioms of distress and explanatory models, social stigma, and acculturative stress, should be included in these trainings and evaluated in a comprehensive psychosocial assessment.
• High expressed emotion among family caregivers is associated with higher rates of psychiatric symptom relapse, whereas families with above-average bicultural self-efficacy have more positive attitudes toward mental health services.
• Clinicians should incorporate culturally appropriate educational materials (for example, CHR warning signs) and interventions to engage underserved patients and their families in mental health treatment.

Contributors

Emily Wu, MD – Harvard Medical School, Boston

Francis Lu, MD – University of California, Davis

John Sargent, MD – Tufts Medical Center, Boston

Roberto Lewis-Fernández, MD – Columbia College of Physicians & Surgeons, New York



If you would like to a submit case in which your understanding and treatment are affected by challenging cultural and family values, send it to [email protected]. We will then write back with our best answers about how one might proceed in such a case. Your case and our response will then be published at mdedge.com/psychiatry. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they are employed by or affiliated with or the Group for the Advancement of Psychiatry.

References

1. J Nerv Ment Dis. 2013 Jun;20(6);484-9.

2. Schizophr Res. 2014 Feb;152(2-3):391-9.

3. Perspect Psychiatr Care. 2013;49(4):288-92.

4. Ment Health Serv Res. 2001 Dec;3(4):201-14.

5. Br J Psychiatry. 2000 Jul;177;20-5.

6. Cultr Divers Ethnic Minor Psychol. 2008 Jan;14(1):10-8.

7. Couns Psychol. 2003 May1;31:343-61.

8. Emotion. 2002 Dec;2(4):341-60.

9. Am J Psychiatry. 1986 Nov;143(11):1361-73.

10. J Nerv Ment Dis. 2013 Oct;201(10):833-40.

11. Schizophr Bull. 1981;7(1):43-4.

12. Schizophr Bull. 2010 Jul;36(4):836-45.

13. Am J Orthopsychiatry. 2011 Oct;81(4):489-97.

14. Patient Educ Couns. 2009 Apr;75(1):67-76.

Editor’s Note: This is the third installment of Curbside Consult, written by two Group for the Advancement of Psychiatry (GAP) committees – the Committee on Family Psychiatry and the Committee on Cultural Psychiatry.

Erica is a 19-year-old woman from an ethnically mixed background. Her father is an African American retired U.S. military officer who met her mother while he was stationed in Japan, where her mother was born and raised. Erica lived in Japan until she was 8, when the family moved to Seattle, and her father began a new career in a large company.

At age 10, she began to have episodes during which she felt her heart racing, was short of breath, and was diaphoretic. These episodes often took place when the family went out to large public spaces, like a shopping mall, and she would be separated from her parents. They increased in frequency until she was taken to a pediatrician and saw a counselor. Her panic symptoms gradually disappeared during high school, but since starting college and moving away from home, she has felt lost in her environment, and feels as though no one understands her background and upbringing. For example, she abruptly left the first college party she attended, feeling that “everybody had met everybody already and nobody noticed me; maybe they don’t like the way I look.” She has had a return of panic episodes that are now more frequent, coming on without warning, and they have begun to wake her from sleep.

Discussion

Incorporating a family and culture lens to the case can improve assessment and treatment planning. Given the brevity of the case description, many of our recommendations focus on obtaining additional information. It is also important to rule out any medical conditions that could be causing her symptoms. Finally, since great heterogeneity exists within every culture, the clinician should investigate the meanings associated with specific cultural backgrounds for each person to avoid stereotyping that would interfere with an accurate assessment and treatment plan.

Possible cultural conflicts

Although the identified patient in this case is the young woman, the number of culture- and family-related stresses experienced by each member of her family cannot be overstated. The family is truly multicultural, in every sense of the word. Many Americans associate the word “culture” with the influence of race, ethnicity, and country of origin, but the term encompasses many other aspects of the family’s background as well, including the father’s immersion in military culture as an officer of color, the culture of American ex-pats in Japan and of Japanese immigrants to the West Coast of the United States, multiracial children’s adaptations to Japanese and state schools, and U.S. corporate culture. Every member of the family has therefore had to adapt to many cultural transitions. All of these moves require new relationships with the dominant culture and immediate community, which increases stresses within the family as well as between the family and the broader society in which they live. Conflict between the parents increases vigilance and anxiety in children, and since Erica does not have siblings, the likelihood of being caught in a conflict between both parent would be high.

One adaptation that the family has undergone involves negotiating variations in “individualism” – a cultural ideology that prizes the role and desires of the individual over that of the group – and “collectivism” – in which the values and expectations of the social group are prioritized. Each society (for example, urban Japan) and social group (for example, the U.S. military) is characterized by a combination of individualistic and collectivistic traits, though a certain cultural flavor tends to predominate.

If Erica’s mother’s family of origin in Japan was very traditionally collectivistic, she may have experienced a difficult cultural shift when she moved to the United States, which tends to value more individualistic self-presentation. This conflict may have affected Erica’s development, particularly if it were an area of difficulty during her mother’s adaptation to her move or a potential sore spot in the father’s relationship with his wife. It would be good to explore to what extent the mother embraced her move to her new home in Seattle, and whether she also tried to keep her culture of origin alive in the family, while she negotiated her acculturation to U.S. society. In a cosmopolitan city like Seattle with a growing Asian population, this may be easier than in past years, but still might require a great deal of effort. The mother’s adaptation seems an important topic for further assessment, including discovering whether she found work in the United States, if she created new social networks, or whether she remained isolated with her husband and her daughter.

As to the father, if he grew up in a U.S. community that relied on a direct communication style that valued individual assertion as a component of identity and self-esteem, he may have seen his wife’s approach to communication as too reserved, private, or other-directed, especially if her English proficiency or his Japanese fluency was limited. These conflicts may have affected Erica’s sense of self but must be evaluated directly rather than assumed; each parent’s fluency and communication style are fruitful questions to explore. It is possible that conflicts in this area may have interfered with Erica’s incorporation of either parent as a role model for her as a young woman in contemporary U.S. society, threatening her sense of self and leading to anxiety symptoms.

Another area of potential stress for the family involves the experience of discrimination tied to racism or other forms of prejudice. Each family member is vulnerable in this area in his/her own right, given the potential mismatches between their racial/ethnic background and the sometimes intolerant views of dominant social groupings in their societies of origin or their societies of migration. Erica may be most vulnerable in this regard, in light of her dual minority background. The clinician should assess to what extent either or both families of origin may be unhappy about the marriage and biracial child and the possible resulting impact on Erica’s sense of herself. Does she feel more attracted to one aspect of her background? In terms of Erica’s developing identity, it is important to understand whether the family maintains one culture as the family of heritage or works toward developing a multicultural identity. If neither parent can completely identify with Erica, they must work with her to find a way to mesh both cultures. If they do not, she may feel that she has to choose her presentation to the world as African American, Japanese, multiracial, or “post racial.” This may complicate her sense of connection to one or both parents. To some extent this may be affected by which parent she most takes after physically or to which side of the extended family she feels closer. The clinician should consider all these issues in conducting a culturally competent assessment and family-based intervention.

Development context of Erica’s symptom course

Since Erica was asymptomatic during the first 2 years after the move to the United States, it may be possible to assume that early adaptation went reasonably well. The onset of symptoms at age 10 may stem from numerous causes. Biologically, she may have been in prepuberty, which can increase emotional reactivity. Psychologically, this is typically the point at which children become more self-conscious and peer pressure ratchets up, so her possible lack of instinctive understanding of U.S. cultural norms, or her biracial makeup, may have become more salient, either in the form of an intrapsychic racial identity conflict or as an object of interpersonal bullying. It would be helpful to understand these details so as to attend to them in psychotherapy.

If she had begun middle school, academic pressure may have increased. However, her clinicians also should consider the possibility that one or both of her parents may have become stressed by the multiple cultural adaptations required by the move, or that the marriage had become strained, and that she responded to parental stress with increased anxiety. These are possibilities that need to be explored during the assessment.

Her ability to deal with her difficulties and finish high school speaks to her and her family’s resilience. To plan future treatment, it would be useful to explore what aspect of her treatment at age 10 was most helpful (medication, therapy, or both). Ideally, it would be helpful to understand the cultural elements of the relationship between the patient and the pediatrician and counselor. However, given her history, it is no surprise that when she is asked once more to navigate a new culture of college, this time without parental support, that her symptoms reoccur. If she is far from home, in a college where racial tensions are high or where there is not a large multiracial population, or if her parents are having trouble with empty nesting, this would make things more difficult. Her own cultural identity may have been challenged by an environment where she felt “no one understands her background and upbringing,” where “nobody noticed me,” and where “maybe they don’t like the way I look.”

How should clinicians explore these issues?

Erica’s clinicians should seek to understand how she herself defines her background, identity, and upbringing to help her examine possible conflictual issues that are causing distress. The DSM-5 Cultural Formulation Interview is a useful tool for achieving this goal, including its supplementary modules such as the one on Cultural Identity. As part of this assessment, her clinician could ask questions like: How does she see herself and how do other people see her in terms of her identity? How does she present herself? Is she being harassed on campus? Are any of these issues causes of her anxiety? Direct assessment of these topics is necessary to avoid initial impressions that might be affected by the clinician’s own identity, values, and biases. Her clinician should also be conversant in the stresses of the college environment, both at the intrapsychic and interpersonal levels.

While the usual treatments for anxiety, including cognitive-behavioral therapy and medications if necessary, may well be part of her clinical care, helping her understand her own personal cultural identity, how to negotiate the stresses of living on her college campus, and increasing both family and community supports are critical to her well-being and mental health.

While it is true that few people could exactly share Erica’s life experience, there are many pan-nationals and expats who would very much relate to her feelings. Erica faces many of the challenges of those in a group called “third culture kids,” a term coined in the 1950s by social scientists to describe the experience of children raised by Americans working in other countries. The expatriate lifestyle they described as an “interstitial culture” – different from but including elements of both the home culture and the host culture – often is specific to the work group (for example, military, business) that the adults were engaged in. For these children, the question of cultural identity, and “where is home,” is a complex one. For them, unlike their parents, the United States is not home but a foreign land. But their host country is not exactly home, either. Patients like Erica may benefit from reading “Third Culture Kids: The Experience of Growing Up Among Worlds,” by David C. Pollock and Ruth E. Van Reken, and clinicians would likely benefit as well.

Finally, Erica’s therapist could encourage her to find connections in the international student community; there are usually groups on campus for them, and they would understand a multicultural experience. Her therapist also should meet with, or speak with, her parents to see whether there are stresses at home, and could encourage them to support her by frequent visits or calls. When Erica finds a place where she feels at home, we believe her anxiety will decrease.

Key take-home points

1. Ask about, do not assume, the person’s own understanding of his/her background and identity to obtain more specific and precise information so as to guard against stereotyping that could lead to erroneous assessments.

2. Understand the heterogeneity of culture and the complexity of cultural identity.

3. Ask about the family. Who is in the family, both nuclear and extended? Draw a simple genogram. Envision and implement assessment beyond just the individual patient.

4. Assess the impact of culture change on cultural identity and family dynamics.

5. Use the DSM-5 Cultural Formulation Interview to help guide the cultural assessment.

Contributors

Ellen M. Berman, MD – University of Pennsylvania, Perelman School of Medicine, Philadelphia

Roberto Lewis-Fernández, MD – Columbia University and New York State Psychiatric Institute

Francis G. Lu, MD – University of California, Davis

The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they are employed by or those affiliated with GAP.

Resources

Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). (Arlington, Va.: American Psychiatric Association Publishing, 2013).

Lewis-Fernández, R., et al. (eds.) DSM-5 Handbook on the Cultural Formulation Interview (Arlington, Va.: American Psychiatric Association Publishing, 2016).

Lim, R. (ed.). Clinical Manual of Cultural Psychiatry, 2nd edition (Arlington, Va.: American Psychiatric Association Publishing, 2015).

Pollock, D. and Van Reken, R. Third Culture Kids: The Experience of Growing Up Among Worlds (London: Nicholas Breasley Publishing, 2009).

Curbside Consult is inspired by the DSM-5’s emphasis on developing a cultural formulation of patients’ illnesses, and addressing family dynamics and resilience in promoting care that fosters prevention and recovery. We request that you submit cases to [email protected] in which your understanding and treatment are affected by challenging cultural and family issues. We will then write back with our best answers about how one might proceed in such a case. Your case and our response will be published in Clinical Psychiatry News. Please limit your case description to 250 words and include the following details:

1. Patient’s presenting problem or reason for the visit.

2. Patient’s age and gender.

3. Indicators of the patient’s identity – self-identified race/ethnicity, culture, religion/spirituality, socioeconomic status, education, among other variables.

