Lecture 8: Problems and treatment of traumatized refugees in Western countries 


ARQ: organization helping people after traumas.

Who are refugees? Because conflict or persecution they have to flee their country. No longer in their own country, having to cross borders and it is not possible to go back home safely. Countries have a legal obligation to help refugees and are not allowed to send them back if it is not safe. When do you stop being a refugee: when they can go back? When they integrate in their new country?

2017: 14.716 new asylum application. Mostly from Syria (2.202) and Eritrea (1.095). 14.490 people reunited with their families in the Netherlands. 

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Problems

Syrians are the largest group of refugees in the Netherlands. 40% of male and 45% of female recognised refugees have psychological complaints (anxiety, depression, PTSD).  

The refugee (mental) burden:

  • War, organized crime, persecution 
  • Leaving everything behind
  • Fleeing
  • Asylum procedure: very stressful
  • Integration 
  • Loss of status: for example, when you were a doctor in your home country and have to be a cleaner in the new country. 
  • Takes a long time to be reunited with your family 
  • Conflict in the home country is ongoing, they keep checking the news, very stressful. 
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Posttraumatic stress disorder 

  1. Exposure to actual or threatened death, serious injury, or sexual violence
  2. Intrusion symptoms(need 1 for diagnosis) 
    1. Intrusive memories: the memory keeps the same vividness. 
    2. Destressing dreams
    3. Dissociative reactions 
    4. Cued psychological distress
    5. Cued physiological reactions
  3. Avoidance symptoms(need 1 for diagnosis) 
    1. Avoidance of memories, thoughts, feeling 
    2. Avoidance of external reminders
  4.  Cognitions and mood symptoms(need 2 for diagnosis)
    1. Inability to recall important aspect of event
    2. Exaggerated negative beliefs or expectations
    3. Distorted cognitions leading to blame 
    4. Persistent negative emotional state
    5. Diminished interest or participation in activities
    6. Detachment or estrangement from others
    7. Persistent inability to experience positive emotions
  5. Arousal and reactivity symptoms(need 2 for diagnosis) 
    1. Irritable behaviour and angry outburst
    2. Reckless or self-destructive behaviour
    3. Hypervigilance (extremely alert) 
    4. Exaggerated startle response
    5. Problems with concentration 
    6. Sleep disturbance
  6. Dissociative symptoms
    1. Depersonalization
    2. Derealization 
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Complicated grief (persistent complicated bereavement disorder)

Complicated grief is unusually severe and prolonged, and it impairs function in important domains. Characteristic symptoms include intense yearning, longing, or emotional pain, frequent preoccupying thoughts and memories of the deceased person, a feeling of disbelief or an inability to accept the loss, and difficulty imagining a meaningful future without the deceased. Complicated grief affects about 2 to 3% of the population worldwide and is more likely after the loss of a child or a life partner and after a sudden death by violent means. 

PTSD prevalence

  • Dutch general population: 7,4% 
  • Displaced people worldwide: 30,6%
  • Refugees in Western countries: 9%, 5% major depression 
  • Treatment seeking refugees: 14-95%

Predicting PTSD in refugees

Elements that predict PTSD: 

  • 23,6% torture
  • 10% cumulative number of traumatic experiences
  • 10% time since conflict 
  • 3,5% level of political terror in country of origin 
  • I.e. 1/3 predicted by traumatic experiences 

Prediction depression in refugees

  • 22% cumulative number of traumatic experiences
  • 21.9% time since conflict
  • 11.4% torture
  • 5.0% residency status
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Treatment

Guideline for PTSD treatment in adults

  • Trauma-focused cognitive-behavioural treatment (TF-CBT)
  • Eye Movement Desensitization and Reprocessing (EMDR)

Discussion in refugees: should we follow the treatment guidelines in refugees? We have to stabilise them instead of focusing on the PTSD, but now a lot of research is done, and we know it is not true. There is no reason to wait.  

