Challenges and Rewards of a culturally-informed approach to mental health | Jessica Dere | TEDxUTSC

Dr. Jessica Dere explains how culture makes a difference when thinking about mental health and mental illness. Across mental health research, clinical care and teaching, there are profound rewards to be had by truly understanding individuals in context.

Dr. Jessica Dere is a clinical lecturer in the Department of Psychology and the Graduate Department of Psychological Clinical Science at UTSC. She obtained her Ph.D in Clinical Psychology from Concordia University in 2012, and completed a post-doctoral fellowship in the Social Aetiology of Mental Illness (SAMI) training program at the Centre for Addiction and Mental Health (CAMH). Her research interests include the role of cultural factors in emotional processes and cultural variations in symptom presentation of depression and anxiety.

This talk was given at a TEDx event using the TED conference format but independently organized by a local community. Learn more at http://ted.com/tedx

[Music]

{Applause.}

Thank you. It's truly an honor to be here.

I would like to start my talk today with a little exercise,

introducing you to a person named Pat.

Pat is 31 years old and lives at home with one sibling and their parents.

Pat has always lived in the family home.

And would not consider moving out to live alone.

Except after getting married.

Pat's parents always play a significant role

in making decisions about all aspects of Pat's life

including education, work decisions, Pat's friendships and romantic life.

This has been the case since Pat was a child.

Pat rarely makes decisions without consulting family members

and rarely expresses disagreement with others

out of fear of disapproval or loss of support.

Pat feels very uncomfortable when alone

and tends to cling to others out of fear of being abandoned.

Now take a moment to picture Pat.

Are you picturing a young man?

A young woman?

Are you picturing a person of a particular ethnic or cultural background.

Maybe similar to your own. Or different.

And consider for a moment whether such information

would make a difference in how you think about Pat

and whether or not you think that Pat might have some kind of mental health concern.

Now what if I added the following information.

Specifying that Pat is Patricia Lee

and that she and her family immigrated to Canada from China

when she was five years old.

Or the following.

Where Pat is Patrick Smith whose maternal and paternal grandparents

immigrated to Canada from the United Kingdom and whose parents grew up in the Toronto area.

Judging from some faces that I can see,

this information indeed makes a difference in how you think about Pat.

Simply adding some basic demographic information,

can significantly shift how we think about the very same behaviors.

This exercise has elicited similar responses in my classroom

when I have used it in teaching about personality disorders,

which offer a particularly striking example

of the need to consider cultural factors when defining mental illness,

since they are themselves defined by patterns of behavior that deviate from cultural expectations.

I use this exercise to introduce the role of cultural factors

in thinking about mental health and illness

and to introduce the central idea that culture matters.

In my experience, once introduced to this idea,

people seem to intuitively know that culture

makes a difference when thinking about mental health and mental illness.

Without specifically talking about cultural differences

in things like parent-child relationships, independence and interdependence,

or assertiveness,

we seem to just know that it makes a difference if we're talking about Patricia or Patrick.

But not only does culture matter when it comes to mental health, it is fundamental.

Many people including myself argue

that a culturally informed approach is really critical to effective healthcare.

And that only by including cultural factors in our discussions of this field

will we truly make advances.

Recently a group of medical and social scientists

writing in one of the world's most prestigious medical journals,

stated the following:

That the systematic neglect of culture in health and healthcare

is the single biggest barrier to the advancement of the highest standard of health worldwide.

A pretty powerful statement. So this is great.

I see a number of you nodding and you seem to be in agreement

that reflecting on Pat illustrates for you at least at a basic level

the importance of considering cultural questions when it comes to mental health.

But stopping here would be problematic for a number of reasons.

First of all I still have 15 minutes and 52 seconds left on the clock.

But more importantly,

stopping here could serve to reinforce certain cultural stereotypes.

Contrasting the Lees versus the Smiths.

And would not really leave you with any idea of how to actually

go about considering cultural factors.

Or worse, it might leave you with an overly simplistic idea of how to do this.

Suggesting perhaps that simply knowing a person's ethnic background

or immigration history provides enough information

to really understand the meaning of their behaviors and relationships.

So acknowledging that culture matters is a crucial initial step,

sort of like the first piece of a puzzle.

