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Friday, April 1

Mental health forum: “The Impact of Cultural Diversity on Mental Health”

Billie Terrell, PhD, ACSW

There is a growing realization that celebrating cultural diversity nourishes the psychological well-being and pride of those in historically moppressed groups. At the same time, social workers and other mental health professionals have had to acknowledge the possible impact of prejudice and hostility and how it further complicates mental illness.

 Recognizing the significance of cultural diversity is not a new concept in mental health. However, its role as an effective tool to treatment has just begun to emerge.

 Over the past decade, providing relevant and appropriate services to persons with histories of serious mental illness has become a major priority in the United States (HHS, 2003). Currently, the service delivery system which was previously aimed at institutional placement has undergone major changes. One  focus of this change is to treat the current population of patients in community-based settings, many of whom are defined as culturally diverse.

 Professionals in local, state and federal mental health agencies have made a commitment to finding culturally diverse, trained professionals who can address the needed changes required to provide and maintain a service network that will be flexible and responsive to the needs of this multi-cultural population of men, women and children.

 According to the (2000) United States Census Bureau, during the last part of the 20th century, there has been a steady increase of white, non-Hispanic population and a significant growth of people of color in the United States which includes Black, African Americans, American Indians, Alaskan natives, native Hawaiians and other Pacific Islanders. As of 2003, the most rapidly growing groups nationally continue to be Hispanic, Latino and Asian American. This significant growth of Asians is due to immigrants and refugees from Southeast Asia, the Philippines, and the Republic of China. Lum (2003) further defines culturally diverse populations beyond these groups as many types of people characterized by age, class, culture, disability, gender, marital status, national origin, race, religion and sexual orientation.

 Historically, people of color—particularly African Americans, Latino Americans, Asian Americans, and First Nations Peoples—who have suffered oppression and continue to endure subtle forms of racism, prejudice, and discrimination, have their lives further complicated by a variety of mental illnesses. However, there is evidence that current treatment approaches do not address the significant impact of those problems.

 According to Bell (1996), “to underestimate the impact of discriminatory behavior on self-esteem would be counter therapeutic.” He suggests placing a special emphasis on the strength of ethnic identity and ethnic socialization and how it reduces the negative feelings that result from discrimination. His research supports the theory that strong ethnic identity does not allow negative interactions or the anticipation of them to become a dominant force in the life of the multicultural individual who has a strong sense of ethnic identity.

 If we are to effectively treat this population, based on current research, suggestions regarding contact and relationship building should include the following objectives:

• Relieve anxiety and fear about treatment (negative attitudes) which may be based on their families’ previous experience with the health and social welfare bureaucracy.

• Use an informal, friendly style to defuse anxiety and to establish initial rapport.

• Respect the traditional sex- and age – role relationships of a particular ethnic group.

• Offer a brief explanation of therapy, its similarity to familiar roles of cultural healers and the relief it offers for the client’s symptoms.

• Communicate warmth and acceptance to the client who may have natural cultural paranoia and may be expecting distance and a superior attitude.

• Share some limited personal information for the purpose of selfdisclosure.

• Build rapport and increase the client’s self-disclosure level by respecting the pace of discussing culturally sensitive topics.

• Emphasize confidentiality in a businesslike relationship.

• Structure sessions with flexible, clear guidelines.

 Therapists who successfully exercise these principles are more effective in working with individuals of multicultural groups regardless of the psychological level of their mental health needs.

 Once a relationship is established, common psychological identity issues among culturally diverse populations are identified and may include some of the following:

— Ethnic-identity confusion, conflict, ambivalence

— Self-hatred/negative identification/ rebellion

— Cultural-value conflict

— Family role conflict/husband-wife role conflict

— Women’s liberation/emancipation/sexuality/divorce

— Dating/mate selection/intermarriage

— Parent-child conflict

— Youth delinquency/gangs/rebellion

— Major mental illness (acute, chronic psychosis, affective disorder)

— Inadequate treatment in public, private facilities (few bilingual staff members)

— Stigma of mental illness

— Family rejection

— Lack of support system

— Elderly problems

— Isolation/despair

— Confusion

— Disorientation

TREATMENT IMPLICATIONS

According to Corsini and Wedding (2000), cultural diversity poses difficulties for therapists uninformed about the cultural values of their clients, as well as therapists who respond to clients on the basis of cultural stereotypes. Striking the proper balance between cultural sensitivity and stereotyping requires good clinical assessment skills as well as an understanding and appreciation of cultural differences.

 From a historical perspective, Carter (1979) notes in his research on African American men in therapy that the inability of therapists to confront anxieties about racial differences is crucial and that the inquiry about the patient’s feelings associated with working with someone of a difference race should be raised as part of the initial contact. Carter asserts that black patients also want to see evidence of assertiveness from their therapists. They want their therapists to respond to their real and pressing needs before moving on to a more introspective approach to their problems.

