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Assignment # 1
This the book I need a book report done 3 full pgs and title page
Question #4 on the instruction sheet gives details due 6/7/16
Question 4.Review More Than A Carpenter by Josh Mcdowell 3Page book report and reference page
# 2 Asignment
These are the instructions for Article
Paper One: Locate the following article: Dein, S & Huline-Dickens, S. (1997). Cultural aspects of aging and psychopathology, on EBSCOhost and
# Write a one- to two-page reaction paper. Include a brief summary of the article and what you learned. APA Style,12 Font ,Times Roman
Due 6/7/2016 (Title page is : (Cultural aspects of aging and psychopathology)
This is the article I have to read and write on:
Cultural aspects of aging and psychopathology. Authors: Dein, S.
Huline-Dickens, S. Source: Aging & Mental Health. May97, Vol. 1 Issue 2, p112-120. 9p.Document Type: Article Subject Terms:
Abstract: A knowledge of cultural factors is essential to an understanding of aging and mental health. This paper surveys cultural aspects and folk theories of aging, attitudes to the elderly, death, disengagement and role theory. The cultural aspects of psychopathology are then reviewed and the evidence for differing prevalences of depression and dementia considered, concluding with a comment on the provision of care for this group. It is argued that an understanding of systems of prestige and esteem gained from anthropology is important in understanding how culture influences the development of mental illness, but clearly also patterns of urbanization and industrialization worldwide influence the position of the aged. The importance of studying attitudes to the elderly is that the elderly come to perceive themselves in the same way. The prevalence of depression and dementia in Japan may be lower than in the West, which implies this culture may exert a protective influence. The position in China is less clear. Differences in family structures, attitudes, integration in the community and fulfilment of roles may account for these findings. [ABSTRACT FROM AUTHOR]Copyright of Aging & Mental Health is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)Full Text Word Count:7838ISSN:1360-7863DOI:10.1080/13607869757209Accession Number:6654531Publisher Logo:
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CULTURAL ASPECTS OF AGING AND PSYCHOPATHOLOGY
2. Age and aging
3. Cultural aspects of psychopathology
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A knowledge of cultural factors is essential to an understanding of aging and mental health. This paper surveys cultural aspects and folk theories of aging, attitudes to the elderly, death, disengagement and role theory. The cultural aspects of psychopathology are then reviewed and the evidence for differing prevalences of depression and dementia considered, concluding with a comment on the provision of care for this group. It is argued that an understanding of systems of prestige and esteem gained from anthropology is important in understanding how culture influences the development of mental illness, but clearly also patterns of urbanization and industrialization worldwide influence the position of the aged. The importance of studying attitudes to the elderly is that the elderly come to perceive themselves in the same way. The prevalence of depression and dementia in Japan may be lower than in the West, which implies this culture may exert a protective influence. The position in China is less clear. Differences in family structures, attitudes, integration in the community and fulfilment of roles may account for these findings.
The elderly population is rapidly growing worldwide, and it is therefore fortunate that research on aging has now been chosen as a global theme issue for over a hundred international medical journals (Rochon & Smith, 1996). Although attention has been traditionally focused on the physical health of people aged over 65, aging clearly affects every dimension of health care, and there is an impression that the mental health of this group has been neglected.
It is a difficult task to separate cultural factors from other social factors which may be influencing the personal environment, particularly when there has been migration to another country and the associated stresses of disrupted family relationships, increased isolation and breakdown of community support. It is within this context that the assumptions held by Western society that the elderly from ethnic minorities are supported by local communities and extended families may be false and indeed discriminatory (Ballard, 1979).
Other stresses for immigrants are transgenerational conflict, racism and often disadvantages in education and language. 'Double jeopardy' is the term recently used to describe the double challenge of racism and agism faced by people from ethnic minorities (Dowd & Bengston, 1978) and 'triple jeopardy' when they also experience socioeconomic deprivation (Norman, 1985).
