Donald R. Morrison, MSW, LCSW

The NASW Code of Ethics (section 1.05) mandates that social workers maintain cultural competence and social diversity in three ways:

❖Understand culture and its functions with a strong emphasis on the strengths perspective.

❖Develop a strong working knowledge about clients’ cultures and the many differences between cultural groups.

❖ Seek education and understanding about the nature of social diversity and oppression for all cultural groups.

Charlotte by the Numbers

Cultural Identity McGoldrick (2005) stated that cultural identity

profoundly affects our sense of well-being and our mental and physical health.

Cultural background refers to:

❖Social class

❖Religion

❖Migration

❖Geography

❖Gender Oppression

❖Racism

❖Sexual Orientation

❖Family Dynamics

Culture and Mental Health

McGoldrick (2005) maintains that mental health record-keeping systems do not even focus on patients’ ethnic backgrounds, settling for minimal reference to race as the only background marker.

Culture takes less of a focus as managed care took control of mental health services and minimized attention to the family context.

The authors maintain that mental health clinicians only pay “lip service” to the concept of “cultural competence.”

Therapeutic models are generally presented as having universal applicability.

DSM-5 now utilizes the Cultural Formulation Interview (CFI).

Cultural Differences in Worldview and Basic Values

Families differ in the following:

Their experience of pain.

What they label as a symptom.

How they communicate about their pain or symptom.

Their beliefs about its cause.

Their attitudes toward helpers (doctors and therapists).

The treatment that they desire or expect.

Cultural Attitudes Toward Therapy

The dominant assumption is that talk is good and can heal a person.

Therapy has been referred to as the “talking cure.”

Therapists need to take into consideration that not all cultural groups feel this way.

Therapists should consider their clients’ values as well as their own internal bias.

Groups differ in their attitudes toward seeking help.

Charlotte-Area Mental Health Assessments

Two well-known mental health agencies in the Charlotte area address cultural concerns by using only one question…

AGENCY #1: “Do you have any cultural, ethnic, spiritual, gender or sexual orientation needs that could possibly impact your treatment?”

AGENCY #2: “What are your cultural considerations or implications for treatment?”

❖Clinicians must also take into account the client’s cultural context when considering mental health diagnoses.

❖Be mindful that in some cultures, trances or possession states are sometimes considered normative/adaptive.

❖In the “Westernized” medical model, however, these responses may be identified as mental illness.

DSM-IV-TR defines a culture-bound syndrome as . . .

❖ recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV-TR diagnostic category.

❖ non-normative behaviors that have a unique set of symptoms, which generally belong to a particular cultural group.

❖ indigenously considered to be “illnesses” or afflictions that have local names and are usually treated by the folk medicine of the culture.

❖Amok: a trance syndrome common in Southeast Asia.

❖Characterized by a sudden outburst of unrestrained violent and aggressive behavior, usually of a homicidal nature.

❖Preceded by a period of anxious brooding and followed by exhaustion.

❖Precipitated by a perceived slight or insult and is generally more prevalent in males.

❖Often co-morbid with psychotic disorders.

❖ Ataques de nervios: a noted response to acute stress in Latin American and Hispanic cultures.

❖ Features include: uncontrollable crying, screaming, shouting, seizure-like behaviors and a failure to remember the incident afterwards.

❖ Frequently occurs as a direct result of a stressful event related to the family (i.e. death of a close relative, separation or divorce from a spouse, familial conflicts).

❖ Perceived within the culture to be a beneficial or adaptive way to cope with stress. Gray & Zide(2013) indicated that this condition may also be the result of Latina females’ perceived lack of power and social status.

❖ Rootwork: cultural interpretations that ascribe illness to hexing, witchcraft, sorcery or the evil influence of another person.

❖ Symptoms might include generalized anxiety and physical responses such as nausea, vomiting or diarrhea.

❖ Clients also experience weakness, dizziness and the fear of being poisoned or killed (i.e. the “voodoo death.”)

❖ “Roots,” “spells” or “hexes” can be “put” (or placed) on their intended victims and cause significant emotional distress.

❖ The intended victim will worry until the “root” has been “taken off” or eliminated, usually through the work of a “root doctor.”

❖ Found in the southern United States among both African American and European American cultures and in some Caribbean societies.

