Culture And Mental Health Research Paper

As a nation of immigrants, the USA has evolved into a multicultural society. The demographic changes that are occurring due to immigration and high fertility rates among the non-white population will continue to enhance the country’s cultural diversity. Most re-searchers, however, address race and ethnicity as demographic characteristics rather than as distinct predisposing cultural and social environmental orientations. This approach has resulted in research and analyses that ignore the contributory role of socio-cultural factors to mental health behaviors. Research is needed to understand how these factors contribute to individual and group coping and adaptive mechanisms, in alleviating the distinct socioeconomic and psychological disadvantages of categorical member-ship. Culture should be conceptualized as a potential individual and group resource, providing psychological, social, and personal identification and group connectedness for racial minorities in particular, and humans in general (Jackson et al. 1995).

In general, culture consists of those aspects of life that people construct and share within a specific reference group (e.g., race, ethnic, social class, age cohort, gender, nationality, and profession). The term ‘culture’ is so widely used and multidimensional in its applications (e.g., learned as opposed to instinctive behavior; tools humans create; and values and traditions) that its precise meaning varies from one situation to another (MacLachlan 1997). Culture can be seen as the collective heritage of a people handed down from generation to generation. It includes language, religious beliefs, customs, rules of etiquette, and ideas used by people to organize and interpret their lives and existence. Thus, culture refers to the way a people live, the rules of behavior, and conduct they set for themselves.

The interplay between culture and mental health is complex and multidimensional with respect to antecedents, perceptions, expressions, and treatments for numerous mental illnesses ( Marsella and Dash-Scheuer 1988). Successful social adjustment, in effect, is the process of learning the habits, norms, and ways of thinking essential for fitting into one’s society. This research paper investigates the cultural determinants of mental health, from the standpoint that culture provides a general design for living and a pattern for interpreting reality that impacts mental health. The emphasis here is on the pragmatic role of culture that is especially pertinent to mental health. The likelihood that different cultures encourage different worldviews that buffer or predispose its members to certain disorders is examined. In particular, the role of culture in psycho-therapy is discussed in terms of preventing and treating ‘non-dominant’ cultural minority members within the USA: African Americans, Latinos, Asian Americans, and Native Americans. In sum, the specific focus is on how ideas, values, and assumptions about life guide both client and practitioner.

2. Coping And Prevention

Each culture transmits itself through the process of socialization. Throughout this process, what is conditioned are both general and specific behavioral patterns for promoting human survival and growth. What are learned are acceptable standards and idealized norms that reflect the hard-won wisdom of previous generations. Through culture, biological adaptive capacities are extended to deal with environ-mental demands. By understanding the ways that individuals from various cultural traditions cope, health researchers and practitioners can gain unique insights into the promotion of human health and prevention of human illness ( Marsella and Dash-Scheuer 1988).

For non-dominant minority group members, the problems of living are not only the products of biological dysfunctions, aberrant intrapsychic development, and familial dysfunctions, social forces also contribute to the onset and course of mental illness (Kleinman 1988). Political, social, economic, and historical and present day relationships (e.g., slavery, legal discrimination and segregation, immigration exclusion and restrictions, internment, poverty, and forced removal to reservations) with the dominant group in the USA, contributes to mental illness among minorities ( Murray 1998). In effect, the larger society has played a major role in the developmental etiology of certain mental health disturbances ( Wilson et al. 2000). How do the majority of people of color, in spite of ethnic and racial exploitation, cope, adapt, and succeed?

To answer this question, culturally defined strengths indicative of ethnic minority group life should be illuminated. While racial and ethnic groups of color vary widely in the content of cultural beliefs about time, harmony with nature, reciprocity, use of traditional medical substances, and community healers, certain common themes emerge (Jackson et al. 1995). These include deep and abiding community respect for elders, extended kin network, predominant family commitment, cultural aversion to institutional care, and a clear expectation for respect and dignity in the delivery of health care. Some researchers have specifically commented on the elaborate support networks, extended family relationships, and role flexibility of African Americans; the strong sense of communalism, generosity, and harmony characteristic of Native Americans; the socialization of children to respect the entire family system and put family needs over individual needs in Asian American communities; the socializing toward cooperativeness, and the comfort of their Catholicism in times of stress found in Latino communities ( Wilson et al. 2000). These group characteristics facilitate coping and mental health, and lessen the nature and expression of disease and chronic conditions, and are necessary to consider for successful care and treatment.