4. Patient’s living situation, family composition, and genogram information (if available).

5. Patient’s geographic location (rural, suburban, urban) and occupation.

6. Patient’s and family’s degree of participation in their identified culture.

7. Questions of the individual submitting the case, including concerns about the role of the family and culture in the case, diagnosis, and treatment planning.

8. Please follow local ethical requirements, disguise the case to protect confidentiality and attend to HIPAA requirements, so that patients or family members reading the article would not recognize themselves.

Additional information might be requested, and editing of the case, questions, and commentary might be needed prior to final publication.

Editor’s Note: This is the third installment of Curbside Consult, written by two Group for the Advancement of Psychiatry (GAP) committees – the Committee on Family Psychiatry and the Committee on Cultural Psychiatry.

Erica is a 19-year-old woman from an ethnically mixed background. Her father is an African American retired U.S. military officer who met her mother while he was stationed in Japan, where her mother was born and raised. Erica lived in Japan until she was 8, when the family moved to Seattle, and her father began a new career in a large company.

At age 10, she began to have episodes during which she felt her heart racing, was short of breath, and was diaphoretic. These episodes often took place when the family went out to large public spaces, like a shopping mall, and she would be separated from her parents. They increased in frequency until she was taken to a pediatrician and saw a counselor. Her panic symptoms gradually disappeared during high school, but since starting college and moving away from home, she has felt lost in her environment, and feels as though no one understands her background and upbringing. For example, she abruptly left the first college party she attended, feeling that “everybody had met everybody already and nobody noticed me; maybe they don’t like the way I look.” She has had a return of panic episodes that are now more frequent, coming on without warning, and they have begun to wake her from sleep.

Discussion

Incorporating a family and culture lens to the case can improve assessment and treatment planning. Given the brevity of the case description, many of our recommendations focus on obtaining additional information. It is also important to rule out any medical conditions that could be causing her symptoms. Finally, since great heterogeneity exists within every culture, the clinician should investigate the meanings associated with specific cultural backgrounds for each person to avoid stereotyping that would interfere with an accurate assessment and treatment plan.

Possible cultural conflicts

Although the identified patient in this case is the young woman, the number of culture- and family-related stresses experienced by each member of her family cannot be overstated. The family is truly multicultural, in every sense of the word. Many Americans associate the word “culture” with the influence of race, ethnicity, and country of origin, but the term encompasses many other aspects of the family’s background as well, including the father’s immersion in military culture as an officer of color, the culture of American ex-pats in Japan and of Japanese immigrants to the West Coast of the United States, multiracial children’s adaptations to Japanese and state schools, and U.S. corporate culture. Every member of the family has therefore had to adapt to many cultural transitions. All of these moves require new relationships with the dominant culture and immediate community, which increases stresses within the family as well as between the family and the broader society in which they live. Conflict between the parents increases vigilance and anxiety in children, and since Erica does not have siblings, the likelihood of being caught in a conflict between both parent would be high.

One adaptation that the family has undergone involves negotiating variations in “individualism” – a cultural ideology that prizes the role and desires of the individual over that of the group – and “collectivism” – in which the values and expectations of the social group are prioritized. Each society (for example, urban Japan) and social group (for example, the U.S. military) is characterized by a combination of individualistic and collectivistic traits, though a certain cultural flavor tends to predominate.

If Erica’s mother’s family of origin in Japan was very traditionally collectivistic, she may have experienced a difficult cultural shift when she moved to the United States, which tends to value more individualistic self-presentation. This conflict may have affected Erica’s development, particularly if it were an area of difficulty during her mother’s adaptation to her move or a potential sore spot in the father’s relationship with his wife. It would be good to explore to what extent the mother embraced her move to her new home in Seattle, and whether she also tried to keep her culture of origin alive in the family, while she negotiated her acculturation to U.S. society. In a cosmopolitan city like Seattle with a growing Asian population, this may be easier than in past years, but still might require a great deal of effort. The mother’s adaptation seems an important topic for further assessment, including discovering whether she found work in the United States, if she created new social networks, or whether she remained isolated with her husband and her daughter.

As to the father, if he grew up in a U.S. community that relied on a direct communication style that valued individual assertion as a component of identity and self-esteem, he may have seen his wife’s approach to communication as too reserved, private, or other-directed, especially if her English proficiency or his Japanese fluency was limited. These conflicts may have affected Erica’s sense of self but must be evaluated directly rather than assumed; each parent’s fluency and communication style are fruitful questions to explore. It is possible that conflicts in this area may have interfered with Erica’s incorporation of either parent as a role model for her as a young woman in contemporary U.S. society, threatening her sense of self and leading to anxiety symptoms.

Another area of potential stress for the family involves the experience of discrimination tied to racism or other forms of prejudice. Each family member is vulnerable in this area in his/her own right, given the potential mismatches between their racial/ethnic background and the sometimes intolerant views of dominant social groupings in their societies of origin or their societies of migration. Erica may be most vulnerable in this regard, in light of her dual minority background. The clinician should assess to what extent either or both families of origin may be unhappy about the marriage and biracial child and the possible resulting impact on Erica’s sense of herself. Does she feel more attracted to one aspect of her background? In terms of Erica’s developing identity, it is important to understand whether the family maintains one culture as the family of heritage or works toward developing a multicultural identity. If neither parent can completely identify with Erica, they must work with her to find a way to mesh both cultures. If they do not, she may feel that she has to choose her presentation to the world as African American, Japanese, multiracial, or “post racial.” This may complicate her sense of connection to one or both parents. To some extent this may be affected by which parent she most takes after physically or to which side of the extended family she feels closer. The clinician should consider all these issues in conducting a culturally competent assessment and family-based intervention.

Development context of Erica’s symptom course

Since Erica was asymptomatic during the first 2 years after the move to the United States, it may be possible to assume that early adaptation went reasonably well. The onset of symptoms at age 10 may stem from numerous causes. Biologically, she may have been in prepuberty, which can increase emotional reactivity. Psychologically, this is typically the point at which children become more self-conscious and peer pressure ratchets up, so her possible lack of instinctive understanding of U.S. cultural norms, or her biracial makeup, may have become more salient, either in the form of an intrapsychic racial identity conflict or as an object of interpersonal bullying. It would be helpful to understand these details so as to attend to them in psychotherapy.

If she had begun middle school, academic pressure may have increased. However, her clinicians also should consider the possibility that one or both of her parents may have become stressed by the multiple cultural adaptations required by the move, or that the marriage had become strained, and that she responded to parental stress with increased anxiety. These are possibilities that need to be explored during the assessment.

Her ability to deal with her difficulties and finish high school speaks to her and her family’s resilience. To plan future treatment, it would be useful to explore what aspect of her treatment at age 10 was most helpful (medication, therapy, or both). Ideally, it would be helpful to understand the cultural elements of the relationship between the patient and the pediatrician and counselor. However, given her history, it is no surprise that when she is asked once more to navigate a new culture of college, this time without parental support, that her symptoms reoccur. If she is far from home, in a college where racial tensions are high or where there is not a large multiracial population, or if her parents are having trouble with empty nesting, this would make things more difficult. Her own cultural identity may have been challenged by an environment where she felt “no one understands her background and upbringing,” where “nobody noticed me,” and where “maybe they don’t like the way I look.”

How should clinicians explore these issues?

Erica’s clinicians should seek to understand how she herself defines her background, identity, and upbringing to help her examine possible conflictual issues that are causing distress. The DSM-5 Cultural Formulation Interview is a useful tool for achieving this goal, including its supplementary modules such as the one on Cultural Identity. As part of this assessment, her clinician could ask questions like: How does she see herself and how do other people see her in terms of her identity? How does she present herself? Is she being harassed on campus? Are any of these issues causes of her anxiety? Direct assessment of these topics is necessary to avoid initial impressions that might be affected by the clinician’s own identity, values, and biases. Her clinician should also be conversant in the stresses of the college environment, both at the intrapsychic and interpersonal levels.

While the usual treatments for anxiety, including cognitive-behavioral therapy and medications if necessary, may well be part of her clinical care, helping her understand her own personal cultural identity, how to negotiate the stresses of living on her college campus, and increasing both family and community supports are critical to her well-being and mental health.

While it is true that few people could exactly share Erica’s life experience, there are many pan-nationals and expats who would very much relate to her feelings. Erica faces many of the challenges of those in a group called “third culture kids,” a term coined in the 1950s by social scientists to describe the experience of children raised by Americans working in other countries. The expatriate lifestyle they described as an “interstitial culture” – different from but including elements of both the home culture and the host culture – often is specific to the work group (for example, military, business) that the adults were engaged in. For these children, the question of cultural identity, and “where is home,” is a complex one. For them, unlike their parents, the United States is not home but a foreign land. But their host country is not exactly home, either. Patients like Erica may benefit from reading “Third Culture Kids: The Experience of Growing Up Among Worlds,” by David C. Pollock and Ruth E. Van Reken, and clinicians would likely benefit as well.

Finally, Erica’s therapist could encourage her to find connections in the international student community; there are usually groups on campus for them, and they would understand a multicultural experience. Her therapist also should meet with, or speak with, her parents to see whether there are stresses at home, and could encourage them to support her by frequent visits or calls. When Erica finds a place where she feels at home, we believe her anxiety will decrease.

Key take-home points

1. Ask about, do not assume, the person’s own understanding of his/her background and identity to obtain more specific and precise information so as to guard against stereotyping that could lead to erroneous assessments.

2. Understand the heterogeneity of culture and the complexity of cultural identity.

3. Ask about the family. Who is in the family, both nuclear and extended? Draw a simple genogram. Envision and implement assessment beyond just the individual patient.

4. Assess the impact of culture change on cultural identity and family dynamics.

5. Use the DSM-5 Cultural Formulation Interview to help guide the cultural assessment.

Contributors

Ellen M. Berman, MD – University of Pennsylvania, Perelman School of Medicine, Philadelphia

Roberto Lewis-Fernández, MD – Columbia University and New York State Psychiatric Institute

Francis G. Lu, MD – University of California, Davis

The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they are employed by or those affiliated with GAP.

Resources

Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). (Arlington, Va.: American Psychiatric Association Publishing, 2013).

Lewis-Fernández, R., et al. (eds.) DSM-5 Handbook on the Cultural Formulation Interview (Arlington, Va.: American Psychiatric Association Publishing, 2016).

Lim, R. (ed.). Clinical Manual of Cultural Psychiatry, 2nd edition (Arlington, Va.: American Psychiatric Association Publishing, 2015).

Pollock, D. and Van Reken, R. Third Culture Kids: The Experience of Growing Up Among Worlds (London: Nicholas Breasley Publishing, 2009).

Curbside Consult is inspired by the DSM-5’s emphasis on developing a cultural formulation of patients’ illnesses, and addressing family dynamics and resilience in promoting care that fosters prevention and recovery. We request that you submit cases to [email protected] in which your understanding and treatment are affected by challenging cultural and family issues. We will then write back with our best answers about how one might proceed in such a case. Your case and our response will be published in Clinical Psychiatry News. Please limit your case description to 250 words and include the following details:

1. Patient’s presenting problem or reason for the visit.

2. Patient’s age and gender.

3. Indicators of the patient’s identity – self-identified race/ethnicity, culture, religion/spirituality, socioeconomic status, education, among other variables.

4. Patient’s living situation, family composition, and genogram information (if available).

5. Patient’s geographic location (rural, suburban, urban) and occupation.

6. Patient’s and family’s degree of participation in their identified culture.

7. Questions of the individual submitting the case, including concerns about the role of the family and culture in the case, diagnosis, and treatment planning.

8. Please follow local ethical requirements, disguise the case to protect confidentiality and attend to HIPAA requirements, so that patients or family members reading the article would not recognize themselves.

Additional information might be requested, and editing of the case, questions, and commentary might be needed prior to final publication.

Editor’s Note: This is the third installment of Curbside Consult, written by two Group for the Advancement of Psychiatry (GAP) committees – the Committee on Family Psychiatry and the Committee on Cultural Psychiatry.

Erica is a 19-year-old woman from an ethnically mixed background. Her father is an African American retired U.S. military officer who met her mother while he was stationed in Japan, where her mother was born and raised. Erica lived in Japan until she was 8, when the family moved to Seattle, and her father began a new career in a large company.

At age 10, she began to have episodes during which she felt her heart racing, was short of breath, and was diaphoretic. These episodes often took place when the family went out to large public spaces, like a shopping mall, and she would be separated from her parents. They increased in frequency until she was taken to a pediatrician and saw a counselor. Her panic symptoms gradually disappeared during high school, but since starting college and moving away from home, she has felt lost in her environment, and feels as though no one understands her background and upbringing. For example, she abruptly left the first college party she attended, feeling that “everybody had met everybody already and nobody noticed me; maybe they don’t like the way I look.” She has had a return of panic episodes that are now more frequent, coming on without warning, and they have begun to wake her from sleep.

