1 00:00:00,000 --> 00:00:06,156 [Music] 2 00:00:06,352 --> 00:00:07,813 {Applause.} 3 00:00:07,851 --> 00:00:10,201 Thank you. It's truly an honor to be here. 4 00:00:11,092 --> 00:00:14,802 I would like to start my talk today with a little exercise, 5 00:00:14,802 --> 00:00:17,432 introducing you to a person named Pat. 6 00:00:18,843 --> 00:00:24,003 Pat is 31 years old and lives at home with one sibling and their parents. 7 00:00:24,643 --> 00:00:26,853 Pat has always lived in the family home. 8 00:00:26,853 --> 00:00:29,513 And would not consider moving out to live alone. 9 00:00:29,513 --> 00:00:31,423 Except after getting married. 10 00:00:32,130 --> 00:00:35,130 Pat's parents always play a significant role 11 00:00:35,130 --> 00:00:39,700 in making decisions about all aspects of Pat's life 12 00:00:39,700 --> 00:00:45,010 including education, work decisions, Pat's friendships and romantic life. 13 00:00:45,644 --> 00:00:48,164 This has been the case since Pat was a child. 14 00:00:48,664 --> 00:00:52,664 Pat rarely makes decisions without consulting family members 15 00:00:52,664 --> 00:00:55,434 and rarely expresses disagreement with others 16 00:00:55,434 --> 00:00:58,774 out of fear of disapproval or loss of support. 17 00:00:59,691 --> 00:01:02,011 Pat feels very uncomfortable when alone 18 00:01:02,011 --> 00:01:06,251 and tends to cling to others out of fear of being abandoned. 19 00:01:07,926 --> 00:01:10,026 Now take a moment to picture Pat. 20 00:01:11,448 --> 00:01:13,868 Are you picturing a young man? 21 00:01:13,868 --> 00:01:15,228 A young woman? 22 00:01:15,770 --> 00:01:19,770 Are you picturing a person of a particular ethnic or cultural background. 23 00:01:19,770 --> 00:01:22,560 Maybe similar to your own. Or different. 24 00:01:23,230 --> 00:01:25,910 And consider for a moment whether such information 25 00:01:25,910 --> 00:01:29,110 would make a difference in how you think about Pat 26 00:01:29,110 --> 00:01:34,142 and whether or not you think that Pat might have some kind of mental health concern. 27 00:01:35,714 --> 00:01:38,214 Now what if I added the following information. 28 00:01:38,585 --> 00:01:40,895 Specifying that Pat is Patricia Lee 29 00:01:41,347 --> 00:01:44,527 and that she and her family immigrated to Canada from China 30 00:01:44,527 --> 00:01:46,357 when she was five years old. 31 00:01:47,657 --> 00:01:48,767 Or the following. 32 00:01:48,767 --> 00:01:53,087 Where Pat is Patrick Smith whose maternal and paternal grandparents 33 00:01:53,087 --> 00:01:58,887 immigrated to Canada from the United Kingdom and whose parents grew up in the Toronto area. 34 00:01:59,925 --> 00:02:02,405 Judging from some faces that I can see, 35 00:02:02,405 --> 00:02:06,635 this information indeed makes a difference in how you think about Pat. 36 00:02:06,940 --> 00:02:09,800 Simply adding some basic demographic information, 37 00:02:09,800 --> 00:02:13,800 can significantly shift how we think about the very same behaviors. 38 00:02:14,935 --> 00:02:18,545 This exercise has elicited similar responses in my classroom 39 00:02:18,545 --> 00:02:21,975 when I have used it in teaching about personality disorders, 40 00:02:21,975 --> 00:02:25,005 which offer a particularly striking example 41 00:02:25,005 --> 00:02:29,005 of the need to consider cultural factors when defining mental illness, 42 00:02:29,005 --> 00:02:35,405 since they are themselves defined by patterns of behavior that deviate from cultural expectations. 43 00:02:37,677 --> 00:02:42,037 I use this exercise to introduce the role of cultural factors 44 00:02:42,037 --> 00:02:44,962 in thinking about mental health and illness 45 00:02:44,962 --> 00:02:49,062 and to introduce the central idea that culture matters. 46 00:02:50,544 --> 00:02:53,184 In my experience, once introduced to this idea, 47 00:02:53,184 --> 00:02:55,584 people seem to intuitively know that culture 48 00:02:55,584 --> 00:02:59,584 makes a difference when thinking about mental health and mental illness. 