While there are group commonalties, intragroup differences exist in life-course environmental conditions, degree of acculturation, and cultural traditions and beliefs. Thus, there is an indisputable need for mental health care providers to treat each client as an individual, while gathering information on the degree to which cultural coping strategies may facilitate mental health. It is imperative to conduct cross-cultural research on ethnic minorities within the US to identify the relationship between culture-specific coping skills and mental health outcomes.

3. Cross-Cultural Differences In The Perception Of Mental Illness

Although most, if not all cultures, have a notion of madness, ethnographic studies demonstrate that concepts of emotions, self and body, and illness categories differ so significantly cross-culturally that it can be said that each culture’s beliefs about normal and abnormal behavior are distinctive ( Kleinman 1988). The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, APA 1994) recognizes the importance of cultural factors in diagnosing mental illness. Therapists who work with culturally different clients are instructed to take into account (a) the predominant characteristics of manifesting disorders (e.g., possessing spirits, nerves, fatalism), (b) perceived causes or explanatory models, and (c) preferences for professional and indigenous interventions (Sue and Sue 1999). The DSM-IV (APA 1994) describes culture-bound syndromes, which are patterns of abnormality only expressed in a particular group, including ghost sickness (a preoccupation with death and the deceased appearing among Native Americans), nervous (symptoms associated with distress and somatic disturbances, such as brain aches and tingling sensations reported by Latinos), and root-work (illnesses attributed to hexes, spells, and voodoo by African Americans).

The prevalence and course of mental illness also varies cross-ethnically. Recent research comparing African Americans to Whites indicated no difference between the two groups with regard to panic disorders. However, African Americans exhibit a greater frequency of reported tingling in the extremities and a higher mean number of symptoms ( Draguns 2000). A comparison of Mexican Americans and Whites, Mexican Americans presented higher rates of generalized anxiety disorder, agoraphobia, and simple phobia than Whites. While there is a dearth of research comparing Asian Americans to Whites, Lin and Endler (1993, cited in Al-Issa and Oudji 1998) reported that anxiety levels were higher among Chinese immigrants. Their findings were attributed to the stress of adapting to a new environment, which resulted in a sense of insecurity and inadequacy.

Another classical difference ignored by Western practitioners is the finding that bodily states and psychological experiences are monitored, perceived, assessed, and reported differently by members of different cultural groups. A consistent finding is that body complaints predominate over psychological complaints in depressive and anxiety disorders among members of non-Western societies, ethnic minorities in the US, and among less educated members of the lower socioeconomic classes ( Kleinman 1988).

Culture may influence how depression is experienced and communicated. Some cultures perceive the physician as a healer of physical ailments rather than psychological ailments. The urgency surrounding physical as opposed to psychological ailments may vary across cultures, as may the degree to which psychological weakness is stigmatizing. The biology of depression and anxiety disorders underwrites the inner form of these disorders, but cultural beliefs and values shape the expression of the illness (Kleinman 1988).

4. Etiological Beliefs And Folk Approaches

All healing systems are shaped by the values, world-views, and self-views of the cultures in which they develop and are utilized. Therefore, all healing systems are ‘ethnomedical.’ Rules and principles guiding the various ethnomedical models form discreet and different genre altogether, making cross-ethnic comparisons difficult. However, while distinction among the non-Western groups are difficult to delineate, very salient differences exist between various ethnomedical models and traditional Western methods in psychotherapy. For instance, Western psychotherapy is traditionally a one-on-one activity that encourages clients to discuss the most intimate aspects of their lives. In Latino culture, clients rarely describe their complaints as the main step in an intake process, expecting the healer to already know the client’s complaints ( Koss-Chioino 2000). Due to experience with oppression, African Americans are hesitant to self-disclose. This may serve a protective function against possible physical and psychological harm (Sue and Sue 1990), but individuals who do not self-disclose may be seen as resistant, defensive, or superficial by therapists. Many minorities who are reluctant to self-disclose are judged to be mentally unhealthy and, in the case of African Americans, are diagnosed as ‘paranoid’ ( Murray 1998).

In spite of the differences in each group’s healing practices, cultural commonalties do exist across the four ethnic groups described in this paper. Specifically, the commonalties consist of (a) a widespread belief that the causes of mental illness exist outside the person, (b) a group orientation to healing (i.e., family and/or community) as opposed to an individual orientation to treatment, (c) an emphasis on morality as a cause and condition for recovery ( Koss-Chioino 2000), and (d) an emphasis on short range goals, as opposed to long range goals (Sue and Sue 1990). These similar healing practices among non-Western groups differ from Western therapeutic practices.