This paper, which is intended to stimulate discussion, focuses on the cultural aspects of aging. The elderly have the greatest cumulative experience of culture, and through examining different cultures comparisons can be made of the systems of prestige, esteem, kinship and dependency. Clearly, this task is not an easy one, as cultures are in a constant state of flux. Modernization is a process whereby knowledge of tradition may become less valued, and there is a complex relationship between modernization and the prestige of the aged: although prestige may be depressed in industrializing societies, it may be elevated in more mature systems which can support more provision of care (Fry, 1980).
This paper firstly examines age and aging, folk theories of aging, attitudes and stereotypes and death and grieving and briefly considers the concepts of disengagement and role theory. It then secondly considers the cultural aspects of psychopathology, the evidence for differing prevalences of the major psychiatric conditions and provision of care.
Age and aging
Although anthropologists have noted structural and demographic aspects in many groups, the experience of aging is a largely neglected topic. Age is an essential ingredient of all cultures, since age is an inscribed characteristic of all individuals and all cultures must resolve the question of how to structure age differences. Age boundaries are enforced by means of formal laws and social sanctions. Age grades appear to be universal and denote the progression of individuals through the major divisions of the life cycle. For example, among the Tiriki nomads of sub Saharan Africa, each boy born over a 15-year period becomes a member of an age set. Members remain together for life, and move through four age grades 'Warrior', 'Elder Warrior', 'Judicial Elders' and 'Ritual Elders', each implying certain duties and responsibilities. (Haviland, 1996). Every known society has a named social category of people who are old and in every case these people have different rights, duties, privileges and burdens from those enjoyed or suffered by their juniors. Public acknowledgement of discontinuities, which punctuate the life cycle, occurs through rites of passage (Van Gennep, 1960; Webster, 1908). These are rare in fragmented societies, but the celebrations surrounding retirement from work, and the symbolic act of presenting a gold watch, may be seen as a rite of passage in the West.
Conceptions of what constitutes 'old age' are culturally variable and may be based on chronological age, social performance or work capacity. In many non-Western societies, people are considered young or at least middle aged if they continue to carry out responsibilities required of them. Definitions of old age, then, are said to be functional rather than chronological. For example, in Samoa there is a term for old age (matua) but it is unclear when precisely this begins. It appears that many societies divide the aged into two classes: people who are no longer fully productive economically but who can still physically and emotionally attend to their own needs and those who are totally dependent and require custodial care and supervision. This is equivalent to the third and fourth ages in Britain. Those who are mentally incompetent are everywhere regarded as a burden, but some groups make more provision for their care than others. At the most extreme they are abandoned to die when the burden of supporting them endangers the existence of the family. Such was the case until fairly recently among the Chipewyan, a group of hunter gatherers in northern Canada. The elderly are sacrificed in favour of the young and fit. But this does not occur in all hunter gatherer societies. For instance, among the Kung San of southern Africa, old men are able to assert political leadership even after hunting skills have deteriorated. Furthermore, in several polygynous Australian cultures (Warner, 1958) and African societies (Goody, 1969), a man's career and power does not mature until he is old, at which time he marries several young women (Fry, 1980).
Amoss and Harrell (1981) argue that what has been missing has been any attempt to put aging in a cross-cultural or comparative perspective. What is needed is an examination of those aspects of aging that are universal and have to be planned for as inevitable, and those aspects which are culturally specific and can be avoided, modified or strengthened under certain social conditions. An examination of those cultural factors related to aging may help us understand psychopathological processes in old age, such as the high prevalence of depression in the elderly in Western cultures (Blazer et al., 1991).
Those texts which have examined aging from a cross-cultural perspective adopt a number of perspectives emphasizing roles, statuses, treatment and prestige of the elderly. Leo Simmon's monograph (1945), The role of the aged in primitive society, remains a cornerstone of anthropological investigations of the aged. It examines factors relating to the status of the elderly in 71 non-Western cultures. Over 100 sociocultural variables were correlated with 112 variables relating to status and treatment of the elderly. For 20 years following the publication of this book, there was little research done into cultural aspects of aging and it was only in the second half of the 1960s that there was a commitment to investigate aging and the aged from an anthropological perspective, beginning in 1967 with Margaret Clark and Barbara Anderson's Culture and ageing, which identified five adaptive tasks for the elderly: recognition, redefinition, substitution, reassessment and reintegration. Since then there have been a number of books examining the process of aging in a number of cultures (Amoss & Harrell, 1981; Bond et al., 1993; Clark, 1973; Fry, 1980; Hazan, 1994).