49 00:02:59,883 --> 00:03:02,993 Without specifically talking about cultural differences 50 00:03:02,993 --> 00:03:07,433 in things like parent-child relationships, independence and interdependence, 51 00:03:07,433 --> 00:03:08,843 or assertiveness, 52 00:03:08,843 --> 00:03:13,993 we seem to just know that it makes a difference if we're talking about Patricia or Patrick. 53 00:03:15,053 --> 00:03:19,803 But not only does culture matter when it comes to mental health, it is fundamental. 54 00:03:20,176 --> 00:03:22,626 Many people including myself argue 55 00:03:22,626 --> 00:03:27,236 that a culturally informed approach is really critical to effective healthcare. 56 00:03:27,713 --> 00:03:31,713 And that only by including cultural factors in our discussions of this field 57 00:03:31,713 --> 00:03:33,703 will we truly make advances. 58 00:03:34,912 --> 00:03:37,882 Recently a group of medical and social scientists 59 00:03:37,882 --> 00:03:41,052 writing in one of the world's most prestigious medical journals, 60 00:03:41,052 --> 00:03:42,402 stated the following: 61 00:03:43,240 --> 00:03:47,610 That the systematic neglect of culture in health and healthcare 62 00:03:47,610 --> 00:03:54,320 is the single biggest barrier to the advancement of the highest standard of health worldwide. 63 00:03:54,932 --> 00:04:00,562 A pretty powerful statement. So this is great. 64 00:04:00,562 --> 00:04:03,742 I see a number of you nodding and you seem to be in agreement 65 00:04:03,742 --> 00:04:07,742 that reflecting on Pat illustrates for you at least at a basic level 66 00:04:07,742 --> 00:04:12,532 the importance of considering cultural questions when it comes to mental health. 67 00:04:13,218 --> 00:04:16,918 But stopping here would be problematic for a number of reasons. 68 00:04:17,207 --> 00:04:21,917 First of all I still have 15 minutes and 52 seconds left on the clock. 69 00:04:22,658 --> 00:04:24,018 But more importantly, 70 00:04:24,018 --> 00:04:28,418 stopping here could serve to reinforce certain cultural stereotypes. 71 00:04:28,418 --> 00:04:30,958 Contrasting the Lees versus the Smiths. 72 00:04:31,500 --> 00:04:34,040 And would not really leave you with any idea of how to actually 73 00:04:34,040 --> 00:04:37,060 go about considering cultural factors. 74 00:04:37,654 --> 00:04:41,944 Or worse, it might leave you with an overly simplistic idea of how to do this. 75 00:04:41,944 --> 00:04:45,604 Suggesting perhaps that simply knowing a person's ethnic background 76 00:04:45,604 --> 00:04:49,044 or immigration history provides enough information 77 00:04:49,044 --> 00:04:53,044 to really understand the meaning of their behaviors and relationships. 78 00:04:53,873 --> 00:04:57,873 So acknowledging that culture matters is a crucial initial step, 79 00:04:57,873 --> 00:04:59,973 sort of like the first piece of a puzzle. 80 00:04:59,973 --> 00:05:02,623 But we need to go much further. 81 00:05:04,980 --> 00:05:06,970 So if knowing Pat's cultural background 82 00:05:06,970 --> 00:05:09,770 is like having a first piece of the puzzle, much more 83 00:05:09,770 --> 00:05:13,770 needs to be learned before getting even close to a complete picture. 84 00:05:14,329 --> 00:05:17,739 For example, based on common cultural ideas, 85 00:05:17,739 --> 00:05:21,529 you may have had the sense that the description of Pat's behavior 86 00:05:21,529 --> 00:05:24,959 became somehow more acceptable when it was Patricia. 87 00:05:24,959 --> 00:05:28,589 A young woman of Chinese-Canadian background. 88 00:05:28,589 --> 00:05:33,959 Compared to Patrick, a young man and second generation Canadian of British descent. 89 00:05:34,939 --> 00:05:38,049 However, although interdependence and social harmony 90 00:05:38,049 --> 00:05:42,499 are values more commonly endorsed among people of Chinese background 91 00:05:42,499 --> 00:05:44,509 compared to western European background, 92 00:05:44,509 --> 00:05:51,629 is it necessarily the case that Patricia's parents are happy with her level of dependence on them? 93 00:05:52,197 --> 00:05:57,587 Maybe their migration to Canada was driven by their own traits of independence. 