Chinese American man with high risk of psychosis

Editors’ Note: Curbside Consult is an occasional column aimed at helping psychiatrists think through family and cultural considerations when treating patients. It examines case vignettes and is written by two Group for the Advancement of Psychiatry (GAP) committees – the Committee on Family Psychiatry and the Committee on Cultural Psychiatry. The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements.

Case vignette

Bill is a 25-year-old man of Chinese descent who sought psychiatric evaluation of his psychosis risk. His parents emigrated from China to Canada more than 30 years ago; Bill was born in Canada, and moved to the United States with his parents and two siblings at age 7.

His family has a strong history of mental illness. His older sister was diagnosed with schizophrenia; she frequently got into verbal altercations with her parents. When Bill was 15, she walked out of the house after a fight with the family and never returned. Bill’s family thinks his father has had paranoid delusions. In the past, he attempted to call the police multiple times because he suspected the neighbors had planted a listening device in his front yard. The family stopped him from making the actual calls. However, the family never brought him to psychiatric evaluation because of perceived stigma and social discrimination in their community. He also was emotionally and physically abusive to Bill during his childhood by calling him names and hitting him with a belt. As an adult, Bill still has posttraumatic stress disorder symptoms including flashbacks, nightmares, and avoidance when thinking about his father.

Bill identifies himself as Chinese American and speaks English only. He often perceives himself as a newcomer to U.S. society, making comments such as: “I guess I should live my life like this to fulfill the American dream.” Bill’s parents placed a strong emphasis on academic success, often at the expense of their children’s social interaction and playtime activities. Bill describes himself as a “loner” with few friends. He maintained high academic achievement during high school and was accepted by a prestigious college. Although he was interested in music composition, Bill was “forced” by his parents to major in courses deemed good preparation for law school.

During college, he suffered severe depression with insomnia, low energy, hopelessness, anhedonia, social withdrawal, poor appetite with weight loss, and ruminative thoughts but without delusional thoughts or perceptual disturbances. He had one near-lethal suicide attempt, during which he impulsively took the contents of an entire bottle of Tylenol in the context of family conflicts, resulting in psychiatric hospitalization. Bill recalled with animosity the inpatient psychiatrists who put him on psychotropic medications during a 3-day hospitalization. He was not adherent to the medication and did not follow up with postdischarge outpatient care. He did not remember the medication trial he had during the hospitalization, nor did he give consent to obtain medical records from there. Bill withdrew from college in sophomore year, because of his declining academic performance secondary to his mental illness. He currently works at a gas station.

Over the last year, Bill’s interpersonal communication has become disorganized in both work and social settings, and he has developed thought blocking, causing him substantial distress. He intermittently hears voices of strangers in the background; these have gradually become more frequent, now occurring 3-4 times a week. Bill also is more depressed, with frequent crying episodes and worsening social isolation. He often thinks that life is not worth living, but he has no active suicidal plans or intent.

Bill’s supervisor and coworkers strongly suggested that he seek medical evaluation. As an outpatient, Bill started weekly cognitive-behavioral therapy (CBT) and biweekly medication sessions for early psychosis symptoms, receiving low-dose risperidone (1 mg b.i.d.) and fluoxetine (20 mg daily). Despite initial improvement, he was very skeptical about continuing the medications because of concern that they will cause a “change in his identity” by altering his body chemistry. His parents have been reluctant to join family meetings, because they were ambivalent about Bill’s ongoing psychiatric treatment.
 

 

Treatment team’s impressions

Clinical high risk (CHR) syndrome refers to the prodromal phase before a full psychotic disorder. As one of the three subcategories of CHR, genetic risk and deterioration (GRD) prodromal syndrome is defined by having a genetic risk for psychosis (first-degree relative with a psychotic disorder or meeting criteria for schizotypal personality disorder) and a recent decline in daily functioning equivalent to a 30% drop in Global Assessment of Functioning rating.¹ Due to Bill’s family history of psychosis, new difficulties in self-care, psychotic-spectrum symptoms, and declining social/executive function, he meets criteria for GRD prodromal syndrome. In addition, major depressive disorder should be considered on his differential diagnosis.

Bill has not received a diagnosis of acute psychosis, and instead is judged to be in the CHR spectrum for psychosis, because of his level of insight that the occasional perceptual disturbance and abnormal thought content are in his own mind. Since 26% of individuals with CHR in mainland China² and 35% in the general U.S. population develop fully psychotic symptoms within 2-3 years, Bill’s current presentation warrants secondary preventive care (early intervention) to promote improved clinical outcomes. Given the high rates of comorbid depressive and anxiety disorders among individuals with CHR, Bill’s mood symptoms and passive suicidality also require psychiatric intervention. The treatment team raised three questions, which are answered below.
 

1. How can we understand Bill’s and his family’s resistance to mental health treatment?

Chinese Americans tend to access mental health services at a lower rate than that of the general U.S. population.³ They also tend to exhibit elevated discontinuation from mental health care, compared with non-Latino whites.⁴ Since first- and second-generation Chinese Americans have similar use rates, it is likely the barriers to care are not immigration specific but also related to factors that endure across generations, including culture-related aspects. These include cultural concepts of illness and how to interpret prodromal symptoms such as Bill’s, stigma and interpersonal shame regarding mental illness and psychiatric treatment, and value orientations such as self-reliance, avoidance of direct expressions of interpersonal conflict, and family privacy.

