The making of contemporary American psychiatry, part 1: patients, treatments, and therapeutic rationales before and after World War II

This article, the 1st in a 2-part series, uses patient records from California's Stockton State Hospital to unearth the midcentury roots of contemporary American psychiatry. These patient records allow the authors to examine 2 transformations: the post-World War II expansion of psychiatry to include the diagnosis and treatment not only of psychotic patients but also of nonpsychotic patients suffering from problems of everyday living, and the 1950s introduction of the first psychotropic drugs, which cemented the medical status of these new disorders, thus linking a new therapeutic rationale to biological understandings of disease. These transformations laid the groundwork for a contemporary psychiatry characterized by voluntary outpatient care, pharmacological treatment of a wide range of behaviors and distress, and a doctor-patient relationship and cultural acceptance of disease that allow psychiatric patients to identify themselves as consumers.     

Gender, Power, and Relationship Ethics In Family Therapy Education

Awareness and sensitivity about gender issues have central positions in family therapy education. Traditionally gender relationships have been treated as either a reflection of cultural values and norms or as a dynamic of the way that men and women deal with the other sex. This paper presents the findings of a qualitative study that examines the meaning and enactment of gender issues in the supervisory process in family therapy. Based on that study, the authors developed a strategy for raising issues of gender equity in clinical training and describe the effects of that strategy on one practicum.Professor of Family and Child Sciences and the director of the Interdivisional Program in Marriage and Family Therapy at Florida State UniversityAn associate professor of Family and Child Sciences and the co-director of the Family Policy and Research Unit in the Family Institute at Florida State University     

Understanding Islamic Perspective of Mental Health and Psychotherapy

This paper is an attempt to provide foundational information about Islamic perspective of mental health and psychotherapy. It further highlights the historical contribution of Muslim philosophers and physicians to the field of psychotherapy. In the aftermath of the 9/11 and 7/7 tragedies, there has been a growing need to understand the Islamic perspective of mental health and gain insight into the followers of this faith otherwise perceived as ‘mysterious and Far Eastern’. A case example illustrates how counselors/therapists can effectively incorporate religious-cultural aspects of Islam in their work with Muslim clients so that they could work more effectively with their Muslim clients in the post 9/11 climate. Health care professionals must be sensitive to and fully aware of the unique religious traditions, cultural norms and gender sensitive values of their Islamic psychiatric patients so that they could introduce modern therapeutic interventions with less resistance from their clients.     

Subverting Culture: Promoting HIV/AIDS Prevention Among Puerto Rican and Dominican Women

This article discusses the challenges faced by researchers and interventionists when attempting to promote change in social norms and normative beliefs that promote HIV/AIDS risk-related behaviors among Puerto Rican and Dominican women. The article focuses on the role of culture in HIV/AIDS prevention with women by analyzing the sociohistorical context of some cultural beliefs and by illustrating the tension between risk-related and protective cultural beliefs in research conducted by the authors with women in both New York and Puerto Rico. The authors propose that promoting changes in sex-related social norms and normative beliefs might be constructed as a subversive act and present the challenge this analysis poses for community psychology. They conclude that this conceptualization might be construed as subversive because rather than idealizing culture, it promotes changes that respect diversity within the culture and foster participation in the development of new cultural values, beliefs and norms.     

OPPOSING STANDARDS WITHIN THE CULTURAL WORLDVIEW: TERROR MANAGEMENT AND AMERICAN WOMEN'S DESIRE FOR UNIQUENESS VERSUS INCLUSIVENESS

Two different standards within American women's overall cultural worldview were examined in two studies: standing out and fitting in. American culture prescribes and values uniqueness, yet gender norms for women prescribe and value inclusiveness. Thus, unlike American men, American women encounter incongruent cultural norms that make it unclear which she will uphold when faced with thoughts of death. We hypothesized that, for women (and not men), gender salience would moderate worldview adherence. Using standard terror management manipulations, American women were subjected to a self or gender prime (Study 1) as well as a non-gender-group prime and compared to men (Study 2). Results showed that under mortality salience, women primed with gender identified more with their gender group, were more likely to behave inclusively, and were more likely to desire affiliation. In contrast, those primed with the self, a non-gender-group prime, as well as men, were more likely to desire uniqueness. These findings suggest that, for an American woman, both inclusiveness and uniqueness are responses to mortality salience, depending on her momentary reference point.     