Discussion

Incorporating a family and culture lens to the case can improve assessment and treatment planning. Given the brevity of the case description, many of our recommendations focus on obtaining additional information. It is also important to rule out any medical conditions that could be causing her symptoms. Finally, since great heterogeneity exists within every culture, the clinician should investigate the meanings associated with specific cultural backgrounds for each person to avoid stereotyping that would interfere with an accurate assessment and treatment plan.

Possible cultural conflicts

Although the identified patient in this case is the young woman, the number of culture- and family-related stresses experienced by each member of her family cannot be overstated. The family is truly multicultural, in every sense of the word. Many Americans associate the word “culture” with the influence of race, ethnicity, and country of origin, but the term encompasses many other aspects of the family’s background as well, including the father’s immersion in military culture as an officer of color, the culture of American ex-pats in Japan and of Japanese immigrants to the West Coast of the United States, multiracial children’s adaptations to Japanese and state schools, and U.S. corporate culture. Every member of the family has therefore had to adapt to many cultural transitions. All of these moves require new relationships with the dominant culture and immediate community, which increases stresses within the family as well as between the family and the broader society in which they live. Conflict between the parents increases vigilance and anxiety in children, and since Erica does not have siblings, the likelihood of being caught in a conflict between both parent would be high.

One adaptation that the family has undergone involves negotiating variations in “individualism” – a cultural ideology that prizes the role and desires of the individual over that of the group – and “collectivism” – in which the values and expectations of the social group are prioritized. Each society (for example, urban Japan) and social group (for example, the U.S. military) is characterized by a combination of individualistic and collectivistic traits, though a certain cultural flavor tends to predominate.

If Erica’s mother’s family of origin in Japan was very traditionally collectivistic, she may have experienced a difficult cultural shift when she moved to the United States, which tends to value more individualistic self-presentation. This conflict may have affected Erica’s development, particularly if it were an area of difficulty during her mother’s adaptation to her move or a potential sore spot in the father’s relationship with his wife. It would be good to explore to what extent the mother embraced her move to her new home in Seattle, and whether she also tried to keep her culture of origin alive in the family, while she negotiated her acculturation to U.S. society. In a cosmopolitan city like Seattle with a growing Asian population, this may be easier than in past years, but still might require a great deal of effort. The mother’s adaptation seems an important topic for further assessment, including discovering whether she found work in the United States, if she created new social networks, or whether she remained isolated with her husband and her daughter.

As to the father, if he grew up in a U.S. community that relied on a direct communication style that valued individual assertion as a component of identity and self-esteem, he may have seen his wife’s approach to communication as too reserved, private, or other-directed, especially if her English proficiency or his Japanese fluency was limited. These conflicts may have affected Erica’s sense of self but must be evaluated directly rather than assumed; each parent’s fluency and communication style are fruitful questions to explore. It is possible that conflicts in this area may have interfered with Erica’s incorporation of either parent as a role model for her as a young woman in contemporary U.S. society, threatening her sense of self and leading to anxiety symptoms.

Another area of potential stress for the family involves the experience of discrimination tied to racism or other forms of prejudice. Each family member is vulnerable in this area in his/her own right, given the potential mismatches between their racial/ethnic background and the sometimes intolerant views of dominant social groupings in their societies of origin or their societies of migration. Erica may be most vulnerable in this regard, in light of her dual minority background. The clinician should assess to what extent either or both families of origin may be unhappy about the marriage and biracial child and the possible resulting impact on Erica’s sense of herself. Does she feel more attracted to one aspect of her background? In terms of Erica’s developing identity, it is important to understand whether the family maintains one culture as the family of heritage or works toward developing a multicultural identity. If neither parent can completely identify with Erica, they must work with her to find a way to mesh both cultures. If they do not, she may feel that she has to choose her presentation to the world as African American, Japanese, multiracial, or “post racial.” This may complicate her sense of connection to one or both parents. To some extent this may be affected by which parent she most takes after physically or to which side of the extended family she feels closer. The clinician should consider all these issues in conducting a culturally competent assessment and family-based intervention.

Development context of Erica’s symptom course

Since Erica was asymptomatic during the first 2 years after the move to the United States, it may be possible to assume that early adaptation went reasonably well. The onset of symptoms at age 10 may stem from numerous causes. Biologically, she may have been in prepuberty, which can increase emotional reactivity. Psychologically, this is typically the point at which children become more self-conscious and peer pressure ratchets up, so her possible lack of instinctive understanding of U.S. cultural norms, or her biracial makeup, may have become more salient, either in the form of an intrapsychic racial identity conflict or as an object of interpersonal bullying. It would be helpful to understand these details so as to attend to them in psychotherapy.

If she had begun middle school, academic pressure may have increased. However, her clinicians also should consider the possibility that one or both of her parents may have become stressed by the multiple cultural adaptations required by the move, or that the marriage had become strained, and that she responded to parental stress with increased anxiety. These are possibilities that need to be explored during the assessment.

Her ability to deal with her difficulties and finish high school speaks to her and her family’s resilience. To plan future treatment, it would be useful to explore what aspect of her treatment at age 10 was most helpful (medication, therapy, or both). Ideally, it would be helpful to understand the cultural elements of the relationship between the patient and the pediatrician and counselor. However, given her history, it is no surprise that when she is asked once more to navigate a new culture of college, this time without parental support, that her symptoms reoccur. If she is far from home, in a college where racial tensions are high or where there is not a large multiracial population, or if her parents are having trouble with empty nesting, this would make things more difficult. Her own cultural identity may have been challenged by an environment where she felt “no one understands her background and upbringing,” where “nobody noticed me,” and where “maybe they don’t like the way I look.”

How should clinicians explore these issues?

Erica’s clinicians should seek to understand how she herself defines her background, identity, and upbringing to help her examine possible conflictual issues that are causing distress. The DSM-5 Cultural Formulation Interview is a useful tool for achieving this goal, including its supplementary modules such as the one on Cultural Identity. As part of this assessment, her clinician could ask questions like: How does she see herself and how do other people see her in terms of her identity? How does she present herself? Is she being harassed on campus? Are any of these issues causes of her anxiety? Direct assessment of these topics is necessary to avoid initial impressions that might be affected by the clinician’s own identity, values, and biases. Her clinician should also be conversant in the stresses of the college environment, both at the intrapsychic and interpersonal levels.

While the usual treatments for anxiety, including cognitive-behavioral therapy and medications if necessary, may well be part of her clinical care, helping her understand her own personal cultural identity, how to negotiate the stresses of living on her college campus, and increasing both family and community supports are critical to her well-being and mental health.

While it is true that few people could exactly share Erica’s life experience, there are many pan-nationals and expats who would very much relate to her feelings. Erica faces many of the challenges of those in a group called “third culture kids,” a term coined in the 1950s by social scientists to describe the experience of children raised by Americans working in other countries. The expatriate lifestyle they described as an “interstitial culture” – different from but including elements of both the home culture and the host culture – often is specific to the work group (for example, military, business) that the adults were engaged in. For these children, the question of cultural identity, and “where is home,” is a complex one. For them, unlike their parents, the United States is not home but a foreign land. But their host country is not exactly home, either. Patients like Erica may benefit from reading “Third Culture Kids: The Experience of Growing Up Among Worlds,” by David C. Pollock and Ruth E. Van Reken, and clinicians would likely benefit as well.

Finally, Erica’s therapist could encourage her to find connections in the international student community; there are usually groups on campus for them, and they would understand a multicultural experience. Her therapist also should meet with, or speak with, her parents to see whether there are stresses at home, and could encourage them to support her by frequent visits or calls. When Erica finds a place where she feels at home, we believe her anxiety will decrease.

Key take-home points

1. Ask about, do not assume, the person’s own understanding of his/her background and identity to obtain more specific and precise information so as to guard against stereotyping that could lead to erroneous assessments.

2. Understand the heterogeneity of culture and the complexity of cultural identity.

3. Ask about the family. Who is in the family, both nuclear and extended? Draw a simple genogram. Envision and implement assessment beyond just the individual patient.

4. Assess the impact of culture change on cultural identity and family dynamics.

5. Use the DSM-5 Cultural Formulation Interview to help guide the cultural assessment.

Contributors

Ellen M. Berman, MD – University of Pennsylvania, Perelman School of Medicine, Philadelphia

Roberto Lewis-Fernández, MD – Columbia University and New York State Psychiatric Institute

Francis G. Lu, MD – University of California, Davis

The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they are employed by or those affiliated with GAP.

Resources

Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). (Arlington, Va.: American Psychiatric Association Publishing, 2013).

Lewis-Fernández, R., et al. (eds.) DSM-5 Handbook on the Cultural Formulation Interview (Arlington, Va.: American Psychiatric Association Publishing, 2016).

Lim, R. (ed.). Clinical Manual of Cultural Psychiatry, 2nd edition (Arlington, Va.: American Psychiatric Association Publishing, 2015).

Pollock, D. and Van Reken, R. Third Culture Kids: The Experience of Growing Up Among Worlds (London: Nicholas Breasley Publishing, 2009).

Curbside Consult is inspired by the DSM-5’s emphasis on developing a cultural formulation of patients’ illnesses, and addressing family dynamics and resilience in promoting care that fosters prevention and recovery. We request that you submit cases to [email protected] in which your understanding and treatment are affected by challenging cultural and family issues. We will then write back with our best answers about how one might proceed in such a case. Your case and our response will be published in Clinical Psychiatry News. Please limit your case description to 250 words and include the following details:

1. Patient’s presenting problem or reason for the visit.

2. Patient’s age and gender.

3. Indicators of the patient’s identity – self-identified race/ethnicity, culture, religion/spirituality, socioeconomic status, education, among other variables.

4. Patient’s living situation, family composition, and genogram information (if available).

5. Patient’s geographic location (rural, suburban, urban) and occupation.

6. Patient’s and family’s degree of participation in their identified culture.

7. Questions of the individual submitting the case, including concerns about the role of the family and culture in the case, diagnosis, and treatment planning.

8. Please follow local ethical requirements, disguise the case to protect confidentiality and attend to HIPAA requirements, so that patients or family members reading the article would not recognize themselves.

Additional information might be requested, and editing of the case, questions, and commentary might be needed prior to final publication.

Muslim Bangladeshi female presents

The patient is a 31-year-old married Muslim Bangladeshi female homemaker admitted to an inpatient unit in a private hospital in a large urban area in the northeastern United States because of postpartum psychosis. She recently had immigrated to the United States and spoke no English. She lived with her husband, his parents, and his siblings in a city neighborhood predominantly comprised of South Asian immigrants. Her sole source of financial support was her husband, who worked as a cab driver. Both patient and her husband were uninsured. They identified strongly with their religion and culture of origin.

Key questions

Communication was a challenge and was accomplished using an interpreter, who was not always available. The patient did not seem to respond to treatment, and there was a question about the possibility that she was “cheeking” her medications. Her husband requested her discharge against medical advice, despite her still showing signs of psychosis. He appeared ambivalent about outpatient follow-up.

What is the duty of care in this situation, given the complexities inherent in a cross-cultural situation, the presence of communication barriers, the question of patient and infant safety, the husband’s role (given the understanding that his actions were probably culturally sanctioned and consistent with his role), issues regarding financing their current and follow-up care, and their ambivalence toward follow-up care?

Family perspective

Working with a qualified medical interpreter is imperative, and hospitals and health care providers who accept federal funds are obliged to provide language assistance services under Title VI of the Civil Rights Act of 1964.

First, it is important to accurately assess the woman’s psychosis, including risk of self-harm, risk of harming the infant or others, and capacity to care adequately and safely for the infant.

Second, the team should assess the patient’s and husband’s beliefs about the illness, hospitalization, and treatment. For some Muslim patients, the daily practice of Islam may necessitate the separation of sexes, meaning that female nurses and physicians might be optimal. Accessing professional spiritual or pastoral care in meeting the patient’s and family’s religious needs should be considered. Additional cultural practices that might help increase the acceptability of inpatient psychiatric care for the family include practices regarding diet, dress, hygiene, and prayer. The husband also might want to stay and sleep in the patient’s room during her hospitalization.

It also might be challenging for some North American therapists to understand and focus on the entire family as a functioning unit, rather than seeing the issues as only between husband and wife. Learning about how “normal family functioning” is defined, especially in terms of roles, hierarchy, and intimacy, is critical to supporting this mother and baby. Cultivating “cultural humility” in working with patients and families from diverse backgrounds is extremely important.