TFT in refugees

  • Narrative Exposure Therapy (NET) is effective 
  • Culturally-Adapted Cognitive Behavioural Therapy (CA-CBT) is effective 
  • TFT is more effective than multimodal treatment
  • TFT reduces PTSD severity and depression

Narrative Exposure Therapy: 

  • Protocol with 10-12 sessions 
  • Laying a lifeline (rope) on the floor, for different memories they put a rock or a flower down. 
  • The other sessions are used for narrative (imaginary) exposure, reliving the memories. 
  • The narrative is also written document, in this way they can give it to someone (children, lawyers). 

EMDR - helps to lose information and boil it down. 

  1. Activating memory, putting it in the working memory
  2. Focus on the event 
  3. Rapidly moving the fingers across the eyes (burden the working memory)
  4. A lot of information has to be processed by the working memory
  5. The memory will become blurry, fewer emotions

If the memory is in the working memory, then it can be changed. 

EMDR study - Discussion: 

Acceptability 

Acceptability of EMDR significantly lower than of stabilisation → For a subgroup of refugees, acceptability needs to be a focus of treatment.  

Safety 

EMDR and stabilisation equally safe → EMDR may be offered earlier in treatment and to a broader range of refugee patients. 

Efficacy 

EMDR and stabilisation equally efficacious → Efficacy of EMDR with refugees needs to be increased. 

  • With a subgroup of refugee patients?
  • Greater number of sessions?
  • More attention to match in explanatory models? 
  • Phased or multimodal treatment?  

Explanatory model: culturally adapted psychotherapy is more effective than unadapted, bona fide psychotherapy for primary measures of psychological functioning. Adaptation of the illness myth was the sole moderator of superior outcomes via culturally adapted psychotherapy. 

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Cross-Cultural Psychology of Health and Illness (18/19)
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Cross-Cultural Psychology of Health and Illness (18/19)

Lecture 1: Introduction, Methods and Development

Lecture 1: Introduction, Methods and Development


Health and Illness: positive concept of health and negative concepts of disease/ illness/ sickness are defined differently in different cultures! 

Culture influences:

  • What constitutes health or illness? - culture-specific illnesses
  • What causes health or illness? - some cultures take personalistic views, while Western medicine is generally mechanistic
  • What should be done for health or against illness. - habits in terms of seeking health care; acceptable health care practices  
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Culture: what is it?

Culture can be thought of as a set of implicit and explicit guidelines/information that individuals acquire as members of a particular society or context, regarding, eg how to view the world/ how to experience emotions/ how to behave in relation to other people/ to supernatural forces or gods/ to the natural environment. It also provides a way of transmitting these guidelines to the next generation (enculturation).

Enculturation: a 'lens' through which the individual perceives and understands the world that he inhabits and learns how to live with it. The group or context itself. 

Challenges to definitions/ challenges to define cultures:

  • Cultural boundaries are not distinct, often unclear
  • Cultures are dynamic and change over time
  • There are as many variations within cultures as between cultures 
    • Problem with stereotypes: person-related variables are generally continuous and distributed
    • Artificial or false dichotomies should be avoided

 Multiple levels of culture

  1. Tertiary level: explicit manifest culture, visible to the outsider, such as social rituals, traditional dress, national cuisine, festive occasions = 'facade of a culture' 
  2. Secondary level: underlying shared beliefs and rules, known to the insiders but rarely shared with outsiders = 'social norms'
  3. Primary or deepest level: rules that are known to all, obeyed by all, but implicit, and generally out of awareness (hidden, stable and resistant to change) = 'roots'

(Cross-)cultural psychology 

  • Absolutist approach: psychological phenomena are the same across cultures, processes and behaviours vary
  • Relativist approach: psychological phenomena only exist within the context of a culture
  • Somewhere in between: psychological processes are shaped by experience, but all humans share the same biological constraints! 
  • General psychology focuses on universals and (sometimes) tries to control for cultural variation
  • Cultural psychology focuses on cultural variation in terms of the psychological consequences of culture
    • Studies the different meaning systems originating from different environments 
    • Assumes that
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Lecture 2: Cultural transmission, Cross-cultural cognition

Lecture 2: Cultural transmission, Cross-cultural cognition


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Cultural evolution

Cultural variation: differences between cultural groups. Cultures are fluid and dynamic, in most cases changing over time. But cultural ideas and norms don't necessarily emerge to address universal problems. Rathe result from cultural learning. Example: fashion, tertiary level.

