Cultural formulation guidelines.

The outline for the Cultural Formulation (CF) introduced in DSM-IV does not present any method for collecting the required cultural information. The absence of specific guidelines and illustrative cases has hampered its wider use. This article offers a practical approach to preparing a Cultural Formulation as a component of culturally competent clinical care. We summarize the rationale for the four sections of the CF, describe the process of conducting culturally focused clinical interviews, and present examples of questions or lines of inquiry that can be used to collect the information needed to construct the CF. An online supplement provides case examples of cultural formulations applied to patients seen in the US.

How psychiatric conditions were made.

Information on the evolution of brain, culture, and adaptive behavior is discussed in order to explain why an amalgam of behavior and sickness, rather than "psyche" as ordinarily construed, constitutes the fabric which made up the psychiatric condition in evolving human groups. Limitations of the "harmful dysfunction" thesis and of related ideas of evolutionary psychologists about psychiatric condition are discussed. A hierarchical model of information-handling systems involved in brain and behavior relations is proposed as a way of better appreciating the importance of an integrative formulation of the psychiatric condition that incorporates visceral somatic disturbances and equates such conditions with sickness and maladaptation. Why and how a dualistic cultural bias about the "psyche" of psychiatric condition evolved is reviewed along with some of the problems it has conditioned involving the organization of contemporary medical and psychiatric practice.

Why psychiatric conditions are special: an evolutionary and cross-cultural perspective.

In non-Western and premodern societies, approaches to sickness involved moral considerations laden with existential and spiritual implications. Healers and physicians had access to this aspect of their patient's lives, were expected to use it constructively, and often did so. The contemporary biomedical theory of disease no longer assigns to illness such metaphysical connotations. While general physicians are permitted - perhaps even advised - to avoid involvement in morally laden dialogues tied to illness and the self, such dilemmas are more prominent and qualitatively different in psychiatry, as psychiatric conditions often entail changes in self-conception, psychological disaffection, unacceptable behavior, and untoward personal reactions to social circumstances. Manifestations of psychiatric conditions can overwhelm an individual's control in areas of cognition, emotion, autonomy, social responsibility, behavior, and body functions - exactly those matters that "modern" individualistic minds are supposed to master. Consequently, psychiatric conditions challenge basic presuppositions of the modern, secular credo about personhood, disease, and behavior. They comprise a species of human problems ontologically distinct from the conditions handled by other medical disciplines.

Making sense of behavioral irregularities of great apes.

Psychopathology, mental illness, and psychiatric treatment are concepts relevant to modern medicine and medical psychology and replete with cumbersome intellectual and literary baggage. They bear the imprint of suppositions, world views, and general beliefs and values exemplified in the science, history, and general culture of Anglo European societies. The study in higher apes of phenomena addressed by such concepts raises conceptual dilemmas, usually termed speciesism and anthropomorphism, not unlike those encountered in comparative human studies of similar phenomena across cultures and historical periods, namely, ethnocentrism and anachronism. The authors' synthesis of literature and their analysis of the implications of higher ape psychopathology represent an epistemically compelling account that broadens the scope of the comparative study of behavioral irregularities, a topic that provides a different slant for examining challenging questions in evolutionary biology and primatology, such as cognition, self awareness, intentional behavior, culture and behavioral traditions, social intelligence, sickness and healing, and altruism. Theoretical and empirical study of this topic expands formulation and can help provide informative answers about human evolution as well as essential features of human psychiatric syndromes, with potential practical implications. The study of psychopathology of higher apes and other non human primates represents an appropriate focus for neuroscience and bio-behavioral sciences.

An ethno-medical perspective on research participation: a qualitative pilot study.

BACKGROUND: Recruitment of racial/ethnic minorities for clinical research continues to be problematic, yet critical to ensuring that research data will be applicable to diverse populations. There is a paucity of information about culturally appropriate methods for recruiting and retaining racial/ethnic minorities in research. OBJECTIVE: To cross-culturally assess perceptions of research participation by African American and immigrant Latinos living in the inner-city community of Watts, Los Angeles, California, using qualitative methods. DESIGN: Focus groups using ethnically matched moderators were convened with African American and immigrant Latino participants. Discussion was facilitated using a script that focused on perceived "feelings" and "perceptions" about research. Discussions were audiotaped, transcribed, and analyzed using manual and computerized statistically based software (mixed) methods. RESULTS: African Americans and immigrant Latinos shared several barriers and motivators to research. However, they also reported barriers and motivators to research that were distinct to each group. Latinos were more interested in healthcare and health information, and African Americans were more concerned with issues of trust and quality of care. Most participants said they would participate in research if they were better informed, or if they or a family member had an illness. Improving communication was reported as being important for motivating participation in clinical research. Overall, socioecologically and socioeconomically based domains were shared, whereas historically and/or socioculturally based domains were distinct. CONCLUSIONS: Using an ethno-medical science model, we demonstrated that it is possible to identify shared barriers and motivators to research participation between 2 distinct cultural groups. This approach can be useful in developing targeted community-based strategies to increase minority participation in clinical trials.

