Culture Counts - INFLUENCE
The Influence of Culture and Society on Mental Health, Mental Illness
In 2001 the U. S. Department of Health and Human Services published a supplement to the 1999 Surgeon General’s Report on Mental Health. The following excerpts are from that report:
Introduction
This Supplement to Mental Health: A Report of the Surgeon General (U.S. Department of Health and Human Services [DHHS], 1999) documents the existence of striking disparities for minorities in mental health services and the underlying knowledge base. Racial and ethnic minorities have less access to mental health services than do whites. They are less likely to receive needed care. When they receive care, it is more likely to be poor in quality.
These disparities have powerful significance for minority groups and for society as a whole. A major finding of this Supplement is that racial and ethnic minorities bear a greater burden from unmet mental health needs and thus suffer a greater loss to their overall health and productivity.
Mental Health: Cultures, Race and Ethnicity
Culture is broadly defined as a common heritage or set of beliefs, norms, and values (DHHS, 1999). It refers to the shared, and largely learned, attributes of a group of people. Anthropologists often describe culture as a system of shared meanings. People who are placed, either by census categories or through self-identification, into the same racial or ethnic group are often assumed to share the same culture. Yet this assumption is an over-generalization because not all members grouped together in a given category will share the same culture. Many may identify with other social groups to which they feel a stronger cultural tie such as being Catholic, Texan, teenaged, or gay.
Culture is as applicable to groups of whites, such as Irish Americans or German Americans, as it is to racial and ethnic minorities. As noted, the term “culture” is also applicable to the shared values, beliefs, and norms established in common social groupings, such as adults trained in the same profession or youth who belong to a gang. The culture of clinicians, for example, can be used to help explain interactions between patients and clinicians.
The phrase “cultural identity” refers to the culture with which someone identifies and to which he or she looks for standards of behavior (Cooper & Denner, 1998). Given the variety of ways in which to define a cultural group, many people consider themselves to have multiple cultural identities.
A key aspect of any culture is that it is dynamic: Culture continually changes and is influenced both by people’s beliefs and the demands of their environment (Lopez & Guarnaccia, 2000). Immigrants from different parts of the world arrive in the United States with their own culture but gradually begin to adapt. The term “acculturation” refers to the socialization process by which minority groups gradually learn and adopt selective elements of the dominant culture. Yet that dominant culture is itself transformed by its interaction with minority groups. And, to make matters more complex, the immigrant group may form its own culture, distinct from both its country of origin and the dominant culture. The Chinatowns of major cities in the United States often exemplify the blending of Chinese traditions and an American context.
The dominant culture for much of U.S. history has centered on the beliefs, norms, and values of white Americans of Judeo-Christian origin, but today’s America is much more multicultural in character. Still, its societal institutions, including those that educate and train mental health professionals, have been shaped by white American culture and, in a broader characterization, Western culture. That cultural legacy has left its imprint on how mental health professionals respond to patients in all facets of care, beginning with their very first encounter, the diagnostic interview.
Diagnosis and Culture
Western medicine has become a cornerstone of health worldwide because it is based on evidence from scientific research. A hallmark of Western medicine is its reliance on accurate diagnosis, the identification and classification of disease. An accurate diagnosis dictates the type of treatment and supportive care, and it sheds light on prognosis and course of illness. The diagnosis of a mental disorder is arguably more difficult than diagnoses in other areas of medicine and health because there are usually no definitive lesions (pathological abnormalities) or laboratory tests. Rather, a diagnosis depends on a pattern, or clustering, of symptoms (i.e., subjective complaints), observable signs, and behavior associated with distress or disability. Disability is impairment in one or more areas of functioning at home, work, school, or in the community (American Psychiatric Association [APA], 1994).
The formal diagnosis of a mental disorder is made by a clinician and hinges upon three components: a patient’s description of the nature, intensity, and duration of symptoms; signs from a mental status examination; and a clinician’s observation and interpretation of the patient’s behavior, including functional impairment. The final diagnosis rests on the clinician’s judgment about whether the patient’s signs, symptom patterns, and impairments of functioning meet the criteria for a given diagnosis. The American Psychiatric Association sets forth those diagnostic criteria in a standard manual known as the Diagnostic and Statistical Manual of Mental Disorders. This is the most widely used classification system, both nationally and internationally, for teaching, research, and clinical practice (Maser et al., 1991).
Mental disorders are found worldwide. Schizophrenia, bipolar disorder, panic disorder, and depression have similar symptom profiles across several continents (Weissman et al., 1994, 1996, 1997, 1998). Yet diagnosis can be extremely challenging, even to the most gifted clinicians, because the manifestations of mental disorders and other physical disorders vary with age, gender, race, ethnicity, and culture. Take some of the symptoms of depression — persistent sadness or despair, hopelessness, social withdrawal — and imagine the difficulty of communication and interpretation with-in a culture, much less from one culture to another. The challenge rests not only with the patient, but also with the clinician, as well as with their dynamic interactions. Patients from one culture may manifest and communicate symptoms in a way poorly understood in the culture of the clinician. Consider that words such as “depressed” and “anxious” are absent from the languages of some American Indians and Alaska Natives (Manson et al., 1985). However, this does not preclude them from having depression or anxiety.