94 00:05:57,587 --> 00:05:59,977 And they are really quite concerned that their daughter 95 00:05:59,977 --> 00:06:03,907 has not developed greater autonomy or self-reliance. 96 00:06:04,435 --> 00:06:07,925 Maybe Patricia has never felt that she fits in among her peers 97 00:06:07,925 --> 00:06:13,605 and really feels incapable of attaining the level of independence as encouraged by her parents. 98 00:06:14,368 --> 00:06:17,668 On the other hand, although independence and autonomy 99 00:06:17,668 --> 00:06:20,798 are commonly endorsed values in North America, 100 00:06:21,317 --> 00:06:23,647 maybe it's normative within Patrick's family 101 00:06:23,647 --> 00:06:28,597 to defer to one's parents and to view life decisions as communal endeavors. 102 00:06:29,982 --> 00:06:33,622 These examples illustrate that we cannot simply make sweeping assumptions 103 00:06:33,622 --> 00:06:36,982 about people purely based on their cultural background, 104 00:06:37,527 --> 00:06:41,337 nor can we make simple comparisons or distinctions between people 105 00:06:41,337 --> 00:06:44,277 simply because they're from different contexts. 106 00:06:45,305 --> 00:06:51,415 Now this might suggest to you then that cultural information is of not much use at all 107 00:06:51,415 --> 00:06:55,975 and that we should simply focus on the individual and their unique experiences. 108 00:06:56,774 --> 00:07:00,274 But this would also be problematic and incomplete 109 00:07:00,274 --> 00:07:03,724 because to truly understand Patricia Lee's experience 110 00:07:03,724 --> 00:07:09,754 we must know that her parents' level of emphasis on independence may be relatively uncommon -- 111 00:07:09,754 --> 00:07:12,514 uncommon within their cultural community. 112 00:07:13,733 --> 00:07:16,383 And on the other hand, or similarly, 113 00:07:16,383 --> 00:07:20,983 Patrick Smith's experience of his level of dependence upon his family 114 00:07:20,983 --> 00:07:24,153 would likely carry different meaning if he and his family 115 00:07:24,153 --> 00:07:28,913 were from a cultural community that particularly emphasized family bonds. 116 00:07:29,554 --> 00:07:34,684 So in other words, in order to really develop a full understanding of mental health, 117 00:07:34,684 --> 00:07:39,784 we must develop an understanding of individuals in context. 118 00:07:41,329 --> 00:07:47,699 So this discussion illustrates one of the key challenges of a culturally informed approach to mental health. 119 00:07:47,699 --> 00:07:50,679 And in teaching this field to undergraduate students 120 00:07:50,679 --> 00:07:56,819 I have the privileged opportunity of working with them as they wrestle with these varied types of challenges. 121 00:07:57,750 --> 00:08:02,670 The path that I often see my students take is one of initial excitement 122 00:08:02,670 --> 00:08:05,624 as they engage with the idea that culture matters 123 00:08:05,624 --> 00:08:09,314 and often tend to appreciate the indepth discussion of a topic 124 00:08:09,314 --> 00:08:13,314 that tends to be lacking or minimized in teachings about mental health. 125 00:08:14,355 --> 00:08:20,125 This initial excitement, though, then turns often to some level of feeling overwhelmed 126 00:08:20,125 --> 00:08:23,625 as they begin to really grapple with the complexity of culture 127 00:08:23,625 --> 00:08:29,205 and begin to recognize the number of different factors to consider and questions to pose. 128 00:08:30,460 --> 00:08:33,400 In helping my students to navigate these questions 129 00:08:33,400 --> 00:08:36,780 it has helped me to distill my own thinking about this field 130 00:08:36,780 --> 00:08:38,450 and how best to teach it. 131 00:08:39,197 --> 00:08:43,727 I recognize that dealing with cultural matters can indeed be daunting. 132 00:08:44,207 --> 00:08:50,947 And I also have the concern that feeling overwhelmed can sometimes lead to the avoidance of new ideas or experiences. 