Sources of cultural variation: ecological geographical differences are important and can lead to far-reaching consequences. Eg availability of food sources, ease of living in specific habitats, interdependence among groups, etc. Local ecologies influence cultural values and norms and can lead to cultural in different ways: proximal causes vs distal causes and evoked culture vs transmitted culture.

Proximal causes: influenced that have direct and immediate effects. - eg when Spanish conquistadors invading had good armour, allowing a quick victory over the Incans, who lacked such technology. 

Distal causes: initial differences that lead to effects over long periods of time. - eg because of sufficient food, people could devote their time to nonfood activities such as creating tools.

Evoked culture: specific environmental conditions evoke specific responses from (all) people within that environment, becoming part of a culture. - eg acting in an intimidating manner when your children are being threatened. 

Transmitted culture: cultural information passed on or learned via social transmission or modeling. - eg copying behaviour, clothing, aspects of etiquette, etc, from food-finding to social interaction. 

Evoked and transmitted culture are not always clearly separated! Eg more emphasis on physical attractiveness due to greater parasite prevalence, vs parents teaching their children to pay attention to physical attractiveness. Transmitted culture is arguably always involved in maintaining cultural norms, even when evoked cultural responses are also present. Evoked culture based on ecological pressures alone cannot explain cultural variation. Transmitted culture represents situation-specific AND group-specific knowledge. 

Transmission of cultural information, how is information transferred

  1. ideas need to be retained
  2. ideas need to be passed on

Parallel with biological evolution, the main mechanisms are natural selection: increasing proportions of traits that confer a survival advantage; sexual selection: increasing proportion of traits that confer reproductive advantages. Sometimes conflicting!

Cultural evolution

Similarities with biological evolution: Ideas can be persistent (high survival rate) and ideas can be more prone to being passed around (reproduced more).

Differences: cultural ideas can be transmitted horizontally among peers, not only vertically across generations.

What makes ideas interesting and sticky?

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Lecture 3: Emotions, Motivation and Acculturation Stress

Lecture 3: Emotions, Motivation and Acculturation Stress


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Emotions 

Started with Darwin: Emotions and emotional expressions are universal; everyone has the same. Later there was discovered by Ekman & Friesen that there were six basic emotions: happiness, surprise, sadness, disgust, fear and anger. 

How did they do the research: They asked different people, who have never met, how they would express certain sentences. These were checked with different societies. 

Assessing universality: in particular, pride has been proposed to be universally recognized expression. Pride is different in that it involves much of the body, not just the face: erect posture, head tilted back, slight smile, arms extending away.  Even people who are born blind, show this emotion. 

What is an emotion: face, posture, subjective feeling, caused by the environment, combination of physiological reaction and cognitive, 

Perspectives on emotions

  1. James-Lange Theory of Emotion: there is some kind of stimulus--> physical reaction from your body, cannot prevent it from happening --> emotion
    • Stimulus/situation --> response --> subjective feeling 
    • This theory states that if there is no physiological response, there is no emotion. 
  2. Two-Factor Theory of Emotions: Response can also be because of something else. Two different situations can lead to the same response. The interpretation makes it the emotion. Emotions are interpretations of our physiological responses. How do you attribute it? (Zie bb voor model)

Universality vs cultural variability 

The JL theory predicts that emotions should be universal due to physiological similarities of all humans. If JL was right, then emotions would be universal, the same in every human being. 

