How do your cultural and religious beliefs affect your attitude toward mental health treatment?

Theorists within the Sociocultural Perspective emphasize the circumstances surrounding individuals and how their behaviors are affected specifically by other people, social institutions and social forces. According to Catherine A. Sanderson (2010) “Sociocultural perspective: A perspective describing people’s behavior and mental processes as shaped in part by their social and/or cultural contact, including race, gender, and nationality.”  Therefore the sociocultural perspective looks at you, your behaviors, and your symptoms in the context of your culture and background. Clinicians using this approach integrate cultural and religious beliefs into the therapeutic process. Research has shown that ethnic minorities are less likely to access mental health services than their White middle-class American counterparts. Barriers to treatment include lack of insurance, transportation, and time; cultural views that mental illness is a stigma; fears about treatment; and language barriers.

Theories

Socioeconomic Factors

Low socioeconomic status has been linked to higher rates of mental and physical illness (Ng, Muntaner, Chung, & Eaton, 2014) due to persistent concern over unemployment or under-employment, low wages, lack of health insurance, no savings, and the inability to put food on the table, which can then lead to feeling hopeless, helpless, and dependent on others. This situation places considerable stress on an individual and can lead to higher rates of anxiety disorders and depression. Borderline personality disorder has also been found to be higher in people in low-income brackets (Tomko et al., 2014).

Gender Factors

Gender plays an important, though at times, unclear role in mental illness. It is important to understand that gender is not the cause of mental illness, though differing demands placed on males and females by society and their culture can influence the development and course of a disorder. Consider the following:

• Rates of eating disorders are higher among women than, men, though both genders are affected. In the case of men, muscle dysphoria is of concern and is characterized by extreme concern over not be muscular enough.
• OCD has an earlier age of onset in boys than girls, with most people being diagnosed by age 19.
• Women are at greater risk for developing an anxiety disorder than men.
• ADHD is more common in males than females, though females are more likely to have inattention issues.
• Boys are more likely to be diagnosed with Autism Spectrum Disorder.
• Depression occurs with greater frequency in women than men.
• Women are more likely to develop PTSD compared to men.
• Rates of SAD (Seasonal Affective Disorder) are four times greater in women than men.

Environmental Factors

Environmental factors also play a role in the development of mental illness. How so?

• In the case of borderline personality disorder, many people report experiencing traumatic life events such as abandonment, abuse, unstable relationships or hostility, and adversity during childhood.
• Cigarette smoking, alcohol use, and drug use during pregnancy are risk factors for ADHD.
• Divorce or the death of a spouse can lead to anxiety disorders.
• Trauma, stress, and other extreme stressors are predictive of depression.
• Malnutrition before birth, exposure to viruses, and other psychosocial factors are potential causes of schizophrenia.
• SAD occurs with greater frequency for those living far north or south from the equator (Melrose, 2015). Horowitz (2008) found that rates of SAD are just 1% for those living in Florida while 9% of Alaskans are diagnosed with the disorder.

Proponents of the family perspective view abnormal behavior as caused by dysfunction of interactions and relationships that exist in the family.These disturbances account for the choice of the term ‘identified patient’ in order to refer to the family member who is reported as the one who is in need of therapy. He/she is the person blamed for the family’s distress and the rest of the family members’ problem definition positions him/her as the source of their difficulties. Consequently, the systemic therapist is faced with the challenge of how to reduce the blaming of the identified patient for the family’s reported difficulties 

Social Discrimination, characterized by an unfair behavior towards members of a given group, not based on a supposed merit or reciprocity, but on the belonging to those social categories. This phenomenon manifests itself through negative behaviors in relation to the victims or through actions which unfairly favor the group of the perpetrator, creating, maintaining or reinforcing patterns of inequality.

Discriminatory experiences are considered a stress factor that may impact the overall health of their victims and which are relatively uncontrollable and unpredictable. This negative impact on their health may occur in a direct way, resulting in mental disorders and reducing levels of well-being, or indirect, through physiological pathways, such as the release of hormones related to stress and the adoption of harmful behaviors towards health as a way of coping with these experiences.

Stigma and discrimination can worsen someone's mental health problems, and delay or impede their getting help and treatment, and their recovery. Social isolation, poor housing, unemployment and poverty are all linked to mental ill health. So stigma and discrimination can trap people in a cycle of illness.

Treatment

Appreciating diversity in communities includes understanding dimensions of diversity and how to work within diverse community contexts, but also includes a consideration of how to work within systems of inequality.

The ability to understand, appreciate and interact with people from cultures or belief systems different from one's own has been a key aspect of psychological thinking and practice for some 50 years. Outside of biological and psychological factors on mental illness, race, ethnicity, gender, religious orientation, socioeconomic status, sexual orientation, etc. also play a role, and this is the basis of the sociocultural perspective.  For example, José is an 18-year-old Hispanic male from a traditional family. José comes to treatment because of depression. During the intake session, he reveals that he is gay and is nervous about telling his family. He also discloses that he is concerned because his religious background has taught him that homosexuality is wrong. How does his religious and cultural background affect him? How might his cultural background affect how his family reacts if José were to tell them he is gay?

As our society becomes increasingly multiethnic and multiracial, mental health professionals must develop cultural competence , which means they must understand and address issues of race, culture, and ethnicity. They must also develop strategies to effectively address the needs of various populations for which Eurocentric therapies have limited application (Sue, 2004). For example, a counselor whose treatment focuses on individual decision making may be ineffective at helping a Chinese client with a collectivist approach to problem solving (Sue, 2004).