Exploring cultural concepts of distress common among Chinese American families might help clinicians address barriers to mental health service use and persistence. For example, Chinese Americans tend to emphasize the physical-symptom components of psychiatric problems, partly because of mind-body holism – which combines physical and psychological symptoms into cultural syndromes and idioms of distress – and partly because of concerns about stigma and shame regarding mental health symptoms. Hence, they are more likely to seek help from primary care clinicians for psychological distress before any mental health provider. Many Chinese Americans interpret mild to moderate psychological distress as “mental weakness” or “excessive thinking” (xiang tai duo), which does not require clinical evaluation. In this view, only alarmingly bizarre or disruptive behaviors warrant formal psychiatric treatment.

Some Chinese parents perceive psychosocial stressors, including hardships, interpersonal conflicts, and academic burdens, as understandable triggers for symptoms that clinicians would classify as schizophrenia or attenuated psychosis syndrome.⁵ Those views of illness can be associated in the Chinese American community with delayed diagnosis and intervention for emerging psychiatric disorders.

Social stigma regarding mental illness is pervasive in many Chinese American communities. Stigma hinders service use, to avoid shame and save the family’s “face.” Although many Chinese Americans acknowledge the efficacy of biomedical treatments for mental illness, they also remain concerned about enduring shame in their communities if they access those services.⁶ In line with collectivistic values traditionally held by many Chinese Americans, individuals tend to turn to relatives for help first and keep mental illness confidential within the family group to avoid disgracing the family name.⁷ Hence, social stigma in the Chinese community can be a key barrier to early detection and early intervention for youth at high risk of psychosis.

Culturally influenced cognitions, emotions, and values also might contribute to underuse of formal mental health services in this population. Many Chinese Americans perceive the roots of mental illness in a lack of willpower and the unwise indulgence of morbid thoughts. In these communities, direct communication of strong emotions can be discouraged – in the name of maintaining harmony, collective interests, and tolerance.⁸ Hence, many Chinese Americans find Western models of psychotherapy that focus on intrapsychic conflicts and/or intense interpersonal emotions incongruous with their treatment expectations. Psychiatric interview processes that explore gloomy or disturbing thoughts can be perceived as disquieting and antithetical to the goals of treatment. In addition, some individuals rooted in collectivist communities would rather keep personal psychological problems private within the family than seek counseling from an expert who is an out-group stranger.
 

 

2. How does Bill’s cultural and social context affect his prognosis?

Individuals with psychosis and their close relatives are generally vulnerable to stigma and discrimination. Mental health stigma has a substantial effect on the lives of patients with psychosis and their family members. The magnitude of the perceived stigma tends to be greater if the patient has more severe positive symptoms, is more educated, or resides in a highly urbanized area.

Acutely ill patients usually face more negative community responses than do milder cases, since their close relatives are blamed for failing to uphold the moral and legal responsibility of ensuring that the patients control their behavior. The effect of stigma in Chinese society also is greater among male patients with early-onset illness, because of the expectation that men marry and become the family breadwinner to attain higher social status. Hence, young males who are unable to achieve these socially determined adult milestones can be considered socially inferior, and suffer more community discrimination and exclusion, which are risk factors for clinical deterioration and functional impairment.

Social stigma can intensify relationship conflicts within the family and magnify expressed emotion (EE), which is defined as caregivers’ attitude toward a person with mental illness as reflected by their comments and interaction patterns. “High EE” comprises three behavioral patterns: criticism, hostility, and emotional overinvolvement. High EE is associated with psychiatric symptom relapse among individuals with schizophrenia and other disorders.⁹

Currently, most of the literature on EE is limited to white samples in Western countries. Some researchers have studied the relationship between the EE index of emotional overinvolvement and schizophrenia relapse among Hispanic populations.¹⁰ However, there are limited data on cultural congruence of EE research in Asian populations. Therefore, clinicians should carefully evaluate the contribution of high EE to Bill’s family’s situation during his course of treatment.

Higher education often is associated with greater levels of EE and can result in anxious and fearful responses to the person’s illness.¹¹ This may be attributable to more negative reactions to actual or feared stigma and discrimination, possibly because relatives feel they have more to lose regarding the family’s social status, especially in densely populated urban areas where it might be harder to keep the patient’s mental illness as a “family secret.”

On the other hand, certain explanatory models of psychosis can modulate Chinese community members’ perceptions and allow ill individuals to remain socially integrated. Cultural idioms such as “excessive thinking” (xiang tai duo), “taking things too hard” (xiang bu kai), and “narrow-mindedness” (xiao xin yan) promote socially accommodating behaviors that facilitate acceptance of mildly to moderately ill individuals as full-status community members.¹²

Another important contributor to psychosis risk is Bill’s acculturative stress about his cultural identity. Linguistic challenges, limited social support, perceived discrimination, and an acculturation gap between parents and children are major sources of acculturative stress among Chinese American college students.¹³ Greater acculturative stress elevates the risk of mental illness and symptom deterioration. However, highly acculturated Chinese Americans with above-average bicultural self-efficacy tend to express more positive attitudes toward mental health services.
 

 

3. Are there culturally appropriate interventions that can help Bill and his family?

A major predictor among Chinese Americans of the intent to use services is the perceived credibility of the treatment and the provider. Ethnic-specific services staffed by bicultural/bilingual mental health clinicians delivering culturally responsive interventions are increasingly available in many metropolitan areas with major Asian communities. These programs have shown clinical efficacy in encouraging service use and promoting treatment persistence. Bill and his family may benefit from referral to ethnic-specific services, where they can obtain culturally sensitive psychoeducation about his mental illness and treatment plan.

