Do you consider that contemporary theories of mental health ignore the cultural values of 'others'?
Do you consider that contemporary theories of mental health ignore the cultural values of 'others'?
Word Count: 2509
Interest in the relationship between culture and mental illness is not new (Kluckhohn 1944). However, in recent years, there has been a greater recognition and realization of cultures' influence over individual expression of mental distress, in psychiatric diagnosis and treatment, and in the delivery of mental health care community-wide.
It is clear that cultural values shape the way in which mental symptoms are expressed and how individuals and their families respond to such distresses. Thus dictating when a cluster of symptoms and behaviours are labelled 'normal' or 'abnormal'. Cultural values also determine the accessibility and acceptability of mental health services. Consequently, effective mental health care cannot be separated from the cultural context in which the formation and expression of psychiatric distress occurs.
Nonetheless, diagnosis of mental illness is still by and large taken from peoples' behaviour, often received via second-hand accounts or self reports of emotional state and cognitive processes, which may be inaccurate. Furthermore, there are very few objective, scientific tests that can be carried out to help with this diagnosis or to monitor treatment effectiveness. Therefore, even though a medical model is usually adopted, in many cases there is no real distinction between the symptoms and the hypothesised underlying disease.
Despite these contradictions, the process of diagnosis aims to go beyond a mere description of symptoms and attempts to identify a (hidden) disease entity which is producing these symptoms. This would make the process problematic (and unreliable) at the best of times, so when cultural overlays are added to the behaviour upon which diagnosis is based in the first place, these problems are multiplied even further. . Fernando (1991) makes an interesting observation regarding this phenomenon in the quote overleaf:
"In the present state of social and medical knowledge, the diagnosis of schizophrenia tells us as much about the biases in our society and in the person making the diagnosis, as it does about the patient."
(Fernando 1989 quoted in Fernando, 1991: 143)
Charles Hughes (1993) an anthropologist who explores the interface between anthropology and clinical psychiatry, builds on this viewpoint in his statement that 'contemporary theories of mental health alongside our present healing system, are products of Western civilization and culture'. The fact that systems of 'psychiatry' akin to Western psychiatry have not developed in other cultures is significant and when this Western system of mental health care is applied to patients of 'other' ethnic backgrounds, sensitivity to areas of potential cultural differences is essential. Hughes suggests that a clinician can become better informed on cultural issues relevant to his or her patients by building upon their personal background, including relevant readings, in addition to cultural information gathered from the patient's family (if that is possible). In this way he can use the clinical encounter as a method for continuous education to develop and enhance a better operational understanding of the patient's 'normal' culturally shaped world, rather than simply imposing a predefined assessment of problems as suggested by a diagnostic manual or text-based directive.
Cochrane (1983) helps us to understand why contemporary theories of mental health underemphasize social and cultural aspects in his book: 'The Social Creation of Mental Illness.' Using a historical context, he explains how views of mental illness have evolved to become analogous to physical illness. Whereby, the discovery that certain mental conditions did in fact have a physical basis led to an assumption, which is still widespread, that all mental illness could be traced to an underlying biological cause, whether it be biochemical or genetic. Accordingly, psychiatrists desire to advance the treatment of the mentally ill through funding, was achieved by acquiring something of the special status and tolerance reserved for the physically ill.
Although the development of contemporary mental illness models may be understandable when presented in a historical context, what is not readily apparent is why despite advancing knowledge over the last 20 years, changes within the mental health system, have not taken place more rapidly. Especially, in consideration of the problematic implications of over-reliance on the physical disease analogy, which correspondingly produces an orientation to therapy which is ultimately physical. Thus the most commonly used treatments so far developed for the major psychological disorders are based upon drugs or other attempts to modify biological functioning, such as electro-convulsive therapy ...
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Although the development of contemporary mental illness models may be understandable when presented in a historical context, what is not readily apparent is why despite advancing knowledge over the last 20 years, changes within the mental health system, have not taken place more rapidly. Especially, in consideration of the problematic implications of over-reliance on the physical disease analogy, which correspondingly produces an orientation to therapy which is ultimately physical. Thus the most commonly used treatments so far developed for the major psychological disorders are based upon drugs or other attempts to modify biological functioning, such as electro-convulsive therapy (ECT). Where, all of these forms of treatment have been developed in advance of any clear idea of why they should work.
One of the most striking features revealed by the study of mental illness is the variability in the way in which people are affected and the surprisingly different vulnerabilities of different individuals. Cochrane (1983) provides statistical evidence over several decades that black people of African and Caribbean origin are over-represented in more restrictive levels of mental health services, that is as in-patients, either voluntarily or by compulsion under the powers of the Mental Health Act. He believes that 'social factors' are principally responsible for the creation of mental health differentials. He states that:
"Obviously there will be individual and biological differences in the extent to which people are vulnerable to mental illness, but it will be contended that these differences are far outweighed by the impact of the social situation in which people find themselves and even more importantly, the definition that is placed upon that situation. More than this a person's values and general outlook will influence the extent to which his responses will become defined as indicative of mental illness whatever the underlying psychological state."