During the hospitalization as the patient improves, a plan for care needs to be developed with the patient and her family. This plan should include adequate support of the mother and her baby. The husband should bring his parents and siblings to an initial meeting early during the hospitalization, being mindful of addressing any HIPAA-related issues. This will allow for a uniform understanding of the patient’s illness and treatment. At this meeting, all family members should express their concerns, worries, beliefs, and perceived barriers to optimal care. If the family members feel listened to, they are more likely to feel understood and adhere to recommendations.

At the initial meeting and subsequent ones, the following questions might be helpful to ask to gather information in negotiating a mutually acceptable treatment plan:

1. What is the family’s understanding of her illness? What do they think may have caused it? How do they understand postpartum psychosis? Do they think there is a role for medication? Are any other alternative healing modalities being considered or used?

2. Who is caring for the baby now? Is the baby healthy? Does the family understand how the mother’s illness affects the baby? Can the family provide adequate care for the baby?

3. How are decisions made in the family? Are there any other issues in the family, such as ill health in a parent?

4. Was this an arranged marriage? How long have they known the patient? Do they care for her? What is the family’s attitude toward her?

5. Besides the mother-in-law, are there other adult females (for example, her husband’s sisters and his brothers’ wives) living in the household? How old is the mother-in-law? Who runs the household? Who does all the work? If possible, it will be important to interview anyone else in the household. How long have the couple and the family been in the United States? Did they all come at the same time?

6. Does the family have a supportive community? What are their beliefs about mental illness? Whom do they trust in their community? A religious leader? A local doctor? Who treats the women in the community?

7. If there is time, other issues can be explored. For example, what were the circumstances of their immigration? What has the transition from Bangladesh to life in the United States been like for the family?

8. Who will care for her at home? Who will ensure she takes her medications? Who will take her to follow-up visits?

There are many unknowns in this case that require further exploration. Time taken to arrange for a medically qualified interpreter and an extended family meeting will help the physician and psychiatric team understand the current situation and set up an appropriate plan of care.

Cultural perspective

The case material raises many questions. In the first place, there is no need to assume that the husband was behaving in a “culturally sanctioned and consistent way.” In a large population like that of Bangladeshi Muslims, significant heterogeneity exists, and there are more ways than one to respond. Although access to care is increasing for some population segments, Bangladesh still has limited mental health services and resources.

What were the reasons for the patient to be admitted to a psychiatric unit? How many days after the delivery? Were there any hostile actions or reactions to the baby? What is the patient’s pregnancy history? What meaning was ascribed to the symptoms and behavior that the patient manifested prior to hospitalization? Was this the first episode of psychiatric illness for the patient? Has she shown any dangerous behaviors before?

The reason why the husband is taking the wife home against medical advice is unclear. What reason did the husband give for this decision? Could stigma toward mental illness or hospitalization play a role? Was an interpreter used to help understand his reasoning? Was the husband dissatisfied about something? This is important, because it is likely that the husband brought the wife for hospitalization in the first place. Were the inpatient physician and nurses male or female, and could gender-related issues have been a barrier to accepting care? Might there have been a Muslim chaplain in the hospital or in the community or someone else who could have served as a cultural broker earlier in the hospitalization to have prevented this impasse?

The Cultural Formulation Interview (CFI) in the DSM-5 and the CFI-Informant Version for family members provide a framework to explore these questions and the questions recommended in the Family Perspective throughout the course of treatment.

Additional relevant questions include the following: What are cultural norms for their expectations for support of a new mother during the postpartum period? What are the norms for who, besides the mother, provides infant care? Are normative postpartum practices possible, or have they been disrupted in the hospital setting and/or in their home? If the mother and baby are both on the unit, is the request motivated by a desire to bring the baby home? If the baby is not on the unit, is this driving the family’s concern?

How isolated will the woman feel when she is home with the baby and her husband is out working as a taxi driver? Are there community-based organizations that the clinicians could collaborate with to provide resources and support for this woman (for example, women’s groups, immigrant groups, religious groups)? This would require learning more about what appeals to her, which groups she might identify with, and what is available in her neighborhood/community that aligns with what appeals to her.

It also would be important to determine if the patient was having any side effects from her psychotropic medications. Many South Asians have a low tolerance for side effects. Did the patient or family have any religious or cultural concerns about how the medications were manufactured or their composition (for example, worries about alcohol content)? Could any of these factors be related to the patient’s possible “cheeking” of her medications?

The major ethical/legal question to address is the patient’s attitude toward and relationship with the baby, and whether she was and is currently a danger to herself or others. Was the baby with the patient in the hospital? Did she feed the baby? What were the signs of psychosis that the patient exhibited, and what were the bases of her diagnosis? Was there an opportunity to discuss these issues with the husband? If so, what was his response?

Unless the patient is found to be dangerous to herself or others, including the baby, there is no option but to discharge. If a Bengali-speaking psychiatrist/therapist could be located within a reasonable driving distance, every effort should be made to connect the two. Husband and wife certainly should be instructed at the first sign of trouble to seek medical/psychiatric assistance, with or without insurance. Is there a possibility of home visits with an interpreter given the potential risks of patient and infant safety? Close follow-up and coordination of care with the patient’s and baby’s primary care physician is needed. Seeking support from the patient’s religious community also is worth considering.

Contributors

Alison M. Heru, M.D. – University of Colorado Denver, Aurora

Ellen Berman, M.D. – University of Pennsylvania, Philadelphia

Annelle B. Primm, M.D., M.P.H. – Johns Hopkins University, Baltimore (adjunct faculty)

Anne E. Becker, M.D., Ph.D. – Harvard Medical School, Boston

Robert C. Like, M.D., M.S. – Rutgers University, Robert Wood Johnson Medical School, New Brunswick

Resources

Farooq S., Fear C. Working Through Interpreters. (Adv Psychiatr Treat. 2003 Mar;9[2]:104-9. doi: 10.1192/apt.01.12 http://apt.rcpsych.org/content/9/2/104.full.)

Chandra P.S. Postpartum Psychiatric Care in India: The need for Integration and Innovation. (World Psychiatry. 2004;3[2]:99-100.)

Ahmad F., Shik A., Vanza R., Cheung A.M., George U, Stewart D.E. Voices of South Asian Women: Immigration and Mental Health. (Women Health 2004; 40[4]:113-130.)

Mantle F. Developing a Culture-Specific Tool to Assess Postnatal Depression in the Indian Community. (Br J Community Nurs. 2003;8[4]:176-180.)

To read about the goals of Curbside Consult, the guiding principles for assessment, and the guidelines for case submission, see “Considering patients’ family, culture,” Clinical Psychiatry News, January 2015, p. 12. The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they are employed by or affiliated with or the Group for the Advancement of Psychiatry (GAP).

This column is in memory of Dr. Prakash N. Desai, who contributed to this piece before his death earlier this year.

Muslim Bangladeshi female presents

The patient is a 31-year-old married Muslim Bangladeshi female homemaker admitted to an inpatient unit in a private hospital in a large urban area in the northeastern United States because of postpartum psychosis. She recently had immigrated to the United States and spoke no English. She lived with her husband, his parents, and his siblings in a city neighborhood predominantly comprised of South Asian immigrants. Her sole source of financial support was her husband, who worked as a cab driver. Both patient and her husband were uninsured. They identified strongly with their religion and culture of origin.

Key questions

Communication was a challenge and was accomplished using an interpreter, who was not always available. The patient did not seem to respond to treatment, and there was a question about the possibility that she was “cheeking” her medications. Her husband requested her discharge against medical advice, despite her still showing signs of psychosis. He appeared ambivalent about outpatient follow-up.

What is the duty of care in this situation, given the complexities inherent in a cross-cultural situation, the presence of communication barriers, the question of patient and infant safety, the husband’s role (given the understanding that his actions were probably culturally sanctioned and consistent with his role), issues regarding financing their current and follow-up care, and their ambivalence toward follow-up care?

Family perspective

Working with a qualified medical interpreter is imperative, and hospitals and health care providers who accept federal funds are obliged to provide language assistance services under Title VI of the Civil Rights Act of 1964.

First, it is important to accurately assess the woman’s psychosis, including risk of self-harm, risk of harming the infant or others, and capacity to care adequately and safely for the infant.

Second, the team should assess the patient’s and husband’s beliefs about the illness, hospitalization, and treatment. For some Muslim patients, the daily practice of Islam may necessitate the separation of sexes, meaning that female nurses and physicians might be optimal. Accessing professional spiritual or pastoral care in meeting the patient’s and family’s religious needs should be considered. Additional cultural practices that might help increase the acceptability of inpatient psychiatric care for the family include practices regarding diet, dress, hygiene, and prayer. The husband also might want to stay and sleep in the patient’s room during her hospitalization.

It also might be challenging for some North American therapists to understand and focus on the entire family as a functioning unit, rather than seeing the issues as only between husband and wife. Learning about how “normal family functioning” is defined, especially in terms of roles, hierarchy, and intimacy, is critical to supporting this mother and baby. Cultivating “cultural humility” in working with patients and families from diverse backgrounds is extremely important.

During the hospitalization as the patient improves, a plan for care needs to be developed with the patient and her family. This plan should include adequate support of the mother and her baby. The husband should bring his parents and siblings to an initial meeting early during the hospitalization, being mindful of addressing any HIPAA-related issues. This will allow for a uniform understanding of the patient’s illness and treatment. At this meeting, all family members should express their concerns, worries, beliefs, and perceived barriers to optimal care. If the family members feel listened to, they are more likely to feel understood and adhere to recommendations.

At the initial meeting and subsequent ones, the following questions might be helpful to ask to gather information in negotiating a mutually acceptable treatment plan:

1. What is the family’s understanding of her illness? What do they think may have caused it? How do they understand postpartum psychosis? Do they think there is a role for medication? Are any other alternative healing modalities being considered or used?

2. Who is caring for the baby now? Is the baby healthy? Does the family understand how the mother’s illness affects the baby? Can the family provide adequate care for the baby?

3. How are decisions made in the family? Are there any other issues in the family, such as ill health in a parent?

4. Was this an arranged marriage? How long have they known the patient? Do they care for her? What is the family’s attitude toward her?

5. Besides the mother-in-law, are there other adult females (for example, her husband’s sisters and his brothers’ wives) living in the household? How old is the mother-in-law? Who runs the household? Who does all the work? If possible, it will be important to interview anyone else in the household. How long have the couple and the family been in the United States? Did they all come at the same time?

6. Does the family have a supportive community? What are their beliefs about mental illness? Whom do they trust in their community? A religious leader? A local doctor? Who treats the women in the community?

7. If there is time, other issues can be explored. For example, what were the circumstances of their immigration? What has the transition from Bangladesh to life in the United States been like for the family?

8. Who will care for her at home? Who will ensure she takes her medications? Who will take her to follow-up visits?

There are many unknowns in this case that require further exploration. Time taken to arrange for a medically qualified interpreter and an extended family meeting will help the physician and psychiatric team understand the current situation and set up an appropriate plan of care.

Cultural perspective

The case material raises many questions. In the first place, there is no need to assume that the husband was behaving in a “culturally sanctioned and consistent way.” In a large population like that of Bangladeshi Muslims, significant heterogeneity exists, and there are more ways than one to respond. Although access to care is increasing for some population segments, Bangladesh still has limited mental health services and resources.

What were the reasons for the patient to be admitted to a psychiatric unit? How many days after the delivery? Were there any hostile actions or reactions to the baby? What is the patient’s pregnancy history? What meaning was ascribed to the symptoms and behavior that the patient manifested prior to hospitalization? Was this the first episode of psychiatric illness for the patient? Has she shown any dangerous behaviors before?

The reason why the husband is taking the wife home against medical advice is unclear. What reason did the husband give for this decision? Could stigma toward mental illness or hospitalization play a role? Was an interpreter used to help understand his reasoning? Was the husband dissatisfied about something? This is important, because it is likely that the husband brought the wife for hospitalization in the first place. Were the inpatient physician and nurses male or female, and could gender-related issues have been a barrier to accepting care? Might there have been a Muslim chaplain in the hospital or in the community or someone else who could have served as a cultural broker earlier in the hospitalization to have prevented this impasse?

The Cultural Formulation Interview (CFI) in the DSM-5 and the CFI-Informant Version for family members provide a framework to explore these questions and the questions recommended in the Family Perspective throughout the course of treatment.

Additional relevant questions include the following: What are cultural norms for their expectations for support of a new mother during the postpartum period? What are the norms for who, besides the mother, provides infant care? Are normative postpartum practices possible, or have they been disrupted in the hospital setting and/or in their home? If the mother and baby are both on the unit, is the request motivated by a desire to bring the baby home? If the baby is not on the unit, is this driving the family’s concern?

How isolated will the woman feel when she is home with the baby and her husband is out working as a taxi driver? Are there community-based organizations that the clinicians could collaborate with to provide resources and support for this woman (for example, women’s groups, immigrant groups, religious groups)? This would require learning more about what appeals to her, which groups she might identify with, and what is available in her neighborhood/community that aligns with what appeals to her.

