Editors’ Note: This is the first installment of Curbside Consult, written by two Group for the Advancement of Psychiatry (GAP) committees – the Committee on Family Psychiatry and the Committee on Cultural Psychiatry.
Come back home
The patient is an unmarried Japanese man in his early 40s who presents with symptoms of social phobia. He was born and raised in Japan, and migrated to the United States to pursue a PhD. In Japan, he enjoyed middle-class status, but after immigrating to the United States, he has faced many financial difficulties. His language barriers have made him uncomfortable in front of his colleagues and supervisors and he has not been able to do well in his PhD program, ultimately leading to his expulsion. He does not want to go back to Japan, thinking he will not have a “good life” there. He believes that there is no respect for a person’s individuality in Japan. He is currently living in an urban location of New Jersey and works odd jobs. He states that his family does not understand his feelings about not returning to Japan, and instead they want him to support them. He has engaged in supportive psychotherapy and cognitive-behavioral therapy in the outpatient clinic along with psychopharmacological treatment.
Key questions
1. How is Japanese culture different from U.S. culture in terms of respecting a person’s individuality?
2. The expectations of the patient’s family are considered excessive by the patient. What is the role of Japanese culture in this situation?
3. In moving forward with treatment planning, what aspects of the patient’s culture should the clinician keep in mind?
Family perspective
This middle-aged Japanese man has had a challenging time since coming to the United States to study. He lives here alone. He has failed to achieve his goal of earning a PhD. He has had financial difficulties because of his job challenges. He has had the courage to seek mental health treatment, although the goals of his treatment are unclear. He is in contact with his family in Japan, who has asked that he come home, presumably to support his somewhat older parents. It is unclear who constitutes his “family.”
From a family perspective, it seems that the family/parents in Japan are expecting that family obligation will draw the man home while the patient is defying that expectation by seeking and building individuality in the United States. A family-oriented therapist would consider the patient’s relationship with his family and help him consider how to make his decision on where to live. The therapist also would support the patient in maintaining a connection with his family. The therapist would help the patient avoid both passively capitulating to his family and defiantly cutting off from them. This would entail discussing the role of family in the United States and Japan. It would be important to empower the patient to explore his reasons for wanting to stay in the United States, what he means by “a good life,” and what he senses as his obligation to his family.
The history of this man’s life in Japan, including recollections of his childhood and an understanding of the job history of other members of his family, will help the therapist understand this man and his experience of his family. The telling of the family narrative, from his perspective, may help the patient understand his wishes and his fears. Exploring his relationships with his mother and his father will help the therapist and the patient understand some of the problems he has had in the United States.
Given his current life circumstances, work, and social stresses, lack of social support, and problems functioning, he also should be clinically assessed for depression and any other significant mental health problems. Additional questions to explore include: Does he define himself as a “failure,” and what would it be like going back to Japan? Are there concerns about “losing face”? If his parents want him to support them, do they know about his financial situation? Would he be able to get a job in Japan, or would he end up living with his parents? Are their requests that he “come home” based on their need for support, or are they afraid that he really needs their help given his difficulties establishing a life here? As the patient explores these issues in more detail, he can begin the process of resolving his future.
Cultural psychiatry perspective
This case raises important cultural questions, which deserve further exploration in psychotherapy. Alternate approaches to evaluating culture in clinical settings have moved away from conceptualizing “U.S.” or “Japanese” cultures monolithically to understand how cultural dynamics matter to the individual.
Notably, clarifying what the patient means by the “individuality” that is “not respected in Japan” would be essential, as well as what he perceives as “excessive” in his family’s demands. Alan Roland, Ph.D., in his book “In Search of Self in India and Japan: Toward a Cross-Cultural Psychology” describes marked differences between traditional Japanese and U.S. expectations of family obligation and relationship: “dependence and interdependence with close emotional connectedness versus independence and autonomy; receptivity and deference to superiors in hierarchical relationships versus self-assertion and self-promotion in egalitarian-contractual relationships; communication on multiple levels and by innuendo versus verbal articulateness and forthrightness; maintaining and enhancing esteem at all costs versus forthright criticism and expressing the truth of the matter” (pp. 292-3).
Of course, these are intentionally polarized descriptions; yet many Japanese in the United States find themselves negotiating contrasting expectations about what it means to be a person in a family and a society, some finding value in at least parts of each tradition, some holding on to traditional Japanese values, and some adopting values related to the new environment.
A key question in this case is what made the situation so difficult for this patient. Going forward, the clinician will want to characterize the biopsychosocial etiologies of his symptoms. Are the social phobia symptoms related to premorbid developmental issues hindering communication, planning, and sociability? Were they exacerbated by language difficulties and the acculturation challenges of finding himself in a new country and institution with potentially different expectations of fulfillment and success?
One wonders how he was accepted into this PhD program and why his performance led to expulsion so quickly. Are there additional symptoms and impairments beyond the breakdown in communication? For example, are there depressive symptoms? Does he have other somatic symptomatology as part of his idiom of distress that may be magnifying his impairment? Were academic supports in place that could have prevented his expulsion? Does he have other social supports and relationships? Is he struggling with intense isolation and, potentially, individuation issues triggered by his new setting?
The DSM-5 Cultural Formulation Interview ( CFI ), a standardized method for conducting a cultural assessment in mental health care, could help the clinician elicit the patient’s understandings of the problem, its causes and contextual stressors and supports, cultural identity, the cultural features of the relationship between the patient and the clinician, and options for self-coping and clinical care. This exploration of the patient’s lifeworld may clarify how to intervene. Selected supplementary modules to the CFI also may also be useful to ‘amplify’ the core CFI and to further explore the patient’s perception of the family’s role in his illness, including the Social Network Module and the Psychosocial Stressors Module.
Contributors
John Sargent, M.D. – Tufts University School of Medicine
Ellen Berman, M.D. – University of Pennsylvania, Perelman School of Medicine
Roberto Lewis-Fernández, M.D. – Columbia University and New York State Psychiatric Institute
Robert C. Like, M.D., M.S. – Rutgers University, Robert Wood Johnson Medical School
Resources
Culture and psychiatric evaluation: Operationalizing cultural formulation for DSM-5 ( Psychiatry 2014;77:130-54 ).
In Search of Self in India and Japan: Toward a Cross-Cultural Psychology (Princeton,
N.J.: Princeton University Press, 1988).
Ethnicity and Family Therapy , 3rd edition, chapter by T. Shibusawa T. called “Japanese Families,” (New York: Guilford Press, 2005, pp. 339-48).
Asian Culture and Psychotherapy: Implications for East and West (Honolulu: University of Hawai’i Press).
To read about the goals of Curbside Consult, the guiding principles for assessment, and the guidelines for case submission, see “Considering patients’ family, culture,” Clinical Psychiatry News, January 2015, p. 12. To contribute a case, send it to cpnews@frontlinemedcom.com. The contributors will make sure that all patient details shield the identities of the patient/cases and are HIPAA compliant. This column is meant to be educational and does not constitute medical advice.