Other services that might be useful for Bill and his family include family psychoeducation programs and supportive groups specifically designed for Chinese American families; these can improve the entire family’s psychosocial health, promote medication adherence, and reduce the risk of symptom relapse through family-centered intervention models.¹⁴ Connecting with local National Alliance on Mental Illness (NAMI) programs might help Bill’s parents obtain social support from Chinese American families with similar caregiver experiences.

However, services that are not designed specifically for Chinese-origin patients also can provide excellent care for these patients, and be perceived as credible and effective. A thorough cultural assessment is necessary, as well as inclusion of the information obtained in the treatment plan. As described in the DSM-5 Outline for Cultural Formulation and operationalized in the Cultural Formulation Interview, clinicians should assess possible cultural differences among Bill, his family, his community, and his clinicians regarding their cultural concepts of distress and illness and expectations of care in order to formulate a treatment plan acceptable to patient and family. Practical cultural barriers should be addressed, such as Bill’s parents’ limited English proficiency, in which case a bilingual clinician or trained interpreter should be included in the treatment team.

With Bill’s consent, the treatment team also should consider reaching out to his parents, especially his mother, to understand and empathize with their cultural concepts of distress and illness as well as expectations for care. In addition to providing psychoeducation, the clinicians should validate the parents’ experience of shame, fear, and worry about their son. Bill’s brother, for example, might be a useful bridge in communicating with the parents given his higher acculturation and potentially greater acceptance of psychiatric care. He might help alleviate the tension between Bill and his parents and encourage them to seek family-based help.
 

Take-home points

• Clinical training programs should offer cultural competency training about underserved populations, including communities of color.
• Certain key concepts, such as traditional idioms of distress and explanatory models, social stigma, and acculturative stress, should be included in these trainings and evaluated in a comprehensive psychosocial assessment.
• High expressed emotion among family caregivers is associated with higher rates of psychiatric symptom relapse, whereas families with above-average bicultural self-efficacy have more positive attitudes toward mental health services.
• Clinicians should incorporate culturally appropriate educational materials (for example, CHR warning signs) and interventions to engage underserved patients and their families in mental health treatment.

 

Contributors

Emily Wu, MD – Harvard Medical School, Boston

Francis Lu, MD – University of California, Davis

John Sargent, MD – Tufts Medical Center, Boston

Roberto Lewis-Fernández, MD – Columbia College of Physicians & Surgeons, New York



If you would like to a submit case in which your understanding and treatment are affected by challenging cultural and family values, send it to [email protected]. We will then write back with our best answers about how one might proceed in such a case. Your case and our response will then be published at mdedge.com/psychiatry. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they are employed by or affiliated with or the Group for the Advancement of Psychiatry.

References

1. J Nerv Ment Dis. 2013 Jun;20(6);484-9.

2. Schizophr Res. 2014 Feb;152(2-3):391-9.

3. Perspect Psychiatr Care. 2013;49(4):288-92.

4. Ment Health Serv Res. 2001 Dec;3(4):201-14.

5. Br J Psychiatry. 2000 Jul;177;20-5.

6. Cultr Divers Ethnic Minor Psychol. 2008 Jan;14(1):10-8.

7. Couns Psychol. 2003 May1;31:343-61.

8. Emotion. 2002 Dec;2(4):341-60.

9. Am J Psychiatry. 1986 Nov;143(11):1361-73.

10. J Nerv Ment Dis. 2013 Oct;201(10):833-40.

11. Schizophr Bull. 1981;7(1):43-4.

12. Schizophr Bull. 2010 Jul;36(4):836-45.

13. Am J Orthopsychiatry. 2011 Oct;81(4):489-97.

14. Patient Educ Couns. 2009 Apr;75(1):67-76.

Editors’ Note: Curbside Consult is an occasional column aimed at helping psychiatrists think through family and cultural considerations when treating patients. It examines case vignettes and is written by two Group for the Advancement of Psychiatry (GAP) committees – the Committee on Family Psychiatry and the Committee on Cultural Psychiatry. The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements.

Case vignette

Bill is a 25-year-old man of Chinese descent who sought psychiatric evaluation of his psychosis risk. His parents emigrated from China to Canada more than 30 years ago; Bill was born in Canada, and moved to the United States with his parents and two siblings at age 7.

His family has a strong history of mental illness. His older sister was diagnosed with schizophrenia; she frequently got into verbal altercations with her parents. When Bill was 15, she walked out of the house after a fight with the family and never returned. Bill’s family thinks his father has had paranoid delusions. In the past, he attempted to call the police multiple times because he suspected the neighbors had planted a listening device in his front yard. The family stopped him from making the actual calls. However, the family never brought him to psychiatric evaluation because of perceived stigma and social discrimination in their community. He also was emotionally and physically abusive to Bill during his childhood by calling him names and hitting him with a belt. As an adult, Bill still has posttraumatic stress disorder symptoms including flashbacks, nightmares, and avoidance when thinking about his father.

Bill identifies himself as Chinese American and speaks English only. He often perceives himself as a newcomer to U.S. society, making comments such as: “I guess I should live my life like this to fulfill the American dream.” Bill’s parents placed a strong emphasis on academic success, often at the expense of their children’s social interaction and playtime activities. Bill describes himself as a “loner” with few friends. He maintained high academic achievement during high school and was accepted by a prestigious college. Although he was interested in music composition, Bill was “forced” by his parents to major in courses deemed good preparation for law school.