 In response to a need for more effective therapeutic care, specific strategies that have been proposed for conducting therapy with multicultural patients include: action-oriented and directive approaches for African-American clients, de emphasizing the need for self-disclosure and reframing psychological problems as medical disorders with Hispanics with Asian-Americans. Sue and Zane (1987) note that these approaches may not be the same theoretical base or values of the therapies and, for that reason, therapists tend to ignore the broad range of individual differences within these ethnic groups.

 To avoid the problem of cultural stereotyping by therapists, Fukuyama (1990) argues for a global, trans-cultural approach to training in which social workers and other mental health professionals learn the dangers of stereotyping, the power of language and its significance in therapy, the importance of pride I one’s own culture, and the influence of political and social oppression. Others have argued that therapists need to devote sufficient time to learning as much as possible about the specific cultural groups likely to be seen in their day-to-day practices.

 CLINICAL IMPLICATIONS

Even with the mentally ill, a secure, committed sense of one’s racial or ethnic group membership is assumed to provide the foundation for healthy adjustment among members of culturally diverse groups (Cross, 1991; Phinney, 1993). The connection between socialization, ethnic or cultural, to cultural identity is achieved by combining internal and environmental experiences to provide a framework for perceiving and responding to the world. These shape identity, both personal and social, by establishing values, norms and expectations for appropriate behavior.

 Maintenance of culture asserts the importance of the ideas, customs, skills, arts, and language of a people. It is particularly useful to trace the history of an ethnic group to identify moments of crisis and challenge through which it survived and triumphed. Applying such lessons of history to the present situation inspires the client to overcome obstacles and serves as a source of strength on which the client draws. From maintenance of culture, the multicultural patient creates his or her identity as an ethnic individual.

 Rounds, Weil, and Bishop (1994) offer five principles of culturally competent practice that are applicable to the individuals with mental illness:

1. Acknowledge and value diversity in terms of understanding how race, culture, and ethnicity contribute to the uniqueness of the individual, family, and community and recognize the differences among and with ethnic, cultural, and racial groups.

2. Conduct a cultural self-assessment in terms of your awareness of your own culture and how it shapes your personal and professional beliefs and behaviors.

3. Recognize and understand the dynamics of difference in terms of the client’s and practitioner’s behavioral expectations, their interactions, their degrees of self disclosure, the client’s collective orientation (extended family and community), and issues of racism, rapport, and trust levels.

4. Acquire cultural knowledge in terms of client background (socioeconomic status, education, family history, ethnic group identification, immigration) and in terms of community (informal social network, help-seeking and helping norms, and perception of agency accessibility and roles).

5. Adapt social work skills to the needs and styles of the client’s culture (assessment of problems and delayed intervention).

 In summary, it is very important to remember the patient’s strengths regardless of level of mental functioning. Any creative use of their cultural identity improves their chances of achieving their treatment goals and objectives.

 Several assets that underscore the creative use of the client’s cultural strengths include:

 Support from extended family members and siblings, a strong sense of obligation, focus on educational achievement, a work ethic, and a high tolerance for loneliness and separation. The loyalties of friends or between employer and employee should also be respected and used effectively in the therapeutic process.

 REFERENCES

Bell, C. (1996). Treatment issues for African-American men. Psychiatric Annals, 26 (1), 33-36.

 Corsini and Wedding (2000). “Current Psychotherapies.” 6th edition. F.E. Peacock Publisher, Itasca, IL

 Cross, W. (1991). Shades of black: Diversity in African-American identity. Philadelphia: Temple University Press.

 Lum, Domain (2003), “Social Work Practice and People of Color.” 4th Edition. Pacific Grove: California.

 Ostrow, M. (1991). Opening doors: Perspective in race relations in contemporary America. Tuscaloosa, AL: University of Alabama Press.

 Phinney, J. (1993). “The multigroup ethnic identity measure”. Journal of Adolescent Research, volume 7, Pp. 156-176.

 Rounds, Weil, and Bishop (1994). “Practice with Culturally Diverse Families of Young Children with Disabilities.” Families in Society.

 S. Sue and N. Zane. In M.R. Miranda and H.H. L. Kitano (Eds., 1987). Mental health research and practice in minority communities: Development of culturally sensitive training program. Pp. 168-170. Rockville, MD: The National Institute of Mental Health.

 U.S. Department of Health Human Services (1993). Clinical training in serious mental illness. In Proceedings of the National Forum for Educating Mental Health Professionals to Work With the Seriously Mentally Ill and their Families. Rockville, MD: U.S. Department of Health & Human Services.

Posted on 04/01/05 at 01:43 PM

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