To better understand what happens inside the clinical setting, this chapter looksoutside. It reveals the diverse effects of culture and society on mental health,mental illness, and mental health services. This understanding is key to developingmental health services that are more responsive to the cultural and social contextsof racial and ethnic minorities.
With a seemingly endless range of subgroups and individual variations, culture isimportant because it bears upon what all people bring to theclinical setting. It can account for minor variations in how people communicatetheir symptoms and which ones they report. Some aspects of culture may also underlieculture-bound syndromes - sets of symptoms much more common insome societies than in others. More often, culture bears on whether people even seekhelp in the first place, what types of help they seek, what types of coping stylesand social supports they have, and how much stigma they attach to mental illness.Culture also influences the meanings that people impart to theirillness. Consumers of mental health services, whose cultures vary both between andwithin groups, naturally carry this diversity directly to the service setting.
The cultures of the clinician and the service system also factor into the clinicalequation. Those cultures most visibly shape the interaction with the mental healthconsumer 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 thecountry. Travelers from the United States, while visiting some distant frontier, mayfind themselves stranded in miscommunications and seemingly unorthodox treatments ifthey seek care for a sudden deterioration in their mental health.
What follows are numerous examples of the ways in which culture influences mentalhealth, mental illness, and mental health services. This chapter is meant to beillustrative, not exhaustive. It looks at the culture of the patient, the culture ofthe clinician, and the specialty in which the clinician works. With respect to thecontext of mental health services, the chapter deals with the organization,delivery, and financing of services, as well as with broader social issues - racism,discrimination, and poverty - which affect mental health.
Culture refers to a groups shared set of beliefs, norms, and values (Chapter 1). Because common social groupings(e.g., people who share a religion, youth who participate in the same sport, oradults trained in the same profession) have their own cultures, this chapter hasseparate sections on the culture of the patient as well as the culture of theclinician. Where cultural influences end and larger societal influences begin, thereare contours not easily demarcated by social scientists. This chapter takes a broadview about the importance of both culture and society, yet recognizes that theyoverlap in ways that are difficult to disentangle through research.
What becomes clear is that culture and social contexts, while not the onlydeterminants, shape the mental health of minorities and alter the types of mentalhealth services they use. Cultural misunderstandings between patient and clinician,clinician bias, and the fragmentation of mental health services deter minoritiesfrom accessing and utilizing care and prevent them from receiving appropriate care.These possibilities intensify with the demographic trends highlighted at the end ofthe chapter.
The culture of the patient, also known as the consumer of mental health services,influences many aspects of mental health, mental illness, and patterns of healthcare utilization. One important cautionary note, however, is that general statementsabout cultural characteristics of a given group may invite stereotyping ofindividuals based on their appearance or affiliation. Because there is usually morediversity within a population than there is between populations (e.g., in terms oflevel of acculturation, age, income, health status, and social class), informationin the following sections should not be treated as stereotypes to be broadly appliedto any individual member of a racial, ethnic, or cultural group.
The symptoms of mental disorders are found worldwide. They cluster into discretedisorders that are real and disabling (U.S.Department of Health and Human Services [DHHS], 1999). As noted inChapter 1, mental disorders aredefined in the Diagnostic and Statistical Manual of MentalDisorders(American PsychiatricAssociation [APA], 1994). Schizophrenia, bipolar disorder, panicdisorder, obsessive compulsive disorder, depression, and other disorders havesimilar and recognizable symptoms throughout the world (Weissman et al., 1994, 1996, 1997, 1998). Culture-boundsyndromes, which appear to be distinctive to certain ethnic groups, are theexception to this general statement. Research has not yet determined whetherculture-bound syndromes are distinct 1 from established mental disorders, are variants of them, or whetherboth mental disorders and culture-bound syndromes reflectdifferent ways in which the cultural and social environment interacts with genesto shape illness (Chapter 1).