During college, he suffered severe depression with insomnia, low energy, hopelessness, anhedonia, social withdrawal, poor appetite with weight loss, and ruminative thoughts but without delusional thoughts or perceptual disturbances. He had one near-lethal suicide attempt, during which he impulsively took the contents of an entire bottle of Tylenol in the context of family conflicts, resulting in psychiatric hospitalization. Bill recalled with animosity the inpatient psychiatrists who put him on psychotropic medications during a 3-day hospitalization. He was not adherent to the medication and did not follow up with postdischarge outpatient care. He did not remember the medication trial he had during the hospitalization, nor did he give consent to obtain medical records from there. Bill withdrew from college in sophomore year, because of his declining academic performance secondary to his mental illness. He currently works at a gas station.

Over the last year, Bill’s interpersonal communication has become disorganized in both work and social settings, and he has developed thought blocking, causing him substantial distress. He intermittently hears voices of strangers in the background; these have gradually become more frequent, now occurring 3-4 times a week. Bill also is more depressed, with frequent crying episodes and worsening social isolation. He often thinks that life is not worth living, but he has no active suicidal plans or intent.

Bill’s supervisor and coworkers strongly suggested that he seek medical evaluation. As an outpatient, Bill started weekly cognitive-behavioral therapy (CBT) and biweekly medication sessions for early psychosis symptoms, receiving low-dose risperidone (1 mg b.i.d.) and fluoxetine (20 mg daily). Despite initial improvement, he was very skeptical about continuing the medications because of concern that they will cause a “change in his identity” by altering his body chemistry. His parents have been reluctant to join family meetings, because they were ambivalent about Bill’s ongoing psychiatric treatment.
 

 

Treatment team’s impressions

Clinical high risk (CHR) syndrome refers to the prodromal phase before a full psychotic disorder. As one of the three subcategories of CHR, genetic risk and deterioration (GRD) prodromal syndrome is defined by having a genetic risk for psychosis (first-degree relative with a psychotic disorder or meeting criteria for schizotypal personality disorder) and a recent decline in daily functioning equivalent to a 30% drop in Global Assessment of Functioning rating.¹ Due to Bill’s family history of psychosis, new difficulties in self-care, psychotic-spectrum symptoms, and declining social/executive function, he meets criteria for GRD prodromal syndrome. In addition, major depressive disorder should be considered on his differential diagnosis.

Bill has not received a diagnosis of acute psychosis, and instead is judged to be in the CHR spectrum for psychosis, because of his level of insight that the occasional perceptual disturbance and abnormal thought content are in his own mind. Since 26% of individuals with CHR in mainland China² and 35% in the general U.S. population develop fully psychotic symptoms within 2-3 years, Bill’s current presentation warrants secondary preventive care (early intervention) to promote improved clinical outcomes. Given the high rates of comorbid depressive and anxiety disorders among individuals with CHR, Bill’s mood symptoms and passive suicidality also require psychiatric intervention. The treatment team raised three questions, which are answered below.
 

1. How can we understand Bill’s and his family’s resistance to mental health treatment?

Chinese Americans tend to access mental health services at a lower rate than that of the general U.S. population.³ They also tend to exhibit elevated discontinuation from mental health care, compared with non-Latino whites.⁴ Since first- and second-generation Chinese Americans have similar use rates, it is likely the barriers to care are not immigration specific but also related to factors that endure across generations, including culture-related aspects. These include cultural concepts of illness and how to interpret prodromal symptoms such as Bill’s, stigma and interpersonal shame regarding mental illness and psychiatric treatment, and value orientations such as self-reliance, avoidance of direct expressions of interpersonal conflict, and family privacy.

Exploring cultural concepts of distress common among Chinese American families might help clinicians address barriers to mental health service use and persistence. For example, Chinese Americans tend to emphasize the physical-symptom components of psychiatric problems, partly because of mind-body holism – which combines physical and psychological symptoms into cultural syndromes and idioms of distress – and partly because of concerns about stigma and shame regarding mental health symptoms. Hence, they are more likely to seek help from primary care clinicians for psychological distress before any mental health provider. Many Chinese Americans interpret mild to moderate psychological distress as “mental weakness” or “excessive thinking” (xiang tai duo), which does not require clinical evaluation. In this view, only alarmingly bizarre or disruptive behaviors warrant formal psychiatric treatment.

Some Chinese parents perceive psychosocial stressors, including hardships, interpersonal conflicts, and academic burdens, as understandable triggers for symptoms that clinicians would classify as schizophrenia or attenuated psychosis syndrome.⁵ Those views of illness can be associated in the Chinese American community with delayed diagnosis and intervention for emerging psychiatric disorders.

Social stigma regarding mental illness is pervasive in many Chinese American communities. Stigma hinders service use, to avoid shame and save the family’s “face.” Although many Chinese Americans acknowledge the efficacy of biomedical treatments for mental illness, they also remain concerned about enduring shame in their communities if they access those services.⁶ In line with collectivistic values traditionally held by many Chinese Americans, individuals tend to turn to relatives for help first and keep mental illness confidential within the family group to avoid disgracing the family name.⁷ Hence, social stigma in the Chinese community can be a key barrier to early detection and early intervention for youth at high risk of psychosis.