The Two-Factor theory predicts that emotions should vary across cultures because different cultural experiences may lead us to have different interpretations of physiological responses. If the Two-factor theory was right and it would depend on how you would interpret it, then not universal. 

Do differences in emotional expressions affect emotional experiences, too?

Do people experience emotions the same?  Is there a link with how emotions are expressed and how they are felt? If that is true, then you could either feel the emotion and express it and express the emotion and feel it. If the second thing is the case, then you could influence how you feel. 

Facial feedback hypothesis provides one reason to expect cultural variability. The hypothesis proposes that we use our facial expression to infer our emotional state. This suggests that by making a particular emotional expression, we can think that we are experiencing the corresponding emotion. Pencil test:

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Lecture 4: Culture and Body-Image, Life-Style and Health

Lecture 4: Culture and Body-Image, Life-Style and Health


Overall key points

Commonalities and culture differences in: 

  • Body-image - what is perceived as attractive
  • Biology - weight, length and age
  • Life-style and health behaviour 
  • Health and medicine - views on health and illness and use of health care. 

Body and lifestyle are influenced by our culture 

Note that: Influence of culture on health is very broad and complex. In these notes only some of the relevant topics will be discussed. The main aim is to raise awareness of differences, open mind to variety and views other than those that are so standard to you that you wouldn't even think about them. Differences between individuals from one culture can sometimes be larger than those between cultures. 

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Culture and Body-Image

What is universally attractive? Evolutionary psychologists suggest preferences for visual appearances have evolutionary roots. Communalities across culture in what is perceived as attractive: clear complexion, bilateral symmetry and average features. Signs that you are healthy. People are attracted to healthy mates. 

Skin signals health more directly than any other visible aspect. The cosmetics industry provides people with ways to make their complexion look clearer. People have strong aversive reactions to skin conditions. Skin conditions often associated with stigmatization. Example: 2 Nigerian girls with skin disorder were hidden to protect the other children in the family, as marriage with member of family in which the skin disorder occurs is discouraged. 

Bilateral symmetry is a marker of health. When an organism develops under ideal conditions its right and left sides will be symmetrical. Genetic mutations, pathogens or stressors in the womb can lead to asymmetrical development. On average, asymmetrical faces are views as less attractive. 

Faces with average features are more attractive than faces that deviate from average. Average features are less likely to contain genetic abnormalities and are more symmetrical. We can more easily process any kind of stimulus that is closer to a prototype than one that is further from a prototype. And easy processing is associated with a pleasant feeling that gets interpreted as attractive. 

"Average is attractive" does not apply to aspects beyond facial features. This is seen with people's weight, height, muscles, breasts and hips. For such aspects, it's often bodies that depart from average that are seen as more attractive. The kinds of body weights that are perceived to be most attractive vary considerably across cultures. 

Body-weight 

In 1951, anthropologist and psychologist concluded

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Lecture 5: Intercultural communication in serious illness

Lecture 5: Intercultural communication in serious illness


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What is serious illness is and what the role of communication in serious illness is

There is no direct explanation but, a serious illness can be explained as a condition that carries a high risk of mortality, negatively impact the quality of life and daily function, and/or is burdensome in symptoms, treatments or caregivers stress.

Examples of serious illnesses: cancer, dementia, heart failure, diabetes, lung diseases.

Importance of communication: The moment patients are diagnosed, they need good communication: what is going on, what are their options, feel they are seen, someone is caring for them (patient and family).  

Patient: Priority: complaints; Outcomes: satisfaction, bereavement outcomes, how they're loved ones feel after they died.

Healthcare professionals: Intrinsic motivation: we all have intrinsic motivation for good communication. But it is difficult, especially breaking the bad news. Poor communication is related to burnout.     

Communication errors are related with culture. 

