Advocating for persons who are mentally ill: a history of mutual empowerment of patients and profession.

The author reviews the history of advocacy for mentally ill individuals. Through organizations such as the National Mental Health Association and the National Alliance for the Mentally Ill, collaboration among professionals, consumers, and concerned citizens is enhanced. The common causes and differences among organizations are discussed within the context of how psychiatrists can realize leadership strategies to further advance advocacy for mentally ill persons and for the profession.

Racial identity and its assessment in a sample of African-American men in treatment for cocaine dependence.

Substance abuse treatment studies frequently include subjects from different ethnic and racial groups, but many investigations limit the examination of race and ethnicity to the use of nominal labels. This approach reveals little about the social or psychological significance of racial and ethnic group membership to the subjects of study or about the potential effects of these factors on substance-involved behaviors. In this study, a principal components analysis (PCA) with varimax rotation was conducted on the 50-item long form of the Racial Identity Attitude Scale (RIAS) (1) in a sample of 294 African-American men in treatment for cocaine dependence. The RIAS was developed to measure attitudes about race and racial status among blacks, but it has not been utilized widely in substance abuse research. Our findings provide evidence for the structural validity of this instrument in this sample of substance abusers. We discuss how recent advances in racial identity theory and its measurement may provide an important avenue for understanding the psychological consequences of racial group membership and for examining the potential effects of these factors on treatment response in studies of substance misuse.

A two-rate hypothesis for patterns of retention in psychosocial treatments of cocaine dependence: findings from a study of African-American men and a review of the published data.

In this article, we examine patterns of retention in psychosocial treatment programs for cocaine dependence. We present new data from a comparison trial of Drug Counseling and Supportive-Expressive Psychotherapy and review published data from all studies utilizing psychosocial interventions alone. We compared Drug Counseling and Psychotherapy on rates of pretreatment and during-treatment attrition in a sample of 294 African-American men seeking treatment for cocaine dependence (mean age, 37.6). Survival analyses were utilized to identify significant differences in during-treatment attrition between the two treatments and to identify significant changes in the rate of attrition during the course of each treatment. We then compared the patterns of retention in this study with those from other available published reports of psychosocial treatments for cocaine abuse. The weekly during-treatment attrition rate was not constant in either treatment condition, and the change in rate of attrition occurred at week six for both Drug Counseling and Psychotherapy. Comparison with other studies suggested that the during-treatment pattern of attrition among most psychosocial treatments for cocaine abuse is typified by two rates, with the rate of subject attrition early in treatment being greater than the rate of later attrition and also exhibiting greater variance. Future studies of treatment retention should identify significant shifts in the rate of during-treatment attrition, examine if the pattern of attrition is typified by two rates, and, if so, determine where the shift occurs. Future studies should also assess if changes in the rate of during-treatment attrition signal the timeframes within which strategies that enhance retention can be implemented in the treatment program.

Clinical relevance of contemporary cultural psychiatry.

In recent years, the field of cultural psychiatry has gained recognition and accumulated evidence of its clinical relevance. This article examines the intersections of culture and psychopathology and describes five independent but interrelated clinical dimensions that identify and define culture as: a) an interpretive/explanatory tool, b) a pathogenic/pathoplastic agent, c) a diagnostic/nosological factor, d) a therapeutic/protective element, and e) a service/management instrument. Along these lines, conceptual boundaries, clinical findings, specific applications, and research implications for each of the five dimensions are systematically reviewed. Cultural psychiatry adds significantly to the comprehensiveness of psychiatric evaluation and management and addresses prominent issues regarding understanding, classification, diagnosis, and competent treatment of most psychiatric disorders in every society and region of the world. Based on the strength of these clinical dimensions, and on the related educational and research efforts, cultural psychiatry can also contribute decisively to the design of comprehensive mental health policies.

Ethnicity and psychotherapy. A component in the treatment of cocaine addiction in African Americans.

With a focus on the use of psychotherapy as a component in the comprehensive treatment of African Americans addicted to cocaine, this article reviews the literature on ethnicity and psychotherapy and discusses the main problems relevant to the planning of mental health and substance abuse services to minority populations in the United States. Some of the more salient areas are the relationship of cultural factors and substance abuse, the culturally determined possibilities and constraints in the treatment of substance abuse, the establishment of a culturally responsive psychotherapeutic approach that takes into account notions such as ethnic consciousness and self-esteem, and the therapist's effects on the proximal treatment situation. Research issues also are discussed, among them therapist-matching strategies, therapist's clinical skills, culturally responsive adaptations of psychotherapeutic frames and processes, and their effect on outcome.

