While the usual treatments for anxiety, including cognitive-behavioral therapy and medications if necessary, may well be part of her clinical care, helping her understand her own personal cultural identity, how to negotiate the stresses of living on her college campus, and increasing both family and community supports are critical to her well-being and mental health.
While it is true that few people could exactly share Erica’s life experience, there are many pan-nationals and expats who would very much relate to her feelings. Erica faces many of the challenges of those in a group called “third culture kids,” a term coined in the 1950s by social scientists to describe the experience of children raised by Americans working in other countries. The expatriate lifestyle they described as an “interstitial culture” – different from but including elements of both the home culture and the host culture – often is specific to the work group (for example, military, business) that the adults were engaged in. For these children, the question of cultural identity, and “where is home,” is a complex one. For them, unlike their parents, the United States is not home but a foreign land. But their host country is not exactly home, either. Patients like Erica may benefit from reading “Third Culture Kids: The Experience of Growing Up Among Worlds,” by David C. Pollock and Ruth E. Van Reken, and clinicians would likely benefit as well.
Finally, Erica’s therapist could encourage her to find connections in the international student community; there are usually groups on campus for them, and they would understand a multicultural experience. Her therapist also should meet with, or speak with, her parents to see whether there are stresses at home, and could encourage them to support her by frequent visits or calls. When Erica finds a place where she feels at home, we believe her anxiety will decrease.
Key take-home points
1. Ask about, do not assume, the person’s own understanding of his/her background and identity to obtain more specific and precise information so as to guard against stereotyping that could lead to erroneous assessments.
2. Understand the heterogeneity of culture and the complexity of cultural identity.
3. Ask about the family. Who is in the family, both nuclear and extended? Draw a simple genogram. Envision and implement assessment beyond just the individual patient.
4. Assess the impact of culture change on cultural identity and family dynamics.
5. Use the DSM-5 Cultural Formulation Interview to help guide the cultural assessment.
Contributors
Ellen M. Berman, MD – University of Pennsylvania, Perelman School of Medicine, Philadelphia
Roberto Lewis-Fernández, MD – Columbia University and New York State Psychiatric Institute
Francis G. Lu, MD – University of California, Davis
The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements. 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 those affiliated with GAP.
Resources
Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). (Arlington, Va.: American Psychiatric Association Publishing, 2013).
Lewis-Fernández, R., et al. (eds.) DSM-5 Handbook on the Cultural Formulation Interview (Arlington, Va.: American Psychiatric Association Publishing, 2016).
Lim, R. (ed.). Clinical Manual of Cultural Psychiatry, 2nd edition (Arlington, Va.: American Psychiatric Association Publishing, 2015).
Pollock, D. and Van Reken, R. Third Culture Kids: The Experience of Growing Up Among Worlds (London: Nicholas Breasley Publishing, 2009).
Curbside Consult is inspired by the DSM-5’s emphasis on developing a cultural formulation of patients’ illnesses, and addressing family dynamics and resilience in promoting care that fosters prevention and recovery. We request that you submit cases to cpnews@frontlinemedcom.com in which your understanding and treatment are affected by challenging cultural and family issues. We will then write back with our best answers about how one might proceed in such a case. Your case and our response will be published in Clinical Psychiatry News. Please limit your case description to 250 words and include the following details:
1. Patient’s presenting problem or reason for the visit.
2. Patient’s age and gender.
3. Indicators of the patient’s identity – self-identified race/ethnicity, culture, religion/spirituality, socioeconomic status, education, among other variables.
4. Patient’s living situation, family composition, and genogram information (if available).
5. Patient’s geographic location (rural, suburban, urban) and occupation.
6. Patient’s and family’s degree of participation in their identified culture.
7. Questions of the individual submitting the case, including concerns about the role of the family and culture in the case, diagnosis, and treatment planning.