In the Netherlands there is a lot of focus on what the patient wants, the family comes second. Autonomy: discuss everything with the patient first, and then maybe the relatives.  Don't speak about the patient without his/her permission. Tell everything clearly and honestly. The patient decides, not the family. A lot of cultures are more family-centred. 

The stress-coping model of communication

Patient Need to know and understand stress Need to feel known and understood Clinician Instrumental communication Problem- oriented coping Health Emotional coping Affective communication

 

 

 

It really about the 'need to know' (cognitive information) and the 'need to feel known' (affective empathy). 

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Cultural differences in serious illness perceptions

Illness attributions: When facing serious illness, patients attribute these illnesses to several causes. Where you attribute the illness to, is dependent of the culture. 

Study among White British vs Black Caribbean MS patients in London. Two illness attributes: genetic/medical/environment vs supernatural. How people attribute their illness, could also change the information you have to give. 

The role of religion: religion can play a large role in illness perceptions. Islam: disease can be a divine test

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Lecture 6: Cultural Aspects of Clinical Neuropsychology

Lecture 6: Cultural Aspects of Clinical Neuropsychology


Culture and Clinical Neuropsychology: Theory

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How can culture affect neuropsychological function?

Neuropsychology: study of the relationship between behaviour, emotion and cognition on one hand, and brain function on the other. 

Clinical neuropsychology(NP): assessing and cognitive, emotional and behavioural function after suspecting brain damage for diagnosis and potential treatment. 

Brain damage after trauma, vascular accidents, tumours, toxicity, infections, also (neurodegenerative) diseases, or just ageing. 

NP assessment: 'imperfect index of brain function'

Physical differences: brain - Brain plasticity can be affected by: specialized skill acquisition, enrichment, deprivation, education, health, stress, correlates of differing cognitive mechanisms, experience more generally. 

Cultural neuroscience: field with focus on factors that affect biologicals and psychological processes that reciprocally shape beliefs and norms shared by groups of individuals. 

Physical differences: genetics - Core of nature/nurture interactions!

Heredity: passing on characteristics from parents to children based on genetic material. Although about 99% of genes are fixed, 1% differs across individuals. Genes can have effects that depend on external variables.

Epigenetics: environmental factors cause genes to switch on or off without modification of the DNA sequence. Chemical tags can control genes in specific cells. Epigenetic tags can result from lifestyle choices or specific experience. Some epigenetic tags are hereditary! Part of our genetics that only become available in certain circumstances.

Physiological approach is relatively new! Questions:

  • How can the same physiological characteristics lead to different outcomes depending on one's culture?
  • How can the same culture lead to different outcomes depending on one's physiological characteristics?

The relation between biology and behaviours may depend on the cultural meaningsof behaviours, rather than on the actual behaviours. 

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How does culture influence neuropsychological assessment?

Measuring brain function: NP assessment: intelligence; memory; verbal abilities; executive functions; visuo-spatial functions; attention; syndrome-related combinations; general batteries. The scores will be compared to normative data, sometimes with correlations for age or education level. 

Culture and NP assessment: Normative data based on very limited subsample WEIRD patients: which is partial and biased. 

There are

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Lecture 7: Case study: Understanding HIV risk in the aids Pandemic's Epicentre

Lecture 7: Case study: Understanding HIV risk in the aids Pandemic's Epicentre


The epicentre: eastern/southern Afrika. 10% of the world population lives there. 75% of all people infected with HIV and 75% of newly infected people live there. 

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Differences between psychology and anthropology

Anthropology: how individuals’ behaviour is shaped more by group norms and values, but they have been too focused on group norms. They studied only the cultures and took themselves as the norm and the other as needed of explanation. We still see this today. But, our own point of view needs explanation too. The individual perspective of a culture lacked, not everyone in a culture is the same. The lay people still see their own culture as the norm and that everyone within a culture thinks the same. 

  • The cultural difference within nations and cultural similarity across nations. 
  • People think that the way they learned it, is the way it should be/ it ought to be. 

