Expressed emotion and schizophrenic outcome among Mexican-American families

This study has demonstrated that among low-income, relatively unacculturated Mexican-American households, a high level of expressed emotion on the part of key relatives significantly increases the risk of relapse for remitted schizophrenics who return home to live with their families after hospital discharge. This cross-cultural replication of earlier research findings in London and southern California suggests that critical, hostile, or emotionally overinvolved attitudes and behaviors may be general major stressors that adversely influence the fragile adaptation of schizophrenic individuals in diverse cultural settings. The finding of a lower prevalence of high levels of expressed emotion among Mexican-American compared to Anglo-American and British households lends support to the hypothesis that intrafamilial behaviors may account for different schizophrenic outcomes in different cultures.     

Expressed emotion: from predictive index to clinical construct

Expressed emotion, a measure of family attitudes toward psychiatric patients that is predictive of relapse, has attracted renewed attention recently as interest in the chronic psychiatric patient has widened. The authors review the development of the concept and the limits of its meaning. In seeking the core clinical construct underlying the expressed emotion variable, the authors also review recent studies of the relationship of expressed emotion to family interaction patterns, physiological arousal states, precipitants of relapse, and parental personality style. While family intervention studies are necessary to demonstrate that expressed emotion influences outcome in psychiatric patients, methodological limitations in currently available studies leave this issue unresolved.     

How culture shapes social cognition deficits in mental disorders: A review

Social cognitive skills are indispensable for successful communication with others. Substantial research has determined deficits in these abilities in patients with mental disorders. In neurobiological development and continuing into adulthood, cross-cultural differences in social cognition have been demonstrated. Moreover, symptomatic patterns in mental disorders may vary according to the cultural background of an individual. Cross-cultural studies can thus help in understanding underlying (biological) mechanisms and factors that influence behavior in health and disease. In addition, studies that apply novel paradigms assessing the impact of culture on cognition may benefit and advance neuroscience research. In this review, the authors give an overview of cross-cultural research in the field of social cognition in health and in mental disorders and provide an outlook on future research directions, taking a neuroscience perspective.     

Expressed emotion in families: a critical review

Research on expressed emotion in the families of schizophrenic patients has seemed to offer a new perspective on environmental factors that cause relapse in schizophrenia. A review of the literature, however, reveals that while expressed emotion may predict relapse, there is no evidence that it causes relapse. Nor does the evidence support the continued linkage of the three components of expressed emotion--criticism, hostility, and emotional overinvolvement--in a single global variable. The authors also question the clinical significance of expressed emotion ratings and believe that treatment strategies based on them tend to blame relatives for the patient's continuing difficulties. They suggest that clinicians assess family responses in the context of the patient's behavior and life situation before helping families develop more effectual coping strategies.     

Cross-cultural patterns in eating disorders: a review.

Eating disorders were previously thought to be isolated to achievement-oriented, upper and middle class individuals in Western countries. It now appears that these disorders may be increasing in other sectors of society and in a number of diverse cultural settings. We review the studies that comprise the relevant cross-cultural research literature on eating disorders. We also discuss the changing cultural factors that may be contributing to the apparent increase in these disorders around the world and directions for future research on such factors.     

Evaluation of expressed emotion in schizophrenia: a comparison of Caucasians and Mexican-Americans

Social desirability, while a recognized source of respondent bias among Mexican-Americans, has not been evaluated as an explanation for the lower rate of high expressed emotion (EE) found in the family members of Mexican-Americans versus Caucasians with schizophrenia. In this study, we tested the hypothesis that the lower rate of high EE (hostility and criticism) among Mexican-Americans was the result of cultural factors impacting on how information was reported by the Mexican-American relative of a patient with schizophrenia. We compared the ratings of EE between Caucasian (N = 17) and Mexican-American (N = 44) patients with schizophrenia or schizoaffective disorder and their key relatives using the level of expressed emotion (LEE) scale (paper and pencil instrument rated by the patient and relative separately) and the Five Minute Speech Sample (observational experimenter rated). The ability of the various measures to predict relapse over two years was also examined. Contrary to our hypothesis, there were no differences between patient and family measures within ethnic group. Mexican-American patients and relatives reported lower rates of high EE than Caucasians across all measures. High EE predicted relapse across measures for Caucasian participants, but did not predict relapse for Mexican-Americans on any of the measurement instruments. We discuss the implications of these findings on cross-cultural research and family interventions for individuals with psychotic disorders.     