Managed Care's Reconstruction of Human Existence: The Triumph of Technical Reason

To achieve its goals of managing and restricting access to psychiatric care, managed care organizations rely on an instrument, the outpatient treatment report, that carries significant implications about how they view psychiatric patients and psychiatric care. In addition to involving ethical transgressions such as violation of patient confidentiality, denial of access to care, spurious use of concepts like quality of care, and harassment of practitioners, the managed care approach also depends on an overly technical, instrumental interpretation of human beings and psychiatric treatment. It is this grounding of managed care in technical reason that I will explore in this study. I begin with a review of a typical outpatient treatment report and show how, with its dependence on the DSM-IV, on behavioral symptoms and patient 'functioning', on the biomedical model of psychiatric illness, and on gross quantitative measures, the report results in a crude, skeletonized view of the human being as a congeries of behavioral symptoms and functions. I then develop the managed care construal of human existence further by showing its grounding in technical reason, exploring the latter in its modern embodiment and deriving it and its opposite, practical reason, from Aristotle's distinction between technical and practical reason, techne and phronesis. In this analysis of the role of technical reason in managed care, I point out that managed care did not have to develop its rationale de novo but could rather lift its arguments, e.g. the biomedical model, from contemporary psychiatry and simply apply them in a restrictive manner. Finally, I conclude this study by arguing for psychiatry's status as a discipline of practical knowledge.     

An enquiry concerning the principles of cultural norms and values: The impact of uncertainty and mortality salience on reactions to violations and bolstering of cultural worldviews

This enquiry concerning the principles of cultural norms and values focuses on the impact of mortality and uncertainty salience on people’s reactions to events that violate or bolster their cultural norms and values. Five experiments show that both mortality and uncertainty salience influence people’s reactions to violations and bolstering of their cultural worldviews, yielding evidence for both terror and uncertainty management theories. Interestingly, the five experiments consistently reveal that uncertainty salience has a bigger impact on people’s reactions than mortality salience, suggesting that the former may be a more important antecedent of reactions to norms and values than the latter. Findings further suggest that uncertainty salience did not instigate death-thoughts whereas reactions to norms and values were stronger among mortality salient participants who thought of uncertainty as a result of the mortality salience manipulation than mortality salient participants who did not think of uncertainty following this manipulation. Implications are discussed.     

Expressed emotion, communication deviance, and culture in families of patients with schizophrenia: a review of the literature

The aim of this article is to critically review the literature on expressed emotion (EE), communication deviance (CD), and culture in families of patients with schizophrenia. There is growing evidence that EE and CD are highly linked. Yet the two constructs together predict the development of schizophrenia and the associated symptoms better than either construct alone. In this article, the authors review data indicating that both the expression and the levels of high EE and CD vary by ethnicity. It may be especially difficult for family members to communicate coherently and in a less critical manner when focusing on patients' inability to sustain particular cultural norms and values that are endorsed by their family and ethnic background. The authors propose that more attention to the role of culture in EE and CD and greater focus on the proper assessment of these variables would further enhance our understanding of these constructs.     

Confidentiality and the rape victim: ethical intent versus political reality

...The clinician who works with the victim of rape, either in hospital emergency departments, community mental health settings, college environments, or private practice, should consider ways that would effect the many overdue reforms for which this specialty cries out. The need for sensitivity in the area of record keeping, particularly as to how such records might be used, can hardly be debated. Beyond this, there is the role of patient advocate, calling upon the clinician to serve an educative function with reference to the members of his profession and of the larger society. Confidentiality of patient records can be preserved only to the extent that the cultural context in which they exist values such privacy.     