Culturally influenced cognitions, emotions, and values also might contribute to underuse of formal mental health services in this population. Many Chinese Americans perceive the roots of mental illness in a lack of willpower and the unwise indulgence of morbid thoughts. In these communities, direct communication of strong emotions can be discouraged – in the name of maintaining harmony, collective interests, and tolerance.⁸ Hence, many Chinese Americans find Western models of psychotherapy that focus on intrapsychic conflicts and/or intense interpersonal emotions incongruous with their treatment expectations. Psychiatric interview processes that explore gloomy or disturbing thoughts can be perceived as disquieting and antithetical to the goals of treatment. In addition, some individuals rooted in collectivist communities would rather keep personal psychological problems private within the family than seek counseling from an expert who is an out-group stranger.
 

 

2. How does Bill’s cultural and social context affect his prognosis?

Individuals with psychosis and their close relatives are generally vulnerable to stigma and discrimination. Mental health stigma has a substantial effect on the lives of patients with psychosis and their family members. The magnitude of the perceived stigma tends to be greater if the patient has more severe positive symptoms, is more educated, or resides in a highly urbanized area.

Acutely ill patients usually face more negative community responses than do milder cases, since their close relatives are blamed for failing to uphold the moral and legal responsibility of ensuring that the patients control their behavior. The effect of stigma in Chinese society also is greater among male patients with early-onset illness, because of the expectation that men marry and become the family breadwinner to attain higher social status. Hence, young males who are unable to achieve these socially determined adult milestones can be considered socially inferior, and suffer more community discrimination and exclusion, which are risk factors for clinical deterioration and functional impairment.

Social stigma can intensify relationship conflicts within the family and magnify expressed emotion (EE), which is defined as caregivers’ attitude toward a person with mental illness as reflected by their comments and interaction patterns. “High EE” comprises three behavioral patterns: criticism, hostility, and emotional overinvolvement. High EE is associated with psychiatric symptom relapse among individuals with schizophrenia and other disorders.⁹

Currently, most of the literature on EE is limited to white samples in Western countries. Some researchers have studied the relationship between the EE index of emotional overinvolvement and schizophrenia relapse among Hispanic populations.¹⁰ However, there are limited data on cultural congruence of EE research in Asian populations. Therefore, clinicians should carefully evaluate the contribution of high EE to Bill’s family’s situation during his course of treatment.

Higher education often is associated with greater levels of EE and can result in anxious and fearful responses to the person’s illness.¹¹ This may be attributable to more negative reactions to actual or feared stigma and discrimination, possibly because relatives feel they have more to lose regarding the family’s social status, especially in densely populated urban areas where it might be harder to keep the patient’s mental illness as a “family secret.”

On the other hand, certain explanatory models of psychosis can modulate Chinese community members’ perceptions and allow ill individuals to remain socially integrated. Cultural idioms such as “excessive thinking” (xiang tai duo), “taking things too hard” (xiang bu kai), and “narrow-mindedness” (xiao xin yan) promote socially accommodating behaviors that facilitate acceptance of mildly to moderately ill individuals as full-status community members.¹²

Another important contributor to psychosis risk is Bill’s acculturative stress about his cultural identity. Linguistic challenges, limited social support, perceived discrimination, and an acculturation gap between parents and children are major sources of acculturative stress among Chinese American college students.¹³ Greater acculturative stress elevates the risk of mental illness and symptom deterioration. However, highly acculturated Chinese Americans with above-average bicultural self-efficacy tend to express more positive attitudes toward mental health services.
 

 

3. Are there culturally appropriate interventions that can help Bill and his family?

A major predictor among Chinese Americans of the intent to use services is the perceived credibility of the treatment and the provider. Ethnic-specific services staffed by bicultural/bilingual mental health clinicians delivering culturally responsive interventions are increasingly available in many metropolitan areas with major Asian communities. These programs have shown clinical efficacy in encouraging service use and promoting treatment persistence. Bill and his family may benefit from referral to ethnic-specific services, where they can obtain culturally sensitive psychoeducation about his mental illness and treatment plan.

Other services that might be useful for Bill and his family include family psychoeducation programs and supportive groups specifically designed for Chinese American families; these can improve the entire family’s psychosocial health, promote medication adherence, and reduce the risk of symptom relapse through family-centered intervention models.¹⁴ Connecting with local National Alliance on Mental Illness (NAMI) programs might help Bill’s parents obtain social support from Chinese American families with similar caregiver experiences.

However, services that are not designed specifically for Chinese-origin patients also can provide excellent care for these patients, and be perceived as credible and effective. A thorough cultural assessment is necessary, as well as inclusion of the information obtained in the treatment plan. As described in the DSM-5 Outline for Cultural Formulation and operationalized in the Cultural Formulation Interview, clinicians should assess possible cultural differences among Bill, his family, his community, and his clinicians regarding their cultural concepts of distress and illness and expectations of care in order to formulate a treatment plan acceptable to patient and family. Practical cultural barriers should be addressed, such as Bill’s parents’ limited English proficiency, in which case a bilingual clinician or trained interpreter should be included in the treatment team.

With Bill’s consent, the treatment team also should consider reaching out to his parents, especially his mother, to understand and empathize with their cultural concepts of distress and illness as well as expectations for care. In addition to providing psychoeducation, the clinicians should validate the parents’ experience of shame, fear, and worry about their son. Bill’s brother, for example, might be a useful bridge in communicating with the parents given his higher acculturation and potentially greater acceptance of psychiatric care. He might help alleviate the tension between Bill and his parents and encourage them to seek family-based help.
 

Take-home points

• Clinical training programs should offer cultural competency training about underserved populations, including communities of color.
• Certain key concepts, such as traditional idioms of distress and explanatory models, social stigma, and acculturative stress, should be included in these trainings and evaluated in a comprehensive psychosocial assessment.
• High expressed emotion among family caregivers is associated with higher rates of psychiatric symptom relapse, whereas families with above-average bicultural self-efficacy have more positive attitudes toward mental health services.
• Clinicians should incorporate culturally appropriate educational materials (for example, CHR warning signs) and interventions to engage underserved patients and their families in mental health treatment.