Folk theories of aging
Anthropological methodology employs a number of ethnographic techniques, including participant observation and surveys using standardized procedures such as formal sets of questions or card sorts. The latter two are derived from cognitive anthropology (Conklin, 1955; Frake, 1962; Romnay & D'Andrade, 1964) and elicit an 'emic' or 'inside view' through an analysis of native classifications. This type of information was used by Kagan (1980) in her examination of folk theories of aging in a Columbian peasant village, detailed below.
Kagan used a folk taxonomy, which gives information on what the categories are and how they relate to one another from the perspective of the informant. Thus she was able to ask informants to provide vocabulary appropriate to age grades in Bojaca and their responses would become the basis for formulating questions that would map the life-span and age-related behaviour of the community.
In Bojaca, a Columbian peasant village, older adults are referred to as 'vejez'. Being a 'viejo' does not accord prestige, nor is it associated with isolation and abandonment. Older adults are integrated into family and community life, and actively contribute to areas such as religion, food preparation, manual skills, simple curing, the growth of plants, questions of justice and personal counselling. They are sometimes excluded from economic activities, using machinery, village planning and formal education. Old age is seen as a tranquil period with the family. Deference is shown in a quiet manner, with allowance made for the childlike behaviour of the senile.
Attitudes and stereotypes
In Britain, the notion of old age has a number of connotations. On the one hand, it is seen as a time when one is free from the constraints of work to pursue leisure activities and, if one's financial position allows, to follow desired activities one has been unable to do when one is younger. However, for many, old age is associated with a number of negative cultural stereotypes associated with powerlessness, decline, sickness, dependency and ultimately death. Additionally, the elderly are seen as conservative, inflexible and incapable of creativity (Hazan, 1994).
These stereotypes are supported by age-related expectations concerning appearance, clothing, countenance, posture, hair style and other visible features and their associated implications for attitudes and behaviour. Those elderly people who engage in younger activities such as sport or studying at university are seen as exceptional, almost having evaded the aging process by some mysterious means. Similarly, it is not expected that the elderly will be engaging in sexual activity (Hendricks & Hendricks, 1977).
There have been a number of studies examining attitudes towards the elderly in non-Western cultures, such as Hong Kong and Japan. The two most prominent religions in Hong Kong emphasize the positive qualities of old age. Taoism emphasizes acceptance and reverence for the elderly. Similarly, Confucianism is associated with images of the elderly being wise and demanding respect. However, although cultural practices and religious beliefs remain an important consideration, they are in tension with the demands of modern society where there is a demise of the traditional family and its valuing of filial piety. Leung (1987) examines evidence that Hong Kong families are becoming less caring towards the elderly and concluded that this evidence remains controversial. Among Asian families in Britain, a number of authors (Blakemore & Boneheim, 1994; Walker & Armed, 1994) point out that it can no longer be taken for granted that the immediate family is on hand to provide care when needed.
Japan has often been held up as the last repository of traditional family values and Westerners have often idealized the stability of Japanese family life. However, the feelings of younger Japanese people may be less idealistic (Koyamo, 1989) and attitudes and behaviour may be moving away from according greater status for the elderly and not towards it. The elderly population in Japan is estimated to rise by 50% between 1986 and 2000. Japanese life expectancy is now the highest in the world: 81 years for women and 75 years for men. Looking after elderly relatives becomes a heavier burden as more of them last longer and grow sicker. Caring children are fewer and older. It appears that the family life of elderly people is becoming more stressful and there is a rising incidence of suicide among elderly women which may be associated with family conflict (Ineichen, 1996).