133 00:08:51,913 --> 00:08:52,903 So with that in mind, 134 00:08:52,903 --> 00:08:58,063 I propose two related suggestions that I believe can help people to engage 135 00:08:58,063 --> 00:09:01,073 with a culturally informed approach to mental health 136 00:09:01,073 --> 00:09:07,503 rather than avoid it. And these are to take a stance of informed curiosity, 137 00:09:08,366 --> 00:09:12,366 and to ask different questions and ask questions differently. 138 00:09:13,900 --> 00:09:17,260 So a stance of informed curiosity stands in contrast 139 00:09:17,260 --> 00:09:19,930 to some models of culture and mental health 140 00:09:19,930 --> 00:09:24,190 which suggests that one needs to be an expert in a particular cultural group 141 00:09:24,190 --> 00:09:29,170 in order to work with or understand the experiences of a member of that group. 142 00:09:29,601 --> 00:09:32,421 For example many articles and book chapters 143 00:09:32,421 --> 00:09:36,421 talk about working with Asian clients or working with Hispanic clients. 144 00:09:37,243 --> 00:09:40,183 Although well intentioned, that type of approach 145 00:09:40,183 --> 00:09:44,183 can inadvertently lead to the perpetuation of cultural stereotypes. 146 00:09:44,183 --> 00:09:47,303 There's the assumption, at least at some level, 147 00:09:47,303 --> 00:09:50,153 that members of a given group share values, 148 00:09:50,153 --> 00:09:54,153 beliefs and experiences simply based on group membership. 149 00:09:54,572 --> 00:09:58,572 Though that can be the case, it is certainly not necessarily true. 150 00:09:58,892 --> 00:10:01,252 A clinician working from such a perspective 151 00:10:01,252 --> 00:10:04,682 may have easily assumed that Patricia Lee's level of dependence 152 00:10:04,682 --> 00:10:08,192 upon her family was encouraged or supported. 153 00:10:09,528 --> 00:10:13,238 I have also always found the more expertise based approach 154 00:10:13,238 --> 00:10:16,328 problematic from a personal perspective. 155 00:10:16,328 --> 00:10:20,028 As the daughter of a Chinese-Canadian father and Anglo-Canadian mother, 156 00:10:20,028 --> 00:10:23,688 born and raised in bilingual Montreal with English as a first language, 157 00:10:23,688 --> 00:10:26,908 there is unlikely to ever be a book chapter devoted 158 00:10:26,908 --> 00:10:30,208 to working with people of my particular cultural makeup. 159 00:10:30,805 --> 00:10:34,805 I think my own lived experience as a person of mixed cultural heritage, 160 00:10:34,805 --> 00:10:39,965 informs my thinking about culture and how it plays a role in mental health. 161 00:10:40,611 --> 00:10:43,891 And my experience also plays a role in my emphasis 162 00:10:43,891 --> 00:10:47,891 on a stance of informed curiosity rather than expertise. 163 00:10:48,646 --> 00:10:52,326 I believe that such a stance promotes an attitude of humility 164 00:10:52,326 --> 00:10:55,206 and really encourages one to develop hypotheses 165 00:10:55,206 --> 00:10:58,586 and questions rather than make assumptions. 166 00:10:59,536 --> 00:11:03,526 So one of the key ways that I work to promote a stance of informed curiosity 167 00:11:03,526 --> 00:11:07,526 among my students is by helping them to ask different questions 168 00:11:07,526 --> 00:11:10,686 and ask questions differently about mental health. 169 00:11:11,897 --> 00:11:15,697 My own passion for the area of culture and mental health really began 170 00:11:15,697 --> 00:11:19,697 when I took a course, an introductory course in medical anthropology 171 00:11:19,697 --> 00:11:22,407 in the second year of my undergraduate studies. 172 00:11:23,132 --> 00:11:25,282 This course proved to be a key turning point 173 00:11:25,282 --> 00:11:27,862 in my academic path and looking back, 174 00:11:27,862 --> 00:11:29,852 I think that one of its lasting effects 175 00:11:29,852 --> 00:11:34,512 was that it forced me to ask different questions about health and mental health, 176 00:11:34,512 --> 00:11:39,022 questions to which I had not previously been exposed in my psychology courses. 177 00:11:39,840 --> 00:11:41,330 Working with a different discipline, 178 00:11:41,330 --> 00:11:47,920 with its own set of theories and frameworks also instilled in me the value of asking questions differently. 