Latinos, Asians, Native Americans, and African Americans are all heterogeneous groups including many specific traditions that differ from each other in profound ways. Divination (i.e., beliefs in the super-natural and practices to connect with the spirit world) was originally part of each of these groups’ healing practices. Unlike Western cultural groups who have discarded such practices, divination to some extent is still part of the healing practices of many, but not all of the subcultural groups within each of the broader categories. Among Native Americans, for example, traditional healing practices vary along tribal lines, and are largely shamanic (spiritual intervention to heal the sick). One of the major shamanic healing entities is the Native American Church, which is a pan-Indian religion based on a ritual that facilitates direct contact with the Great Spirit (also God) through peyote, pipe and cigarette smoking, drumming, and songs and prayer ( Koss-Chioino 2000). African American healing practices differ in beliefs, practices, and types of healers based on locale (e.g., north vs. south, and places of special tradition such as the Sea Islands of South Carolina). Overall, the underlying belief system of African Americans is a blend of medical beliefs of an earlier day, African beliefs about voodoo, European folklore regarding the supernatural world, and fundamentalist Christianity. Etiological notions are divided into natural and unnatural categories, varying from unhealthy lifestyles and non-productive worry to beliefs in evil influence or God taking punitive action. Physicians or herbalists can cure the first two causes, but the latter two causes demand intercession of a religious healer or a contract with God.

Among Latinos, divination may involve healer’s use of shells or tarot cards as a guide to see into the spirit world to identify the cause of the client’s problem. The healer describes the client’s problems (somatic distress, bad feelings, and persistent interpersonal or social problems), and then the client confirms (most frequently) or denies. Very little epidemiological data are available on the utilization of ethnomedical treatments by Latinos in the USA. The existing data, however, indicate that the utilization of divination varies across Latino ethnic populations. Within the USA divination appears to be a flourishing mental health alternative in Miami, Florida, among the Cuban population. Estimates among Mexican Americans vary from 7 percent in San Diego to 54 percent in South Texas (see discussion in Koss-Chioino 2000). It is important to note that some studies separate the belief in traditional healing practices from reports of actual use, so discrepancies may not be so extreme.

Variations are especially salient among Asian Americans (e.g., Chinese, Japanese, Vietnamese, Koreans, and tribal people such as the Hmong or Lao). Among the Chinese, shamanic healing (e.g., divination) has not been reported in the USA. The Chinese-American ethno-healers emphasize a balanced and disciplined life to maintain physical and psychology health. In addition, physical bodily manipulation, acupuncture, massage, and breathing exercises are common. In contrast, Southeast Asians in the USA see shamans (e.g., folk healers, witch doctors, etc.) when they are available (see discussion in Koss-Chioino 2000). This propensity to visit shamans is motivated by the belief that spirits are omnipresent throughout nature and can cause or heal illness. For example, there occurs among adult Southeast Asians, particularly male Hmong refugees living in the USA, a ‘Sudden Death Syndrome.’ Autopsies produce no identifiable cause of the death: A person in apparently good health went to sleep and died without awakening. Often, the victim displayed labored breathing, screams, and frantic movements just before death. Prior to their deaths, these men reported that they were experiencing spirit visitations, and that the spirits were unhappy and were punishing them. Clearly, these deaths do not appear to have a primary biological basis, whereas the deaths do appear to involve psycho-logical factors, including a belief in the imminence of death—either by a curse (e.g., voodoo suggestion) or some form of punishment (Sue and Sue 1999).

Western-trained therapists too often dismiss these belief systems and impose their own explanations and treatment upon culturally different clients. Without an understanding of the underlying cultural beliefs, there exists the tendency for the therapist to overestimate the degree of pathology. In the case of Southeast Asian men who report spirit attacks, a Western traditional therapist would most likely diagnose these persons as paranoid schizophrenic, suffering from delusions and hallucinations (Sue and Sue 1999). Such a diagnosis would most likely lead the therapist to prescribe a powerful antipsychotic drug and perhaps institutionalization. Studies indicate, however, that shaman techniques cure these symptoms (Sue and Sue 1999). The effectiveness of such treatment may lie in the client’s belief in the power of the doctor (shaman) and the treatment (divination) received.