❖ Falling Out: otherwise known as “blacking out.” From Caribbean groups and southern United States. Characterized by the individual collapsing, sometimes without warning, into a trance. Eyes are usually still open, but the individual claims that he/she can’t see. The person is not able to move yet they are able to hear and understand what is going on around them.

❖ Mal de Ojo: Spanish phrase translated into the “evil eye.” Generally found in Mediterranean cultures and elsewhere around the world. Magical curses are placed on victims as a result of a magical, malevolent eye. Children are especially at risk, and symptoms include fitful sleep, crying without apparent cause, diarrhea, vomiting and fever.h

Dhat syndrome: generally found in areas of South Asia.

o A common clinical presentation for young male patients who attribute their various symptoms to semen loss.

o Patients experience anxiety, fatigue, weakness, weight loss, impotence, depression.

o Dhatu (semen) is described in the Hindu system of medicine as one of the seven essential body fluids whose balance is necessary for body health.

Susto: translated to “fright” in some Latino cultures in Mexico, Central America and South America.

o A frightening event causes the soul to leave the body and results in unhappiness and sickness.

o Symptoms include: appetite/sleep disturbances, nightmares, depression, anxiety, headache, stomachache.

❖ Research has indicated that culture bound syndromes often co-exist with numerous psychiatric illnesses.

❖ An epidemiological research study of individuals in Puerto Rico found that the co-morbid rates of mental illness among those reporting ataques de nervios were high: 63 percent met DSM-IV-TR diagnostic criteria for a psychiatric diagnosis compared to 28 percent of the rest of the sample.

❖ It was also determined that these individuals were 3.5 times more likely to meet criteria for an anxiety disorder and 2.75 times more likely to develop a mood disorder (Guarnaccia & Rogler, 1999).

❖ According to NASW, the CFI is a 16-question clinical interview that is to be completed during the initial assessment.

❖ Questions include: “What problems or concerns contribute to you seeking treatment at this time?”

❖ “People often understand their problems in their own way, which may be similar or different from the way doctors explain the problem. How would you describe your problem to someone else?”

❖ “Is there anything about your background, for example your culture, race, ethnicity, religion, or geographical origin that is causing problems for you in your current life situation?”

The DSM-5 Cultural Formulation Interview

❖ “Do you know anyone else who faced similar problems or situations?”

❖ “How did they handle the problem?”

❖ “How are such situations handled where you come from?”

❖ “What foods do you eat?”

❖ “What holidays do you celebrate?”

❖ “What books , magazines, TV shows, radio stations, or movies do you like?”

❖ “What values of your culture do you share or reject?”

❖ “How close do you feel to your community?”

(cont.)

❖ There is generally no single type of therapeutic approach.

❖ According to Simons (2001), some behaviors are simply “eccentricities” that do not need treatment and might best respond to local customs or traditions. Others require a more intensive, multi-faceted approach.

❖ Simons recognized the importance of culturally significant beliefs and practices alongside modern medicines and counseling approaches, calling for varied treatments ranging from shamanistic healing ceremonies to anti-psychotics to anti-depressants to antibiotics.

❖ ADVOCACY!

❖ Evaluate your own views on cultural issues.

❖ Meet and talk with people of other cultures.

❖ If you don’t know, ASK!

❖ Do not automatically assume . . .

❖ Be aware of language used in your agency’s paperwork.

❖ Do not neglect to ask about cultural values during your assessment process. (However, do not expect full disclosure immediately.)

❖ Promote client self-determination.

❖ Educate yourself.

❖ Have resources available regarding local and national multi-cultural organizations.

❖ Include magazines, books and publications in your office that address multi-cultural concerns.

“What would it be like to have not only color vision but culture vision, the ability to see the multiple worlds of others?”

---BATESON (1995)

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manual of mental disorders (5th edition). Washington DC: Author.

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model for social workers. Belmont, CA: Thomson Brooks/Cole.

Guarnaccia, P.J. & Rogler, L.H. (1999). Research on culture-bound

syndromes: New directions. American journal of psychiatry, 156:

1322-1327.

McGoldrick, M., Giordano, J., & Garcia-Preto, Nydia (2005). Ethnicity

& Family Therapy, 3rdEdition. New York: Guilford Press.

National Association of Social Workers (2003). Code of Ethics.

Washington, DC: Author.

Simons, R.C. (2001). Introduction to culture-bound syndromes.

Psychiatric Times, Vol. 18, No. 11.