To arrive at a diagnosis, clinicians must determine whether patients’ signs and symptoms significantly impair their functioning at home, school, work, and in their communities. This judgment is based on deviation from social norms (cultural standards of acceptable behavior) (Scadding, 1996). For example, among some cultural groups, perceiving visions or voices of religious figures might be part of normal religious experience on some occasions and aberrant social functioning on other occasions. It becomes obvious that the interaction between clinician and patient is rife with possibilities for miscommunication and misunderstanding when they are from different cultures. According to the American Psychiatric
Diagnostic assessment can be especially challenging when a clinician from one ethnic or cultural group uses the DSM–IV Classification to evaluate an individual from a different ethnic or cultural group. A clinician who is unfamiliar with the nuances of an individual’s cultural frame of reference may incorrectly judge as psychopathology those normal variations in behavior, beliefs, or experience that are particular to the individual’s culture. (APA, 1994)
The issuance in 1994 of the fourth edition of the (DSM–IV) marked a new level of acknowledgment of the role of culture in shaping the symptom presentation, expression, and course of mental disorders. Whereas prior editions referred to such matters only in passing, this edition specifically included some discussion of cultural variations in the clinical presentation of each DSM–IV disorder, a glossary of some idioms of distress and “culture-bound syndromes”, and a brief outline to assist the clinician in formulating the cultural dimensions for an individual patient (APA, 1994).
The “Outline for Cultural Formulation” in DSM–IV systematically calls attention to five distinct aspects of the cultural context of illness and their relevance to diagnosis and care. The clinician is encouraged to:
(1) Inquire about patients’ cultural identity to determine their ethnic or cultural reference group, language abilities, language use, and language preference,
(2) Explore possible cultural explanations of the illness, including patients’ idioms of distress, the meaning and perceived severity of their symptoms in relation to the norms of the patients’ cultural reference group, and their cur-rent preferences for, as well as past experiences with, professional and popular sources of care,
(3) Consider cultural factors related to the psychosocial environment and levels of functioning. This assessment includes culturally relevant interpretations of social stressors, available support, and levels of functioning, as well as patients’ disability,
(4) Critically examine cultural elements in the patient-clinician relationship to determine differences in culture and social status between them and how those differences affect the clinical encounter, ranging from communication to rapport and disclosure,
(5) Render an overall cultural assessment for diagnosis and care, meaning that the clinician synthesizes all of the information to determine a course of care.
The Influence of Culture
To better understand what happens inside the clinical setting, look to the outside to. It reveals the diverse effects of culture and society on mental health, mental illness, and mental health services. This understanding is key to developing mental health services that are more responsive to the cultural and social contexts of racial and ethnic minorities.
With a seemingly endless range of subgroups and individual variations, culture is important because it bears upon what all people bring to the clinical setting. It can account for minor variations in how people communicate their symptoms and which ones they report. Some aspects of culture may also underlie culture-bound syndromes -- sets of symptoms much more common in some societies than in others. More often, culture bears on whether people even seek help in the first place, what types of help they seek, what types of coping styles and social supports they have, and how much stigma they attach to mental illness. Culture also influences the meanings that people impart to their illness. Consumers of mental health services, whose cultures vary both between and within groups, naturally carry this diversity directly to the service setting.
The cultures of the clinician and the service system also factor into the clinical equation. Those cultures most visibly shape the interaction with the mental health consumer through diagnosis, treatment, and organization and financing of services. It is all too easy to lose sight of the importance of culture -- until one leaves the country. Travelers from the United States, while visiting some distant frontier, may find themselves stranded in mis-communications and seemingly unorthodox treatments if they seek care for a sudden deterioration in their mental health.
Health and mental health care in the United States are embedded in Western science and medicine, which emphasize scientific inquiry and objective evidence. The self-correcting features of modern science – new methods, peer review, and openness to scrutiny through publication in professional journals – ensure that as knowledge is developed, it builds on, refines, and often replaces older theories and discoveries. The achievements of Western medicine have become the cornerstone of health care worldwide.
What becomes clear is that culture and social contexts, while not the only determinants, shape the mental health of minorities and alter the types of mental health services they use. Cultural misunderstandings between patient and clinical, clinician bias, and the fragmentation of mental health services deter minorities from accessing and utilizing care and prevent them from receiving appropriate care.
SOURCE: “Mental Health: Culture, Race, and Ethnicity. A supplement to Mental Health: A Report of the Surgeon General.” 2001. U.S. Dept. of Health and Human Services, Public Health Service, Office of the Surgeon General, Rockville MD
For the full report go to
http://www.surgeongeneral.gov/library/mentalhealth/cre/