But we need to go much further.

So if knowing Pat's cultural background

is like having a first piece of the puzzle, much more

needs to be learned before getting even close to a complete picture.

For example, based on common cultural ideas,

you may have had the sense that the description of Pat's behavior

became somehow more acceptable when it was Patricia.

A young woman of Chinese-Canadian background.

Compared to Patrick, a young man and second generation Canadian of British descent.

However, although interdependence and social harmony

are values more commonly endorsed among people of Chinese background

compared to western European background,

is it necessarily the case that Patricia's parents are happy with her level of dependence on them?

Maybe their migration to Canada was driven by their own traits of independence.

And they are really quite concerned that their daughter

has not developed greater autonomy or self-reliance.

Maybe Patricia has never felt that she fits in among her peers

and really feels incapable of attaining the level of independence as encouraged by her parents.

On the other hand, although independence and autonomy

are commonly endorsed values in North America,

maybe it's normative within Patrick's family

to defer to one's parents and to view life decisions as communal endeavors.

These examples illustrate that we cannot simply make sweeping assumptions

about people purely based on their cultural background,

nor can we make simple comparisons or distinctions between people

simply because they're from different contexts.

Now this might suggest to you then that cultural information is of not much use at all

and that we should simply focus on the individual and their unique experiences.

But this would also be problematic and incomplete

because to truly understand Patricia Lee's experience

we must know that her parents' level of emphasis on independence may be relatively uncommon --

uncommon within their cultural community.

And on the other hand, or similarly,

Patrick Smith's experience of his level of dependence upon his family

would likely carry different meaning if he and his family

were from a cultural community that particularly emphasized family bonds.

So in other words, in order to really develop a full understanding of mental health,

we must develop an understanding of individuals in context.

So this discussion illustrates one of the key challenges of a culturally informed approach to mental health.

And in teaching this field to undergraduate students

I have the privileged opportunity of working with them as they wrestle with these varied types of challenges.

The path that I often see my students take is one of initial excitement

as they engage with the idea that culture matters

and often tend to appreciate the indepth discussion of a topic

that tends to be lacking or minimized in teachings about mental health.

This initial excitement, though, then turns often to some level of feeling overwhelmed

as they begin to really grapple with the complexity of culture

and begin to recognize the number of different factors to consider and questions to pose.

In helping my students to navigate these questions

it has helped me to distill my own thinking about this field

and how best to teach it.

I recognize that dealing with cultural matters can indeed be daunting.

And I also have the concern that feeling overwhelmed can sometimes lead to the avoidance of new ideas or experiences.

So with that in mind,

I propose two related suggestions that I believe can help people to engage

with a culturally informed approach to mental health

rather than avoid it. And these are to take a stance of informed curiosity,

and to ask different questions and ask questions differently.

So a stance of informed curiosity stands in contrast

to some models of culture and mental health

which suggests that one needs to be an expert in a particular cultural group

in order to work with or understand the experiences of a member of that group.

For example many articles and book chapters

talk about working with Asian clients or working with Hispanic clients.

Although well intentioned, that type of approach

can inadvertently lead to the perpetuation of cultural stereotypes.

There's the assumption, at least at some level,

that members of a given group share values,

beliefs and experiences simply based on group membership.

Though that can be the case, it is certainly not necessarily true.

A clinician working from such a perspective

may have easily assumed that Patricia Lee's level of dependence

upon her family was encouraged or supported.

I have also always found the more expertise based approach

problematic from a personal perspective.

As the daughter of a Chinese-Canadian father and Anglo-Canadian mother,

born and raised in bilingual Montreal with English as a first language,

there is unlikely to ever be a book chapter devoted

to working with people of my particular cultural makeup.

I think my own lived experience as a person of mixed cultural heritage,

informs my thinking about culture and how it plays a role in mental health.

And my experience also plays a role in my emphasis

on a stance of informed curiosity rather than expertise.

I believe that such a stance promotes an attitude of humility

and really encourages one to develop hypotheses

and questions rather than make assumptions.

So one of the key ways that I work to promote a stance of informed curiosity

among my students is by helping them to ask different questions

and ask questions differently about mental health.