Personality disorders and culture: contemporary clinical views (Part A).

This article reviews the basic concepts surrounding the clinical relationships between culture and personality disorders (PDs). Culture plays a significant role in the construction of self-concept and self-image, the egocentric/sociocentric dichotomy, and the determination of biases in the clinical study of PDs. Cultural contextualization is, therefore, crucial in the demarcation between normal and abnormal personalities. From a clinical perspective, culture has three roles vis-à-vis the psychopathology of personality: (a) as an interpretive/explanatory tool; (b) as a pathogenic/pathoplastic agent; and (c) as a diagnostic/nosological factor. The first of two parts, this article examines the interpretive/explanatory and pathogenic/pathoplastic roles, substantiated by clinical examples gleaned from the existing literature.

Personality disorders and culture: contemporary clinical views (Part B).

This article reviews the basic concepts surrounding the clinical relationships between culture and personality disorders (PDs). Part A of this article, which appeared in Cultural Diversity and Mental Health, Vol. 1, No. 1, pp 3-17 (1995), examined the interpretive/explanatory and pathogenic/ pathoplastic roles of culture. Herein, culture's role as a diagnostic/nosological factor is discussed through the use of measurement instruments and the cultural formulation included in DSM-IV (American Psychiatric Association, 1994). In addition to these three roles, some authors would also consider a therapeutic/protective function for cultured in PDs. Following a critique of the biological perspective, a research model based on the definition of the cultural profile and the estimation of the cultural distance between clinical examiners and populations is proposed. It is important to reject both biological reductionism and the extremes of cultural determinism, in order to better assess the intraethnic distribution of psychopathology, and interethnic variations represented by the notion of cultural relativism.

Reflections on dream material from Arctic Native people.

This article presents several theoretical and methodological perspectives from which psychoanalytic understanding of the dreams of people in a foreign culture might be obtained. The dreams of two Inuit (Eskimos) are examined as they reflect the cosmologies, narrative styles, and individual psychologies of each dreamer. Caveats are noted regarding notions of universal symbolism, typical cultural character, and facile interpretations of dreams.

Misalliances in the Barrow Alcohol Study.

The Center for Research on the Acts of Man conducted a survey of the use of alcohol among the Inupiat of Barrow, Alaska, in 1979. The study resulted in grievances among many individuals and institutions associated with the community. In a retrospective analysis of the factors contributing to these misalliances, the author raises important ethical and procedural questions to be considered carefully in future projects of this nature.

The effect of patients' beliefs about their illnesses on compliance in psychotherapy.

Sixty patients treated in the outpatient psychiatric clinic of a large urban teaching hospital were surveyed regarding their beliefs about the causes of their illness. Patients' beliefs were found to be related to two measures of compliance: number of visits and manner of termination from therapy. Subjects endorsing more medical and fewer nonmedical explanations for their illness made more visits to the clinic and ended treatment in a more compliant manner than did patients who endorsed more nonmedical beliefs about the causes of their illness. Results also showed that, except for age, demographic and diagnostic variables were not related to compliance.

Persistent dysarthria with apraxia associated with a combination of lithium carbonate and haloperidol.

Reported is a 19-year-old manic-depressive patient who developed persistent dysarthria with coexisting apraxia while on a combination of high dose haloperidol and lithium carbonate. The speech disability occurred as a solitary symptom in a patient with normal serum lithium levels and no other signs or symptoms of lithium toxicity and persisted after lithium was discontinued and the neuroleptic changed. There were several factors which favored an association between the speech disability and the drug therapy. These included improvement during a drug-free trial: the absence of a prior history of a speech problem; the patient's marked psychotic state and anxiety: and the high dosage of haloperidol.

The concept of culture in psychiatric residency education.

Diagnosis and treatment in psychiatry are heavily influenced by cultural factors. The author argues that the subject of culture warrants a place in the curriculum of psychiatric residency education. He outlines approaches to the teaching of cultural psychiatry that have been used successfully in several departments of psychiatry. He feels that although the medical model of understanding mental illness has demonstrated its effectiveness in chemotherapeutic, psychotherapeutic, and other treatments, the cultural model can often provide unique insights and approaches in patient care.