Diversity initiatives in academic psychiatry: applying cultural competence.

OBJECTIVE: This article describes the process of change in an academic department of psychiatry that has led to the development of a diversity initiative in teaching, research, recruitment, and services. METHODS: The authors performed a literature review of diversity initiatives using PubMed. The authors then wrote a case study of the development of a diversity initiative at UC Davis. RESULTS: Some articles on diversity initiatives were found, but none that detailed the administrative process, funding, or sustainability of such initiatives. In 1999, the UC Davis Department of Psychiatry and Behavioral Sciences recognized the importance of issues of diversity and established the Diversity Advisory Committee, a group of department faculty and residents that explores and addresses the diversity needs of the department. In our observations, there are at least three requirements for a successful diversity initiative: a diverse patient population, a "critical mass" of interested faculty, and support of the administration. With these three factors in place, the Diversity Advisory Committee produced four Continuing Medical Education symposia focused on diversity topics, developed a 4-year cultural psychiatry curriculum and a 4-year religion and spirituality curriculum within the residency, and supported nine residents who received awards from the APA's Minority Fellowships in 8 years. Future plans include department-wide and medical school faculty-wide diversity training, educational research, and a postgraduate fellowship in cultural psychiatry. CONCLUSION: This article shows that a diversity initiative can be undertaken with interested minority and nonminority faculty, administrative support, and a diverse patient population. The authors hope this article will provide assistance to other academic departments in developing diversity initiatives.     

An integrative approach to cultural competence in the psychiatric curriculum

OBJECTIVE: As it is increasingly recognized that cultural competence is an essential quality for any practicing psychiatrist, postgraduate psychiatry training programs need to incorporate cultural competence training into their curricula. This article documents the unique approach to resident cultural competence training being developed in the Department of Psychiatry at the University of Toronto, which has the largest residency training program in North America and is situated in an ethnically diverse city and country. METHODS: The authors conducted a systematic review of cultural competence by searching databases including PubMed, PsycINFO, PsycArticles, CINAHL, Social Science Abstracts, and Sociological Abstracts; by searching government and professional association publications; and through on-site visits to local cross-cultural training programs. Based on the results of the review, a resident survey, and a staff retreat, the authors developed a deliberate "integrative" approach with a mindful, balanced emphasis on both generic and specific cultural competencies. RESULTS: Learning objectives were derived from integrating the seven core competencies of a physician as defined by the Canadian Medical Education Directions for Specialists (CanMEDS) roles framework with the tripartite model of attitudes, knowledge, and skills. The learning objectives and teaching program were further integrated across different psychiatric subspecialties and across the successive years of residency. Another unique strategy used to foster curricular and institutional change was the program's emphasis on evaluation, making use of insights from modern educational theories such as formative feedback and blueprinting. Course evaluations of the core curriculum from the first group of residents were positive. CONCLUSION: The authors propose that these changes to the curriculum may lead to enhanced cultural competence and clinical effectiveness in health care.     

Ethnographic Analysis of Expressed Emotions in Pakistani Families of Patients with Schizophrenia

Family expressed emotions (EE) have been found to be closely linked with the course of the disorder in patients with schizophrenia. Despite substantial cross-cultural differences in rates and impact of EE, a qualitative understanding of the construct is missing in relevant literature. This work was undertaken in Pakistan to understand the indigenous expression of emotional overinvolvement, criticism, and hostility as the primary components of the construct. We transcribed and conducted content analysis on the audio-recorded Camberwell Family Interviews of sixty-four caregivers to search the statements indicating these three elements. The frequency of statements showing overinvolved behavior surpasses all other accounts indicating criticism or hostility. Although many emotionally overinvolved behaviors are culturally relevant, some behaviors of the relatives, particularly of mothers, are above and beyond the cultural expectations. Outcome studies are warranted to determine whether extreme sacrificing and devoted behavior is pathological or a part of the culture. Criticism is mostly directed to socially objectionable behavior followed by personality traits of the patients. The higher frequency of hostility may be explained by specific socio-cultural factors. This ethnographic analysis shows that expressed emotions is not a culture specific construct. However, cultural distinctive patterns of emotional overinvolvement and critical attitude may exist across cultures.     

