Shame and the moral emotions: Issues in cross-cultural clinical practice.

RATIONALE AND METHOD: Three interrelated topics are examined in this paper. These are (1) the study of shame and the other moral emotions (guilt, regret, remorse) as it relates to clinical approaches in cross-cultural psychiatry; (2) the examination of methodological problems and choices in researching and treating shame in persons who have experienced forced departure from their country of origin and immigration into ambivalent host countries, in which shame experienced as part of the power differentials between host and refugee is added to whatever shaming experiences the person endured within the violence of the country of origin; and (3) an examination of the suitability of evidence-based psychiatry (EBP) and narrative psychiatry as vehicles for providing clinical assessment and care that is scientifically rigorous and also establishes a reciprocally respectful relationship between two humans working on a single task of developing and understanding the life story of the person who has experienced the stresses of life as a refugee. DISCUSSION: The three topics outlined above (shame viewed at many levels; experience of entering and receiving hospitality from a host country fraught with political resentment and bureaucratic institutional procedures, yet holding the possibility of rebuilding a life with the support and assistance of the healthcare professions and other agencies; the limitations of EBP and suitability of Narrative Psychiatry are discussed at theoretical and practical levels as these domains interact in seeking, through a true partnership, the common ethical goals of providing the best course of action for this patient at this moment. CONCLUSIONS: We present two case vignettes as illustrations of how shame or respect arises and is responded to in the context of a psychiatry session.

To cross or not to cross: Clinical boundary considerations with persons who are refugees.

Recent studies suggest that culturally divergent explanatory models of illness and treatment practices, differing physician-patient goals and expectations, and mistrust and misunderstandings between refugee patients and health care professionals are associated with lower health care utilization and outcomes among refugees in Western host countries. In our experience working as psychiatrists with persons who are refugees, we have found that attention to the processes that define and redefine boundary relationships has important implications for therapeutic care, as well as for training residents and others in culturally-responsive care. This article examines the manner and micro-processes by which boundaries are established, maintained, or altered between medical provider and person who is a refugee as a key pathway in the development of working relationships that are culturally sensitive. We work from an expanded concept of boundaries in psychiatry, viewing boundaries as a way of describing interactions that play important and even critical roles in advancing, impeding, and redefining significant aspects of the therapeutic relationship between practitioner and patient. The quality of the interactions occurring minute by minute within treatment sessions provides the foundation from which relationships are defined, parameters of openness or closure of communication are conveyed, and the power structure is laid out. We offer Martin Buber's formulation of the I-Thou relationship as the philosophical grounding of flexible, culturally sensitive boundary behaviors. At its best, boundaries of mutual engagement that are respectful and cognizant of a patient's individuality and cultural history and values are conveyed to the refugee patient.

Deconstructing Risk Management in Psychotherapy Supervision.

In the ongoing controversy over how much regulation and standardization to impose on clinical practice and research, it is not surprising that the activity of psychotherapy supervision should be swept up in the drive for uniformity. The managers amongst us want to regulate and institutionalize all aspects of practice. In opposition, many clinicians resist the relentless march toward the safety of uniformity travel alongside managerial imposition of regulations. Psychotherapy supervision's method of a close apprenticeship relationship between supervisor and trainee and its focus on the process and ethics of professional interaction stand at the humanistic core of what is otherwise becoming an increasingly mechanistic model of providing care to persons with mental illness. Our commentary picks up on these themes as it reviews the work by Mehrtens et al about strengthening awareness of liability in psychiatry residency training programs. We argue that the practice of psychiatry is overburdened by documentation requirements. In imposing further record-keeping on psychotherapy supervision, we lose much more than we gain. We recommend that the supervisory process focus on the characterological virtues essential to functioning as an ethical therapist. We also argue that self-protective rules place restraints on possibilities for imaginative insights and innovations in psychotherapy.

Khat Use is Associated with Tobacco, Alcohol, and Illicit Drug Use: A Cross-Sectional Examination in the United States.

No study has systematically examined khat (Catha edulis) use and its linkages with other substance use in the United States. This study provides novel findings related to the associations of khat with other substance use among immigrants in metropolitan areas of Minnesota where large East African communities reside. Using a convenience sampling, a total of 261 individuals completed a brief face-to-face interview during which demographic information and substance use were assessed. The proportion of lifetime and current use were 30% and 6.6% for khat, 35% and 18% for tobacco, 35% and 21% for alcohol, and 13% and 10% for other illicit drugs. Self-report history of khat use was associated with tobacco, alcohol, and other drug use. Tobacco use was related to alcohol and use of other drugs. The results suggest that a history of khat use is useful in identifying individuals who are vulnerable to substance-use-related problems. The findings indicate the need for more research on khat in the U.S.

The Ethics of APA's Goldwater Rule.

Section 7.3 of the code of ethics of the American Psychiatric Association (APA) cautions psychiatrists against making public statements about public figures whom they have not formally evaluated. The APA's concern is to safeguard the public perception of psychiatry as a scientific and credible profession. The ethic is that diagnostic terminology and theory should not be used for speculative or ad hominem attacks that promote the interests of the individual physician or for political and ideological causes. However, the Goldwater Rule presents conflicting problems. These include the right to speak one's conscience regarding concerns about the psychological stability of high office holders and competing considerations regarding one's role as a private citizen versus that as a professional figure. Furthermore, the APA's proscription on diagnosis without formal interview can be questioned, since third-party payers, expert witnesses in law cases, and historical psychobiographers make diagnoses without conducting formal interviews. Some third-party assessments are reckless, but do not negate legitimate reasons for providing thoughtful education to the public and voicing psychiatric concerns as acts of conscience. We conclude that the Goldwater Rule was an excessive organizational response to what was clearly an inflammatory and embarrassing moment for American psychiatry.