 

Contributors

Emily Wu, MD – Harvard Medical School, Boston

Francis Lu, MD – University of California, Davis

John Sargent, MD – Tufts Medical Center, Boston

Roberto Lewis-Fernández, MD – Columbia College of Physicians & Surgeons, New York



If you would like to a submit case in which your understanding and treatment are affected by challenging cultural and family values, send it to [email protected]. We will then write back with our best answers about how one might proceed in such a case. Your case and our response will then be published at mdedge.com/psychiatry. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they are employed by or affiliated with or the Group for the Advancement of Psychiatry.

References

1. J Nerv Ment Dis. 2013 Jun;20(6);484-9.

2. Schizophr Res. 2014 Feb;152(2-3):391-9.

3. Perspect Psychiatr Care. 2013;49(4):288-92.

4. Ment Health Serv Res. 2001 Dec;3(4):201-14.

5. Br J Psychiatry. 2000 Jul;177;20-5.

6. Cultr Divers Ethnic Minor Psychol. 2008 Jan;14(1):10-8.

7. Couns Psychol. 2003 May1;31:343-61.

8. Emotion. 2002 Dec;2(4):341-60.

9. Am J Psychiatry. 1986 Nov;143(11):1361-73.

10. J Nerv Ment Dis. 2013 Oct;201(10):833-40.

11. Schizophr Bull. 1981;7(1):43-4.

12. Schizophr Bull. 2010 Jul;36(4):836-45.

13. Am J Orthopsychiatry. 2011 Oct;81(4):489-97.

14. Patient Educ Couns. 2009 Apr;75(1):67-76.

Editors’ Note: Curbside Consult is an occasional column aimed at helping psychiatrists think through family and cultural considerations when treating patients. It examines case vignettes and is written by two Group for the Advancement of Psychiatry (GAP) committees – the Committee on Family Psychiatry and the Committee on Cultural Psychiatry. The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements.

Case vignette

Bill is a 25-year-old man of Chinese descent who sought psychiatric evaluation of his psychosis risk. His parents emigrated from China to Canada more than 30 years ago; Bill was born in Canada, and moved to the United States with his parents and two siblings at age 7.

His family has a strong history of mental illness. His older sister was diagnosed with schizophrenia; she frequently got into verbal altercations with her parents. When Bill was 15, she walked out of the house after a fight with the family and never returned. Bill’s family thinks his father has had paranoid delusions. In the past, he attempted to call the police multiple times because he suspected the neighbors had planted a listening device in his front yard. The family stopped him from making the actual calls. However, the family never brought him to psychiatric evaluation because of perceived stigma and social discrimination in their community. He also was emotionally and physically abusive to Bill during his childhood by calling him names and hitting him with a belt. As an adult, Bill still has posttraumatic stress disorder symptoms including flashbacks, nightmares, and avoidance when thinking about his father.

Bill identifies himself as Chinese American and speaks English only. He often perceives himself as a newcomer to U.S. society, making comments such as: “I guess I should live my life like this to fulfill the American dream.” Bill’s parents placed a strong emphasis on academic success, often at the expense of their children’s social interaction and playtime activities. Bill describes himself as a “loner” with few friends. He maintained high academic achievement during high school and was accepted by a prestigious college. Although he was interested in music composition, Bill was “forced” by his parents to major in courses deemed good preparation for law school.

During college, he suffered severe depression with insomnia, low energy, hopelessness, anhedonia, social withdrawal, poor appetite with weight loss, and ruminative thoughts but without delusional thoughts or perceptual disturbances. He had one near-lethal suicide attempt, during which he impulsively took the contents of an entire bottle of Tylenol in the context of family conflicts, resulting in psychiatric hospitalization. Bill recalled with animosity the inpatient psychiatrists who put him on psychotropic medications during a 3-day hospitalization. He was not adherent to the medication and did not follow up with postdischarge outpatient care. He did not remember the medication trial he had during the hospitalization, nor did he give consent to obtain medical records from there. Bill withdrew from college in sophomore year, because of his declining academic performance secondary to his mental illness. He currently works at a gas station.

Over the last year, Bill’s interpersonal communication has become disorganized in both work and social settings, and he has developed thought blocking, causing him substantial distress. He intermittently hears voices of strangers in the background; these have gradually become more frequent, now occurring 3-4 times a week. Bill also is more depressed, with frequent crying episodes and worsening social isolation. He often thinks that life is not worth living, but he has no active suicidal plans or intent.

Bill’s supervisor and coworkers strongly suggested that he seek medical evaluation. As an outpatient, Bill started weekly cognitive-behavioral therapy (CBT) and biweekly medication sessions for early psychosis symptoms, receiving low-dose risperidone (1 mg b.i.d.) and fluoxetine (20 mg daily). Despite initial improvement, he was very skeptical about continuing the medications because of concern that they will cause a “change in his identity” by altering his body chemistry. His parents have been reluctant to join family meetings, because they were ambivalent about Bill’s ongoing psychiatric treatment.
 