Original Adult MMPI Norms in Normal Samples: A Review With Implications for Future Developments

Among the most consistent criticisms of the Minnesota Multiphasic Personality inventory (MMPI) has been the adequacy of the standardly employed adult norms. Recent work at the Mayo Foundation has provided revised adult norms, and the Restandardization Project at the University of Minnesota Press will soon provide an additional norm set. This article reviews findings from 21 studies of normal adults, comparing obtained MMPI scale values to the standard norms. These comparisons indicate that the traditional adult norms may have contained detectable degrees of bias since their publication, and that consistent patterns of differences from standard MMPI norms can be found in independent studies published as early as 1949. Two separate considerations impact on the development of new adult norms: the research need for adult norms which accurately reflect the response patterns of the general population and the clinical need to evaluate individual psychiatric patients on norms that produce codetypes related to an empirical literature spanning more than 40 years. This study notes the inherent tension between these two purposes and discusses the implications of new adult MMPI norms for research and clinical practice.     

Differential efficacy of standard inpatient treatment between Mormon and non-Mormon patients

Despite differences in doctrine and belief structure, much of current research and most therapeutic practice continue to treat the thirty six recognised denominations of Christianity identically. Analysis of 298 inpatients (37.6% Mormon) at a large state psychiatric hospital found differential efficacy based on denomination (Mormon versus Non-Mormon) on seven of the 24 items of the Brief Psychiatric Rating Scale. Differential efficacy of treatment was also found based on gender for four of the 24 items with those differences possibly stemming from gender differences in openness to therapy. Finally, two denominations by gender interactions were noted as well. Taken together, the results of the current study indicate that specific denomination membership may have a more significant impact on the outcome of therapy than current practice implies. Additionally, the current study documents some of the unique challenges and issues in treating Mormon patients.     

Premodern, modern, and postmodern perspectives on sex and gender mixes

Postmodern sensibilities, generally associated with relational psychoanalysis, are applicable also in traditional and contemporary Freudian psychoanalytic contexts. Historically speaking, views of femininity and female sexuality may be ordered according to positions designated as premodern, modern, and postmodern. This temporal continuum provides a basis for incorporating aspects of postmodern feminist approaches to deconstructing gender into a more traditional yet contemporary psychoanalytic framework. The postmodern "crisis of category" is addressed through a critique from a modern psychoanalytic point of view of the gender stereotyping inherent in certain false binaries and either/or thinking of premodern psychoanalytic thinking regarding female (as well as male) sex and gender. The cultural changes brought about by the consciousness-raising of postmodern feminist and contemporary psychoanalytic thinking contribute significantly to evolutionary changes in the understanding of gender that are further internalized and represented intrapsychically. That is, sequential transformations in the internalization of new cultural norms influence the development of still more new cultural norms, so that progression in these identificatory markers of gender can be observed over successive generations.     

Judgments of marital rape as a function of honor culture,masculine reputation threat,and observer gender: A cross-cultural comparison between Turkey,Germany, and the UK

Previous research has shown that there is higher tolerance of violence against women in cultures with salient gender-specific honor norms, especially when the violence occurs in intimate relationships and in response to threat to male honor. The present cross-cultural study (N = 398) extended these findings to sexual aggression (i.e., marital rape) by comparing participants from a culture that emphasizes honor (Turkey) and participants from cultures without strong honor traditions (Germany and Britain). Turkish participants blamed the victim and exonerated the perpetrator more than did German and British participants. In all cultural groups, participants blamed the victim and exonerated the perpetrator more when the husband's reputation was threatened than in the absence of such threat, and in all cultural groups, men blamed the victim and exonerated the perpetrator more than women. Yet, the effect of masculine reputation threat and this pattern of gender differences were somewhat more pronounced among Turkish than German or British participants. Results exploring the predictive role of honor norms at the individual level beyond rape myth acceptance and traditional gender role attitudes revealed that honor norms were the primary predictor of rape perceptions and blame attributions in Turkey (an honor culture), but not in Germany and Britain (dignity cultures) where rape myth acceptance was the strongest predictor. These results provide insights into the cultural factors influencing marital rape judgments in ways that may undermine victim's well-being and fair handling of rape cases, and highlight the domains most urgently in need of potential intervention.     

The Planned Obsolescence of the Humanities: Is It Unethical?