It also would be important to determine if the patient was having any side effects from her psychotropic medications. Many South Asians have a low tolerance for side effects. Did the patient or family have any religious or cultural concerns about how the medications were manufactured or their composition (for example, worries about alcohol content)? Could any of these factors be related to the patient’s possible “cheeking” of her medications?

The major ethical/legal question to address is the patient’s attitude toward and relationship with the baby, and whether she was and is currently a danger to herself or others. Was the baby with the patient in the hospital? Did she feed the baby? What were the signs of psychosis that the patient exhibited, and what were the bases of her diagnosis? Was there an opportunity to discuss these issues with the husband? If so, what was his response?

Unless the patient is found to be dangerous to herself or others, including the baby, there is no option but to discharge. If a Bengali-speaking psychiatrist/therapist could be located within a reasonable driving distance, every effort should be made to connect the two. Husband and wife certainly should be instructed at the first sign of trouble to seek medical/psychiatric assistance, with or without insurance. Is there a possibility of home visits with an interpreter given the potential risks of patient and infant safety? Close follow-up and coordination of care with the patient’s and baby’s primary care physician is needed. Seeking support from the patient’s religious community also is worth considering.

Contributors

Alison M. Heru, M.D. – University of Colorado Denver, Aurora

Ellen Berman, M.D. – University of Pennsylvania, Philadelphia

Annelle B. Primm, M.D., M.P.H. – Johns Hopkins University, Baltimore (adjunct faculty)

Anne E. Becker, M.D., Ph.D. – Harvard Medical School, Boston

Robert C. Like, M.D., M.S. – Rutgers University, Robert Wood Johnson Medical School, New Brunswick

Resources

Farooq S., Fear C. Working Through Interpreters. (Adv Psychiatr Treat. 2003 Mar;9[2]:104-9. doi: 10.1192/apt.01.12 http://apt.rcpsych.org/content/9/2/104.full.)

Chandra P.S. Postpartum Psychiatric Care in India: The need for Integration and Innovation. (World Psychiatry. 2004;3[2]:99-100.)

Ahmad F., Shik A., Vanza R., Cheung A.M., George U, Stewart D.E. Voices of South Asian Women: Immigration and Mental Health. (Women Health 2004; 40[4]:113-130.)

Mantle F. Developing a Culture-Specific Tool to Assess Postnatal Depression in the Indian Community. (Br J Community Nurs. 2003;8[4]:176-180.)

To read about the goals of Curbside Consult, the guiding principles for assessment, and the guidelines for case submission, see “Considering patients’ family, culture,” Clinical Psychiatry News, January 2015, p. 12. The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they are employed by or affiliated with or the Group for the Advancement of Psychiatry (GAP).

This column is in memory of Dr. Prakash N. Desai, who contributed to this piece before his death earlier this year.

Muslim Bangladeshi female presents

The patient is a 31-year-old married Muslim Bangladeshi female homemaker admitted to an inpatient unit in a private hospital in a large urban area in the northeastern United States because of postpartum psychosis. She recently had immigrated to the United States and spoke no English. She lived with her husband, his parents, and his siblings in a city neighborhood predominantly comprised of South Asian immigrants. Her sole source of financial support was her husband, who worked as a cab driver. Both patient and her husband were uninsured. They identified strongly with their religion and culture of origin.

Key questions

Communication was a challenge and was accomplished using an interpreter, who was not always available. The patient did not seem to respond to treatment, and there was a question about the possibility that she was “cheeking” her medications. Her husband requested her discharge against medical advice, despite her still showing signs of psychosis. He appeared ambivalent about outpatient follow-up.

What is the duty of care in this situation, given the complexities inherent in a cross-cultural situation, the presence of communication barriers, the question of patient and infant safety, the husband’s role (given the understanding that his actions were probably culturally sanctioned and consistent with his role), issues regarding financing their current and follow-up care, and their ambivalence toward follow-up care?

Family perspective

Working with a qualified medical interpreter is imperative, and hospitals and health care providers who accept federal funds are obliged to provide language assistance services under Title VI of the Civil Rights Act of 1964.

First, it is important to accurately assess the woman’s psychosis, including risk of self-harm, risk of harming the infant or others, and capacity to care adequately and safely for the infant.

Second, the team should assess the patient’s and husband’s beliefs about the illness, hospitalization, and treatment. For some Muslim patients, the daily practice of Islam may necessitate the separation of sexes, meaning that female nurses and physicians might be optimal. Accessing professional spiritual or pastoral care in meeting the patient’s and family’s religious needs should be considered. Additional cultural practices that might help increase the acceptability of inpatient psychiatric care for the family include practices regarding diet, dress, hygiene, and prayer. The husband also might want to stay and sleep in the patient’s room during her hospitalization.

It also might be challenging for some North American therapists to understand and focus on the entire family as a functioning unit, rather than seeing the issues as only between husband and wife. Learning about how “normal family functioning” is defined, especially in terms of roles, hierarchy, and intimacy, is critical to supporting this mother and baby. Cultivating “cultural humility” in working with patients and families from diverse backgrounds is extremely important.

During the hospitalization as the patient improves, a plan for care needs to be developed with the patient and her family. This plan should include adequate support of the mother and her baby. The husband should bring his parents and siblings to an initial meeting early during the hospitalization, being mindful of addressing any HIPAA-related issues. This will allow for a uniform understanding of the patient’s illness and treatment. At this meeting, all family members should express their concerns, worries, beliefs, and perceived barriers to optimal care. If the family members feel listened to, they are more likely to feel understood and adhere to recommendations.

At the initial meeting and subsequent ones, the following questions might be helpful to ask to gather information in negotiating a mutually acceptable treatment plan:

1. What is the family’s understanding of her illness? What do they think may have caused it? How do they understand postpartum psychosis? Do they think there is a role for medication? Are any other alternative healing modalities being considered or used?

2. Who is caring for the baby now? Is the baby healthy? Does the family understand how the mother’s illness affects the baby? Can the family provide adequate care for the baby?

3. How are decisions made in the family? Are there any other issues in the family, such as ill health in a parent?

4. Was this an arranged marriage? How long have they known the patient? Do they care for her? What is the family’s attitude toward her?

5. Besides the mother-in-law, are there other adult females (for example, her husband’s sisters and his brothers’ wives) living in the household? How old is the mother-in-law? Who runs the household? Who does all the work? If possible, it will be important to interview anyone else in the household. How long have the couple and the family been in the United States? Did they all come at the same time?

6. Does the family have a supportive community? What are their beliefs about mental illness? Whom do they trust in their community? A religious leader? A local doctor? Who treats the women in the community?

7. If there is time, other issues can be explored. For example, what were the circumstances of their immigration? What has the transition from Bangladesh to life in the United States been like for the family?

8. Who will care for her at home? Who will ensure she takes her medications? Who will take her to follow-up visits?

There are many unknowns in this case that require further exploration. Time taken to arrange for a medically qualified interpreter and an extended family meeting will help the physician and psychiatric team understand the current situation and set up an appropriate plan of care.

Cultural perspective

The case material raises many questions. In the first place, there is no need to assume that the husband was behaving in a “culturally sanctioned and consistent way.” In a large population like that of Bangladeshi Muslims, significant heterogeneity exists, and there are more ways than one to respond. Although access to care is increasing for some population segments, Bangladesh still has limited mental health services and resources.

What were the reasons for the patient to be admitted to a psychiatric unit? How many days after the delivery? Were there any hostile actions or reactions to the baby? What is the patient’s pregnancy history? What meaning was ascribed to the symptoms and behavior that the patient manifested prior to hospitalization? Was this the first episode of psychiatric illness for the patient? Has she shown any dangerous behaviors before?

The reason why the husband is taking the wife home against medical advice is unclear. What reason did the husband give for this decision? Could stigma toward mental illness or hospitalization play a role? Was an interpreter used to help understand his reasoning? Was the husband dissatisfied about something? This is important, because it is likely that the husband brought the wife for hospitalization in the first place. Were the inpatient physician and nurses male or female, and could gender-related issues have been a barrier to accepting care? Might there have been a Muslim chaplain in the hospital or in the community or someone else who could have served as a cultural broker earlier in the hospitalization to have prevented this impasse?

The Cultural Formulation Interview (CFI) in the DSM-5 and the CFI-Informant Version for family members provide a framework to explore these questions and the questions recommended in the Family Perspective throughout the course of treatment.

Additional relevant questions include the following: What are cultural norms for their expectations for support of a new mother during the postpartum period? What are the norms for who, besides the mother, provides infant care? Are normative postpartum practices possible, or have they been disrupted in the hospital setting and/or in their home? If the mother and baby are both on the unit, is the request motivated by a desire to bring the baby home? If the baby is not on the unit, is this driving the family’s concern?

How isolated will the woman feel when she is home with the baby and her husband is out working as a taxi driver? Are there community-based organizations that the clinicians could collaborate with to provide resources and support for this woman (for example, women’s groups, immigrant groups, religious groups)? This would require learning more about what appeals to her, which groups she might identify with, and what is available in her neighborhood/community that aligns with what appeals to her.

It also would be important to determine if the patient was having any side effects from her psychotropic medications. Many South Asians have a low tolerance for side effects. Did the patient or family have any religious or cultural concerns about how the medications were manufactured or their composition (for example, worries about alcohol content)? Could any of these factors be related to the patient’s possible “cheeking” of her medications?

The major ethical/legal question to address is the patient’s attitude toward and relationship with the baby, and whether she was and is currently a danger to herself or others. Was the baby with the patient in the hospital? Did she feed the baby? What were the signs of psychosis that the patient exhibited, and what were the bases of her diagnosis? Was there an opportunity to discuss these issues with the husband? If so, what was his response?

Unless the patient is found to be dangerous to herself or others, including the baby, there is no option but to discharge. If a Bengali-speaking psychiatrist/therapist could be located within a reasonable driving distance, every effort should be made to connect the two. Husband and wife certainly should be instructed at the first sign of trouble to seek medical/psychiatric assistance, with or without insurance. Is there a possibility of home visits with an interpreter given the potential risks of patient and infant safety? Close follow-up and coordination of care with the patient’s and baby’s primary care physician is needed. Seeking support from the patient’s religious community also is worth considering.

Contributors

Alison M. Heru, M.D. – University of Colorado Denver, Aurora

Ellen Berman, M.D. – University of Pennsylvania, Philadelphia

Annelle B. Primm, M.D., M.P.H. – Johns Hopkins University, Baltimore (adjunct faculty)

Anne E. Becker, M.D., Ph.D. – Harvard Medical School, Boston

Robert C. Like, M.D., M.S. – Rutgers University, Robert Wood Johnson Medical School, New Brunswick

Resources

Farooq S., Fear C. Working Through Interpreters. (Adv Psychiatr Treat. 2003 Mar;9[2]:104-9. doi: 10.1192/apt.01.12 http://apt.rcpsych.org/content/9/2/104.full.)

Chandra P.S. Postpartum Psychiatric Care in India: The need for Integration and Innovation. (World Psychiatry. 2004;3[2]:99-100.)

Ahmad F., Shik A., Vanza R., Cheung A.M., George U, Stewart D.E. Voices of South Asian Women: Immigration and Mental Health. (Women Health 2004; 40[4]:113-130.)

Mantle F. Developing a Culture-Specific Tool to Assess Postnatal Depression in the Indian Community. (Br J Community Nurs. 2003;8[4]:176-180.)

To read about the goals of Curbside Consult, the guiding principles for assessment, and the guidelines for case submission, see “Considering patients’ family, culture,” Clinical Psychiatry News, January 2015, p. 12. The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they are employed by or affiliated with or the Group for the Advancement of Psychiatry (GAP).

This column is in memory of Dr. Prakash N. Desai, who contributed to this piece before his death earlier this year.

Editors’ Note: This is the first installment of Curbside Consult, written by two Group for the Advancement of Psychiatry (GAP) committees – the Committee on Family Psychiatry and the Committee on Cultural Psychiatry.

Come back home

The patient is an unmarried Japanese man in his early 40s who presents with symptoms of social phobia. He was born and raised in Japan, and migrated to the United States to pursue a PhD. In Japan, he enjoyed middle-class status, but after immigrating to the United States, he has faced many financial difficulties. His language barriers have made him uncomfortable in front of his colleagues and supervisors and he has not been able to do well in his PhD program, ultimately leading to his expulsion. He does not want to go back to Japan, thinking he will not have a “good life” there. He believes that there is no respect for a person’s individuality in Japan. He is currently living in an urban location of New Jersey and works odd jobs. He states that his family does not understand his feelings about not returning to Japan, and instead they want him to support them. He has engaged in supportive psychotherapy and cognitive-behavioral therapy in the outpatient clinic along with psychopharmacological treatment.