Cultural relativism: becoming aware that we are also trained to see the world a certain way. The opposite of ethnocentrism. Differences between groups of people are not biological but cultural (‘man-made’/ taught). Franz Boas: "civilization is not something absolute, but is relative, and our ideas and conceptions are true only so far as our civilization goes”. cultural relativism has consequences for data collection. 

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Cross-cultural research (speciality of anthropologists) 

Data collection: it suggests that the data is out there, has a form/shape, regardless of who finds it. That's not true, data is not easy to find. A lot of the time people just ask what they want to know, but when asked sensitive questions (about HIV for example), people don't always answer honestly. Also, our concepts of things/situations aren't always the same. For example, marriage is very different in the West, then in Afrika. 

Ethnographic research: a qualitative research method centred upon direct and sustained, naturalistic interaction with people in the context of their daily lives in an attempt to grasp the world from their perspective.

  • Etic/outsiders’ perspective: e.g. In ‘experience-distant’, biomedical concepts 
  • Emic/insiders’ perspective: ‘experience-near’, locally meaningful concepts and classifications

How to gain the trust of a culture: participate in the daily lives, activities. Trying to bond with the people. Bodily experiencing helps to understand the people.  

Differences in world views: Gender

Malawi: you squat down when talking to someone older. Social hierarchy is much more related to age/seniority than gender. Gender not a universal social stratifier in that society. In Malawi, you have words for a younger and older sibling, instead of brother or sister. 

Cultural differences in health

Everywhere people try to make sense

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Lecture 8: Problems and treatment of traumatized refugees in Western countries 

Lecture 8: Problems and treatment of traumatized refugees in Western countries 


ARQ: organization helping people after traumas.

Who are refugees? Because conflict or persecution they have to flee their country. No longer in their own country, having to cross borders and it is not possible to go back home safely. Countries have a legal obligation to help refugees and are not allowed to send them back if it is not safe. When do you stop being a refugee: when they can go back? When they integrate in their new country?

2017: 14.716 new asylum application. Mostly from Syria (2.202) and Eritrea (1.095). 14.490 people reunited with their families in the Netherlands. 

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Problems

Syrians are the largest group of refugees in the Netherlands. 40% of male and 45% of female recognised refugees have psychological complaints (anxiety, depression, PTSD).  

The refugee (mental) burden:

  • War, organized crime, persecution 
  • Leaving everything behind
  • Fleeing
  • Asylum procedure: very stressful
  • Integration 
  • Loss of status: for example, when you were a doctor in your home country and have to be a cleaner in the new country. 
  • Takes a long time to be reunited with your family 
  • Conflict in the home country is ongoing, they keep checking the news, very stressful. 
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Posttraumatic stress disorder 

  1. Exposure to actual or threatened death, serious injury, or sexual violence
  2. Intrusion symptoms(need 1 for diagnosis) 
    1. Intrusive memories: the memory keeps the same vividness. 
    2. Destressing dreams
    3. Dissociative reactions 
    4. Cued psychological distress
    5. Cued physiological reactions
  3. Avoidance symptoms(need 1 for diagnosis) 
    1. Avoidance of memories, thoughts, feeling 
    2. Avoidance of external reminders
  4.  Cognitions and mood symptoms(need 2 for diagnosis)
    1. Inability to recall important aspect of event
    2. Exaggerated negative beliefs or expectations
    3. Distorted cognitions leading to blame 
    4. Persistent negative emotional state
    5. Diminished interest or participation in activities
    6. Detachment or estrangement from others
    7. Persistent inability to experience positive emotions
  5. Arousal and reactivity symptoms(need 2 for diagnosis) 
    1. Irritable behaviour and angry outburst
    2. Reckless or self-destructive behaviour
    3. Hypervigilance (extremely alert) 
    4. Exaggerated startle response
    5. Problems with concentration 
    6. Sleep disturbance
  6. Dissociative symptoms
    1. Depersonalization
    2. Derealization 
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