One theory which has attempted to account for the apparent 'universal marginality' of the elderly is disengagement theory (Cumming & Henry, 1961), which postulates that successful aging is contingent on the mutual disengagement of the elderly and their social environment. It holds that the aged must accept a decline in status and must relinquish leadership roles if societal equilibrium is to he maintained. However, the evidence that the process of disengagement is universal is unsupported in the cross-cultural literature (Talmon-Gaber, 1962). Disengagement theory is to be contrasted to activity theory (Havinghurst, 1954), which argues that successful aging is related to maintaining reasonable levels of activity and substituting new roles for those lost with retirement.
Hazan (1994) argues that ambiguity, alienation and segregation characterize the elderly in Western society. They are forced to retire and leave the working community, which may lead to serious problems of identity since 'in contemporary Western society, work is a central role; intimately associated with our deepest understanding of the value and virtues of a human being and the ethical justification of our very existence; it has significance for identity far beyond the economic sphere'. Beyond this they are often forced to live separately from the rest of society in 'new communities for the aged'. In Britain, the most familiar solution to the 'problem of the aged' is best exemplified by the old age home of which there are a large variety, ranging from those designed for particular categories of the aged--such as the physically impaired--to those whose residents are heterogeneous and arbitrarily lumped together. What characterizes these 'institutions' is the lack of autonomy of their residents. The existence of these institutions reflects the social conception of the elderly as redundant, bothersome and disturbing. For most residents, the old age home is not a transitory stage but the last stage in their lives.
It is interesting to compare the experience of aging in India to that in British society. As outlined in the Vedas, the Hindu scriptures, during the last two stages of one's life, one should withdraw from this worldly activity and interest. The Varnashrama Dhama, the 'duties of social position and stage of life', describe four stages of life in the traditional normative scheme: Brahmacarya, the period of sacred learning; Grhastha, married life and parenthood; Vanaprastha, the stage of dwelling as a forest hermit; and the last stage, Sannyas, the period of asceticism and renunciation. This outline is familiar to all Hindus, but as Vatuk (1980) states: 'few lives as actually lived correspond in detail to the prescriptions of the Sanskrit texts'. 'Disengagement' is thus seen as an ideal and normative process and does not result in loss of status. Old age is seen as a period of rightful dependency, with security contingent upon the support of an extended family. Traditionally, the elderly were accorded high status, but this is rapidly changing under the impact of modernization. As Subrahmanium (1988) states: 'By tradition, religious and cultural, the elders are given a high status in Indian society.' In the past the joint family was the common pattern that existed, with the head of the family enjoying rights and responsibilities and commanding obedience and respect. Under the impact of the industrial revolution the joint family is fast breaking down; old age is now seen as a 'problem'. He examines the growth of old age homes and old age aid groups throughout India, phenomena which would have been unthinkable several years ago.
Parsons (1949) considered the loss of employment as the central feature of aging, which led to loss of purpose in life. In the West, work roles are of enormous significance for self-esteem, social interaction and identity. Thus, on retirement the elderly may face the loss of power, respect and social rewards (Hazan, 1994). The elderly may become volunteers at work to compensate for their eroded social status, and other initiatives, such as the newly established University of the Third Age (Midwinter, 1984), represent attempts to provide new roles. Other roles may also be found as a grandparent, patient, pensioner or other role in the family unit, but as Hazan (1994) points out, the latter is inherently ambivalent, as authority has often passed to the younger generation and many of these roles may represent 'mock inclusions'. In contrast to the above, in many traditional societies where the knowledge and expertise of the elderly are particularly valuable and the society possesses the resources to support them, their power is ensured and may even be enhanced. The elderly receive high status roles. In some societies--for instance, among the Merina of Madagascar--the attainment of old age is a prerequisite for the position of leader, but any deterioration in the ability to transmit this knowledge may result in excommunication (Keith, 1979). The status of the elderly in more complex societies is extremely variable and is dependent on their control over valuable resources and their possession of knowledge. In many societies which follow traditional religions, the possession of ritual knowledge is deemed as vital to the continuation of that society and it is often the elderly who hold this knowledge. This may result in their higher status. On account of this knowledge, the elderly are often seen to have the ability to heal. However, when these societies undergo a process of modernization, this cultural knowledge is no longer considered important, with the consequent decline in status of the elderly (Cogwill & Holmes, 1972).