Key questions

1. How is Japanese culture different from U.S. culture in terms of respecting a person’s individuality?

2. The expectations of the patient’s family are considered excessive by the patient. What is the role of Japanese culture in this situation?

3. In moving forward with treatment planning, what aspects of the patient’s culture should the clinician keep in mind?

Family perspective

This middle-aged Japanese man has had a challenging time since coming to the United States to study. He lives here alone. He has failed to achieve his goal of earning a PhD. He has had financial difficulties because of his job challenges. He has had the courage to seek mental health treatment, although the goals of his treatment are unclear. He is in contact with his family in Japan, who has asked that he come home, presumably to support his somewhat older parents. It is unclear who constitutes his “family.”

From a family perspective, it seems that the family/parents in Japan are expecting that family obligation will draw the man home while the patient is defying that expectation by seeking and building individuality in the United States. A family-oriented therapist would consider the patient’s relationship with his family and help him consider how to make his decision on where to live. The therapist also would support the patient in maintaining a connection with his family. The therapist would help the patient avoid both passively capitulating to his family and defiantly cutting off from them. This would entail discussing the role of family in the United States and Japan. It would be important to empower the patient to explore his reasons for wanting to stay in the United States, what he means by “a good life,” and what he senses as his obligation to his family.

The history of this man’s life in Japan, including recollections of his childhood and an understanding of the job history of other members of his family, will help the therapist understand this man and his experience of his family. The telling of the family narrative, from his perspective, may help the patient understand his wishes and his fears. Exploring his relationships with his mother and his father will help the therapist and the patient understand some of the problems he has had in the United States.

Given his current life circumstances, work, and social stresses, lack of social support, and problems functioning, he also should be clinically assessed for depression and any other significant mental health problems. Additional questions to explore include: Does he define himself as a “failure,” and what would it be like going back to Japan? Are there concerns about “losing face”? If his parents want him to support them, do they know about his financial situation? Would he be able to get a job in Japan, or would he end up living with his parents? Are their requests that he “come home” based on their need for support, or are they afraid that he really needs their help given his difficulties establishing a life here? As the patient explores these issues in more detail, he can begin the process of resolving his future.

Cultural psychiatry perspective

This case raises important cultural questions, which deserve further exploration in psychotherapy. Alternate approaches to evaluating culture in clinical settings have moved away from conceptualizing “U.S.” or “Japanese” cultures monolithically to understand how cultural dynamics matter to the individual.

Notably, clarifying what the patient means by the “individuality” that is “not respected in Japan” would be essential, as well as what he perceives as “excessive” in his family’s demands. Alan Roland, Ph.D., in his book “In Search of Self in India and Japan: Toward a Cross-Cultural Psychology” describes marked differences between traditional Japanese and U.S. expectations of family obligation and relationship: “dependence and interdependence with close emotional connectedness versus independence and autonomy; receptivity and deference to superiors in hierarchical relationships versus self-assertion and self-promotion in egalitarian-contractual relationships; communication on multiple levels and by innuendo versus verbal articulateness and forthrightness; maintaining and enhancing esteem at all costs versus forthright criticism and expressing the truth of the matter” (pp. 292-3).

Of course, these are intentionally polarized descriptions; yet many Japanese in the United States find themselves negotiating contrasting expectations about what it means to be a person in a family and a society, some finding value in at least parts of each tradition, some holding on to traditional Japanese values, and some adopting values related to the new environment.

A key question in this case is what made the situation so difficult for this patient. Going forward, the clinician will want to characterize the biopsychosocial etiologies of his symptoms. Are the social phobia symptoms related to premorbid developmental issues hindering communication, planning, and sociability? Were they exacerbated by language difficulties and the acculturation challenges of finding himself in a new country and institution with potentially different expectations of fulfillment and success?

One wonders how he was accepted into this PhD program and why his performance led to expulsion so quickly. Are there additional symptoms and impairments beyond the breakdown in communication? For example, are there depressive symptoms? Does he have other somatic symptomatology as part of his idiom of distress that may be magnifying his impairment? Were academic supports in place that could have prevented his expulsion? Does he have other social supports and relationships? Is he struggling with intense isolation and, potentially, individuation issues triggered by his new setting?

The DSM-5 Cultural Formulation Interview (CFI), a standardized method for conducting a cultural assessment in mental health care, could help the clinician elicit the patient’s understandings of the problem, its causes and contextual stressors and supports, cultural identity, the cultural features of the relationship between the patient and the clinician, and options for self-coping and clinical care. This exploration of the patient’s lifeworld may clarify how to intervene. Selected supplementary modules to the CFI also may also be useful to ‘amplify’ the core CFI and to further explore the patient’s perception of the family’s role in his illness, including the Social Network Module and the Psychosocial Stressors Module.

Contributors

John Sargent, M.D. – Tufts University School of Medicine

Ellen Berman, M.D. – University of Pennsylvania, Perelman School of Medicine

Roberto Lewis-Fernández, M.D. – Columbia University and New York State Psychiatric Institute

Robert C. Like, M.D., M.S. – Rutgers University, Robert Wood Johnson Medical School

Resources

Lewis-Fernández R., Aggarwal N.K., Baarnhielm, S., et al. Culture and Psychiatric Evaluation: Operationalizing Cultural Formulation for DSM-5 (Psychiatry 2014;77:130-54).

Roland A. In Search of Self in India and Japan: Toward a Cross-Cultural Psychology (Princeton,

N.J.: Princeton University Press, 1988).

Shibusawa T. Japanese Families, in Ethnicity and Family Therapy, 3rd edition. Edited by McGoldrick M., Giordano J., and Garcia-Preto. (New York: Guilford Press, 2005, pp. 339-48).

Tseng W.S., Chang S.C., Nishizono M., eds. Asian Culture and Psychotherapy: Implications for East and West (Honolulu: University of Hawai’i Press).

To read about the goals of Curbside Consult, the guiding principles for assessment, and the guidelines for case submission, see “Considering patients’ family, culture,” Clinical Psychiatry News, January 2015, p. 12. To contribute a case, send it to [email protected]. The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they employed by or affiliated with or the Group for the Advancement of Psychiatry (GAP).

Editors’ Note: This is the first installment of Curbside Consult, written by two Group for the Advancement of Psychiatry (GAP) committees – the Committee on Family Psychiatry and the Committee on Cultural Psychiatry.

Come back home

The patient is an unmarried Japanese man in his early 40s who presents with symptoms of social phobia. He was born and raised in Japan, and migrated to the United States to pursue a PhD. In Japan, he enjoyed middle-class status, but after immigrating to the United States, he has faced many financial difficulties. His language barriers have made him uncomfortable in front of his colleagues and supervisors and he has not been able to do well in his PhD program, ultimately leading to his expulsion. He does not want to go back to Japan, thinking he will not have a “good life” there. He believes that there is no respect for a person’s individuality in Japan. He is currently living in an urban location of New Jersey and works odd jobs. He states that his family does not understand his feelings about not returning to Japan, and instead they want him to support them. He has engaged in supportive psychotherapy and cognitive-behavioral therapy in the outpatient clinic along with psychopharmacological treatment.

Key questions

1. How is Japanese culture different from U.S. culture in terms of respecting a person’s individuality?

2. The expectations of the patient’s family are considered excessive by the patient. What is the role of Japanese culture in this situation?

3. In moving forward with treatment planning, what aspects of the patient’s culture should the clinician keep in mind?

Family perspective

This middle-aged Japanese man has had a challenging time since coming to the United States to study. He lives here alone. He has failed to achieve his goal of earning a PhD. He has had financial difficulties because of his job challenges. He has had the courage to seek mental health treatment, although the goals of his treatment are unclear. He is in contact with his family in Japan, who has asked that he come home, presumably to support his somewhat older parents. It is unclear who constitutes his “family.”

From a family perspective, it seems that the family/parents in Japan are expecting that family obligation will draw the man home while the patient is defying that expectation by seeking and building individuality in the United States. A family-oriented therapist would consider the patient’s relationship with his family and help him consider how to make his decision on where to live. The therapist also would support the patient in maintaining a connection with his family. The therapist would help the patient avoid both passively capitulating to his family and defiantly cutting off from them. This would entail discussing the role of family in the United States and Japan. It would be important to empower the patient to explore his reasons for wanting to stay in the United States, what he means by “a good life,” and what he senses as his obligation to his family.

The history of this man’s life in Japan, including recollections of his childhood and an understanding of the job history of other members of his family, will help the therapist understand this man and his experience of his family. The telling of the family narrative, from his perspective, may help the patient understand his wishes and his fears. Exploring his relationships with his mother and his father will help the therapist and the patient understand some of the problems he has had in the United States.

Given his current life circumstances, work, and social stresses, lack of social support, and problems functioning, he also should be clinically assessed for depression and any other significant mental health problems. Additional questions to explore include: Does he define himself as a “failure,” and what would it be like going back to Japan? Are there concerns about “losing face”? If his parents want him to support them, do they know about his financial situation? Would he be able to get a job in Japan, or would he end up living with his parents? Are their requests that he “come home” based on their need for support, or are they afraid that he really needs their help given his difficulties establishing a life here? As the patient explores these issues in more detail, he can begin the process of resolving his future.

Cultural psychiatry perspective

This case raises important cultural questions, which deserve further exploration in psychotherapy. Alternate approaches to evaluating culture in clinical settings have moved away from conceptualizing “U.S.” or “Japanese” cultures monolithically to understand how cultural dynamics matter to the individual.

Notably, clarifying what the patient means by the “individuality” that is “not respected in Japan” would be essential, as well as what he perceives as “excessive” in his family’s demands. Alan Roland, Ph.D., in his book “In Search of Self in India and Japan: Toward a Cross-Cultural Psychology” describes marked differences between traditional Japanese and U.S. expectations of family obligation and relationship: “dependence and interdependence with close emotional connectedness versus independence and autonomy; receptivity and deference to superiors in hierarchical relationships versus self-assertion and self-promotion in egalitarian-contractual relationships; communication on multiple levels and by innuendo versus verbal articulateness and forthrightness; maintaining and enhancing esteem at all costs versus forthright criticism and expressing the truth of the matter” (pp. 292-3).

Of course, these are intentionally polarized descriptions; yet many Japanese in the United States find themselves negotiating contrasting expectations about what it means to be a person in a family and a society, some finding value in at least parts of each tradition, some holding on to traditional Japanese values, and some adopting values related to the new environment.

A key question in this case is what made the situation so difficult for this patient. Going forward, the clinician will want to characterize the biopsychosocial etiologies of his symptoms. Are the social phobia symptoms related to premorbid developmental issues hindering communication, planning, and sociability? Were they exacerbated by language difficulties and the acculturation challenges of finding himself in a new country and institution with potentially different expectations of fulfillment and success?

One wonders how he was accepted into this PhD program and why his performance led to expulsion so quickly. Are there additional symptoms and impairments beyond the breakdown in communication? For example, are there depressive symptoms? Does he have other somatic symptomatology as part of his idiom of distress that may be magnifying his impairment? Were academic supports in place that could have prevented his expulsion? Does he have other social supports and relationships? Is he struggling with intense isolation and, potentially, individuation issues triggered by his new setting?

The DSM-5 Cultural Formulation Interview (CFI), a standardized method for conducting a cultural assessment in mental health care, could help the clinician elicit the patient’s understandings of the problem, its causes and contextual stressors and supports, cultural identity, the cultural features of the relationship between the patient and the clinician, and options for self-coping and clinical care. This exploration of the patient’s lifeworld may clarify how to intervene. Selected supplementary modules to the CFI also may also be useful to ‘amplify’ the core CFI and to further explore the patient’s perception of the family’s role in his illness, including the Social Network Module and the Psychosocial Stressors Module.

Contributors

John Sargent, M.D. – Tufts University School of Medicine

Ellen Berman, M.D. – University of Pennsylvania, Perelman School of Medicine

Roberto Lewis-Fernández, M.D. – Columbia University and New York State Psychiatric Institute

Robert C. Like, M.D., M.S. – Rutgers University, Robert Wood Johnson Medical School

Resources

Lewis-Fernández R., Aggarwal N.K., Baarnhielm, S., et al. Culture and Psychiatric Evaluation: Operationalizing Cultural Formulation for DSM-5 (Psychiatry 2014;77:130-54).

Roland A. In Search of Self in India and Japan: Toward a Cross-Cultural Psychology (Princeton,

N.J.: Princeton University Press, 1988).

Shibusawa T. Japanese Families, in Ethnicity and Family Therapy, 3rd edition. Edited by McGoldrick M., Giordano J., and Garcia-Preto. (New York: Guilford Press, 2005, pp. 339-48).