Expressed emotion: conceptual, clinical, and social policy issues.

Research on schizophrenia has suggested an association between relapse of patients and high expressed emotion (EE), defined as criticism, hostility, or emotional overinvolvement of at least one family member. In international studies, however, the majority of families of persons with schizophrenia demonstrate low expressed emotion. These families are described as empathic, calm, and respectful by EE researchers, who also reject the idea of family schizophrenogenesis. The author discusses expressed emotion as a construct, its validity and stability over time, and the direction of the relationship between relatives' expressed emotion and patients' symptoms and behavior. She reviews studies indicating significant differences in levels of expressed emotion across cultures, examines the social policy implications of programming based on the construct, and suggests research on EE analogues in clinical and rehabilitative environments.     

Expanding and Clarifying the Role of Emotion Regulation in Nonsuicidal Self-Injury

Objective:

Deficits in emotion regulation have been implicated in nonsuicidal self-injury (NSSI) by both theory and research. Research indicates that NSSI is commonly performed as an emotion regulation strategy, as it often decreases the experience of negative affect. People who engage in NSSI often report greater emotion dysregulation than those without an NSSI history. Further, interventions that have demonstrated effectiveness in reducing NSSI involve a focus on emotion regulation skills. Given the important role of emotion regulation in NSSI, research should continue to develop our understanding of this construct.

Methods:

We conducted a review of relevant research in emotion regulation and dysregulation and specific emotion regulation strategies in NSSI.

Results:

First, we provide an overview of current research on emotion regulation and dysregulation in NSSI. Second, we discuss the application of a specific emotion regulation model to NSSI research, and review research on NSSI supporting the use of this model.

Conclusion:

NSSI has been associated with an emotion regulation function and trait emotion dysregulation among people who self-injure. Relevant research provides initial support for the applicability of a specific model of emotion regulation to NSSI. We suggest directions for future research to continue to cultivate our understanding of emotion regulation in NSSI.     

Cultural aspects of caregiver burden in psychiatric disorders

Caring for a mentally ill family member is well known to be mostly a stressful, distressing and burdensome experience. The dominant model for examining the process of caregiving has been the stress-appraisal-coping paradigm, in which interactions between stressors, appraisals, coping, and various mediators produce the eventual outcomes in terms of distress or well-being among caregivers. Ethnic and cultural factors have traditionally received the least research attention as mediators of the caregiving process. However, a large body of accumulated research evidence has clearly demonstrated that culturally-defined values, norms, and roles are among the major determinants of the caregiving experience. This research is based mainly on cross-cultural comparisons between caregivers of minority ethnic groups residing in the West and the native Caucasian population. It has been supplemented, to a limited extent, by research carried out among caregivers belonging to different cultures and residing in their countries of origin. Most of this research has been carried out among caregivers of elderly people with dementia; other psychiatric disorders such as schizophrenia have received much less attention. Results of this research have documented important differences in caregiving experiences and outcomes across cultural and ethnic groups. Cultural factors which could mediate these differences have been identified, and theories, which could provide a coherent framework to understand these differences, proposed. Though limited by methodological difficulties, this research has provided important insights into the impact of cultural and ethnic factors on the whole spectrum of the caregiving experiences. An improved understanding of the area is, nevertheless, required because it will eventually help in devising appropriate ways to reduce burden and distress among caregivers from diverse ethnic and cultural groups.     

A cultural accommodation model for cross-cultural psychotherapy: Illustrated with the case of Asian Americans

As an extension of F. T. L. Leong's (1996) integrative model, this article presents the cultural accommodation model (CAM), an enhanced theoretical guide to effective cross-cultural clinical practice and research. Whereas F. T. L. Leong's model identifies the importance of integrating the universal, group, and individual dimensions, the CAM takes the next step by providing a theoretical guide to effective psychotherapy with culturally different clients by means of a cultural accommodation process. This model argues for the importance of selecting and applying culture-specific constructs when working with culturally diverse groups. The first step of the CAM is to identify cultural disparities that are often ignored and then accommodate them by using current culturally specific concepts. In this article, several different cultural "gaps" or culture-specific constructs of relevance to Asian Americans with strong scientific foundations are selected and discussed as they pertain to providing effective psychotherapy to this ethnic minority group. Finally, a case study is incorporated to illustrate application of the CAM. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