The humanities have not enjoyed preeminence in academe since the Scientific Revolution marginalized the old trivium. But they long continued to play a subordinate educational role by helping constitute the distinguishing culture of the elite. Now even this subordinate role is becoming expendable as devotees of the profit motive seek to reduce culture to technological delivery of cultural products (Noble, Digital diploma mills: The automation of higher education, New York: Monthly Review Press, 2003). The result is a deliberate downsizing of the humanities as traditionally understood. Personal preferences aside, is this planned obsolescence morally defensible? Arguably not, if one appeals to traditional ethical norms. But what if its legitimacy is assessed instead according to the quite different norms of capitalism that figure so prominently in university administrators’ rationales as they embrace corporatization? The corporatization of American universities has had multiple effects, and some of these have not been entirely positive. In particular, it has had an adverse effect on the professional status and values of faculty. But how faculty respond to these changes varies according to their institutional situation.     

Family Therapy with East Indian Immigrant Parents Rearing Children in the United States: PARENTAL CONCERNS,THERAPEUTIC ISSUES,AND RECOMMENDATIONS

The paper focuses on East Indian immigrant parents and some of the post-immigration difficulties they experience in their attempts to rear culturally East Indian children within the United States cultural context. Concerns specific to parenting children in the US, and therapeutic issues East Indian immigrant parents bring to therapy are presented and discussed. Effective therapy with East Indian immigrant families requires that therapists be flexible in their therapeutic approaches with these families, and become more knowledgeable about the varieties of East Indian families, their cultural beliefs, values, and norms. Recommendations for culturally effective therapy are offered.David A. Baptiste, PhD, is Senior Psychologist, New Mexico Corrections Department, and in the private practice of Marital and Family Therapy, 2709 Sim Ave. Las Cruces, NM 88005 (DAB2709@aol.com).*The author is an immigrant from Guyana, South America, an Indian diaspora country. The experiences and observations discussed here are culled from 30 years of clinical practice in several US locations with a variety of East Indian Families from the Indian subcontinent and other diaspora countries.     

Between pink and blue: a multi-dimensional family approach to gender nonconforming children and their families

Families of gender nonconforming children need to negotiate the interactions between two gender systems: a rigid gender binary imported from familial, social, and cultural experiences and a fluid gender spectrum articulated by their child. This article reviews parental reactions to nonconforming gender developments and poses that the parental mandates of protection and acceptance are problematized by the difference of gender norms between the child and the family, as well as the child and the environment. Through multiple therapeutic modalities-parental coaching and education, parent support group, and child and family therapy-the author illustrates interventions supporting both parents and prepubescent children in their negotiation of safety, connection, and fluidity. Case vignettes illustrate the method in action.     

Back in the mirrored room: the enduring relevance of discursive practice

This article seeks to re‐engage a conversation regarding the importance of acknowledging the discursive content of the therapeutic process. Hare‐Mustin's (1994) article argued that psychotherapy is involved in the generation of values and norms, and thus requires ethical sensibilities. Her analysis recognized how particular socio‐cultural forces go unnoticed and suggested that unless therapists recognize their participation in discursive practices, they may unwittingly collude with and reinforce harmful cultural practices. The goal of this article is to revisit the ‘mirrored room’ so that family therapists can more deliberately evaluate their participation in cultural practices that impact on their work with clients. This article begins with a review of contemporary efforts to grapple with the issues Hare‐Mustin presented, and maintains that even contemporary approaches that assert a commitment to postmodern understandings remain incomplete without an analysis of discourse. The article then outlines the conceptual tools within discursive practice that advance the initial motivation of these contemporary efforts.     

Comparing to perfection: How cultural norms for appearance affect social comparisons and self-image

Theory and research suggests that cultural norms for appearance present unrealistic standards of beauty which may contribute to women's body dissatisfaction. In Study 1, women described their appearance more negatively than men and made more upward social comparisons about their bodies, but not about other domains. Women also compared more than men with unrealistic targets (e.g., models). In Study 2, we explored the role of cultural norms for appearance in social comparisons with relevant (peer) or irrelevant (model) superior targets. When cultural norms were not salient, participants judged a peer to be more relevant, compared more with the peer, and were more negatively affected by the peer. However, when cultural norms were salient, participants judged a professional model to be equally relevant, compared more with the model and felt worse after exposure to the model. We discuss the powerful role of cultural norms in determining social comparison processes and self-appraisals.