Tseng W.S., Chang S.C., Nishizono M., eds. Asian Culture and Psychotherapy: Implications for East and West (Honolulu: University of Hawai’i Press).

To read about the goals of Curbside Consult, the guiding principles for assessment, and the guidelines for case submission, see “Considering patients’ family, culture,” Clinical Psychiatry News, January 2015, p. 12. To contribute a case, send it to [email protected]. The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they employed by or affiliated with or the Group for the Advancement of Psychiatry (GAP).

Editors’ Note: This is the first installment of Curbside Consult, written by two Group for the Advancement of Psychiatry (GAP) committees – the Committee on Family Psychiatry and the Committee on Cultural Psychiatry.

Come back home

The patient is an unmarried Japanese man in his early 40s who presents with symptoms of social phobia. He was born and raised in Japan, and migrated to the United States to pursue a PhD. In Japan, he enjoyed middle-class status, but after immigrating to the United States, he has faced many financial difficulties. His language barriers have made him uncomfortable in front of his colleagues and supervisors and he has not been able to do well in his PhD program, ultimately leading to his expulsion. He does not want to go back to Japan, thinking he will not have a “good life” there. He believes that there is no respect for a person’s individuality in Japan. He is currently living in an urban location of New Jersey and works odd jobs. He states that his family does not understand his feelings about not returning to Japan, and instead they want him to support them. He has engaged in supportive psychotherapy and cognitive-behavioral therapy in the outpatient clinic along with psychopharmacological treatment.

Key questions

1. How is Japanese culture different from U.S. culture in terms of respecting a person’s individuality?

2. The expectations of the patient’s family are considered excessive by the patient. What is the role of Japanese culture in this situation?

3. In moving forward with treatment planning, what aspects of the patient’s culture should the clinician keep in mind?

Family perspective

This middle-aged Japanese man has had a challenging time since coming to the United States to study. He lives here alone. He has failed to achieve his goal of earning a PhD. He has had financial difficulties because of his job challenges. He has had the courage to seek mental health treatment, although the goals of his treatment are unclear. He is in contact with his family in Japan, who has asked that he come home, presumably to support his somewhat older parents. It is unclear who constitutes his “family.”

From a family perspective, it seems that the family/parents in Japan are expecting that family obligation will draw the man home while the patient is defying that expectation by seeking and building individuality in the United States. A family-oriented therapist would consider the patient’s relationship with his family and help him consider how to make his decision on where to live. The therapist also would support the patient in maintaining a connection with his family. The therapist would help the patient avoid both passively capitulating to his family and defiantly cutting off from them. This would entail discussing the role of family in the United States and Japan. It would be important to empower the patient to explore his reasons for wanting to stay in the United States, what he means by “a good life,” and what he senses as his obligation to his family.

The history of this man’s life in Japan, including recollections of his childhood and an understanding of the job history of other members of his family, will help the therapist understand this man and his experience of his family. The telling of the family narrative, from his perspective, may help the patient understand his wishes and his fears. Exploring his relationships with his mother and his father will help the therapist and the patient understand some of the problems he has had in the United States.

Given his current life circumstances, work, and social stresses, lack of social support, and problems functioning, he also should be clinically assessed for depression and any other significant mental health problems. Additional questions to explore include: Does he define himself as a “failure,” and what would it be like going back to Japan? Are there concerns about “losing face”? If his parents want him to support them, do they know about his financial situation? Would he be able to get a job in Japan, or would he end up living with his parents? Are their requests that he “come home” based on their need for support, or are they afraid that he really needs their help given his difficulties establishing a life here? As the patient explores these issues in more detail, he can begin the process of resolving his future.

Cultural psychiatry perspective

This case raises important cultural questions, which deserve further exploration in psychotherapy. Alternate approaches to evaluating culture in clinical settings have moved away from conceptualizing “U.S.” or “Japanese” cultures monolithically to understand how cultural dynamics matter to the individual.

Notably, clarifying what the patient means by the “individuality” that is “not respected in Japan” would be essential, as well as what he perceives as “excessive” in his family’s demands. Alan Roland, Ph.D., in his book “In Search of Self in India and Japan: Toward a Cross-Cultural Psychology” describes marked differences between traditional Japanese and U.S. expectations of family obligation and relationship: “dependence and interdependence with close emotional connectedness versus independence and autonomy; receptivity and deference to superiors in hierarchical relationships versus self-assertion and self-promotion in egalitarian-contractual relationships; communication on multiple levels and by innuendo versus verbal articulateness and forthrightness; maintaining and enhancing esteem at all costs versus forthright criticism and expressing the truth of the matter” (pp. 292-3).

Of course, these are intentionally polarized descriptions; yet many Japanese in the United States find themselves negotiating contrasting expectations about what it means to be a person in a family and a society, some finding value in at least parts of each tradition, some holding on to traditional Japanese values, and some adopting values related to the new environment.

A key question in this case is what made the situation so difficult for this patient. Going forward, the clinician will want to characterize the biopsychosocial etiologies of his symptoms. Are the social phobia symptoms related to premorbid developmental issues hindering communication, planning, and sociability? Were they exacerbated by language difficulties and the acculturation challenges of finding himself in a new country and institution with potentially different expectations of fulfillment and success?

One wonders how he was accepted into this PhD program and why his performance led to expulsion so quickly. Are there additional symptoms and impairments beyond the breakdown in communication? For example, are there depressive symptoms? Does he have other somatic symptomatology as part of his idiom of distress that may be magnifying his impairment? Were academic supports in place that could have prevented his expulsion? Does he have other social supports and relationships? Is he struggling with intense isolation and, potentially, individuation issues triggered by his new setting?

The DSM-5 Cultural Formulation Interview (CFI), a standardized method for conducting a cultural assessment in mental health care, could help the clinician elicit the patient’s understandings of the problem, its causes and contextual stressors and supports, cultural identity, the cultural features of the relationship between the patient and the clinician, and options for self-coping and clinical care. This exploration of the patient’s lifeworld may clarify how to intervene. Selected supplementary modules to the CFI also may also be useful to ‘amplify’ the core CFI and to further explore the patient’s perception of the family’s role in his illness, including the Social Network Module and the Psychosocial Stressors Module.

Contributors

John Sargent, M.D. – Tufts University School of Medicine

Ellen Berman, M.D. – University of Pennsylvania, Perelman School of Medicine

Roberto Lewis-Fernández, M.D. – Columbia University and New York State Psychiatric Institute

Robert C. Like, M.D., M.S. – Rutgers University, Robert Wood Johnson Medical School

Resources

Lewis-Fernández R., Aggarwal N.K., Baarnhielm, S., et al. Culture and Psychiatric Evaluation: Operationalizing Cultural Formulation for DSM-5 (Psychiatry 2014;77:130-54).

Roland A. In Search of Self in India and Japan: Toward a Cross-Cultural Psychology (Princeton,

N.J.: Princeton University Press, 1988).

Shibusawa T. Japanese Families, in Ethnicity and Family Therapy, 3rd edition. Edited by McGoldrick M., Giordano J., and Garcia-Preto. (New York: Guilford Press, 2005, pp. 339-48).

Tseng W.S., Chang S.C., Nishizono M., eds. Asian Culture and Psychotherapy: Implications for East and West (Honolulu: University of Hawai’i Press).

To read about the goals of Curbside Consult, the guiding principles for assessment, and the guidelines for case submission, see “Considering patients’ family, culture,” Clinical Psychiatry News, January 2015, p. 12. To contribute a case, send it to [email protected]. The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they employed by or affiliated with or the Group for the Advancement of Psychiatry (GAP).

We are pleased to introduce Curbside Consult with the Group for the Advancement of Psychiatry's (GAP) Family and Cultural committees. The column is inspired by the DSM-5's emphasis on developing a cultural formulation of patients' illnesses and addressing family dynamics and resilience in promoting care that fosters prevention and recovery.

What is GAP?

GAP was formed in 1946 under the leadership of Dr. William Menninger by a group of young psychiatrists who had served in World War II. They returned to the United States to find an inadequate system of civilian care. They were eager to professionalize the field and collaboratively develop new and creative thinking. They developed an organization that met as a whole twice a year, organized into committees of particular interest to the members and crucial to the needs of psychiatric care. The committees wrote monographs that formed a crucial role in the development of modern psychiatric thought.

Mission of GAP

• Bring together top psychiatrists of all disciplines
• Offer an objective, critical perspective on current issues facing psychiatry
• Develop smart analysis and recommendations
• Shape psychiatric thinking, clinical practice, and mental health programs
• Advocate for necessary changes in the psychiatric field
• Inspire the next generation of leading psychiatric thinkers

The Family and Cultural Psychiatry committees want to focus psychiatrists on the resilience inherent in the families and cultures of our patients in order to promote psychiatric care that focuses on prevention and recovery.

The Family and Cultural Psychiatry committees see every patient as connected to family members and belonging to a network of cultures that might include their national origin, race/ethnicity, religion/spirituality, language, occupation, age, sexual orientation and gender identity, or any other element of the person's background and collective life.

Over time, these family and cultural influences have shaped all aspects of the person’s response to adversity, experience of illness, and expectations of help seeking, even among patients who are currently living alone or do not recognize their background as explicitly cultural. This influence is highly individual; each person has his/her own combination of family and cultural experiences. How does the psychiatrist access this experience and use it to help develop resilience in our patients? How do we encourage them to use strengths/support from their family and culture, and to identify narratives that are helpful?

We see this column as one way to help answer these questions. We will bring to bear both family and cultural perspectives on the care of patients in everyday clinical practice through our comments on case vignettes sent in by readers. It can be challenging to integrate an understanding of family and culture into each patient encounter.

Our committees will work together to develop a coherent response that integrates both family and cultural perspectives and can be applied in real-world patient situations by clinicians who might not have access to specialized consultation. We aim to contribute to the growing awareness in our field of the cultural complexity of our patients, as developed and transmitted in the nexus of their families, which requires from us as clinicians a more inclusive and holistic approach to care.

This column helps to meet the goals of accreditation bodies such as The Joint Commission and the Accreditation Council for Graduate Medical Education (ACGME) for cultural and linguistic competence and patient- and family-centered care. Understanding how to think about, assess, and engage in treatment with the diversity of our patients’ cultural and family backgrounds constitutes important educational topics for all psychiatric trainees. In conjunction with formal didactics, these cases can be used as a focus for discussion in psychiatric residency training programs, ACGME Clinical Learning Environment Review (CLER), health care quality improvement activities, and faculty development programs.

Practicing clinicians also will find the DSM-5 Outline for Cultural Formulation and Cultural Formulation Interview to be a helpful clinical tool for eliciting and organizing cultural information, and in differential diagnosis and treatment planning.

The following is a list of the guiding principles we will use for assessment:

1. Heterogeneity and diversity exists within all families, cultures, and societies.

2. Avoid stereotyping, essentializing, and overgeneralizing.

3. Individualize and tailor diagnostic assessment, treatment, and care.

4. Address any language access barriers through the use of qualified medical interpreters and appropriately translated educational and informational materials.

5. Employ plain language in communicating with patients with limited health and mental health literacy.

6. Recognize the impact on both the patient and the clinician of our families of origin.

7. Engage in reflective, mindful practice and attend to cultural countertransference to provide insight into one’s own values, beliefs, and behaviors.

8. Cultivate cultural humility – the realization that our understanding of the other person’s background is always limited and incomplete.

9. Every encounter is a cross-cultural one.

10. Developing cultural competence is a lifelong journey and not a final destination.

Guidelines for Case Submission

We are requesting that you submit cases to [email protected] in which your understanding and treatment are affected by challenging cultural and family issues. We will then write back with our best answers about how one might proceed in such a case. Your case and our response will be published in Clinical Psychiatry News. Please limit your case description to 250 words and please include the following details:

1. Patient’s presenting problem or reason for the visit.

2. Patient’s age and gender.

3. Indicators of the patient’s identity – self-identified race/ethnicity, culture, religion/spirituality, socioeconomic status, education, among other variables.

4. Patient’s living situation, family composition, and genogram information (if available).

5. Patient’s geographic location (rural, suburban, urban) and occupation.

6. Patient’s and family’s degree of participation in their identified culture.

7. Questions of the individual submitting the case, including concerns about the role of the family and culture in the case, diagnosis, and treatment planning.

8. Please follow local ethical requirements, disguise the case to protect confidentiality and attend to HIPAA requirements, so that patients or family members reading the article would not recognize themselves.

Additional information might be requested, and editing of the case, questions, and commentary might be needed prior to final publication.

Please note that the opinions expressed in the case commentaries should not be seen as formal medical consultations and do not represent the opinions of GAP, CPN, or the institutions where the authors are employed or with which they are affiliated.