Death and grieving
It is impossible to talk of aging in different cultures without taking into account religious views and attitudes towards death:
The separation of the aged from society, the identification of ageing with ugliness, evil and horror, and the reluctance to engage in physical contact with the aged all indicate that ageing is perceived as a dangerous area located, as it were, between life and death (Hazan, 1994).
It is the old who are associated with death. However, this has not always been the case, as in Medieval Europe, where death was primarily associated with high infant mortality (Aries, 1965).
A distinction is made between biological death (the death of the organism) and social death (the termination of social life). The two may not be simultaneous and in complex societies social death, i.e. the loss of social role and cultural identity, precedes biological death. Hertz (1960) has said, 'The problem faced by the bereaved was that the deceased was not only a biological individual but a social being grafted upon the physical individual whose destruction is tantamount to a sacrilege against the social order.' Cultural attitudes to biological and social death are manifest in the preparation for death, theories of afterlife, and the links between the living and the dead (Hazan, 1994). In some groups, such as the Alaskan Eskimo, a man or woman may even determine the date of his or her own death; but the fact that elderly Eskimos are permitted to commit suicide does not mean that they are held in low esteem by their families. In other societies, a continuing link between the living and the dead is manifest in the cult of the ancestors. In societies possessing such cults, the status of the elderly may be high on account of their temporal proximity to the ancestors (Bloch & Parry, 1982). This is exemplified in Madagascar and Mexico, where there are strong cults of the ancestors.
Although it is commonly assumed that fear of death increases with age, there is evidence that elderly people are no more afraid of death than younger age groups and this fear may be greatest in middle age (Kalish, 1976). For middle class Americans, death may mean 'loss of self' (Fulton, 1964; Schultz, 1977) and loss of social success and productivity in a value system which emphasizes youth, health and achievement. Death anxiety, then, is a response to this conflict, and the consequence of this is to suppress conscious awareness of death. American culture is considered to be highly successful in minimizing contact with the phenomenon of death (Schultz, 1980).
Following death, culture determines the modes of grieving. Eisenbruch (1984), in a comprehensive review of the grieving process in a number of cultures (including Chinese, South East Asian refugees and North American blacks), found that the mode of expression of grief was culturally determined, as were the ways of dealing with it. This piece of work emphasized the difficulty in trying to determine what constitutes normal and abnormal grief, and raises important questions for those involved in helping the bereaved of different cultures in Britain. Koenig (1996) points out that religion may be an important coping mechanism in the elderly, especially at times of sickness.
Cultural aspects of psychopathology
It has been recognized that existing instruments used to screen for depression and dementia were developed for use in the Western white population, and thus may be of limited use in ethnic groups who use different languages and communicate distress in different ways (Rait et al., 1996). In the field of cross-cultural research of dementia, in particular, there has been much debate about the appropriacy of using cognitive tests developed for Western people (see below). Not only may education affect the scores obtained on cognitive testing, but there may also be specific cultural factors involved in the performance of cognitive tasks (Salmon et al., 1989). It must also be remembered that consultation behaviour and patients' belief systems may lead them to seek the help of traditional healers before presenting to health services.
Although there is a burgeoning literature examining cross-cultural aspects of psychopathology (Dein, 1994), there has been relatively little work done on cultural aspects of old age psychiatry. In many nonwestern societies, psychiatric services are poorly developed and there are few psychiatrists. For instance, in Tanzania there are six specialist psychiatrists for 30 million people. In those societies with trained psychiatrists, patients of all ages are treated, including children and the very elderly. There are few trained old age psychiatrists. The work done so far on cross-cultural aspects of old age psychiatry concentrates predominantly on depression and dementia and most of this has been carried out in Japan, China and India.