Multicultural counseling and therapy aims to offer both a helping role and process that uses modalities and defines goals consistent with the life experiences and cultural values of clients. It strives to recognize client identities to include individual, group, and universal dimensions, advocate the use of universal and culture-specific strategies and roles in the healing process, and balances the importance of individualism and collectivism in the assessment, diagnosis, and treatment of client and client systems (Sue, 2001).

This therapeutic perspective integrates the impact of cultural and social norms, starting at the beginning of treatment. Therapists who use this perspective work with clients to obtain and integrate information about their cultural patterns into a unique treatment approach based on their particular situation (Stewart, Simmons, & Habibpour, 2012). Sociocultural therapy can include individual, group, family, and couples treatment modalities.

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CULTURAL HUMILITY

As our world becomes increasingly diverse and interconnected, understanding different cultures becomes crucial. Without a basic understanding of the beliefs and experiences of individuals, professionals can unintentionally contribute to prejudice and discrimination or negatively impact professional relationships and effectiveness of services. To understand cultural experiences, it is important to consider the context of social identity, history, and individual and community experiences with prejudice and discrimination. It is also important to acknowledge that our understanding of cultural differences evolves through an ongoing learning process (Tervalon & Murray-Garcia, 1998).

Cultural humility is the ability to remain open to learning about other cultures while acknowledging one’s own lack of competence and recognizing power dynamics that impact the relationship. Within cultural humility it is important to engage in continuous self-reflection, recognize the impact of power dynamics on individuals and communities, embrace “not knowing”, and commit to lifelong learning. This approach to diversity encourages a curious spirit and the ability to openly engage with others in the process of learning about a different culture. As a result, it is important to address power imbalances and develop meaningful relationships with community members in order to create positive change.

A guide to cultural humility is offered by Culturally Connected. Cultural competence is generally defined as possessing the skills and knowledge of a culture in order to effectively work with individual members of the culture. This definition includes an appreciation of cultural differences and the ability to effectively work with individuals. The assumption that any individual can gain enough knowledge or competence to understand the experiences of members of any culture, however, is problematic. Gaining expertise in cultural competence as traditionally defined seems unattainable, as it involves the need for knowledge and mastery. Instead, true cultural competence requires engaging in an ongoing process of learning about the experiences of other cultures (Tervalon & Murray-Garcia, 1998).

Further reading on cultural competence by Stanley Sue can be found here.

BARRIERS TO TREATMENT

Statistically, ethnic minorities tend to utilize mental health services less frequently than White, middle-class Americans (Alegría et al., 2008; Richman, Kohn-Wood, & Williams, 2007). Why is this so? Perhaps the reason has to do with access and availability of mental health services. Ethnic minorities and individuals of low socioeconomic status (SES) report that barriers to services include lack of insurance, transportation, and time (Thomas & Snowden, 2002). However, researchers have found that even when income levels and insurance variables are taken into account, ethnic minorities are far less likely to seek out and utilize mental health services. And when access to mental health services is comparable across ethnic and racial groups, differences in service utilization remain (Richman et al., 2007).

In a study involving thousands of women, it was found that the prevalence rate of anorexia was similar across different races, but that bulimia nervosa was more prevalent among Hispanic and African American women when compared with non-Hispanic whites (Marques et al., 2011). Although they have similar or higher rates of eating disorders, Hispanic and African American women with these disorders tend to seek and engage in treatment far less than Caucasian women. These findings suggest ethnic disparities in access to care, as well as clinical and referral practices that may prevent Hispanic and African American women from receiving care, which could include lack of bilingual treatment, stigma, fear of not being understood, family privacy, and lack of education about eating disorders.

Perceptions and attitudes toward mental health services may also contribute to this imbalance. A recent study at King’s College, London, found many complex reasons why people do not seek treatment: self-sufficiency and not seeing the need for help, not seeing therapy as effective, concerns about confidentiality, and the many effects of stigma and shame (Clement et al., 2014). And in another study, African Americans exhibiting depression were less willing to seek treatment due to fear of possible psychiatric hospitalization as well as fear of the treatment itself (Sussman, Robins, & Earls, 1987). Instead of mental health treatment, many African Americans prefer to be self-reliant or use spiritual practices (Snowden, 2001; Belgrave & Allison, 2010). For example, it has been found that the Black church plays a significant role as an alternative to mental health services by providing prevention and treatment-type programs designed to enhance the psychological and physical well-being of its members (Blank, Mahmood, Fox, & Guterbock, 2002).

Additionally, people belonging to ethnic groups that already report concerns about prejudice and discrimination are less likely to seek services for a mental illness because they view it as an additional stigma (Gary, 2005; Townes, Cunningham, & Chavez-Korell, 2009; Scott, McCoy, Munson, Snowden, & McMillen, 2011). For example, in one recent study of 462 older Korean Americans (over the age of 60) many participants reported suffering from depressive symptoms. However, 71% indicated they thought depression was a sign of personal weakness, and 14% reported that having a mentally ill family member would bring shame to the family (Jang, Chiriboga, & Okazaki, 2009).

Language differences are a further barrier to treatment. In the previous study on Korean Americans’ attitudes toward mental health services, it was found that there were no Korean-speaking mental health professionals where the study was conducted (Orlando and Tampa, Florida) (Jang et al., 2009). Because of the growing number of people from ethnically diverse backgrounds, there is a need for therapists and psychologists to develop knowledge and skills to become culturally competent (Ahmed, Wilson, Henriksen, & Jones, 2011). Those providing therapy must approach the process from the context of the unique culture of each client (Sue & Sue, 2007).

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