Contributors:

Michael S. Ascher, M.D. – University of Pennsylvania, Perelman School of Medicine

Alison M. Heru, M.D. – University of Colorado at Denver, Aurora

Roberto Lewis-Fernández, M.D. – Columbia University and New York State Psychiatric Institute

Robert C. Like, M.D., M.S. – Rutgers University, Robert Wood Johnson Medical School

Resources:

DSM-5 – Outline for Cultural Formulation and Cultural Formulation Interview: http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Cultural

Clinical Manual of Couples and Family Therapy, Washington: American Psychiatric Publishing Inc., 2009.

Thinking Through Cultures: Expeditions in Cultural Psychology. Cambridge, Mass.: Harvard University Press, 1991.

Clinical Manual of Cultural Psychiatry, 2nd Edition, Washington: American Psychiatric Publishing Inc., 2015.

We are pleased to introduce Curbside Consult with the Group for the Advancement of Psychiatry's (GAP) Family and Cultural committees. The column is inspired by the DSM-5's emphasis on developing a cultural formulation of patients' illnesses and addressing family dynamics and resilience in promoting care that fosters prevention and recovery.

What is GAP?

GAP was formed in 1946 under the leadership of Dr. William Menninger by a group of young psychiatrists who had served in World War II. They returned to the United States to find an inadequate system of civilian care. They were eager to professionalize the field and collaboratively develop new and creative thinking. They developed an organization that met as a whole twice a year, organized into committees of particular interest to the members and crucial to the needs of psychiatric care. The committees wrote monographs that formed a crucial role in the development of modern psychiatric thought.

Mission of GAP

• Bring together top psychiatrists of all disciplines
• Offer an objective, critical perspective on current issues facing psychiatry
• Develop smart analysis and recommendations
• Shape psychiatric thinking, clinical practice, and mental health programs
• Advocate for necessary changes in the psychiatric field
• Inspire the next generation of leading psychiatric thinkers

The Family and Cultural Psychiatry committees want to focus psychiatrists on the resilience inherent in the families and cultures of our patients in order to promote psychiatric care that focuses on prevention and recovery.

The Family and Cultural Psychiatry committees see every patient as connected to family members and belonging to a network of cultures that might include their national origin, race/ethnicity, religion/spirituality, language, occupation, age, sexual orientation and gender identity, or any other element of the person's background and collective life.

Over time, these family and cultural influences have shaped all aspects of the person’s response to adversity, experience of illness, and expectations of help seeking, even among patients who are currently living alone or do not recognize their background as explicitly cultural. This influence is highly individual; each person has his/her own combination of family and cultural experiences. How does the psychiatrist access this experience and use it to help develop resilience in our patients? How do we encourage them to use strengths/support from their family and culture, and to identify narratives that are helpful?

We see this column as one way to help answer these questions. We will bring to bear both family and cultural perspectives on the care of patients in everyday clinical practice through our comments on case vignettes sent in by readers. It can be challenging to integrate an understanding of family and culture into each patient encounter.

Our committees will work together to develop a coherent response that integrates both family and cultural perspectives and can be applied in real-world patient situations by clinicians who might not have access to specialized consultation. We aim to contribute to the growing awareness in our field of the cultural complexity of our patients, as developed and transmitted in the nexus of their families, which requires from us as clinicians a more inclusive and holistic approach to care.

This column helps to meet the goals of accreditation bodies such as The Joint Commission and the Accreditation Council for Graduate Medical Education (ACGME) for cultural and linguistic competence and patient- and family-centered care. Understanding how to think about, assess, and engage in treatment with the diversity of our patients’ cultural and family backgrounds constitutes important educational topics for all psychiatric trainees. In conjunction with formal didactics, these cases can be used as a focus for discussion in psychiatric residency training programs, ACGME Clinical Learning Environment Review (CLER), health care quality improvement activities, and faculty development programs.

Practicing clinicians also will find the DSM-5 Outline for Cultural Formulation and Cultural Formulation Interview to be a helpful clinical tool for eliciting and organizing cultural information, and in differential diagnosis and treatment planning.

The following is a list of the guiding principles we will use for assessment:

1. Heterogeneity and diversity exists within all families, cultures, and societies.

2. Avoid stereotyping, essentializing, and overgeneralizing.

3. Individualize and tailor diagnostic assessment, treatment, and care.

4. Address any language access barriers through the use of qualified medical interpreters and appropriately translated educational and informational materials.

5. Employ plain language in communicating with patients with limited health and mental health literacy.

6. Recognize the impact on both the patient and the clinician of our families of origin.

7. Engage in reflective, mindful practice and attend to cultural countertransference to provide insight into one’s own values, beliefs, and behaviors.

8. Cultivate cultural humility – the realization that our understanding of the other person’s background is always limited and incomplete.

9. Every encounter is a cross-cultural one.

10. Developing cultural competence is a lifelong journey and not a final destination.

Guidelines for Case Submission

We are requesting that you submit cases to [email protected] in which your understanding and treatment are affected by challenging cultural and family issues. We will then write back with our best answers about how one might proceed in such a case. Your case and our response will be published in Clinical Psychiatry News. Please limit your case description to 250 words and please include the following details:

1. Patient’s presenting problem or reason for the visit.

2. Patient’s age and gender.

3. Indicators of the patient’s identity – self-identified race/ethnicity, culture, religion/spirituality, socioeconomic status, education, among other variables.

4. Patient’s living situation, family composition, and genogram information (if available).

5. Patient’s geographic location (rural, suburban, urban) and occupation.

6. Patient’s and family’s degree of participation in their identified culture.

7. Questions of the individual submitting the case, including concerns about the role of the family and culture in the case, diagnosis, and treatment planning.

8. Please follow local ethical requirements, disguise the case to protect confidentiality and attend to HIPAA requirements, so that patients or family members reading the article would not recognize themselves.

Additional information might be requested, and editing of the case, questions, and commentary might be needed prior to final publication.

Please note that the opinions expressed in the case commentaries should not be seen as formal medical consultations and do not represent the opinions of GAP, CPN, or the institutions where the authors are employed or with which they are affiliated.

Contributors:

Michael S. Ascher, M.D. – University of Pennsylvania, Perelman School of Medicine

Alison M. Heru, M.D. – University of Colorado at Denver, Aurora

Roberto Lewis-Fernández, M.D. – Columbia University and New York State Psychiatric Institute

Robert C. Like, M.D., M.S. – Rutgers University, Robert Wood Johnson Medical School

Resources:

DSM-5 – Outline for Cultural Formulation and Cultural Formulation Interview: http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Cultural

Clinical Manual of Couples and Family Therapy, Washington: American Psychiatric Publishing Inc., 2009.

Thinking Through Cultures: Expeditions in Cultural Psychology. Cambridge, Mass.: Harvard University Press, 1991.

Clinical Manual of Cultural Psychiatry, 2nd Edition, Washington: American Psychiatric Publishing Inc., 2015.

We are pleased to introduce Curbside Consult with the Group for the Advancement of Psychiatry's (GAP) Family and Cultural committees. The column is inspired by the DSM-5's emphasis on developing a cultural formulation of patients' illnesses and addressing family dynamics and resilience in promoting care that fosters prevention and recovery.

What is GAP?

GAP was formed in 1946 under the leadership of Dr. William Menninger by a group of young psychiatrists who had served in World War II. They returned to the United States to find an inadequate system of civilian care. They were eager to professionalize the field and collaboratively develop new and creative thinking. They developed an organization that met as a whole twice a year, organized into committees of particular interest to the members and crucial to the needs of psychiatric care. The committees wrote monographs that formed a crucial role in the development of modern psychiatric thought.

Mission of GAP

• Bring together top psychiatrists of all disciplines
• Offer an objective, critical perspective on current issues facing psychiatry
• Develop smart analysis and recommendations
• Shape psychiatric thinking, clinical practice, and mental health programs
• Advocate for necessary changes in the psychiatric field
• Inspire the next generation of leading psychiatric thinkers

The Family and Cultural Psychiatry committees want to focus psychiatrists on the resilience inherent in the families and cultures of our patients in order to promote psychiatric care that focuses on prevention and recovery.

The Family and Cultural Psychiatry committees see every patient as connected to family members and belonging to a network of cultures that might include their national origin, race/ethnicity, religion/spirituality, language, occupation, age, sexual orientation and gender identity, or any other element of the person's background and collective life.

Over time, these family and cultural influences have shaped all aspects of the person’s response to adversity, experience of illness, and expectations of help seeking, even among patients who are currently living alone or do not recognize their background as explicitly cultural. This influence is highly individual; each person has his/her own combination of family and cultural experiences. How does the psychiatrist access this experience and use it to help develop resilience in our patients? How do we encourage them to use strengths/support from their family and culture, and to identify narratives that are helpful?

We see this column as one way to help answer these questions. We will bring to bear both family and cultural perspectives on the care of patients in everyday clinical practice through our comments on case vignettes sent in by readers. It can be challenging to integrate an understanding of family and culture into each patient encounter.

Our committees will work together to develop a coherent response that integrates both family and cultural perspectives and can be applied in real-world patient situations by clinicians who might not have access to specialized consultation. We aim to contribute to the growing awareness in our field of the cultural complexity of our patients, as developed and transmitted in the nexus of their families, which requires from us as clinicians a more inclusive and holistic approach to care.

This column helps to meet the goals of accreditation bodies such as The Joint Commission and the Accreditation Council for Graduate Medical Education (ACGME) for cultural and linguistic competence and patient- and family-centered care. Understanding how to think about, assess, and engage in treatment with the diversity of our patients’ cultural and family backgrounds constitutes important educational topics for all psychiatric trainees. In conjunction with formal didactics, these cases can be used as a focus for discussion in psychiatric residency training programs, ACGME Clinical Learning Environment Review (CLER), health care quality improvement activities, and faculty development programs.

Practicing clinicians also will find the DSM-5 Outline for Cultural Formulation and Cultural Formulation Interview to be a helpful clinical tool for eliciting and organizing cultural information, and in differential diagnosis and treatment planning.

The following is a list of the guiding principles we will use for assessment:

1. Heterogeneity and diversity exists within all families, cultures, and societies.

2. Avoid stereotyping, essentializing, and overgeneralizing.

3. Individualize and tailor diagnostic assessment, treatment, and care.

4. Address any language access barriers through the use of qualified medical interpreters and appropriately translated educational and informational materials.

5. Employ plain language in communicating with patients with limited health and mental health literacy.

6. Recognize the impact on both the patient and the clinician of our families of origin.

7. Engage in reflective, mindful practice and attend to cultural countertransference to provide insight into one’s own values, beliefs, and behaviors.

8. Cultivate cultural humility – the realization that our understanding of the other person’s background is always limited and incomplete.

9. Every encounter is a cross-cultural one.

10. Developing cultural competence is a lifelong journey and not a final destination.

Guidelines for Case Submission

We are requesting that you submit cases to [email protected] in which your understanding and treatment are affected by challenging cultural and family issues. We will then write back with our best answers about how one might proceed in such a case. Your case and our response will be published in Clinical Psychiatry News. Please limit your case description to 250 words and please include the following details:

1. Patient’s presenting problem or reason for the visit.

2. Patient’s age and gender.

3. Indicators of the patient’s identity – self-identified race/ethnicity, culture, religion/spirituality, socioeconomic status, education, among other variables.

4. Patient’s living situation, family composition, and genogram information (if available).

5. Patient’s geographic location (rural, suburban, urban) and occupation.

6. Patient’s and family’s degree of participation in their identified culture.

7. Questions of the individual submitting the case, including concerns about the role of the family and culture in the case, diagnosis, and treatment planning.

8. Please follow local ethical requirements, disguise the case to protect confidentiality and attend to HIPAA requirements, so that patients or family members reading the article would not recognize themselves.

Additional information might be requested, and editing of the case, questions, and commentary might be needed prior to final publication.

Please note that the opinions expressed in the case commentaries should not be seen as formal medical consultations and do not represent the opinions of GAP, CPN, or the institutions where the authors are employed or with which they are affiliated.

Contributors:

Michael S. Ascher, M.D. – University of Pennsylvania, Perelman School of Medicine

Alison M. Heru, M.D. – University of Colorado at Denver, Aurora

Roberto Lewis-Fernández, M.D. – Columbia University and New York State Psychiatric Institute

Robert C. Like, M.D., M.S. – Rutgers University, Robert Wood Johnson Medical School

Resources:

DSM-5 – Outline for Cultural Formulation and Cultural Formulation Interview: http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Cultural

Clinical Manual of Couples and Family Therapy, Washington: American Psychiatric Publishing Inc., 2009.

Thinking Through Cultures: Expeditions in Cultural Psychology. Cambridge, Mass.: Harvard University Press, 1991.

Clinical Manual of Cultural Psychiatry, 2nd Edition, Washington: American Psychiatric Publishing Inc., 2015.