Applicability of the Chinese Beck Depression Inventory

Using a sample of 329 currently depressed patients from 24 hospitals across China, this study assesses the reliability and validity of the Chinese version of Beck Depression Inventory (CBDI). Even though the internal reliability and the concurrent validity were good (Cronbach alpha = 0.846; r = 0.566), the results showed that the item of Loss of Libido was most weakly correlated with the CBDI's total score; the items of Sense of Punishment, Sense of Hate, Self Accusations, Crying Spells, Irritability, and Somatic Preoccupation were poorly associated with the intensity of depression measured by the total score of the Chinese version of Hamilton Depression Rating Scale (CHDS). The CBDI's construct validity was rather poor by principal component analysis: three of six factors were unexplainable in terms of clinical features of depression. The results demonstrated that CBDI, even though it was semantically translated into Chinese language, still could not be effectively applied in clinic and research settings in China. Using the theory and methods of psychometrics to develop China's own culturally sensitive self-report inventory is the correct way to eliminate cultural bias and make cross-cultural research more valid. This is the most rigorous scientific approach to cross-cultural comparisons.     

Type A behavior and the social production of cardiovascular disease

Since the turn of the century, there has been a continued interest within medicine in the psychosocial and behavioral risks for cardiovascular disease. Current research supports type A behavior and its components as risk factors. At various points in time, researchers have suggested that the context in which emotion and behavior occurs is an important determinant of the risk-enhancing nature of these factors, but little systematic work has been done. It is argued here that future research on cardiovascular disease should more explicitly take social context into account to provide a better understanding of the nature of disease, and to provide more accurate models for medical education and patient care.     

A critical review of epidemiological studies of Puerto Rican mental health

Through a review of the epidemiological literature on the mental health of Puerto Ricans and other Hispanics, the authors argue that lack of attention to cultural issues in epidemiological studies leaves many questions unanswered and raises concerns about the validity of studies in this area. The authors point out that the mental health status of Puerto Ricans in New York City is still poorly understood after 30 years of research. The roles of cultural response styles and of culturally meaningful expressions of distress in shaping responses to research interviews should be central concerns in developing research in cross-cultural psychiatry.     

Coming together in pain and joy: A multicultural and arts-based suicide awareness project

The issue of suicide is still taboo in many cultures and the silence surrounding this problem is often destructive. Those affected by suicide have few opportunities to express their pain and their communities are left feeling helpless. The creative arts therapies have been used to address the emotions surrounding suicide, however few projects have studied the use of the arts to promote suicide awareness. Furthermore, there is a lack of multicultural research in this area. This article describes a two-day arts-based symposium that brought together members from diverse cultural communities including Inuit, Mohawk, Jewish, Christian, Baha’i, South-Asian Canadian, Senior and LGBTQ (Lesbian, Gay, Bisexual, Trans-gendered, Queer) communities. Through drama, music, art-making and writing, participants explored this difficult subject, expressed complex feelings and shared their perspectives. An instrumental case study design was employed for this research project. The objectives were to gather information on participants’ experience of exploring the issue of suicide within an arts-based approach and to determine if cross-cultural themes would emerge. The findings indicate that using the arts helped to facilitate dialogue and communication and specific cross-cultural themes did emerge.     

Social control and expressed emotion

Research shows a higher risk of relapse among schizophrenics in high "expressed emotion" families. In this paper, the measure called "expressed emotion" is conceptualized as an indicator of family attempts to socially control the schizophrenic person's behavior in a particular way. This social control conceptualization is supported by a review of the type of information in the measure. Hypotheses following from this view are examined to assess the construct validity of the measure conceptualized as a type of social control. First, attempts at control are hypothesized to be ways anxious and fearful families try to cope. Second, the family's recognition of the schizophrenic's problem as mental illness is hypothesized to reduce the fearful and anxious family's likelihood of an intense interpersonal social control coping response. This type of social control of involuntary illness behaviors would be abandoned as unjust and unlikely to be effective. Data from the pioneering 1972 study by Brown, Birley, and Wing (Br. J. Psychiatry 121:241-258) provide support for these hypotheses and thus provide support for this social control conceptualization.     