Psychoses, PTSD, and depression in Somali refugees in Minnesota.

INTRODUCTION: Initial clinical observation of Somali patients seen at a busy inner-city community clinic (CUHCC) suggested that, in addition to the expected pictures of Posttraumatic Stress Disorder (PTSD) and depression previously seen in the clinic's Southeast Asian refugee population from 1980 to 2000, there was an unusually high number of young Somali men presenting with acute psychotic disturbances. OBJECTIVES: The aim of this study of health care utilization of Somali refugees (N = 600) seen in the mental health unit of the clinic from 2001 to 2009 was to investigate the major patterns of psychiatric disorders in this outpatient population and compare these findings with a cohort of non-Somali patients (N = 3,009) seen at the same outpatient clinic during the years 2007-2009. If the results supported the initial clinical observations that the rate of psychoses was higher among young Somali men than non-Somali men attending CUHCC clinic, then several areas of further research would recommend itself. First, since this study was not a study of prevalence of mental illness in the Somali community, the next step would be to undertake a study of community prevalence of mental illness among different age and gender cohorts. Second, further research should look into likely causative and contributory risk factors to explain the development of psychoses among Somali young men. METHODS: Somali and non-Somali patients were diagnosed according to DSM-IV-R criteria. Main outcome measures (diagnoses, age cohort, sex) were analyzed by Chi-square tests. Patterns of illness and adjustment varied significantly by age and gender cohorts, reflecting the relevance of age and gender at time of trauma on different trauma and loss experiences and cultural and religious shaping of subsequent adjustment and symptoms. RESULTS: The study confirmed that almost half of the Somali male patients are under age 30, 80% of whom presented with psychoses, compared with the rate of psychosis (13.7%) in the non-Somali control group of same-aged males at the clinic. The older male, and the majority of Somali female patients, show predominantly depressive and PTSD symptomatology. CONCLUSIONS: War trauma experienced in childhood, early malnutrition from famines, head trauma, and excess Khat use in male adolescents provide partial explanations for the large number of young psychotic Somali men seen in the clinic from 2001 to 2009.

New directions in the conceptualization of psychotic disorders.

PURPOSE OF REVIEW: Recent studies raise controversies about the nature of psychotic illnesses, and the role of life experiences and drug abuse as causative agents in the onset of psychoses. RECENT FINDINGS: Evidence from studies across many geographic locales and cultures finds increased risk of psychoses in first- and second-generation immigrant populations. Trauma incurred in war and civil unrest, trauma of child abuse, and the experience of being bullied in childhood are correlated with increased rates of psychoses in the populations at risk. The risk of onset of psychoses is increased by maternal and infant starvation, and by substance misuse (marijuana, khat) in late childhood and adolescence. These studies question the validity of a categorical distinction between the schizophrenic and affective illnesses. SUMMARY: A variety of extrinsic factors, such as in-utero and infant malnutrition, substance abuse, and traumatic experiences, appear to be significant risk factors for the development of schizophrenia-like and psychotic affective disorders. These findings raise the issue of whether the present classification of the psychoses is in urgent need of reconceptualization.

Psychiatry, moral worry, and the moral emotions.

There has been increased philosophical, psychological, and, more recently, psychiatric interest in the moral emotions, most specifically the emotions of guilt, shame, regret, and remorse. Interest in these emotions has not been in their role as symptoms of a particular mental illness, but in their presence in everyday life and in their importance in defining our character and our very humanity. Moral emotions are those emotions that arise in the context of life experiences and daily choices that bear upon our perceptions of the rightness or wrongness of particular actions or inactions. Human beings have a moral scanner that constantly provides both a cognitive judgment and a feeling tone of ease or unease in the moral evaluation of life's moment-to-moment activities. This paper discusses the intersection of psychiatry and the moral emotions, providing case examples and a review of empirical studies to illustrate the relevance of patients' concerns about their moral choices to psychiatric evaluation and practice.

Moral conflict, religiosity, and neuroticism in an outpatient sample.

Our sense of identity is inextricably connected to our sense of ourselves as moral beings. However, concerns about the rightness and wrongfulness of our own actions, and a range of emotions connected to moral worry, such as regret and remorse, rarely receive clinical attention. The present study sought to develop and operationalize the construct of moral concern or worry in a psychiatric outpatient sample and to investigate relationships between moral worry and age, gender, religiosity, and the tendency to worry in general. The Eysenck Personality Inventory, Duke Religiosity Scale, and a 20-item Worry Scale (containing eight moral worry items) were administered to 225 psychiatric outpatients. Data analysis included principal components analysis, repeated measures MANOVA to examine extent of worry among factor scales and interactions between age and sex, and multiple regression to identify significant correlates of each factor scale. Worry about moral issues emerged as a domain distinct from worry about practical matters. Although respondents reported more worry about practical matters than about moral concerns, worry about the former declined with age, whereas worry about the latter did not. Intrinsic religiosity was negatively correlated and neuroticism positively correlated with both scales. Because patients are concerned about the moral aspects of their character and behavior, this area deserves further research and consideration.

Moral conflict as a component of ordinary worry.

This article contributes to the psychology of moral behavior by inquiring into the presence and extent of worrying about moral concerns in one's life relative to worrying about practical concerns. A 20-item questionnaire was developed, mixing eight moral worry questions with twelve ordinary worry items (finances, health) identified in previous research on worry. Factor analysis produced three domains of worrisome thinking: moral concerns, social desirability, and personal and family health. A single item inquiring into worry about not living up to God's expectations did not load onto any other factor and was dropped from further analysis. Internal consistency for the moral worry factor scale was .85. Mean scores for this scale (moral domain) were significantly lower than mean scores for the two practical worry domain factors. Limitations of the study and directions for further research are outlined.