Summary

This chapter outlines a discussion of major physical health and mental health issues from the perspective of cultural and cross-cultural research. Successful treatments of mental health disorders rely on accurate understandings of whether symptoms are considered universal or culturally specific. Research support the importance of cultural sensitivity in delivering empirically verified mental health services in a still heterogeneous world. Sadly there are great disparities in socio-economic status linked to health and provision of treatment services between ethnic and cultural groups. One salient outcome of health disparities is the lower expected lifespan for ethnic groups that are poor, or of low socioeconomic standing. The research clearly supports the relationship between socioeconomic status and access to services and healthy outcomes.

Developing nations have serious challenges in providing proper nutrition and lowering the infant mortality rate. Large families are encouraged in traditional societies as a form of social and psychological support. In addition to overpopulation the world confronts many problems derived from industrialization and globalization that include hypertension and associated illnesses. The economically disadvantaged often suffer more malnutrition and when this occurs during critical stages in development it will negatively impact cognitive development and infant mortality. Poverty also brings greater exposure to negative collateral environments including unhygienic conditions and exposure to disease. Hunger and malnutrition creates passivity and lower motivation to change the status quo.

Ethnic minorities in the U.S. suffer both poverty and the consequences of cultural genocide. Native Americans were not only dispossessed of their natural environment but also marginalized in ways that affect mental health. African Americans also suffer disproportionately from historical discrimination and cultural genocide. This history along with broadly based lower socioeconomic status have resulted in significantly higher rates of mental illness including higher rates of schizophrenia, depression, and personality disorders. Other ethnic groups in the U.S. have fared better as a result of preferential treatment or cohesive group support.

Globalization and wars has motivated many people to migrate legally or illegally into other countries. The stress of living through traumatic events in home countries and problems of cultural adaptation in the new culture produce many health related problems in migrants. These issues are ameliorated when support is present from the migrants ethnic communities already established in the U.S. Cultural adaptation is the critical issue for migrants, and those that fail in adaptation typically have larger mental health issues. An additional factor in adaptation is the degree of divergence between the original culture and the host society.

Culture plays an important role in how symptoms of mental illness are manifested and whether a patient seeks assistance. In some cultures religion and beliefs in the supernatural frame a patient’s understandings of mental illness. Unique cultural understandings affect the judgment of both patient and therapist and determine if relief is found in treatment based on science or by appealing to superstitious beliefs. Cultural health beliefs concerning the causes of mental illness vary between cultures as does the treatment offered. People in collectivistic societies believe in psychosocial etiology and prefer psychosocial treatment. However, superstitious thinking in traditional societies negatively impacts treatment outcomes by negating the patient’s beliefs in the ability to control outcomes.

Definitions of what is abnormal behavior are a function of cultural values. Culture may impact the willingness of a patient to report symptoms of distress for fear of stigma in some societies. We can only understand mental disorder within the framework of cultural values since behaviors considered abnormal in one culture may in another society be viewed as normal activity. The Diagnostic and Statistical Manual is broadly used in the Western world and increasingly applied in culturally sensitive ways elsewhere. That fact makes it increasingly important to understand mental illness as both culturally specific and universal. The culturally specific viewpoint argues that diagnoses of mental illness and rate of occurrence are influenced by cultural values. The universal perspective believes that there is great similarity between symptoms of mental illness in various cultures and diagnostic categories are universally valid. This book argues in favor of the integration of both the culturally specific and universal perspectives.

Nevertheless some mental disorders are not connected to existing diagnostic categories of the DSM and are considered culturally unique. Other disorders are described in the diagnoses outlined in the DSM, but with local features that are culture specific. In treatment the cultural specific approach is useful since it helps the therapist to frame illness within cultural values found in religion or superstition and accepted by the patient. Anorexia nervosa was thought for many years to be culturally specific to Western industrialized societies, but from the influences of globalization is now diagnosed in many other urban cultures. In summary, there is evidence for both universal diagnostic categories but also distress that can best be understood within a specific culture. Globalization is producing more homogeneity in the world that may require rethinking about diagnoses in the future.