Psychiatric conditions and the social sciences.

Psychiatric disorders have a distinct shape, come in types and are inherent in Homo sapiens. To a social scientist, disorders exist by stipulation: contingent on a psychiatric frame of reference. Their materiality has meaning only in that framework. What is important is what that material might correspond to in a society's systems of representation and associated institutions. If one assigns disorders some sort of 'objective' reality (a scientific ontology), then one needs to explain what that corresponds to in cultural terms. Moreover, if disorders exist and have an evolutionary history, one has to formulate how they might have been perceived and understood during phases of biological and cultural evolution. The article provides a way to conceptualize meanings psychiatric disorders have had in these two systems of representation and their change during evolution.

Psychiatric conditions in an evolutionary context.

Psychiatric conditions and the institutions and practices that modern society has evolved to handle them originated during the nineteenth century in Anglo European societies. They are products of a historically contingent and culture specific formulation of a class of social problems of behavior that came to the fore in relation to intellectual and political economic changes of those societies. However, such problems have a long ancestry. They are intrinsic to human species and the social and cultural systems that its members have evolved since their emergence. This article reviews intellectual quandaries raised by evolutionary study of psychiatric conditions, those of crossing the human/animal divide and crossing historically contingent cultures; and of framing history of psychiatry in terms of social and cultural evolution. The biological architecture underlying psychiatric conditions and the breakthroughs that indigenous psychiatry of different types of societies underwent in formulating signs and symptoms are discussed.

Culture and formulations of homicide: two case studies.

The killing of another human being is an execrable act and universally condemned. Simpler societies have informal ways of seeking retribution (Bohannan 1960; Hoebel 1954). Ancient states and civilizations evolved formal procedures and complex institutions for evaluating culpability, apportioning blame, and authorizing appropriate sanctions (Ng 1990; Robinson 1996). The evolution of the insanity defense in Anglo-American society has culminated in assigning to psychiatry and psychology the important task of determining whether the mental state of a person who perpetuates homicide meets criteria for legal sanction. Differences involving the traditional model of reasoning about human action that is standard in psychiatry compared to law have been discussed. A common basis of understanding and procedure for assessing responsibility has evolved (Moore 1984). However, usually neglected is the influence that culture has in shaping behavior of homicide and its forensic psychiatric assessment. Two cases are presented to examine why and how culture is influential in matters of homicide.

On building a clinical cognitive neuroscience.

No one can or has doubted that the brain "lights up" in the context of normal and abnormal experience and behavior. The anatomy of the brain ensures that its regions, circuits, distributed pathways, and cell assemblies have to provide the "electricity" for the lights. Some of the relevant structures light up preferentially for some neurocognitive functions (e.g., language, attention and working memory, spatial orientation). However, many domains of experience and behavior relevant to mental health problems (e.g., motivation, attachment residuals, emotional responses) appear to have a different neural representation than traditional neurocognitive functions. At any rate, the preceding describes the territory that Strumwasser emphasizes should be taken into consideration in context of mental health problems. The territory he wants to connect with involves disturbances of experience and behavior, social inefficiency, behavioral breakdowns, and disordered thought, all of which demarcate the clinical domain. Strumwasser believes that a relevant and clinically useful bridge can be devised to cross and link together these territories in an effective way. He proposes and urges that attention be given to developing a frame of reference by means of which a solid correspondence can be established between the two territories. He provides a stimulating and provocative image of a future clinical cognitive neuroscience. His vision, however, raises many questions. Furthermore, whether future developments in the neural sciences will or can accommodate Strumwasser's wishes remains to be seen.

Medical validity in Eastern and Western traditions.

When comparing biomedical treatments and traditional treatments from China and India, validity is established by a randomized placebo-controlled trial (RPCT). While the advantages of RPCT are uncontestable, its requirements handicap validation of treatments from Eastern traditions, which are integrated within a worldview that encompasses natural philosophy, theology, empirically based clinical experience, and spiritual and moral tenets. RPCT evolved during a time when comparatively little was known about Eastern medical traditions; about the effects of emotional, cognitive, and cultural factors on healing; or about the evolutionary biology and psychology of innate mind/body mechanisms, such as those producing placebo responses, which may constitute evolved adaptations naturally selected during human evolution. A fair way of both securing the advantages provided by RPCT and balancing them with a methodology that ensures safe and efficacious treatments from other traditions can be facilitated by examining medical validity in light of generalizations from evolutionary psychology and the cultural study of medicine.