My own passion for the area of culture and mental health really began

when I took a course, an introductory course in medical anthropology

in the second year of my undergraduate studies.

This course proved to be a key turning point

in my academic path and looking back,

I think that one of its lasting effects

was that it forced me to ask different questions about health and mental health,

questions to which I had not previously been exposed in my psychology courses.

Working with a different discipline,

with its own set of theories and frameworks also instilled in me the value of asking questions differently.

In many ways that forced me to re-evaluate ideas I had previously taken for granted.

And that type of experience is often at the heart of cultural discussions about mental health.

The interdisciplinary nature of my early experience also corresponds to the interdisciplinarity

that often characterizes discussions of culture and mental health.

Thinking back to that image of the complex set of puzzle pieces,

a cultural approach to mental health truly benefits from the integration of different perspectives.

Each offering their own sets and types of questions.

Now taking a stance of informed curiosity

by no means minimizes the importance of developing indepth knowledge in cultural matters.

Rather, the emphasis is on how to engage with this knowledge

with a focus really on gaining awareness

of the wide range of cultural differences that exist in human experience.

So as to be equipped to pose informed questions.

We know from cultural psychology research

that there are significant cultural differences

across the spectrum of psychological domains.

Including in cognitive and perceptual processes

regarded as basic and therefore often assumed to be universal.

For example, we know that there are significant cultural differences

in how people perceive the world such as to what extent they focus on background information

when examining a photograph, versus focusing on the photograph's central figure.

We also know that there are significant differences

in how people think about the world such as to what extent they use contextual information

when grouping different objects together.

These types of differences suggest that some of you may be viewing

the slide behind me as a single wholistic image

whereas others may be more focused on specific constituent parts.

More directly relevant to mental health,

we also know that cultural context plays a profound role

in what types of emotions people most value

and want to feel and how and with whom they express those emotions.

In some cultural contexts,

feeling proud is closely associated with generally feeling good.

Whereas in other contexts the individual focus that pride entails

makes it less desirable and there is a large literature demonstrating important cultural differences

in how people define the very notion of the self.

For some, the self is truly an autonomous and individual entity whereas for others,

their ideas about the self include close interpersonal connections.

So cultural differences in domains such as these

should directly inform our thinking about mental health and illness.

If culture plays such a profound role when things are going right,

it must surely play a similar role when things go awry.

How people experience profound shifts in their emotional life

is deeply influenced by their values and beiefs about emotions

and when and with whom it is appropriate to share their emotions.

In some cultural contexts, physical symptoms of major depression

tend to be more strongly emphasized compared to psychological symptoms.

And this may be linked to cultural differences in values about emotions.

So at this point, I have likely convinced you of a number of the challenges

of taking a culturally informed approach to mental health

and I have offered some suggestions about how to engage with these challenges.

But hopefully I have also at least planted the seed that there are rewards to be had as well.

Not surprisingly I personally believe that the rewards at the level of research,

clinical care and teaching about mental health are numerous and profound.

And ultimately far outweigh the challenges.

At a research level, in order to build a comprehensive understanding of mental illness,

we must integrate cultural factors.

As suggested by the quote near the start of my talk,

"We neglect culture at our own peril."

If what it means to be sad and to share this sadness with others,

is profoundly impacted by our values and beliefs about emotion,

then we will never develop a complete understanding of severe sadness

or depression without a cultural approach.

From a clinical perspective,

integrating cultural factors into our assessment of a person's distress

is crucial to really understand their experience and can contribute to improved treatment.

We know from research that treatments that integrate a person's own cultural beliefs

about the causes of their distress are more effective than treatments that do not.

How best to integrate cultural factors into treatment

is an area of ongoing investigation and debate

but begins with the argument that culture makes a difference.

And thirdly at the level of learning about mental health,

for students and the general public more broadly,

the rewards of a culturally informed approach include greater open mindedness,

increased understanding of experiences different from one's own and less stereotyping.

This approach also offers new perspectives about ideas already learned about mental health.

These are all rewards that my own students have specifically talked about

when discussing the benefits of learning about this field.

So my hope then for today is that you walk away with some of this increased open mindedness,

curiosity, and an interest in asking different questions about mental health,

all rooted in the central premise that culture matters.

Thank you.

{Applause.}.