Cultures also vary with respect to the meaning they impart toillness, their way of making sense of the subjective experience of illness anddistress (Kleinman, 1988). The meaningof an illness refers to deep-seated attitudes and beliefs a culture holds aboutwhether an illness is "real" or "imagined," whether it is of the body or themind (or both), whether it warrants sympathy, how much stigma surrounds it, whatmight cause it, and what type of person might succumb to it. Cultural meaningsof illness have real consequences in terms of whether people are motivated toseek treatment, how they cope with their symptoms, how supportive their familiesand communities are, where they seek help (mental health specialist, primarycare provider, clergy, and/or traditional healer), the pathways they take to getservices, and how well they fare in treatment. The consequences can be grave -extreme distress, disability, and possibly, suicide - when people with severemental illness do not receive appropriate treatment.
The prevalence of schizophrenia, for example, is similar throughout the world(about 1 percent of the population), according to the InternationalPilot Study on Schizophrenia, which examined over 1,300 people in10 countries (World Health Organization [WHO],1973). International studies using similarly rigorous researchmethodology have extended the WHO's findings to two other disorders: Thelifetime prevalence of bipolar disorder (0.3-1.5%) and panic disorder (0.4-2.9%)were shown to be relatively consistent across parts of Asia, Europe, and NorthAmerica (Weissman et al., 1994, 1996, 1997,1998). The global consistency in symptoms and prevalence of thesedisorders, combined with results of family and molecular genetic studies,indicates that they have high heritability (genetic contribution to thevariation of a disease in a population) (National Institute of Mental Health [NIMH], 1998). In other words,it seems that culture and societal factors play a more sub-ordinate role incausation of these disorders.
Many features of family life have a bearing on mental health and mental illness.Starting with etiology, Chapter 1highlighted that family factors can protect against, or contribute to, the riskof developing a mental illness. For example, supportive families and goodsibling relationships can protect against the onset of mental illness. On theother hand, a family environment marked by severe marital discord, overcrowding,and social disadvantage can contribute to the onset of mental illness.Conditions such as child abuse, neglect, and sexual abuse also place children atrisk for mental disorders and suicide Brown etal., 1999; Dinwiddie et al.,2000.
Family risk and protective factors for mental illness vary across ethnic groups.But research has not yet reached the point of identifying whether the variationacross ethnic groups is a result of that group's culture, its social class andrelationship to the broader society, or individual features of family members.
One of the most developed lines of research on family factors and mental illnessdeals with relapse in schizophrenia. The first studies, conducted in GreatBritain, found that people with schizophrenia who returned from hospitalizationsto live with family members who expressed criticism, hostility, or emotionalinvolvement (called high expressed emotion) were more likely torelapse than were those who returned to family members who expressed lowerlevels of negative emotion Leff &Vaughn, 1985; Kavanaugh,1992; Bebbington & Kuipers,1994; Lopez & Guarnaccia,2000. Later studies extended this line of research to MexicanAmerican samples. These studies reconceptualized the role of family as a dynamicinteraction between patients and their families, rather than as static familycharacteristics Jenkins, Kleinman, &Good, 1991; Jenkins, 1993.Using this approach, a study comparing Mexican American and white families foundthat different types of interactions predicted relapse. For the Mexican Americanfamilies, interactions featuring distance or lack of warmth predicted relapsefor the individual with schizophrenia better than interactions featuringcriticism. For whites, the converse was true (Lopez et al., 1998). This example, while not necessarilygeneralizable to other Hispanic groups, suggests avenues by which otherculturally based family differences may be related to the course of mentalillness.
Few doubt the importance of culture in fostering different ways of coping, butresearch is sparse. One of the few, yet well developed lines of research oncoping styles comes from comparisons of children living in Thailand versusAmerica. Thailand's largely Buddhist religion and culture encourageself-control, emotional restraint, and social inhibition. In a recent study,Thai children were two times more likely than American children to reportreliance on covert coping methods such as "not talking back," than on overtcoping methods such as "screaming" and "running away" (McCarty et al., 1999). Other studies by theseinvestigators established that different coping styles are associated withdifferent types and degrees of problem behaviors in children (Weisz et al., 1997). 2b1af7f3a8