179 00:11:48,542 --> 00:11:53,752 In many ways that forced me to re-evaluate ideas I had previously taken for granted. 180 00:11:54,394 --> 00:11:59,754 And that type of experience is often at the heart of cultural discussions about mental health. 181 00:12:01,427 --> 00:12:07,417 The interdisciplinary nature of my early experience also corresponds to the interdisciplinarity 182 00:12:07,417 --> 00:12:11,265 that often characterizes discussions of culture and mental health. 183 00:12:11,449 --> 00:12:15,389 Thinking back to that image of the complex set of puzzle pieces, 184 00:12:15,389 --> 00:12:21,539 a cultural approach to mental health truly benefits from the integration of different perspectives. 185 00:12:21,703 --> 00:12:25,703 Each offering their own sets and types of questions. 186 00:12:27,202 --> 00:12:30,042 Now taking a stance of informed curiosity 187 00:12:30,042 --> 00:12:35,722 by no means minimizes the importance of developing indepth knowledge in cultural matters. 188 00:12:35,722 --> 00:12:39,492 Rather, the emphasis is on how to engage with this knowledge 189 00:12:39,938 --> 00:12:42,588 with a focus really on gaining awareness 190 00:12:42,588 --> 00:12:47,778 of the wide range of cultural differences that exist in human experience. 191 00:12:47,778 --> 00:12:52,348 So as to be equipped to pose informed questions. 192 00:12:52,795 --> 00:12:55,145 We know from cultural psychology research 193 00:12:55,145 --> 00:12:57,575 that there are significant cultural differences 194 00:12:57,575 --> 00:13:00,265 across the spectrum of psychological domains. 195 00:13:00,951 --> 00:13:04,021 Including in cognitive and perceptual processes 196 00:13:04,021 --> 00:13:08,021 regarded as basic and therefore often assumed to be universal. 197 00:13:08,835 --> 00:13:12,195 For example, we know that there are significant cultural differences 198 00:13:12,195 --> 00:13:17,785 in how people perceive the world such as to what extent they focus on background information 199 00:13:17,785 --> 00:13:22,625 when examining a photograph, versus focusing on the photograph's central figure. 200 00:13:23,227 --> 00:13:25,397 We also know that there are significant differences 201 00:13:25,397 --> 00:13:30,517 in how people think about the world such as to what extent they use contextual information 202 00:13:30,517 --> 00:13:32,757 when grouping different objects together. 203 00:13:33,624 --> 00:13:37,084 These types of differences suggest that some of you may be viewing 204 00:13:37,084 --> 00:13:40,104 the slide behind me as a single wholistic image 205 00:13:40,814 --> 00:13:44,984 whereas others may be more focused on specific constituent parts. 206 00:13:46,682 --> 00:13:48,792 More directly relevant to mental health, 207 00:13:48,792 --> 00:13:52,392 we also know that cultural context plays a profound role 208 00:13:52,392 --> 00:13:55,162 in what types of emotions people most value 209 00:13:55,162 --> 00:14:00,122 and want to feel and how and with whom they express those emotions. 210 00:14:00,781 --> 00:14:02,161 In some cultural contexts, 211 00:14:02,161 --> 00:14:06,161 feeling proud is closely associated with generally feeling good. 212 00:14:06,555 --> 00:14:10,945 Whereas in other contexts the individual focus that pride entails 213 00:14:10,945 --> 00:14:18,095 makes it less desirable and there is a large literature demonstrating important cultural differences 214 00:14:18,095 --> 00:14:21,105 in how people define the very notion of the self. 215 00:14:21,812 --> 00:14:27,382 For some, the self is truly an autonomous and individual entity whereas for others, 216 00:14:27,382 --> 00:14:31,892 their ideas about the self include close interpersonal connections. 217 00:14:32,804 --> 00:14:35,474 So cultural differences in domains such as these 218 00:14:35,474 --> 00:14:39,474 should directly inform our thinking about mental health and illness. 