As the racial demographic of the U.S. continues to shift, the mental health field faces the challenge of creating equal, culturally sensitive services for all. Many people are unable to attain their highest level of mental wellness for several reasons, and the culture of mental health is just one barrier. Closely tied to race and ethnicity, “culture” refers to a group of people who share a set of beliefs, norms, values and attitudes. The culture we associate with influences what we think and what we do—especially when it comes to mental health.
In 2001, the U.S. Surgeon General released a report that brought much needed attention to the role of cultural factors in mental health disparities. But 14 years after that report, an analysis published by the American Psychological Association (APA) revealed that there are still significant barriers to obtaining high quality mental health services for ethnic minorities in this country, including African-Americans, Hispanics, Latinos, Asian-Americans and Native Americans.
“While racial and ethnic disparities have decreased somewhat, [they] are still substantial,” says Dr. Timothy B. Smith, co-author of the 2015 APA analysis.
Compared with the U.S.’s majority Caucasian population, “members of racial and ethnic minority groups are less likely to have access to mental health services [and] less likely to use community mental health services,” says Dr. Charlene Le Fauve, program chief of the National Institute of Mental Health’s Minority Health and Mental Health Disparities Program. “[They] are more likely to use inpatient hospitalization and emergency rooms and more likely to receive lower quality care.” All of this increases the burden of mental illness, contributes to poor outcomes and results in greater use of intensive, costly services.
Understanding why cultural disparities exist and persist in the mental health field is difficult because the issue is complex. The following is some of what we do know on the topic.
Interpretations of Mental Illness
Cultures vary in how they interpret and understand mental illness. A 2010 study conducted in inner-city Hartford, Conn., found that European-Americans “tended to express beliefs about mental illness that were aligned with the biomedical perspectives on disease.” In contrast, Latino and African-American study participants more commonly emphasized “non-biomedical interpretations” of mental illness symptoms—meaning that they focused more on spirituality, moral character and social explanations for mental illness.
Stigma
Although the European-Americans in the study described above felt the impact of social stigma and rejection, stigma was far more of a prominent, core theme for Latinos and African-Americans. Latino participants viewed mental illness diagnoses as “potentially very socially damaging,” while African-Americans considered mental illness to constitute “private family business” that should not be dealt with or even acknowledged publicly.
Getting Support and Treatment
Out of the three groups studied, participants of European descent sought out professional mental health treatment most frequently. When faced with a mental health crisis, many ethnic minorities turn to primary care providers and nonprofessional sources of support, such as clergy, family, friends and community groups—anyone who has been deemed trustworthy and speaks the native language. If members of an ethnic minority do seek professional mental health treatment, it is usually only after symptoms have become much more severe.
Symptom Presentation
Culture also accounts for variations in how patients describe their symptoms to clinicians. Jyl Pomeroy, a mental health program manager at the Arlington Free Clinic in Northern Virginia, has observed that many of the clinic’s Latino patients describe anxiety as “my heart is hurting.” Research performed by Abdullah and Brown in 2011 support Pomeroy’s observation. They found that Latino and Asian patients are likely to express psychological distress in the form of physical or somatic complaints, including dizziness and tiredness. If a health provider does not further probe the patient to describe his or her emotional state, the patient may go untreated for an underlying mental health condition.
What We Can Do to Eliminate Disparities Involving the Culture of Mental Health
1) Follow national standards.
The U.S. government has developed standards for culturally appropriate services that all mental health care providers and organizations should follow. Here are a few of the National CLAS (Culturally and Linguistically Appropriate Services) Standards:
- Provide equitable, understandable and respectful quality care and services that are responsive to the cultural health beliefs and practices of the patient demographic.
- Offer free language assistance and other communication needs to individuals with limited English proficiency. Inform all individuals of these services in their preferred language, both verbally and in writing.
- Encourage the recruitment and retention of a diverse, bilingual staff that is representative of the demographic characteristics of the service area.
2) Educate and train mental health staff to be culturally competent.
Mental health organizations must provide ongoing education and training in culturally appropriate service delivery for their staff especially if the staff comes from backgrounds that are different from their clientele’s. This education will help build trust between patient and professional and increase engagement. The training programs should cover what is known about the culture of mental health, including symptom expression and general attitudes and beliefs regarding mental illness.
Staff should be taught to be open and accepting of patients’ preferred coping styles. Elizabeth Wolfe, a mental health therapist in Washington, D.C., sees many Latino clients at Mary’s Center, a federally funded local service agency in Washington, D.C. Wolfe has had several Latino clients who saw a curandero, or spiritual healer, before coming to see her. From listening to her patients, she has realized that many get “a lot of support and strength from their faith.” Consequently, faith and religious experiences are “something I try to bring into the therapy consciously, to help support that person,” Wolfe says.
3) Develop culture-specific mental health education tools.
Public education is an important tool that can be used to combat stigma and reduce the shame surrounding mental illness. Educational materials—such as pamphlets, videos and PowerPoints—should cover the symptoms and signs of mental illness, treatment options, and what mental health services are available and how to access them. Include relatable personal stories from individuals who received care in the community.
These should be easy-to-comprehend materials specifically designed for the ethnic demographic served and provided in the language(s) used by the population. When dispersing educational tools to culturally diverse audiences, also think strategically about where to advertise and distribute the materials.
4) Establish and engage community partners.
The APA recommends facilitating partnerships among behavioral health providers, educators, community leaders, families and government agencies to ensure the development of culturally competent services. These partners can share resources and educate and engage each other to work toward systematic change. NAMI Lane County in Eugene, Ore., accomplished this recently, successfully getting 25 agencies to participate in a minority mental health Hope Starts With You symposium.
Community partnerships are also vital to improving use of local services and reducing culture-based stigmas. Start a mental health conversation or program in a part of the community that makes sense to the target population. Teach community leaders how to respond to mental health concerns, educate on the topic of mental health and start peer-led support groups.
5) Continue conversations and research.
We need more data on culture-based attitudes, beliefs and trends. We also need more research on successful ways to incorporate culture into mental health care, as well as standardized data on access barriers and the current quality of mental health care among ethnic minority communities. But what we need most of all are conversations—conversations that make research on this subject a priority and demand action, implementation and change.
One entity alone cannot move the dial to eliminate culture-based mental health disparities. “Solutions to very complex public health and societal problems require commitment, communication and strategic partnerships in order to leverage resources and effect change,” Dr. Le Fauve says.
As U.S. Surgeon General Dr. David M. Satcher said in 2001, “culture counts” in mental health care, but our culture should not determine the type or quality of care we receive. Help bring awareness to the topic and let it be known today: Culture counts.
Elena Schatell is a former NAMI intern.
Note: This piece is a reprint from the Fall 2016 Advocate.