Dr. Roberto Lewis-Fernandez
Notably, clarifying what the patient means by the “individuality” that is “not respected in Japan” would be essential, as well as what he perceives as “excessive” in his family’s demands. Alan Roland, Ph.D., in his book “In Search of Self in India and Japan: Toward a Cross-Cultural Psychology” describes marked differences between traditional Japanese and U.S. expectations of family obligation and relationship: “dependence and interdependence with close emotional connectedness versus independence and autonomy; receptivity and deference to superiors in hierarchical relationships versus self-assertion and self-promotion in egalitarian-contractual relationships; communication on multiple levels and by innuendo versus verbal articulateness and forthrightness; maintaining and enhancing esteem at all costs versus forthright criticism and expressing the truth of the matter” (pp. 292-3).
Of course, these are intentionally polarized descriptions; yet many Japanese in the United States find themselves negotiating contrasting expectations about what it means to be a person in a family and a society, some finding value in at least parts of each tradition, some holding on to traditional Japanese values, and some adopting values related to the new environment.
Dr. Robert Like
A key question in this case is what made the situation so difficult for this patient. Going forward, the clinician will want to characterize the biopsychosocial etiologies of his symptoms. Are the social phobia symptoms related to premorbid developmental issues hindering communication, planning, and sociability? Were they exacerbated by language difficulties and the acculturation challenges of finding himself in a new country and institution with potentially different expectations of fulfillment and success?
One wonders how he was accepted into this PhD program and why his performance led to expulsion so quickly. Are there additional symptoms and impairments beyond the breakdown in communication? For example, are there depressive symptoms? Does he have other somatic symptomatology as part of his idiom of distress that may be magnifying his impairment? Were academic supports in place that could have prevented his expulsion? Does he have other social supports and relationships? Is he struggling with intense isolation and, potentially, individuation issues triggered by his new setting?
The DSM-5 Cultural Formulation Interview (CFI), a standardized method for conducting a cultural assessment in mental health care, could help the clinician elicit the patient’s understandings of the problem, its causes and contextual stressors and supports, cultural identity, the cultural features of the relationship between the patient and the clinician, and options for self-coping and clinical care. This exploration of the patient’s lifeworld may clarify how to intervene. Selected supplementary modules to the CFI also may also be useful to ‘amplify’ the core CFI and to further explore the patient’s perception of the family’s role in his illness, including the Social Network Module and the Psychosocial Stressors Module.
Contributors
John Sargent, M.D. – Tufts University School of Medicine
Ellen Berman, M.D. – University of Pennsylvania, Perelman School of Medicine
Roberto Lewis-Fernández, M.D. – Columbia University and New York State Psychiatric Institute
Robert C. Like, M.D., M.S. – Rutgers University, Robert Wood Johnson Medical School
Resources
Lewis-Fernández R., Aggarwal N.K., Baarnhielm, S., et al. Culture and Psychiatric Evaluation: Operationalizing Cultural Formulation for DSM-5 (Psychiatry 2014;77:130-54).
Roland A. In Search of Self in India and Japan: Toward a Cross-Cultural Psychology (Princeton,
N.J.: Princeton University Press, 1988).
Shibusawa T. Japanese Families, in Ethnicity and Family Therapy, 3rd edition. Edited by McGoldrick M., Giordano J., and Garcia-Preto. (New York: Guilford Press, 2005, pp. 339-48).
Tseng W.S., Chang S.C., Nishizono M., eds. Asian Culture and Psychotherapy: Implications for East and West (Honolulu: University of Hawai’i Press).
To read about the goals of Curbside Consult, the guiding principles for assessment, and the guidelines for case submission, see “Considering patients’ family, culture,” Clinical Psychiatry News, January 2015, p. 12. To contribute a case, send it to cpnews@frontlinemedcom.com. 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 employed by or affiliated with or the Group for the Advancement of Psychiatry (GAP).