219 00:14:39,474 --> 00:14:43,474 If culture plays such a profound role when things are going right, 220 00:14:43,474 --> 00:14:47,474 it must surely play a similar role when things go awry. 221 00:14:48,086 --> 00:14:52,086 How people experience profound shifts in their emotional life 222 00:14:52,086 --> 00:14:56,786 is deeply influenced by their values and beiefs about emotions 223 00:14:56,786 --> 00:15:00,786 and when and with whom it is appropriate to share their emotions. 224 00:15:00,786 --> 00:15:05,136 In some cultural contexts, physical symptoms of major depression 225 00:15:05,136 --> 00:15:09,568 tend to be more strongly emphasized compared to psychological symptoms. 226 00:15:09,568 --> 00:15:14,698 And this may be linked to cultural differences in values about emotions. 227 00:15:16,777 --> 00:15:21,257 So at this point, I have likely convinced you of a number of the challenges 228 00:15:21,257 --> 00:15:24,367 of taking a culturally informed approach to mental health 229 00:15:24,367 --> 00:15:28,367 and I have offered some suggestions about how to engage with these challenges. 230 00:15:29,156 --> 00:15:34,396 But hopefully I have also at least planted the seed that there are rewards to be had as well. 231 00:15:35,206 --> 00:15:39,946 Not surprisingly I personally believe that the rewards at the level of research, 232 00:15:39,946 --> 00:15:44,596 clinical care and teaching about mental health are numerous and profound. 233 00:15:44,596 --> 00:15:48,086 And ultimately far outweigh the challenges. 234 00:15:49,453 --> 00:15:54,893 At a research level, in order to build a comprehensive understanding of mental illness, 235 00:15:54,893 --> 00:15:57,073 we must integrate cultural factors. 236 00:15:57,884 --> 00:16:00,524 As suggested by the quote near the start of my talk, 237 00:16:00,524 --> 00:16:03,144 "We neglect culture at our own peril." 238 00:16:03,802 --> 00:16:07,802 If what it means to be sad and to share this sadness with others, 239 00:16:07,802 --> 00:16:11,802 is profoundly impacted by our values and beliefs about emotion, 240 00:16:11,802 --> 00:16:15,952 then we will never develop a complete understanding of severe sadness 241 00:16:15,952 --> 00:16:19,242 or depression without a cultural approach. 242 00:16:21,168 --> 00:16:22,918 From a clinical perspective, 243 00:16:22,918 --> 00:16:27,328 integrating cultural factors into our assessment of a person's distress 244 00:16:27,328 --> 00:16:33,598 is crucial to really understand their experience and can contribute to improved treatment. 245 00:16:34,173 --> 00:16:39,513 We know from research that treatments that integrate a person's own cultural beliefs 246 00:16:39,513 --> 00:16:44,713 about the causes of their distress are more effective than treatments that do not. 247 00:16:45,974 --> 00:16:49,324 How best to integrate cultural factors into treatment 248 00:16:49,324 --> 00:16:52,564 is an area of ongoing investigation and debate 249 00:16:53,057 --> 00:16:57,467 but begins with the argument that culture makes a difference. 250 00:16:58,728 --> 00:17:01,998 And thirdly at the level of learning about mental health, 251 00:17:01,998 --> 00:17:05,218 for students and the general public more broadly, 252 00:17:05,218 --> 00:17:10,296 the rewards of a culturally informed approach include greater open mindedness, 253 00:17:10,870 --> 00:17:16,290 increased understanding of experiences different from one's own and less stereotyping. 254 00:17:16,763 --> 00:17:22,873 This approach also offers new perspectives about ideas already learned about mental health. 255 00:17:23,612 --> 00:17:27,392 These are all rewards that my own students have specifically talked about 256 00:17:27,392 --> 00:17:30,932 when discussing the benefits of learning about this field. 257 00:17:32,122 --> 00:17:37,142 So my hope then for today is that you walk away with some of this increased open mindedness, 258 00:17:37,142 --> 00:17:42,332 curiosity, and an interest in asking different questions about mental health, 259 00:17:43,166 --> 00:17:47,766 all rooted in the central premise that culture matters. 260 00:17:48,132 --> 00:17:48,942 Thank you. 261 00:17:48,942 --> 00:17:53,412 {Applause.}.