Expressing Distress

Pre Course Reading for CALD 9

eCALD Supplementary Resources

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Understanding the cultural context of communication is critical in mental health as there is so much variation in the way different cultures express and communicate distress.

Understanding the expression of emotion is particularly complex.  Surveys indicate that clinicians rate their skills in accurately recognising emotions and emotional syndromes more poorly when their clients are from cultures different from their own (Andary et al., 2003).

Western cultures tend to rely heavily on verbal communication, while collective cultures tend to use more non-verbal communication.  Understanding or interpreting non-verbal communication in any culture brings its own challenges since much of a message can be physical or internalised and requires some sensitivity and skill on the part of the listener to read or even recognise the cues. However when it comes to cross-cultural communication in a mental health context, a clinician is faced not only with differences in individual expression but also with verbal and non-verbal expression and then with the cultural variations of these. For example, clinicians in an Australian survey expressed concerns about whether they were misinterpreting South-East Asians’ reticence to display emotion as showing signs of a depressive disorder (Andary et al.,2003). In the same study, clinicians were concerned as well about interpreting  Mediterranean clients’ more ‘expansive’ expression of emotion (as compared to Australians) as  indicative of the elevated mood associated with bipolar disorders. Similarly, clients expressed concern about being appropriately understood by clinicians of a different culture.  

Other aspects of ethno-cultural variations in expressing distress include:

Interpretation of expression

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The interpretation of emotional expression, and the conclusions that clinicians draw about the affective state of client, impacts on diagnosstic and treatment considerations.

Understanding that some mental distress may have unique presentations that are cultural in origin can assist with mental health screening and help avoid misdiagnosis. Cultural understanding of these symptoms can help build a therapeutic alliance with a client.  

Just as standard screening instruments can sometimes be of limited use with culturally diverse populations, so too are standard diagnoses. Expressions of psychological problems are, in part, culturally specific, and behaviour that is aberrant in one culture can be standard in another. For example, seemingly paranoid thoughts are to be expected in clients who have migrated from countries with oppressive governments. It’s important to consider that behavioural phenomena that may  be defined  as mental illness in a Western context may be cultural in origin and understood differently in this context.  

Culturally rooted groups of symptoms previously referred to as “culture-bound syndromes,” are called “cultural concepts of distress” in DSM V (Kohrt et al., 2014). These cultural concepts of distress may or may not be linked to particular DSM V diagnostic criteria (APA 2013a). DSM V lists some cultural concepts of distress but other concepts exist that are not recognized in DSM V (APA 2013d). Cultural concepts of distress comprise three areas (APA, 2013a, p.758):

  1. Cultural syndromes: Clusters of symptoms that tend to co-occur in certain cultural groups, communities, or contexts.
  2. Cultural idioms of distress: Ways of communicating emotional suffering that do not refer to specific disorders or symptoms, yet provide a way to talk about personal or social concerns. Frequently these manifest as physical symptoms (somatisation).
  3. Cultural explanations: Symptoms, illness, or distress are perceived by a culture as having specific, local origins or causes.

Depression is an example of a cultural concept. For Western clinicians, major depressive disorder (MDD) can be considered a “syndrome,” or cluster of symptoms that appear to “hang together”. But depression can also be considered an “idiom of distress,” in the sense that Westerners commonly talk of feeling depressed in everyday life. The label "depression" can imbue a set of behaviours with a particular meaning. No single concept maps onto a specific psychiatric disorder, and conversely, no single psychiatric disorder (eg MDD) maps onto a cultural concept (eg Shenjing shuairuo-neurasthenia). Each illness has to be assessed in its own right. Clinicians must not only draw from diagnostic experience, available categories of illness, and the various dimensions along which aspects of the illness may range, but also recognise and try to understand the client’s cultural  understanding of the illness. The information provided throughout DSM V, and particularly in the cultural formulation chapter, can help practitioners avoid misdiagnosis, obtain clinically useful information, improve clinical rapport and promote therapeutic efficacy (APA, 2013a). 

Examples of APA (2013d) defined cultural concepts of distress are:  

Shenjing shuairuo (neurasthenia) - Chinese

  • A condition characterised by physical and mental fatigue, headaches, difficulty concentrating, dizziness, sleep disturbance, and memory loss. Other symptoms include gastrointestinal problems, sexual dysfunction, irritability, excitability, and autonomic nervous system disturbances.

Taijin kyofusho - Japanese

  • Avoiding interpersonal situations due to intense fear that one’s appearance or actions give offense to others. “Sensitive type” relates to anxiety about interpersonal interactions, while “offensive type” relates to concern about offending others. Related DSM disorder: Social anxiety disorder and obsessive-compulsive disorder

Kufungisisa-Shona - Zimbabwe. 

  • Kufungisisa (“thinking too much”) is an idiom of distress and a cultural explanation among the Shona of Zimbabwe. As an explanation it is considered to be causative of anxiety, depression and somatic problems (eg “my heart is painful because I think too much”). As an idiom of psychosocial distress, it is indicative of interpersonal and social difficulties (eg marital problems, having no money to take care of children). Kufungisisainvolves ruminating on upsetting thoughts, particularly worries. Kufungisisa is associated with a range of psychopathology including anxiety symptoms, excessive worry, panic attacks, depressive symptoms and irritability. 


Non-universality of emotional concepts

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Another incorrect assumption is that emotional concepts are universal. Both the manifestations as well as the meanings of emotions are culturally determined, and the language constructs used to express these differ enormously across cultures. Some cultures have no equivalent concepts or terminology for those used in another culture. For example, there is no word in the Chinese language to express what Westerners refer to as anxiety.

Some cultures may have many descriptions for a concept expressed by only one or two words in another. A relatively well known example is that of the many words in French used to express ‘love’. Another example is of the Aboriginal Pintupi translations for sad (Andary et al., 2003). There are at least five words used to express concern and feeling of sadness – for worry about the land, worry and concern about relatives, sadness at their absence and in sympathy for them. One of these translations (Yulatjarra) might involve self-wounding as ‘sorry-cuts’, which is seen as normal. This example illustrates how concepts themselves may differ and there may be culturally sanctioned behaviours associated with these concepts which are  different to  Western norms.

In addition to cultural differences in expression there are also differences in the value of emotions. Some cultures emphasise different emotions because they have specific values. There is also a difference across cultures regarding the conditions that elicit emotions. For example, being told what to do can elicit anger in some cultures and deference in others.