Editor’s Note: This is the third 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.
Erica is a 19-year-old woman from an ethnically mixed background. Her father is an African American retired U.S. military officer who met her mother while he was stationed in Japan, where her mother was born and raised. Erica lived in Japan until she was 8, when the family moved to Seattle, and her father began a new career in a large company.
At age 10, she began to have episodes during which she felt her heart racing, was short of breath, and was diaphoretic. These episodes often took place when the family went out to large public spaces, like a shopping mall, and she would be separated from her parents. They increased in frequency until she was taken to a pediatrician and saw a counselor. Her panic symptoms gradually disappeared during high school, but since starting college and moving away from home, she has felt lost in her environment, and feels as though no one understands her background and upbringing. For example, she abruptly left the first college party she attended, feeling that “everybody had met everybody already and nobody noticed me; maybe they don’t like the way I look.” She has had a return of panic episodes that are now more frequent, coming on without warning, and they have begun to wake her from sleep.
Incorporating a family and culture lens to the case can improve assessment and treatment planning. Given the brevity of the case description, many of our recommendations focus on obtaining additional information. It is also important to rule out any medical conditions that could be causing her symptoms. Finally, since great heterogeneity exists within every culture, the clinician should investigate the meanings associated with specific cultural backgrounds for each person to avoid stereotyping that would interfere with an accurate assessment and treatment plan.
Possible cultural conflicts
Although the identified patient in this case is the young woman, the number of culture- and family-related stresses experienced by each member of her family cannot be overstated. The family is truly multicultural, in every sense of the word. Many Americans associate the word “culture” with the influence of race, ethnicity, and country of origin, but the term encompasses many other aspects of the family’s background as well, including the father’s immersion in military culture as an officer of color, the culture of American ex-pats in Japan and of Japanese immigrants to the West Coast of the United States, multiracial children’s adaptations to Japanese and state schools, and U.S. corporate culture. Every member of the family has therefore had to adapt to many cultural transitions. All of these moves require new relationships with the dominant culture and immediate community, which increases stresses within the family as well as between the family and the broader society in which they live. Conflict between the parents increases vigilance and anxiety in children, and since Erica does not have siblings, the likelihood of being caught in a conflict between both parent would be high.
One adaptation that the family has undergone involves negotiating variations in “individualism” – a cultural ideology that prizes the role and desires of the individual over that of the group – and “collectivism” – in which the values and expectations of the social group are prioritized. Each society (for example, urban Japan) and social group (for example, the U.S. military) is characterized by a combination of individualistic and collectivistic traits, though a certain cultural flavor tends to predominate.
If Erica’s mother’s family of origin in Japan was very traditionally collectivistic, she may have experienced a difficult cultural shift when she moved to the United States, which tends to value more individualistic self-presentation. This conflict may have affected Erica’s development, particularly if it were an area of difficulty during her mother’s adaptation to her move or a potential sore spot in the father’s relationship with his wife. It would be good to explore to what extent the mother embraced her move to her new home in Seattle, and whether she also tried to keep her culture of origin alive in the family, while she negotiated her acculturation to U.S. society. In a cosmopolitan city like Seattle with a growing Asian population, this may be easier than in past years, but still might require a great deal of effort. The mother’s adaptation seems an important topic for further assessment, including discovering whether she found work in the United States, if she created new social networks, or whether she remained isolated with her husband and her daughter.