Somatization is common in non-Western cultures (Kleinman & Good, 1985), and ethnographic accounts of depression in China and Taiwan suggest that elderly patients present with somatic symptoms. There are parallels with British-born elderly patients where somatization is a common presentation and many elderly subjects complain of physical symptoms or sleep disturbance rather than depressed mood (Brown, 1988). As Katona (1994) says: 'Presentations which minimise depression but focus on somatic complaints are far more frequently found than in the younger age groups.' The reasons for this remain uncertain.
Hasegawa (1985) reviewed the results of several Western and Japanese prevalence studies of late onset depression. The studies utilize different study populations and methods of identifying depressive symptomology. He concludes that rates of depression are higher in Western cultures than in Japanese culture. He speculated that this may be accounted for by differences in family structure between Western and Japanese culture. Komahashi et al. (1994) also found the prevalence of depression among the elderly in Ohira town in Japan to be low, at 0.45% using DSM-III-R criteria.
However, other studies have reported higher prevalences comparable to those in the UK. Nippon and Eisei (1993) examined prevalence rates of depression in a rural village of the Akita perfecture using the Centre for Epidemiological Studies Depression scale (CES-D) and found a prevalence of 5.3%. Horiguchi and Inanmia (1991) using the Zung and self-rating scales, found prevalence of depression in elderly subjects to be 61% (screening level) in nursing homes, compared to 36% in the community. Kashiwase et al. (1991) emphasize that depression is the major functional mental disorder in Japan, occurring in 31% of those over 70. The marked variability in reported prevalence rates are similar to the findings in Western cultures. Although pharmacotherapy and psychotherapy are common treatment modalities, traditional healing methods such as Kampo (using extracts of crude herbs), acupuncture and moxibustion are often used.
Cultural and religious views are likely to determine whether or not suicide is an acceptable course of action. Studies in India show that suicide rates are low among the elderly (Adityanjee, 1986; Bhatia et al., 1987) and this may be a consequence of the support and companionship enjoyed by the senior members of an Indian family. However, in contrast, Shimizu (1990) found that suicide rated highly as a cause of death among elderly Japanese. Although suicide rates have fallen for all age groups in Japan, rates are still significantly higher in the elderly than in younger age groups (Tatai, 1991). This may be due to the tradition of honourable suicide in Japanese culture, which is likely to have more influence on the elderly.
A study by Cohen (1993) reveals that, while the rate of suicide in America is greater in older Americans compared to other US population groups, it is less frequent in older blacks than older whites. Cohen speculates that older African Americans, in reaching later life, have surmounted more threats to self esteem (compared with whites) and are thereby better adapted to new challenges associated with aging.
There have been a number of cross-cultural epidemiological studies on dementia. Ineichen (1981) emphasizes the difficulty of making reliable diagnoses and the importance of taking into account cultural factors when assessing dementia. Several studies have found that the prevalence of dementia is higher in blacks and Hispanics in New York, compared to the white elderly (Escobar et al., 1986; Folstein et al., 1987; Schoenberg et al., 1985). However, these results have been questioned by Gurland (1994), who is critical of dementia rating scales which value certain types of information and are biased so that people with language difficulties and poor educational background score lower. He argues that there is a need to develop a culture free instrument.
In Japan, there have been several epidemiological studies of the prevalence of dementia. Fukunishi et al., (1991) found a prevalence rate of 4.5% in those over 65 years. Shibayama et al. (1986), in a community sample, found a prevalence rate of 5.9% for moderate to severe dementia. Graves et al. (1994) reported the prevalence rates of different subtypes of dementia in Japan and the US. They conclude that in Japan and China the prevalence of multi infarct dementia exceeds that of SDAT; whereas in Western cultures the prevalence of SDAT is higher, but that a diagnosis of multi infarct dementia is more likely to be made since there is a perceived association between vascular disease and rich lifestyle. Similar findings have been reported by Jorm (1991). Of special interest is a recent finding by Homma (1994), which provides good evidence that the prevalence of Alzheimer's disease is greater in the West than in Japan, whilst there is no marked difference in the prevalence of vascular dementia.