While the four groups presented here vary in their degree of homogeneity concerning beliefs in spiritual attacks, a sizeable number of each group does hold these beliefs. Western medicine does not embrace indigenous or alternative healing approaches and often rejects such approaches as unscientific. Using a culturally inappropriate approach may result in harm or even death (e.g., as in the case of Sudden Death Syndrome). In an attempt to insure cultural responsiveness, the mental health practitioner must either incorporate the legacy of ancient wisdom that may be contained in indigenous models of healing, or refer the culturally different client to a culturally appropriate healer.

5. The Impact Of Ignoring Culture In Therapy

Culture (i.e., systems of symbolic meaning) impacts both mental health and therapeutic intervention. Specifically, culture influences our understanding of the major stages of the clinical process: patient and practitioner explanatory models of sickness; perception, labeling, and presentation of symptoms; health-seeking behavior; doctor–patient communication; curing and healing; and lay and health professional evaluations of therapeutic outcomes. Culture exerts its most fundamental and far-reaching influence through the categories we employ to understand and respond to sickness. As previously discussed, different societies and ethnic groups within one society often affix different sickness labels to the same syndrome ( Klein-man 1988). When patient and practitioner explanatory modes reflect different cultural backgrounds, the clinical realities they define can be, and frequently are, quite disruptive to the treatment process. When those explanatory models are in conflict, the results may be client dropout, noncompliance and dissatisfaction, and/or practitioner missed diagnosis, inappropriate treatment, and poor quality of care. All of these reportedly exacerbate existing problems and even create new issues for the client (Sue and Sue 1990, Turner and Kramer 1995).

Although ethnic minorities are increasing in the USA, only superficial interest has been paid to training mental health professionals to deliver culturally sensitive services ( Turner and Kramer 1995). Further-more, the practice of substituting a model stereotype (i.e., the most frequent behaviors of middle class White males) for the real world, while disregarding cultural variations in a dogmatic adherence to some universal notion of truth culminates in a technique-oriented definition of the therapeutic process. The results are that a lack of culturally responsive forms of treatment is the single most important reason given for ethnic minorities being underserved, inappropriately served, and/or their significantly higher drop-out rate (Sue and Sue 1990).

Another significant aspect of cross-cultural aware-ness is the acknowledgment that disadvantaged people often experience oppression, discrimination, and racism. Instead, a lack of sensitivity on the part of mainstream therapists results in further abuse of the minority ethnic client ( Murray 1998). On every index, minorities receive fewer and poorer quality services. Specifically, African Americans and Latinos, in contrast to Whites, holding symptoms constant, were less often given individualized psychotherapy, more often jailed instead of hospitalized, and more often treated with pharmacotherapy instead of talk-therapy (Lawson 1999). Many studies have demonstrated that clinicians given identical test protocols tend to make more negative prognostic statements and judgments of greater maladjustment when the individual was said to come from a lower rather than a middle-class background, or was an ethnic minority member (Lawson 1999).

When ethnic minority clients are met with insensitivity or outright racism on the part of the therapist, poorer outcomes are likely to result ( Kurasaki et al. 2000). Thus, the need for changes in mental health delivery is real. For mental health professionals to effectively deliver services to members of a negatively stereotyped group, they must first become aware of their own culture and assumptions about human behavior, values, biases, preconceived notions, personal limitations and so forth. Secondly, they must actively attempt to understand the worldview of their culturally different clients in terms of the etiology, coping strategies, and course of mental disorders ( Murray 1998). Cross-cultural sensitivity has been accomplished when the therapist has: (a) an under-standing of his or her own culture and achieved self-awareness; (b) an understanding of the client’s culture; (c) an understanding of the client’s relationship to the sociopolitical system; (d) an understanding of the ways in which generic counseling and therapy may limit the potential of the client; (e) an array of therapeutic techniques at his or her disposal; and (f ) a willingness to exercise institutional intervention on behalf of the client when appropriate (Sue and Sue 1990).

