Mental Health Mental Health Systems in Cross-Systems in Cross-Cultural ContextCultural Context

Cultural Belief Systems Cultural Belief Systems

and Mental Illnessand Mental Illness

Culture includes:Culture includes: Belief systemsBelief systems Value orientationsValue orientations Religious practicesReligious practices Medical practicesMedical practices Organization of societyOrganization of society Structure of familiesStructure of families Society’s need for control and orderSociety’s need for control and order Political philosophiesPolitical philosophies Legal systemsLegal systems Economic resourcesEconomic resources

Cultural belief systems Cultural belief systems affect:affect:

Which deviant behaviors are Which deviant behaviors are considered to be illnessconsidered to be illness

Notions of etiology (causation)Notions of etiology (causation) Notions of appropriate treatmentNotions of appropriate treatment Ideas about who is an appropriate Ideas about who is an appropriate

healerhealer How people seek helpHow people seek help How people receive careHow people receive care

Cultural belief systems can Cultural belief systems can be divided into:be divided into:

Western vs. non-WesternWestern vs. non-Western Individualistic orientation: places high Individualistic orientation: places high

value on personal autonomyvalue on personal autonomy Collectivist orientation: places high Collectivist orientation: places high

value on interdependencevalue on interdependence Modern vs. traditionalModern vs. traditional

AttributionsAttributions

People in cultures that are People in cultures that are individualistically oriented tend to individualistically oriented tend to attribute cause of mental illness to attribute cause of mental illness to something within themselves—personal something within themselves—personal responsibilityresponsibility

People in cultures that have a collectivist People in cultures that have a collectivist orientation tend to attribute cause of orientation tend to attribute cause of mental illness to something outside the mental illness to something outside the self—the responsibility of forces beyond self—the responsibility of forces beyond their controltheir control

Result of attribution?Result of attribution?

Personal responsibility for Personal responsibility for illness>>low self-esteem, guilt, illness>>low self-esteem, guilt, social withdrawal—but also can social withdrawal—but also can influence individual to take actions influence individual to take actions on own behalfon own behalf

External responsibility for External responsibility for illness>>sense of helplessness, lack illness>>sense of helplessness, lack of power to do anything—but no loss of power to do anything—but no loss of self-esteem or guiltof self-esteem or guilt

Social status and mental Social status and mental healthhealth

Within each culture, “minority group” Within each culture, “minority group” status affects self-evaluation, opportunities status affects self-evaluation, opportunities available, and quality of life, e.g.:available, and quality of life, e.g.: Socioeconomic statusSocioeconomic status GenderGender Age Age ColorColor EthnicityEthnicity ReligionReligion Sexual orientationSexual orientation CasteCaste Immigration statusImmigration status

Social status and mental Social status and mental healthhealth

Those who are members of groups that are Those who are members of groups that are devalued/discriminated against/oppressed devalued/discriminated against/oppressed by their society are more at-risk of by their society are more at-risk of developing mental illness, especially if developing mental illness, especially if there is a biological vulnerability, e.g.:there is a biological vulnerability, e.g.: Asian American immigrantsAsian American immigrants African AmericansAfrican Americans Native AmericansNative Americans HispanicsHispanics Other immigrant groups, refugees especiallyOther immigrant groups, refugees especially

AcculturationAcculturation

Individual members of minority cultural Individual members of minority cultural groups more at-risk if they are moving groups more at-risk if they are moving away from traditional culture—away from traditional culture—becoming acculturated.becoming acculturated.

Traditional cultural beliefs and practices Traditional cultural beliefs and practices can have a protective effect. Loss of can have a protective effect. Loss of traditional cultural beliefs but lack of traditional cultural beliefs but lack of acceptance into dominant culture puts acceptance into dominant culture puts individuals in an unstable, high-risk individuals in an unstable, high-risk situation.situation.

TherapyTherapy

Return to cultural roots to find Return to cultural roots to find meaningmeaning

Bicultural effectiveness trainingBicultural effectiveness training

Universal modes of mental Universal modes of mental illness?illness?

All cultures appear to have similar types of All cultures appear to have similar types of mental illnesses (e.g., schizophrenia), with mental illnesses (e.g., schizophrenia), with similar symptoms (e.g., cognitive defects, similar symptoms (e.g., cognitive defects, asocial behaviors)asocial behaviors)

Interpretation of symptoms may differ Interpretation of symptoms may differ markedlymarkedly Meaning of symptomsMeaning of symptoms Source of symptomsSource of symptoms Duration of symptomsDuration of symptoms Curability Curability

Content of psychotic delusions, Content of psychotic delusions, hallucinations incorporates cultural hallucinations incorporates cultural elements—differs from culture to cultureelements—differs from culture to culture

Stress and mental illness: Stress and mental illness: alternative hypothesesalternative hypotheses

1.1. Stressful life events can trigger Stressful life events can trigger mental illnessmental illness

2.2. Biological vulnerability alone can Biological vulnerability alone can trigger mental illnesstrigger mental illness

3.3. Diathesis-stress hypothesisDiathesis-stress hypothesis: : stressful environmental events stressful environmental events trigger biological vulnerability and trigger biological vulnerability and lead to mental illnesslead to mental illness

Even Even in uteroin utero events events

Culture-bound Culture-bound syndromessyndromes

Specific forms of mental illness found Specific forms of mental illness found only in specific cultural settings:only in specific cultural settings: KoroKoro Windigo psychosisWindigo psychosis Arctic hysteriaArctic hysteria LatahLatah Susto or espantoSusto or espanto

These disorders may be related to These disorders may be related to local diet, climate, etc.local diet, climate, etc.