Family environment, expressed emotion and adolescent self-harm: a review of conceptual, empirical, cross-cultural and clinical perspectives

Self-harm in young people is a complex and pervasive problem with a number of co-existing risk factors. Although research has implicated a range of family variables in understanding the onset, maintenance and prevention of adolescent self-harm, relatively little attention has been given to the expressed emotion (EE) construct. Based on a narrative review and synthesis of peer-reviewed literature up to and including 2011, this paper considers the conceptual background and empirical evidence for the role of family environment in the expression of adolescent self-harm, with a particular focus on EE. The clinical implications of this literature for working with young people and families from different cultures are also addressed. In summary, the surveyed research provides insufficient evidence for a direct causal link between family environment and adolescent self-harm, with questions raised about the temporal sequencing of measured variables, specificity of implicated family risk factors, and the nature and role of protective factors in families. Emerging evidence for an association between high EE and adolescent self-harm requires replication in well-controlled, prospective studies. There is also a lack of empirically-supported, family-based treatment modalities for adolescents who self-harm. Intervention strategies should be guided by personalised formulation, taking into account individual vulnerabilities, strengths and social contexts, as well as cultural norms for family environment.     

Migrations,trauma and mental health: A literature update on psychological assessment

IntroductionMigrants and refugees often face potentially traumatic events and post-migratory stressors. Upon arrival in the host country, they can be referred to mental health services to assess the impact of their previous experiences. These cross-cultural clinical encounters may raise questions, particularly regarding the assessment of mental health using models based on Western conceptions of psychopathology.Objectives and methodThe objective of the present non-systematic review of the literature is to discuss the psychological evaluation of post-traumatic reactions in migrants and refugees. More specifically, we present current research on psychopathology, resilience and post-traumatic development (PTG) among the migrant and refugee population. We also examine the cross-cultural validity of concepts such as Post-Traumatic Stress Disorder, resilience and PTG. Finally, we describe the most frequently used tools in cross-cultural psychological assessment and briefly reflect on the question of cultural sensitivity of mental health professionals. A bibliographic search was carried out using the databases: PILOTS, Pubmed, APA PsycNET, and Google Scholar using the following keywords: “migrants”, “refugees”, “posttraumatic stress disorder”, “mental health”, “Psychopathology”, “risk factors”, “protection factors”, “posttraumatic growth” and “resilience”. We have also reviewed the reference lists of articles encountered from database searches.ResultsResponses to a potentially traumatic situation are multiple. Regarding the migrant and refugee population, the reviewed articles studied different post-traumatic reactions such as resilience, post-traumatic development, and psychopathologies. The most studied psychopathological responses were depression, anxiety and Post-traumatic Stress Disorder. After reviewing these studies, we asked the following question: considering the complexity of the migration process, what are the factors associated with the development of these different post-traumatic responses? Indeed, several individual and social factors before, during and after migration influence the mental health of individuals in a migration situation. Among the most cited risk factors identified were: to be a victim of or witness to violence in the country of origin and, after migration, to face post-migration difficulties such as asylum denial, to be in a precarious situation with regard to housing and work, as well as the difficulties linked to adaptation to the new culture. We have also described protective factors for the mental health of this population, such as: social support, psychological support, and a good quality of life in the host country. The reviewed articles also describe an important influence of cultural aspects on mental health, such as the perception of an event as traumatic. Although the authors of the reviewed articles accept this influence of culture on post-traumatic responses, most of the tools used to assess the mental health of migrants and refugees were created in a Western context. Studies show a growing concern with these cultural aspects, and certain tools that allow a more culturally sensitive evaluation, such as the “Cultural Formulation Interview”, are being developed.Discussion and conclusionEven if the concern with the sensitivity of the tools used in cross-cultural assessment seems to be more present in the international literature, researchers seem to encounter difficulties in better understanding the effects of culture on the mental health of individuals. With increasingly diverse societies, new research should not be based on participants’ geographic or ethnic origins, but rather try to “unpack” culture with, for example, the exploration of the relationships between certain values or orientations and the different expressions of psychological distress. Finally, given the still lacking development in the field of cross-cultural research, certain practices, such as the participation of interpreters, the supervision of cultural mediators or the use of culturally sensitive tools, can help the clinician to maintain good practices with patients from different cultures in the diagnostic and psychotherapeutical processes.