In China, Zhang et al. (1990) reviewed early studies published in Chinese, reporting low rates of dementia which varied between 0.46% and 1.86% of the aged population. The authors concluded, however, that this may have been accounted for by differences in sampling, data collection and age structure of the samples chosen. The Shanghai study reported by Yu et al. (1989) and Zhang et al. (1990) is the largest performed to date, involving a sample of 5,055 people over the age of 55 (Ineichen, 1996). A modified form of the Mini-Mental State Examination (MMSE) was used as a screening instrument, followed by detailed interviews with low scorers. In the over 65 group 152 cases of dementia were identified, giving a rate of 4.1%. Poor education appeared to increase the likelihood of dementia.
Early research in China, therefore, appears to show low rates of dementia, and later research higher rates, but still below the rates found in Europe. Only the Shanghai study, which is the most rigorous, gives comparable rates to those in Europe (Ineichen, 1996). These findings raise the question of whether the incidence of dementia in China is really increasing, or whether this is a result of improved and more accurate research techniques.
In non-Western cultures, dementia is often seen as a part of the normal process of aging. There is an expected decline in cognitive functioning in old age which is seen as natural and not requiring medical intervention. It is not medicalized until problems become very extreme (such as violence) and it comes to the attention of doctors. Cohen (1995) examined conceptualizations of senility in Banares, Northern India and found that senility was not seen as a medical problem. The local people used the Hindi term dimag or 'weak brain' to refer to senility; a term which suggests that the old person received inadequate support from his or her children: 'Those whose "brains were not quite right" point to a bad family'. This is not surprising in a culture which traditionally emphasizes devotion by the children to their parents. Hernandez (1991) points out that cultural factors may influence the perceived burden associated with caring for an elderly demented relative. One study among caregivers (Hines-Martin, 1995) found that African American carers showed reduced strain in caring for their elderly relatives suffering with senile dementia and institutionalized them to a lesser degree than their white counterparts. However, as Ineichen (1996) explains, although dementia is unlikely to be stigmatized in China, this is at the cost of failing to seek help, and presumably therefore increases the burden on relatives.
In the Far East, as with families elsewhere, the effect on the health, morale and life style of carets of those with dementia is immense (Brown, 1988; Maedal et al., 1989). The Japanese government has responded by spending more on elderly care, but most of this money has been used to provide additional nursing home places, which have been rapidly increasing in numbers. There has been relatively little interest in the quality of care (Kobayashi, 1989) or the development of community services. There are few old age psychiatrists concerned with dementia and there is a resistance to consulting them (Maeda et al., 1989).
Provision of care
According to Littlewood and Lipsedge (1989), elderly black people have been widely ignored in the provision of day care facilities and group homes, perhaps because of a comfortable assumption that they are all part of an extended family network which, unlike the individual white family, continues to care for them. A study by Walker and Ahmed (1994) suggests that it cannot be taken for granted that the immediate family is on hand to provide care when needed. The clinical impression is that statutory services are ill equipped to meet the demands of ethnic minority people. A recent text (Yeo & Gallagher-Thompson, 1996) examines some of these issues in relation to dementia.
Although old age psychiatry has been recognized as a specialty within British psychiatry since 1989, this is not so in many countries. Principles of service delivery identified in the UK have found application in other countries when adapted to the characteristics of local populations and historical views on health care and the elderly (Aries, 1992).
The important components for any old age psychiatry service are the team, facilities used by them, and the structures for collaboration with other agencies. Privately run nursing homes have become an important resource since the mid 1980s, yet this development has often taken place in an unplanned way and without attending to local needs. In the public sector, limits on expenditure have encouraged homes to accept less disabled residents, which may lead to multiply disadvantaged people being difficult to place. The voluntary sector has played an important role in providing specialized services (for example Age Concern initiatives for people of Indian origin in parts of south London) and bringing the needs of the elderly to the attention of the public and politicians.