Anxiety is universally present in all societies, however with rates that vary according to the stress derived from the ecological and socioeconomic environment. Among well off people in the West anxiety is commonly related to achievement challenges that reflect individualistic values whereas in collectivistic societies concern about inclusion is more frequently a source of anxiety. Considerable evidence exists for the ubiquitous presence of depression with cultural variance related to peripheral symptoms. Cultural values affect diagnostic decisions since in some societies depression may carry stigma. Cultural values also influence the attributions of the cause of depression where for example a self-centered explanation is less accepted in collectivistic societies.

Schizophrenia is universal and is believed to have a genetic basis interacting with environmental stress although symptom manifestation is influenced by cultural values. Patients from developing countries have a better prognosis that those living in industrialized nations due to the social support available in collectivistic societies. Ethnic minorities in the U.S have higher rates of schizophrenia that can be attributed to the stress derived from lower socioeconomic status. In evaluating symptoms it is well to remember that behavior considered abnormal in one culture is not necessarily considered such in another society. Attention deficit disorder has now been diagnosed in many cultures although the criteria are not the same everywhere making comparisons difficult. The rate is higher in boys and the disorder is attributed to the greater cultural complexity and rapid change in modern societies. Some researchers also believe it has an as yet undetermined neurological cause. Personality disorders refer to behaviors and psychological experiencing that is markedly different from social standards. Diagnoses must be made within cultural standards. Collectivistic societies typically have less tolerance for social deviance whereas Western countries see some social deviance as manifesting a person’s unique personality and not as matter of great concern to society.

The ability to make culturally sensitive assessment of abnormal behavior is essential to the patient-therapist relationship and the prognosis of treatment outcomes. The understanding of mental disorder depends on cultural values as does the preferred treatment. The chapter addresses the issue of whether assessments developed in one culture can be utilized in different cultural settings. The partial answer to assessment transfer problems is the development of culturally sensitive instruments and utilizing indigenous tools. Cross-cultural assessment of mental disorder emerged out of Western psychological theories and was then transferred into other societies. Cross-cultural psychology has established testing procedures to evaluate the comparability of assessment instruments. However, it is important to recognize unique cultural meanings of what constitute healthy and abnormal behaviors.

Since culture is salient to the definition of what is normal or abnormal there is a broad need for culturally sensitive approaches in both assessment and therapy. The confrontation of cultures with varying values is a direct result of our globalized world. The creation of multicultural societies in various parts of the world and in many countries requires clinical training in culturally competent therapies. Research support the relevance of cultural modifications in existing assessment and therapeutic approaches since for example cultural values determine if a person in distress will seek assistance. Cognitive-behavioral therapies are being validated across cultures today. Cultural adaptation of therapy is beneficial to the client regardless of the therapeutic means employed.

Psychoanalysis that inaugurated Western therapy provided primarily a focus on internal personality dynamics. However, in collectivistic societies a self-focus might actually be considered abnormal because of the importance of relationships and society. Successful therapeutic outcomes therefore depend on the cultural competence of the therapist and ultimately on effective communication between therapist and patient based on shared cultural meanings. Cultural similarity is salient in establishing shared cultural understandings.

Researchers and practitioners that reject universal approaches seek to develop indigenous treatments. Western psychology has been criticized as unfairly dominating theory and treatment in other societies. On the other hand indigenous theories are criticized for contributing to infinite cultural regression in psychology and for promoting ever more local cultural norms. Indigenous theories are also criticized for not paying attention to the manifest similarities in symptoms and behaviors across cultures.

The chapter ended with a discussion of community based approaches the effectiveness of which is supported by research. A pioneering program in Australia trained indigenous health workers in Western disciplines who subsequently offered their services in locations administered by the Aboriginal and Islander community. Studies that followed elsewhere validated the delivery of medical and mental health services that employ cultural sensitivity and thereby achieve greater success in health outcomes. Employing culturally competent staff in treatment centers contribute to their greater use by the indigenous population and more successful outcomes.

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