International studies International studies show:show:

Agreement on core symptom clusters Agreement on core symptom clusters across culturesacross cultures

Comparable incidence rates across Comparable incidence rates across culturescultures

Cultural variables may have significant Cultural variables may have significant effect on how mental illnesses manifest effect on how mental illnesses manifest themselves and on course of illnessthemselves and on course of illness

Compelling evidence that there is a Compelling evidence that there is a genetic factor in schizophrenia and genetic factor in schizophrenia and major affective disorders.major affective disorders.

International Pilot Study of International Pilot Study of SchizophreniaSchizophrenia

Sponsored by World Health Sponsored by World Health Organization (WHO)—1990’sOrganization (WHO)—1990’s

Interviewed first-contact patients in Interviewed first-contact patients in Columbia, Czechoslovakia, Denmark, Columbia, Czechoslovakia, Denmark, India, Nigeria, Taiwan, United Kingdom, India, Nigeria, Taiwan, United Kingdom, former Soviet Union, and United Statesformer Soviet Union, and United States

Found no noticeable differences in Found no noticeable differences in incidence and prevalence of incidence and prevalence of schizophrenia between developed and schizophrenia between developed and developing countries.developing countries.

International Pilot Study of International Pilot Study of Schizophrenia (continued)Schizophrenia (continued)

However, follow-up studies 2 and 5 However, follow-up studies 2 and 5 years later showed:years later showed: Course of illness significantly better in Course of illness significantly better in

developing countries than in developing countries than in technologically advanced countries. technologically advanced countries. Good outcomes:Good outcomes: 58% in Nigeria, 51% in India58% in Nigeria, 51% in India 7% in Moscow, 6% in Denmark7% in Moscow, 6% in Denmark

Why outcomes better in Why outcomes better in developing countries?developing countries?

In developing countries:In developing countries: Lower stressLower stress Higher social supportHigher social support Cultural belief systems that externalize Cultural belief systems that externalize

causalitycausality Greater opportunities for social Greater opportunities for social

reintegration and normalized work roles in reintegration and normalized work roles in rural areasrural areas

Extended kinship networksExtended kinship networks Fewer problems accepting interdependenceFewer problems accepting interdependence

Expressed Emotion Expressed Emotion ResearchResearch

Interactions in the family may have an effect on Interactions in the family may have an effect on course of illnesscourse of illness High EE families: emotional over-involvement, high High EE families: emotional over-involvement, high

degree of critical comments, hostilitydegree of critical comments, hostility Low EE families: calm, empathic, respectful, Low EE families: calm, empathic, respectful,

acceptingaccepting Psychoeducation programs train high EE families to Psychoeducation programs train high EE families to

become low EEbecome low EE Such psychoeducation programs help prevent Such psychoeducation programs help prevent

relapse. (Psychoeducation programs helpful for all relapse. (Psychoeducation programs helpful for all families—focus on providing state-of-the-art families—focus on providing state-of-the-art information about illness, support, behavior information about illness, support, behavior management techniques, problem-solving strategies.management techniques, problem-solving strategies.

Mental health service Mental health service delivery systemsdelivery systems

Developed nations can afford to Developed nations can afford to develop broad-based networks of develop broad-based networks of services. services.

Developing nations, with scarcer Developing nations, with scarcer resources, have developed creative resources, have developed creative service delivery systems:service delivery systems: Integrated mental and physical health care Integrated mental and physical health care

in Indiain India ARO village system—a model rehabilitation ARO village system—a model rehabilitation

system in African countriessystem in African countries

Traditional vs. Biomedical Traditional vs. Biomedical Healing SystemsHealing Systems

Both traditional and biomedical healing Both traditional and biomedical healing systems are used in many countries.systems are used in many countries.

Traditional healing systems are usually the Traditional healing systems are usually the first used in most non-Western countries.first used in most non-Western countries. Presume some imbalance in life forces.Presume some imbalance in life forces. Imbalance can be corrected by ritual, religious Imbalance can be corrected by ritual, religious

or otherwise. Intercession of a supernatural or otherwise. Intercession of a supernatural power, invoked by healer.power, invoked by healer.

In one study in Puerto Rico, patients rated In one study in Puerto Rico, patients rated spiritists as more effective than mental health spiritists as more effective than mental health professionals.professionals.

Rehabilitation, Quality of Rehabilitation, Quality of Life, Life,

Self-HelpSelf-Help As deinstitutionalization progresses around As deinstitutionalization progresses around

the world, there is more of an emphasis on the world, there is more of an emphasis on rehabilitation and enhancing quality of life rehabilitation and enhancing quality of life for people affected by mental illness.for people affected by mental illness. Italian experiment, e.g.Italian experiment, e.g.

Advocacy and consumer self-helpAdvocacy and consumer self-help Organizations have grown world-wideOrganizations have grown world-wide Mostly family members but also consumersMostly family members but also consumers These organizations encourage self-help and These organizations encourage self-help and

also advocate for more resources.also advocate for more resources.