Psychosocial Environment and Levels of Functioning

Psychosocial Environment and Levels of Functioning

Cultural factors have a dual influence on the psychosocial en-vironment: they determine life circumstances and, at the same time, provide interpretations of their meaning and significance for the individual. This dual effect of culture means that the cli-nician must explore both events and their personal and cultural meanings to understand the impact of the social environment.

There are wide cultural variations in the composition and functioning of families including the variety of people living to-gether in a household (not always identical to the family or kin); who is considered close or distant kin; hierarchy, power structure and economic arrangements; age and gender roles; organization of household activities and routines; styles of expression of emo-tion and distress; body practices (arrangements and procedures for sleeping, eating, washing, dressing, recreation and use of physical remedies for ailments); conflict management strate-gies; and the relationship of family to larger social networks and communities.

Social support must be assessed with attention to cultural configurations of the family and community. Extended multigen-erational families, tightly knit religious and ethnocultural com-munities, and transnational networks all may provide specific forms of instrumental and emotional support. Often these sup-ports are inextricably intertwined with interpersonal obligations and demands that may constitute burdens for the individual. This complex relationship of burden and support may have crucial im-plications for clinical interventions.

Similarly, levels of functioning and disability must be assessed against culturally determined notions of social roles and values. It is important to recognize that the clinician’s pri-ority may not be the most important issue for patients or their families.

In addition to these general cultural considerations, cer-tain social situations present specific stressors with which the clinician must become familiar. All immigrants and refugees have arrived in the host country after a migration experience. For some, migration is a personal choice taken in the hope of bet-tering personal and family prospects; for others the experience is borne of extreme difficulty and is only taken under threat of harm or death. Many new arrivals face bleak job prospects, are isolated from family and cultural institutions, and have an uphill battle as they adapt to a new language and unfamiliar social rules and obligations. Furthermore, the path that some immigrants take prior to arriving at their final destination is often lengthy, circuitous and costly, in addition to being dangerous. It is crucial, therefore, to take into account the migration experience when evaluating immigrants and refugees. Questions must be care-fully phrased and asked in a judicious manner, as not all patients will be ready to discuss their reasons for leaving their homeland. Important points to cover include the premigration lifestyle of the patient, the context of migration, the experience of migration, the postmigration experience, and the “aftermath” of migration, or the long-term adjustment and acculturation to the host society (Beiser, 1999).

The stresses experienced by refugees may include the confusion and disorientation of unplanned flight and exile; loss of social status, wealth, security and community; and worry about the safety of family left behind and still in peril. Refugee claimants or asylum seekers usually face a stressful period of uncertainty while waiting to have their status determined. The refugee review process itself may be traumatic because it often occurs in an adversarial atmosphere that questions the veracity of the refugee’s story even as it foregrounds traumatic memory (Silove et al., 2000). Individuals who have endured war-related trauma, torture, or other forms of organized violence have spe-cial needs to insure the safety of the clinical setting and relation-ship (Silove, 1999).

The growing number of undocumented people around the world also presents ethical and pragmatic challenges to the medi-cal profession. These illegal immigrants and families may have particular mental health needs, which are largely unrecognized because there is almost no funded research or services to address them.