(Cochrane, 1983: 1)
Cochrane's interest in differing rates of psychiatric illnesses has lead to the discovery of increased rates of schizophrenia and other psychoses diagnosis among those of West Indian origin and of parasuicide and depression amongst South Asians. These two statistical findings still dominate the debate today (Bhui & Bhugra, 2002; Soni Raleigh et al, 1990).
It is also worth noting the importance of ethnic minority group composition in our attempts to relate ethnicity to mental health and illness-migration. A very substantial (but declining) proportion of ethnic minorities in Britain are first generation immigrants. Therefore, in any discussion of 'ethnicity' as a variable one has to be aware of the fact that many ethnic minority individuals have characteristics and experiences which distinguish them from the white majority in addition to their ethnic origin. For example, it's clear that migrants are far from representative of the population from which they are drawn, and at times it has been argued that they are arguably more predisposed to mental illness and psychological instability (Cochrane, 1983).
Many first generation non-European immigrants in the UK have had to make a transition from a stable, traditional, rural, collective culture to a western, urban, individualistic society in a state of flux. In addition, it is a common feature of economically motivated migration from third world to first world countries that the social class distribution of the first generation of migrants is skewed downwards so the incomers are likely to be exposed to harsh working conditions, economic uncertainty, substandard and overcrowded housing and other forms of social deprivation. Depending upon context, these experiences will, themselves, have mental health implications which may mistakenly be attributed to ethnicity. Nonetheless, these potential factors will reduce, but not disappear entirely, as a greater and greater proportion of minority ethnic groups are born into this country.
One factor which is common for all generations of South Asian and African ethnic minorities in Britain is their exposure to racism. Racism, in so far as it is manifested in discrimination and economic disadvantage, may well affect both physical and mental health, as poverty and low socioeconomic status are among the best predictors of risk for many forms of morbidity. Furthermore, in contrast to physical conditions, further manifestations of racism, such as prejudice, will also impact upon psychological well-being. Whereby experiences of verbal disrespect, social rejection, denial of humanity, stereotyping and assumptions that skin colour is associated with a whole range of problems from academic underachievement to serious criminal activity, have all had considerable influences on self-esteem and mental health.
The health impact of racism, previously sidelined as a focus in research and policy, has recently gathered momentum as a subject of legitimate study. In the UK, institutionalised discrimination has been receiving particular attention. In January this year ministers committed the government to a five-year plan to halt racial discrimination within NHS mental health services in England, which was exposed last year by an inquiry into the death of David Bennett. The plan includes the first comprehensive ethnic monitoring of mental health services, beginning with inpatients this month (April 2005) and developing into an annual survey of all service users. This has come in part, as a response to the governments' official inquiry, which found that Mr. Bennett was killed by being held face down on the floor for 28 minutes by at least four mental health nurses; however it has also been facilitated as a result of the Human Rights Act and the Race Relations Act (Amendment 2000). Rosie Winterton, the health minister, has rejected the inquiry's call for the government to accept that services were affected by 'institutional racism' - the term used by the MacPherson inquiry in 1999 to describe systematic discrimination by the police.
She said:
"We have accepted racism and discrimination exist within our mental health services. We want solutions that deliver real change. Quite frankly, the term institutional racism can be something people hide behind. It can paralyse organisations, as if the admission means there is nothing they can do about it."
(Rosie Mayston for The Guardian, January 12th 2005)
One of the key problems with cultural difference and the mental health service is routed in the constructs of mental health and illness and their arbitrary boundaries that depend on the social and cultural meanings that society attach to different behaviours. Research on race, ethnicity and mental health lags far behind investigations of other factors such as gender, age and socio-factors (Takeuchi & Kim, 2000; Hunt et al. 2000). In observational studies, researchers often code behaviour by meaning. However, it is important to determine whether the actual behaviours have different meanings to different ethnic groups. For example, when a child is observed to lower her eyes when speaking with a parent, an observer may code this behaviour as meaning the child has low self-esteem or fear of their parent. When in reality, for some ethnic minority families, a child who lowers her or his eyes may be showing respect or deference to an elder. For this reason, it is essential that more mental health studies include adequate samples of racial and ethnic minority groups, as many of the screening procedures used to assess mental health and illness and treatment protocols are derived from studies that included few minority samples. (Takeuchi & Kim, 2000: 81)
One study that has included ethnic minority populations is that of Wolff et al. (1996) in their survey of attitudes assessing the success of a de-institutionalisation programme aimed at reintegrating mentally ill individuals into society. They have discovered that certain minority groups have greater reservations about mentally ill people living close to them, being more fearful that their children or family would come to harm.
This highlights the existence of negative stereotypes amongst certain groups which may impede the complete recovery and successful community functioning of people who have had mental illness within these ethnic groups. Consequently, this evidence provides an interesting alternative to the 'institutional racism' arguments, and could possibly explain why certain ethnic minorities have higher prevalence within in-patient areas of the mental health service. On the other hand, it is clearly apparent that institutional racism is still at large, what is needed here is a re-assessment of the mental health service, including new coping strategies for individuals from ethnic minorities and support community wide. The breakdown of stereotyping will be necessary for both the medical professional and the wider community.
