Op-Ed/Editorials – Cultural analysis as a vital tool in substance abuse treatment planning

Valerie Demarinis, Ph.D.

Professor at Uppsala University;
Research Director of The Culture and Gender Research Program
The Stockholm Centre for Dependency Disorders, The Karolinska University Hospital
Visiting Professor at the Division on Addictions, Cambridge Health Alliance

“The term culture means: shared learned meanings and behaviors that are transmitted from within a social activity context for purposes of promoting individual/societal adjustment, growth, and development. Culture has both external (i.e., artifacts, roles, activity contexts, institutions) and internal (i. e., values, beliefs, attitudes, activity contexts, patterns of consciousness, personality styles, epistemology) representations. The shared meanings and behaviors are subject to continuous change and modification in response to changing internal and external circumstances (as quoted in Marsella &Yamada, 2000:12)”.

Cultural analysis needs to play a prominent role in substance abuse treatment planning and research. The reason for this is straightforward. It is impossible to fully understand, interpret, or address treatment issues or clinical problems without cultural analysis. Examples are provided here in several areas as well as suggestions for addressing them through the use of cultural analysis tools. Cultural analysis is not being offered as a substitute for other types of analyses, but rather as a necessary compliment to these, and perhaps the most accurate starting point for analysis.

Examining the definition of culture, quoted above, as a base for approaching cultural analysis, the key for such analysis is the connection between internal and external representations. Trying to understand the complex story of a patient seeking help for substance abuse necessitates that such representations and their interconnections be mapped out in a way that makes this information accessible. This may seem a more or less obvious need when meeting with persons who come from a cultural or ethnic background different from that of the care provider. However, even when the same cultural or ethnic background are shared by clinician and patient, assumptions about what the internal and external representations are for the patient should not be assumed. A simple and efficient way to obtain necessary cultural information is to make use of the five areas of information found in the Outline for Cultural Formulation contained in Appendix I of the Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR (2000:897-898).

• Cultural identity of the individual;
• Cultural explanations of the individual’s illness;
• Cultural factors related to psychosocial environment and levels of functioning;
• Cultural elements of the relationship between the individual and the clinician;
• Overall cultural assessment for diagnosis and care.

With this cultural analysis tool as an integrated part of the intake process, diagnosis as well as treatment planning will be better informed. In addition, being asked about this information helps to create a treatment alliance of respect, trust, and engagement for the patient.

The areas of the Outline for Cultural Formulation can also be used for doing an analysis at the cultural-societal level when the objective is planning treatment programs for individuals and/or groups that have been underrepresented in treatment outcome research. As information begins to be gathered at the group level, cultural analysis can assist with identifying if individuals in the group have common perceptions about the larger culture in which they are living. As an example, in an ongoing research project on ethnic Swedish women in substance abuse treatment in Stockholm, many see themselves as being labeled by society in a negative way, falling into a cultural subgroup with consequences for if and how treatment will be sought. This kind of information is vital for planning treatment and for preparing cultural messages that need to be heard by underrepresented and/or marginalized populations. Cultural analysis needs to go hand in hand with gender analysis in order to identify not only the treatment needs of women in both ethnic dominant and minority populations, but also the means for identifying and implementing prevention strategies into the cultural context in general.

Moving our focus to a third level, assessing research findings, this type of analysis is necessary for facilitating a means of ‘culturally translating’ the results of international research to fit with the cultural context in which one is working. Cultural validity testing is necessary when thinking about the applicability of findings from studies done on populations in ‘other’ cultural contexts. Research studies are themselves cultural products, external representations as noted in the definition above, constructed at specific times, in specific contexts, with specific populations. However, cultural analysis is rarely provided in an explicit way in research related to substance abuse treatment. The search for cross-cultural solutions where it is assumed that diagnostic, treatment, and problem assessment methods can be transferred easily to different cultural contexts and populations is, when carried to the extreme, both futile and potentially dangerous.

Methods that work in one culture may not work the same in others, or at least often need to be culturally modified. Cultural modification of a method, an instrument, or a treatment strategy means that it needs to be tested and where necessary altered to suit the new cultural context. In the area of diagnosis for example, the above-named DSM-IV-TR, a North American publication, is now used internationally as one of the leading systems of mental disorders classification.

Only in the fourth edition of the text has attention to the importance of cultural analysis for diagnosis been provided. “The wide international acceptance of DSM suggests that this classification is useful in describing mental disorders as they are experienced by individuals throughout the world. Nonetheless, evidence also suggests that the symptoms and course of a number of DSM-IV disorders are influenced by cultural and ethnic factors (2000: Introduction, xxxiv).” An important addition in this fourth edition is information provided within the main body of the text relating to cultural variations in the clinical presentations of disorders. Unfortunately, other levels of pertinent cultural information, not least the very Outline for Cultural Formulation presented above, are found only in appendix format and thereby reducing both their status and availability. This has led to the very real consequence that in many foreign translations of the DSM-IV text, including the Swedish version, this information is not included. In the area of substance-related disorders, the research of Schmidt and Room (1999) points to the need for culture-specific analysis related to the limits and limitations of cross-cultural applicability in international classifications and research related to alcohol dependence and the diagnostic process. Culture counts.

The examples provided above at the individual, cultural-societal, and research findings assessment levels, point to the need for cultural analysis to become a part of the substance abuse treatment planning and research process. Enforcing the goal of culture-competent treatment and research planning relating to both diagnosis and treatment of substance abuse problems necessitates that all three levels be attended to in how projects and programs are designed. By so doing, the treatment needs of individuals and populations can be served more thoroughly. In addition, vital information necessary for both primary and secondary prevention efforts will be gained.

What do you think? Comments on this article can be addressed to Valerie Demarinis.

References

Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV-TR) (2000) Washington, DC: American Psychiatric Association.

Marsella, A. J. & Yamada, A. M. (2000) Culture and Mental Health: An Introduction and Overview of Foundations, Concepts, and Issues. In, I. Cuéllar & F. Paniagua (eds.), Handbook of Multicultural Mental Health: Assessment and Treatment of Diverse Populations. San Diego, CA: Academic Press.

Room, R. and Makela, K. (2000) Typologies of the cultural position of drinking. Journal of Studies on Alcohol. 61: 475-83.

Schmidt, L. and Room, R. (1999) Cross-cultural applicability in international classifications and research on alcohol dependence. Journal of Studies on Alcohol. 60: 448-62.