 

Treatment team’s impressions

Clinical high risk (CHR) syndrome refers to the prodromal phase before a full psychotic disorder. As one of the three subcategories of CHR, genetic risk and deterioration (GRD) prodromal syndrome is defined by having a genetic risk for psychosis (first-degree relative with a psychotic disorder or meeting criteria for schizotypal personality disorder) and a recent decline in daily functioning equivalent to a 30% drop in Global Assessment of Functioning rating.¹ Due to Bill’s family history of psychosis, new difficulties in self-care, psychotic-spectrum symptoms, and declining social/executive function, he meets criteria for GRD prodromal syndrome. In addition, major depressive disorder should be considered on his differential diagnosis.

Bill has not received a diagnosis of acute psychosis, and instead is judged to be in the CHR spectrum for psychosis, because of his level of insight that the occasional perceptual disturbance and abnormal thought content are in his own mind. Since 26% of individuals with CHR in mainland China² and 35% in the general U.S. population develop fully psychotic symptoms within 2-3 years, Bill’s current presentation warrants secondary preventive care (early intervention) to promote improved clinical outcomes. Given the high rates of comorbid depressive and anxiety disorders among individuals with CHR, Bill’s mood symptoms and passive suicidality also require psychiatric intervention. The treatment team raised three questions, which are answered below.
 

1. How can we understand Bill’s and his family’s resistance to mental health treatment?

Chinese Americans tend to access mental health services at a lower rate than that of the general U.S. population.³ They also tend to exhibit elevated discontinuation from mental health care, compared with non-Latino whites.⁴ Since first- and second-generation Chinese Americans have similar use rates, it is likely the barriers to care are not immigration specific but also related to factors that endure across generations, including culture-related aspects. These include cultural concepts of illness and how to interpret prodromal symptoms such as Bill’s, stigma and interpersonal shame regarding mental illness and psychiatric treatment, and value orientations such as self-reliance, avoidance of direct expressions of interpersonal conflict, and family privacy.

Exploring cultural concepts of distress common among Chinese American families might help clinicians address barriers to mental health service use and persistence. For example, Chinese Americans tend to emphasize the physical-symptom components of psychiatric problems, partly because of mind-body holism – which combines physical and psychological symptoms into cultural syndromes and idioms of distress – and partly because of concerns about stigma and shame regarding mental health symptoms. Hence, they are more likely to seek help from primary care clinicians for psychological distress before any mental health provider. Many Chinese Americans interpret mild to moderate psychological distress as “mental weakness” or “excessive thinking” (xiang tai duo), which does not require clinical evaluation. In this view, only alarmingly bizarre or disruptive behaviors warrant formal psychiatric treatment.

Some Chinese parents perceive psychosocial stressors, including hardships, interpersonal conflicts, and academic burdens, as understandable triggers for symptoms that clinicians would classify as schizophrenia or attenuated psychosis syndrome.⁵ Those views of illness can be associated in the Chinese American community with delayed diagnosis and intervention for emerging psychiatric disorders.

Social stigma regarding mental illness is pervasive in many Chinese American communities. Stigma hinders service use, to avoid shame and save the family’s “face.” Although many Chinese Americans acknowledge the efficacy of biomedical treatments for mental illness, they also remain concerned about enduring shame in their communities if they access those services.⁶ In line with collectivistic values traditionally held by many Chinese Americans, individuals tend to turn to relatives for help first and keep mental illness confidential within the family group to avoid disgracing the family name.⁷ Hence, social stigma in the Chinese community can be a key barrier to early detection and early intervention for youth at high risk of psychosis.

Culturally influenced cognitions, emotions, and values also might contribute to underuse of formal mental health services in this population. Many Chinese Americans perceive the roots of mental illness in a lack of willpower and the unwise indulgence of morbid thoughts. In these communities, direct communication of strong emotions can be discouraged – in the name of maintaining harmony, collective interests, and tolerance.⁸ Hence, many Chinese Americans find Western models of psychotherapy that focus on intrapsychic conflicts and/or intense interpersonal emotions incongruous with their treatment expectations. Psychiatric interview processes that explore gloomy or disturbing thoughts can be perceived as disquieting and antithetical to the goals of treatment. In addition, some individuals rooted in collectivist communities would rather keep personal psychological problems private within the family than seek counseling from an expert who is an out-group stranger.
 

 

2. How does Bill’s cultural and social context affect his prognosis?

Individuals with psychosis and their close relatives are generally vulnerable to stigma and discrimination. Mental health stigma has a substantial effect on the lives of patients with psychosis and their family members. The magnitude of the perceived stigma tends to be greater if the patient has more severe positive symptoms, is more educated, or resides in a highly urbanized area.

Acutely ill patients usually face more negative community responses than do milder cases, since their close relatives are blamed for failing to uphold the moral and legal responsibility of ensuring that the patients control their behavior. The effect of stigma in Chinese society also is greater among male patients with early-onset illness, because of the expectation that men marry and become the family breadwinner to attain higher social status. Hence, young males who are unable to achieve these socially determined adult milestones can be considered socially inferior, and suffer more community discrimination and exclusion, which are risk factors for clinical deterioration and functional impairment.

Social stigma can intensify relationship conflicts within the family and magnify expressed emotion (EE), which is defined as caregivers’ attitude toward a person with mental illness as reflected by their comments and interaction patterns. “High EE” comprises three behavioral patterns: criticism, hostility, and emotional overinvolvement. High EE is associated with psychiatric symptom relapse among individuals with schizophrenia and other disorders.⁹

Currently, most of the literature on EE is limited to white samples in Western countries. Some researchers have studied the relationship between the EE index of emotional overinvolvement and schizophrenia relapse among Hispanic populations.¹⁰ However, there are limited data on cultural congruence of EE research in Asian populations. Therefore, clinicians should carefully evaluate the contribution of high EE to Bill’s family’s situation during his course of treatment.