There are a number of initiatives in Britain for the care of the elderly of ethnic minorities (for example Leicestershire social services), but resources are patchy and social services budgets limited. With respect to specific treatments, psychotherapy has not traditionally been offered to the elderly, but family therapy is now well described in this age group (Benbow et al., 1990). Family therapy enables a multidisciplinary team to work using flexible models which can be sensitively adapted to families of ethnic minorities. There is a need for more research into how families cope and the kinds of help they would most appreciate.
Health care professionals need to understand the cultural factors which affect all aspects of their patients' lives. There are inter-cultural differences in the prevention, presentation, detection and management of psychiatric disorders. Culture also influences the development of the personality, concept of self, consultation behaviours, what is perceived as stigma, options of adopting the sick role and the patients' own explanatory models for their illnesses. In a recent review of folk theories of aging, Kaufman (1995) found that the elderly hold negative expectations about their health, which may reflect negative experiences of health care, or negative attitudes of society as a whole. It is known that health perceptions are influenced by socioeconomic class (Mechanic, 1972), cultural norms, roles and activities (Boyer, 1980).
The evidence surveyed in this paper seems to suggest that in Japan, at least, the rates of depression and dementia may be lower than in the West; which may indicate that this culture in some way protects its members from these conditions. If validated, the finding that the prevalence of SDAT is lower in Japan is significant, for this challenges the notions that dementia is an invariant biological process. Whether this is due to differences in some environmental or cultural factor has yet to be elucidated. Mortimer (1988) has proposed that limited education, poor nutrition, smoking, alcohol abuse and exposure to toxic substances lower the threshold at which the plaques, tangles and infarctions become manifest in dementia, and thus sex, social class, area of residence and country of birth could therefore have discernible effects on prevalence patterns.
The evidence reviewed on the prevalence of dementia in China may indicate that there is an increase in this condition and it is tempting to speculate that this may be associated with some aspect of the process of 'modernization'; but no clear conclusions can be drawn as studies cannot easily be compared. These cross-cultural variations in psychiatric disorder may be due to differences in family structures, attitudes to the aged, community integration, fulfilment of roles, or other cultural or environmental factors.
Anthropological methods are clearly useful for psychiatry. It has been seen in this paper, that it is far from the case that non-Western societies accord their elderly high status, as cultures everywhere are undergoing the changes of urbanization and industrialization. The examination of other cultures' value systems yields valuable information on patterns in the esteem of older people, family structures, and how attitudes can be informed. The importance of negative attitudes and stereotypes is that the elderly themselves may come to believe that they will become incapable, lonely and needy (Hazan, 1994). Social networks and cultural values may have crucial effects on self-esteem and group membership, which in turn will influence the development of psychiatric disorder.
It was a salutary finding by Clark and Anderson (1967), that within American culture the very person who had absorbed the cultural values of work and ambition makes the poorest adjustment to old age and is most likely to be stigmatized as mentally ill due to the failure to adjust to changed circumstances. As the elderly are increasingly excluded from the technological age, it seems likely that their experience of alienation will be heightened, segregation increased and opportunities for occupying fulfilling roles reduced. It seems likely also that the suicide rate will continue to rise with these trends.
Social policy is needed to plan for the increasing numbers of elderly, who will include a substantial proportion of people from ethnic minorities, by the establishment perhaps of a special ministry, and increased resources. In psychiatry much could be done to extend research and develop services. Already, instruments are being developed to screen for depression and dementia in elderly people from ethnic minorities, in an attempt to assess need for services (Rait et al., 1996). Further attention to the burden faced by carets is also a priority. What is clear is that the elderly from cultural minorities bear additional social, economic and psychological burdens, and may suffer greater physical and mental ill health. The challenge remains to provide services to the most needy.
Correspondence to: Dr Simon Dein, Senior Lecturer in Social and Community Psychiatry, Department of Psychiatry and Behavioural Sciences, University College London Medical School, Wolfson Building, Riding House Street, London W1N 8AA, UK.
Received for publication 16th July 1996. Accepted 21st January 1997.
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By S. Dein, Department of Psychiatry and Behavioural Sciences, University College London Medical School, London and S. Huline-Dickens, Department of Psychiatry, Princess Alexandra Hospital, Harlow, Essex, UK
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