6. Conclusions

In conclusion, culture plays a role in every aspect of mental health. Cultural influences vary greatly from individual to individual. Many mental health problems have culture-common, culture-specific, or both components. In the case of minority ethnic members, too often the larger society’s role in the developmental etiology and maintenance of certain mental health disturbances is ignored. However, the literature does suggest that racial attitudes that poison our society and are internalized by mental health professionals can hamper the efforts of people of color to maintain or regain their mental health ( Turner and Kramer 1995). In addition, despite the fact that coping is fundamental to our understanding of human health, mental health professionals often do not acknowledge characteristics of minority cultures that are adaptive and facilitate coping within a stressful environment. Every culture is a unique solution to the myriad forces imposed on its members. In fact, cross-cultural differences exist in perceptions of mental illness in terms of beliefs about the causes, the prevalence and course, and the experience of symptoms. Within the therapeutic environment, therapist client communication, diagnosis, intervention strategies and techniques, client use of health facilities, and the course of mental disorders have all been impacted by culture. Therefore, mental health care providers must be trained to identify the role culture plays in mental illness. The culturally sensitive professional goes beyond the qualities of concern, empathy, and credibility. They have self-knowledge, and a willingness and ability to take the cultural background of clients into consideration. Without self-knowledge and cultural sensitivity on the part of the therapist, the mental health needs of ethnic minorities will remain underserved and inappropriately served at best, and at worst ethnic minorities will continue to be misdiagnosed and victimized under the guise of therapeutic intervention.

Bibliography:

1. Al-Issa I, Oudji S 1998 Culture and anxiety disorders. In: Kazarian S, Evans D R (eds.) Cultural Clinical Psychology: Theory, Research, and Practice. Oxford University Press, New York, pp. 127–51
2. American Psychiatric Association (APA) 1994 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 4th edn. American Psychiatric Association, Washington, DC
3. Dasen P R, Berry J W, Sartorius N 1988 Introduction. In: Dasen P R, Berry J W, Sartorius N (eds.) Health and Cross-cultural Psychology: Toward Applications. Sage, Newbury Park, CA, pp. 11–21
4. Draguns J G 2000 Psychopathology and ethnicity. In: Aponte J F, Wohl J (eds.) Psychological Intervention and Cultural Diversity. Allyn and Bacon, Boston, MA, pp. 40– 58
5. Jackson J S, Antonucci T C, Gibson R C 1995 Ethnic and cultural factors in research on aging and mental health: A life-course perspective. In: Padgett D K (ed.) Handbook on Ethnicity, Aging, and Mental Health. Greenwood Press, Westport, CT, pp. 22–46
6. Kleinman A 1988 Rethinking Psychiatry: from Cultural Category to Personal Experiences. Free Press, New York
7. Koss-Chioino J D 2000 Traditional and folk approaches among ethnic minorities. In: Aponte J F, Wohl J (eds.) Psychological Intervention and Cultural Diversity. Allyn and Bacon, Boston, pp. 149–66
8. Kurasaki K S, Sue S, Chun C, Gee K 2000 Ethnic minority intervention and treatment research. In: Aponte J F, Wohl J (eds.) Psychological Intervention and Cultural Diversity. Allyn and Bacon, Boston, pp. 234–50
9. Lawson W B 1999 The art and science of ethnopharmaco-therapy. In: Herrera J M, Lawson W B, Sramek J J (eds.) Cross Cultural Psychiatry. Wiley, Chichester, UK, pp. 67–73
10. MacLachlan M 1997 Culture and Health. Wiley, New York
11. Marsella A J, Dash-Scheuer A 1988 Coping, culture, and healthy human development: A research and conceptual overview. In: Dasen P R, Berry J W, Sartorius N (eds.) Health and Cross-Cultural Psychology: Toward Applications. Sage, Newbury Park, CA, pp. 162–76
12. Murray C B 1998 Racism and mental health. In: Friedman H S (ed.) Encyclopedia of Mental Health. Academic Press, San Diego, CA, pp. 345–57
13. Sue D W, Sue D 1990 Counseling the Culturally Different: Theory and Practice. Wiley, New York
14. Sue D W, Sue D 1999 Counseling the Culturally Different: Theory and Practice. Wiley, New York
15. Turner C B, Kramer B M 1995 Connections between racism and mental health. In: Willie C V, Rieker P, Kramer B M, Brown B S (eds.) Mental Health, Racism and Sexism. University of Pittsburgh Press, Pittsburgh, PA
16. Wilson M N, Kohn L P, Lee T S 2000 Cultural relativistic approach toward ethnic minorities in family therapy. In: Aponte J F, Wohl J (eds.) Psychological Intervention and Cultural Diversity. Allyn and Bacon, Boston, pp. 92–109