Littlewood (2001) identifies three tendencies in British psychiatry that act as a useful evaluation of the current mental health service: (1) a selective focus on Black rather than on White immigrants, irrespective of the actual rates of reported illness; (2) emphasis on increased rates rather than decreased rates, and thus on pathology rather than successful coping strategies; (3) research carried out with hospitalised patients, and thus on psychotic illness rather than on unhappiness, adjustment problems, loss and coping. His conclusions highlight this need for the identification of protective factors that decrease the prospect of suffering from mental illness within certain ethnic minority groups. In addition, studies of acculturation need to carefully distinguish between cultural orientation and personal disorganization, by searching for new understandings of the psychological distress that accompanies the acculturation process. In order to achieve this, they will need to explore issues beyond acquiring a new language, cultural information and behaviour to include additional factors such as inter-generational differences, crises of identity and the mental health consequences of racism and racial discrimination (Vega & Rumbaut, 1991: 379).
In agreement with Littlewood, Hunt et al. (2000) explore the extent to which contemporary psychology has incorporated issues of race and ethnicities, arguing that Social Psychologists should, and can, do better in this regard. Looking into the future, they discuss how race can be given more attention in light of recent methodological advances and emerging research programs. An example of this is Heise's (1997) program 'Interact', available on the internet worldwide to simulate social interaction. Technological advancements such as this will help to facilitate social psychological inquiry across racial and ethnic groups, allowing them to be tested more rigorously than ever before.
It is clear that traditional views of mental health have in the past ignored cultural values of 'others', conversely, research in this area has boomed in recent years, and although putting these theories into practice has been slow, contemporary approaches have made distinct progress which incorporate alternative cultural values. Fernando (1991) believes that if we are to progress to a new definition and understanding of mental illness, this will have to be as part of a general move towards greater understanding between people. Where, for an understanding of this unity, a realistic approach must be taken to the problems arising from differences in culture and the divisions arising from racism. The paradox that mental health is different because of culture and race and yet the same irrespective of culture and race, is a reality that we have to face up to.
In conclusion then, although there is still a significant gap in knowledge in transcultural mental health, future research will be advantaged by the availability of sophisticated research designs and statistical techniques that were unavailable two decades ago. Despite a slow start, progress over the next decade will likely outdistance the totality of what has been learned to date. It is possible that aspects of Western psychiatry may be useful if they are integrated into indigenous systems of 'psychiatry' and vice versa.
However, if Western psychiatry is to participate fully in the promotion of mental health, it must break free from ethnocentrisms and racism, and reach out into the world it has so far ignored.
Bibliography
Bhui, K. & Bhugra, D. (2002) Mental Illness in Black and Asian Ethnic Minorities: Pathways to Care and Outcomes. Advances in Psychiatric Treatment, Volume 8, pp 26-33
Cochrane, Raymond (1983) The Social Creation of Mental Illness. Longman Applied Psychology. Longman Group Ltd, Harlow, England.
Fernando, Suman (1991) Mental Health, Race & Culture. Macmillan Press Ltd: London
Heise, David (1997) Interact. http://www.indiana.edu/~socpsy/ACT/interact.htm
Hughes, Charles (1993) Culture in Clinical Psychiatry. In Albert Gaw's (1993) Culture, Ethnicity & Mental Illness. American Psychiatric Press, Inc, London. pp 3-41
Hunt, Matthew; Pamela Jackson; Brian Powell; Lala Steelman (2000) Color-Blind: The Treatment of Race and Ethnicity in Social Psychology. Social Psychology Quarterly, Volume 63, Number 4, December 2000, pp 352-364.
Kluckhohn, C. (1944) The Influence of Psychiatry on Anthropology in America During the Last 100 Years. In Hall et al (1944) One Hundred Years of American Psychiatry. Columbia University Press, New York. pp589-617.
Littlewood, Roland & Maurice Lipsedge (1989) Aliens and Alienists: Ethnic Minorities and Psychiatry. 2nd Edition. Unwin Hyman Ltd, London.
Littlewood, Roland (2001) 'Culture' in the Field of Race and Mental Health. In Macbeth & Shetty (2001) Health and Ethnicity. Taylor & Francis, London.
Soni Raleigh, V., L. Bulusu & R. Balarajan (1990) Suicides among immigrants from the Indian subcontinent, British Journal of Psychiaatry 156, pp 46-50.
Takeuchi, David & Katherine Kim (2000) Enhancing Mental Health Services Delivery for Diverse Populations. Contemporary Sociology, Volume 29, Number 1, January 2000, pp 74-83.
The Guardian (January 12th 2005) Move to End Race Bias in Mental Health Care - By John Carvel, Social Affairs Editor. http://guardian.co.uk
Vega, William & Ruben Rumbaut (1991) Ethnic Minorities & Mental Health. Annual Review of Sociology, Volume 17, pp 351-383.
Wolff, G., Pathare, S., Craig, T. & Leff, J. (1996) Community Knowledge of Mental Illness and Reaction to Mentally Ill People. British Journal of Psychiatry, Vol. 168, No. 2, pp 191-198