Higher education often is associated with greater levels of EE and can result in anxious and fearful responses to the person’s illness.¹¹ This may be attributable to more negative reactions to actual or feared stigma and discrimination, possibly because relatives feel they have more to lose regarding the family’s social status, especially in densely populated urban areas where it might be harder to keep the patient’s mental illness as a “family secret.”

On the other hand, certain explanatory models of psychosis can modulate Chinese community members’ perceptions and allow ill individuals to remain socially integrated. Cultural idioms such as “excessive thinking” (xiang tai duo), “taking things too hard” (xiang bu kai), and “narrow-mindedness” (xiao xin yan) promote socially accommodating behaviors that facilitate acceptance of mildly to moderately ill individuals as full-status community members.¹²

Another important contributor to psychosis risk is Bill’s acculturative stress about his cultural identity. Linguistic challenges, limited social support, perceived discrimination, and an acculturation gap between parents and children are major sources of acculturative stress among Chinese American college students.¹³ Greater acculturative stress elevates the risk of mental illness and symptom deterioration. However, highly acculturated Chinese Americans with above-average bicultural self-efficacy tend to express more positive attitudes toward mental health services.
 

 

3. Are there culturally appropriate interventions that can help Bill and his family?

A major predictor among Chinese Americans of the intent to use services is the perceived credibility of the treatment and the provider. Ethnic-specific services staffed by bicultural/bilingual mental health clinicians delivering culturally responsive interventions are increasingly available in many metropolitan areas with major Asian communities. These programs have shown clinical efficacy in encouraging service use and promoting treatment persistence. Bill and his family may benefit from referral to ethnic-specific services, where they can obtain culturally sensitive psychoeducation about his mental illness and treatment plan.

Other services that might be useful for Bill and his family include family psychoeducation programs and supportive groups specifically designed for Chinese American families; these can improve the entire family’s psychosocial health, promote medication adherence, and reduce the risk of symptom relapse through family-centered intervention models.¹⁴ Connecting with local National Alliance on Mental Illness (NAMI) programs might help Bill’s parents obtain social support from Chinese American families with similar caregiver experiences.

However, services that are not designed specifically for Chinese-origin patients also can provide excellent care for these patients, and be perceived as credible and effective. A thorough cultural assessment is necessary, as well as inclusion of the information obtained in the treatment plan. As described in the DSM-5 Outline for Cultural Formulation and operationalized in the Cultural Formulation Interview, clinicians should assess possible cultural differences among Bill, his family, his community, and his clinicians regarding their cultural concepts of distress and illness and expectations of care in order to formulate a treatment plan acceptable to patient and family. Practical cultural barriers should be addressed, such as Bill’s parents’ limited English proficiency, in which case a bilingual clinician or trained interpreter should be included in the treatment team.

With Bill’s consent, the treatment team also should consider reaching out to his parents, especially his mother, to understand and empathize with their cultural concepts of distress and illness as well as expectations for care. In addition to providing psychoeducation, the clinicians should validate the parents’ experience of shame, fear, and worry about their son. Bill’s brother, for example, might be a useful bridge in communicating with the parents given his higher acculturation and potentially greater acceptance of psychiatric care. He might help alleviate the tension between Bill and his parents and encourage them to seek family-based help.
 

Take-home points

• Clinical training programs should offer cultural competency training about underserved populations, including communities of color.
• Certain key concepts, such as traditional idioms of distress and explanatory models, social stigma, and acculturative stress, should be included in these trainings and evaluated in a comprehensive psychosocial assessment.
• High expressed emotion among family caregivers is associated with higher rates of psychiatric symptom relapse, whereas families with above-average bicultural self-efficacy have more positive attitudes toward mental health services.
• Clinicians should incorporate culturally appropriate educational materials (for example, CHR warning signs) and interventions to engage underserved patients and their families in mental health treatment.

 

Contributors

Emily Wu, MD – Harvard Medical School, Boston

Francis Lu, MD – University of California, Davis

John Sargent, MD – Tufts Medical Center, Boston

Roberto Lewis-Fernández, MD – Columbia College of Physicians & Surgeons, New York



If you would like to a submit case in which your understanding and treatment are affected by challenging cultural and family values, send it to [email protected]. We will then write back with our best answers about how one might proceed in such a case. Your case and our response will then be published at mdedge.com/psychiatry. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they are employed by or affiliated with or the Group for the Advancement of Psychiatry.

References

1. J Nerv Ment Dis. 2013 Jun;20(6);484-9.

2. Schizophr Res. 2014 Feb;152(2-3):391-9.

3. Perspect Psychiatr Care. 2013;49(4):288-92.

4. Ment Health Serv Res. 2001 Dec;3(4):201-14.

5. Br J Psychiatry. 2000 Jul;177;20-5.

6. Cultr Divers Ethnic Minor Psychol. 2008 Jan;14(1):10-8.

7. Couns Psychol. 2003 May1;31:343-61.

8. Emotion. 2002 Dec;2(4):341-60.

9. Am J Psychiatry. 1986 Nov;143(11):1361-73.

10. J Nerv Ment Dis. 2013 Oct;201(10):833-40.

11. Schizophr Bull. 1981;7(1):43-4.

12. Schizophr Bull. 2010 Jul;36(4):836-45.

13. Am J Orthopsychiatry. 2011 Oct;81(4):489-97.

14. Patient Educ Couns. 2009 Apr;75(1):67-76.