The Influence Of Culture On Diagnostics 2
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The Influence Of Culture On Diagnostics 2

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lecture held in September, 2011, on the World Congress in Buenos Aires

lecture held in September, 2011, on the World Congress in Buenos Aires

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The Influence Of Culture On Diagnostics 2 Presentation Transcript

  • 1. The Influence of Culture on Diagnostics Analysis of the use of the Cultural Formulation in Diagnosis Hans Rohlof, Simon Groen, Rob van Dijk, Richard Starmans
  • 2. Stichting Centrum ’45
    • The national institute for specialist diagnostics and the treatment of people with complex psychotrauma complaints
    • These complaints have a broad background:
      • Result of persecution and / or war
      • Result of repeated / job-related violence
      • 60 % of the patients are refugees from 45 different countries.
    October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 3. Rijnzichtweg 35 2342 AX Oegstgeest 071 5191500 Locations Centrum ‘45 Registration and Information Office 0800 2 245 245 Nienoord 5 1112 XE Diemen 020 6274974
  • 4. The Cultural Formulation of Diagnosis (CF)
    • Need of more sensitive diagnostics in different ethnic groups
    • Use of CF in assessment procedure
    • Initial version of Cultural Interview (CI)
    • Book in Dutch to promote use of CF
    October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 5. Content of cultural formulation
    • Cultural identity of the individual
    • Cultural explanation of the individual’s illness
    • Cultural factors related to psychosocial environment and levels of functioning
    • Cultural elements of the relationship between the individual and the clinician
  • 6. Culture, classification and diagnostics October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 7. Use of the Cultural Formulation in Refugees
    • Article (2009) in Transcultural Psychiatry
    • Description of Cultural Interview as used in our clinic
    • Specific adaptation of the CF for refugees
    October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 8. The Cultural Formulation of Diagnosis (CF)
    • Developed on the basis of anthropological theories
    • Attached as a chapter in DSM-IV
    • Mostly unknown by diagnosing mental health workers
    • Lack of sufficient practical applicability
    October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 9. Theoretical backgrounds
    • cultural identity complex, but important with regard to expression of emotions and physician-patient-relationship
    • Idioms of illness, illness explanations and help seeking behavior are important in indications of treatment
    • social interactions important: social element of illness
    • Frequent misinterpretation of resources and level of functioning.
    • Diagnosis has to be reliable but also valid
    October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 10. Research before DSM-IV
    • APA committee on cross-cultural issues: 45 transcultural experts and 15 DSM-experts
    • Field trial with 4 large ethnical groups in the U.S.A.: African Am, Hispanics, Asians, Natives
    October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 11. Literature search
    • The terms: ‘cultural formulation’ and ‘cultural consultation’ related to ‘mental’ in PubMed (1994-present).
    • 112 research articles and describing articles, and 28 case histories.
    October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 12.
        • What is the status of implementation research on the CF?
        • How can the CF be implemented more uniformly? Have implementation guidelines been proposed? If not, which may be recommended?
        • What is the status of empirical effectiveness research on the impact of the CF…
          • On diagnostic validity or reliability?
          • On clinical response?
          • In terms of cost effectiveness?
        • What is the status of research on making the CF more efficient and disseminatable (i.e., simpler, shorter) without sacrificing its value as a narrative, comprehensive assessment?
        • How can the usefulness of the CF for every clinical encounter be emphasized, as opposed to the perceived use of the CF as applicable only in cross-cultural interactions or for “exotic” patients?
        • About the summary of the CF: What proposals have been made or tested to better systematize this application to facilitate dissemination and training?
      • Are there data on adapting the CF specifically for refugees, as opposed to migrants more generally?
    Questions asked October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 13. Status of implementation research
    • 28 articles, in which was described the use of the CF in different clinical populations .
    • describing articles interesting for therapists who treat patients from the described population
    • In The Netherlands important in the education in transcultural mental health care : mental health psychologists, psychiatrists (new curriculum). Also in the education of general practitioners.
    October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 14. Guidelines & clinical interviews
    • EMIC (Weiss, 1997): focused on illness experience.
    • Manual of Cultural Psychiatry (Lim, 2006)
    • McGill Illness Narrative- MINI (Groleau, 2006): focused on illness explanation.
    • Cultural Interview (Rohlof e.a., 2002): semi-structured interview; 90 minutes.
    • Short cultural interview (Groen, 2008): 30 minutes
    October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 15. Status of research
    • Qualitative studies in NL:
    • Borra et al (2002): improvement of diagnostic process, but danger of instrumentalisation without improvement of cultural competencies.
    • Starmans (2005): no diminishment of gap between GP and patient but also no sign of not accepting the status of the GP.
    • Beijers and Tempelman (2009): in mental health care diminishment of gap between patient and therapist.
    October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 16. Status of research
    • Quantitative studies:
    • Lopez-Appelo (2000): research in Latin American patients (n=1003), divided in two groups, one with CF: success of treatment better in CF-group.
    • Neighbors et al (2003): with using the CF African American wer less frequently diagnosed with schizophrenia.
    • Zandi et al (2008): more agreement with clinical diagnosis when adding the CF to the CASH-questionnaire in Moroccan patients.
    • Harris et al, Kirmayer et al: more cultural competency in treatment when using the CF
    • Ton (2005): investigation of all cultural sensitive services in the U.S.A. Ethnic matching impossible, CF meaningful
    October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 17. CF shorter, more applicable?
    • Most important items:
    • Cultural identity: origin, ethnicity, acculturation, self image, gender.
    • Cultural illness explanations: awareness of illness, illness explanations, religious aspects.
    • Social network: position of the family, contacts with relatives, other social contacts, the role of shame, stigmatisation.
    • CF is also important for the relation with the patient: more adherence to therapy.
    October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 18. CF also for native patients?
    • Better: Contextual Formulation of Diagnosis:
    • Social factors: social economical status, housing, discrimination, accessibility of care. Family backgrounds.
    • Juridical factors: procedures, permit to stay.
    • Cultural factors: language, culture differences, migration history.
    October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 19. Systematisation of summary
    • Acculturation and quality of life can be quantified(Mezzich, 2008).
    • Describing cultural elements in terms of problems and possibilities (Rohlof, 2008).
    • Calling culture a process, also in therapy (van Dijk et al, 2002).
    October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 20. Adaptations for refugees
    • Acharya (2009): No adaptations but CF considered as important because of differences in self concept, diffrences in concept of stress involvement and stigmatisation and differences in symptom expression.
    • Rohlof et al (2009): adaptations: working with interpreters, attitude towards own culture of therapist and patient, discrimination and accessibility of care. Next to this cultural interview.
    • Groen (2008): improvement of diagnostics and treatment by interview.
    October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 21. Conclusions and advices for DSM-V
    • Attention to self concept en identity
    • Attention to illness explanations
    • Migration history
    • Discrimination and inaccessibility of care
    • Stigma
    • Social, economical and juridical factors.
    • In short:
    October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 22. Attention to
    • Contextual Formulation of Diagnosis
    October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 23. More information about CF and CI
    • www.rohlof.nl
    • www.centrum45.nl
    October 21, 2011 The Influence of Culture on Diagnostics. Hans Rohlof et al
  • 24. 10/21/11 T I T E L V A N D E P R E S E N T A T I E www.centrum45.nl