NBCC, NAADAC, CAADAC, and California Board of Behavioral Sciences approved Mental Health continuing education and addictions counselor training series. Narrated versions and CEUs available at http://www.allceus.com
Based on the Report from the Surgeon General
Dr. Dawn-Elise Snipes PhD, LMHC, CRC, NCC
Mental health and mental illness require
the broad focus of a public health
Mental disorders are disabling conditions.
Mental health and mental illness are
points on a continuum.
Mind and body are inseparable.
Stigma is a major obstacle preventing
people from getting help.
Mental health is fundamental to health.
Mental illnesses are real health conditions.
The efficacy of mental health treatments is well documented.
A range of treatments exists for most mental disorders.
Minorities have less access to mental health services than do
whites.1 They are less likely to receive needed care. When
they receive care, it is more likely to be poor in quality.
Barriers deterring minorities from seeking treatment or
operating to reduce its quality once they reach treatment
include the cost of care, societal stigma, and the fragmented
organization of services, clinicians’ lack of awareness of
cultural issues, bias, or inability to speak the client’s
language, and the client’s fear and mistrust of treatment.
Minorities’ struggles with racism and
discrimination affect their mental health and
contribute to their lower economic, social,
and political status.
The cumulative interplay of all of these
barriers is likely responsible for mental health
All racial and ethnic groups are highly
heterogeneous, including a diverse mix of
To better understand the nature and
extent of mental health disparities
To present the evidence on the need for
mental health services
To document promising directions toward
the elimination of mental health disparities
The four major minority groups are
projected to account for almost 40 percent
of the population by 2025.
Mental disorders affect about 1 in 5 adults
and children in the U.S.(DHHS, 1999).
Mental Health The successful performance of
mental function, resulting in productive activities,
fulfilling relationships with other people, and the
ability to adapt to change and to cope with
Mental Illness The term that refers collectively
to all mental disorders associated with distress
and/or impaired functioning.
Mental Health Problems Signs and symptoms
of insufficient intensity or duration to meet the
criteria for any mental disorder.
Most people think of “race” as biological.
Different cultures classify people into racial
groups according to a set of characteristics that
are socially significant.
The concept of race is especially potent when
certain social groups are separated, treated as
inferior or superior, and given differential access
to power and other valued resources.
Ethnicity refers to a common heritage shared by a
Heritage includes similar history, language, rituals,
and preferences for music and foods.
Culture is a common set of beliefs, norms, and
“Cultural identity” refers to the culture with which
A key aspect of any culture is that it is dynamic.
“Acculturation” refers to the socialization process by
which minority groups gradually learn and adopt
selective elements of the dominant culture.
The dominant culture for much of U.S. history has
centered on the beliefs, norms, and values of white
Americans of Judeo-Christian origin.
Western medicine has become a cornerstone of
Disability is impairment in one or more areas of
functioning at home, work, school, or in the
community (American Psychiatric Association
The formal diagnosis of a mental disorder is made by
a clinician and hinges upon three components:
1. A patient’s description of the nature, intensity, and
duration of symptoms
2. Signs from a mental status examination
3. A clinician’s observation and interpretation of the
patient’s behavior, including functional
Manifestations of mental disorders and other physical
disorders vary with age, gender, race, ethnicity, and
Patients from one culture may manifest and
communicate symptoms in a way poorly understood in
the culture of the clinician.
Words such as “depressed” and “anxious” are absent
from the languages of some American Indians and
Clinicians must determine whether patients’ symptoms
significantly impair their functioning.
Think of a time when you encountered a
client who was presenting with symptoms
that were significantly culturally influenced.
How did you respond? How were you able to
identify those symptoms as being culturally
based? Please share your responses in the
discussion forum. Thank you.
Idioms of distress are ways in which different cultures
express, experience, and cope with feelings of distress.
Somatization, or the expression of distress through physical
symptoms are common in Puerto Ricans, Mexican Americans,
Culture-bound syndromes are clusters of symptoms much
more common in some cultures than in others.
For example, some Latino patients, especially women from the
Caribbean, display ataque de nervios, a condition that includes
screaming uncontrollably, attacks of crying, trembling, and
verbal or physical aggression.
Numerous culture-bound syndromes are given in the DSM–
IV “Glossary of Culture-Bound Syndromes.”
The “Outline for Cultural Formulation” in DSM–IV
highlights five distinct aspects of the cultural context
of illness and their relevance to diagnosis.
During diagnosis, it is important to:
Inquire about patients’ cultural identity.
Explore possible cultural explanations of the illness,
▪ patients’ idioms of distress
▪ the meaning and perceived severity of their symptoms in
relation to the norms of the patients’ cultural reference group
▪ their current preferences for, as well as past experiences with,
professional and popular sources of care.
Consider cultural factors related to the psychosocial
environment and levels of functioning.
Critically examine cultural elements in the patient-
clinician relationship to assess for communication
Render an overall cultural assessment for diagnosis and
The Public Health Approach
Defines the problem using surveillance
processes to establish the nature, trends,
incidence and prevalence of the problem.
Identifies risk and protective factors
associated with the problem.
Designs, develops, and evaluates the
effectiveness and generalizability of
Disseminates successful models (Hamburg,
1998; Mercy et al., 1993).
Public health goals are points on a continuum.
Promotion refers to active steps to enhance
Prevention refers to active steps to protect against
Promotion and prevention hinge on the
identification of modifiable risk and protective
The modifiability of a risk or protective factor is a
prerequisite for developing interventions.
Risk and protective factors vary across
individuals, ages, genders, and cultures.
Severe marital discord
Overcrowding or large family size
Maternal mental disorder
Admission to foster care
Community or social
Racism and discrimination
Resilience: the capacity to bounce back
Resilient adaptation comes about as a
result of an individual’s situation in
interaction with protective factors in the
10 characteristics of resilient African American families:
1. Strong economic base
2. Achievement orientation
3. Role adaptability
5. Extended family bonds
6. Racial pride
7. Respect and love
9. Community involvement
10. Family unity (Gary et al., 1983)
Think of a client you have worked with who
was remarkably resilient. What qualities or
characteristics did that person have? What
factors contributed to their resiliency? Please
share your responses in the discussion forum.
Spirituality or religion
Smaller family structure
Supportive relationships with parents
Good sibling relationships
Adequate rule setting and monitoring by parents
Community or social
Commitment to schools
Availability of health and social services
Traumatic experiences are particularly common
for certain populations:
Inner city residents
Suicide rates vary greatly across countries and
U.S. ethnic sub-groups (Moscicki, 1995).
Suicide rates among males in the United States
are highest for American Indians and Alaska
Natives (Kachur et al., 1995).
Rates are lowest for African American women
(Kachur et al., 1995).
Culture relates to how people cope with
everyday problems and more extreme
types of adversity.
Culture is integral in fostering different
ways of coping.
Some minority groups are more likely to
delay seeking treatment until symptoms are
Minorities are less inclined to seek
treatment from mental health specialists.
Minorities turn more often to primary care
and informal sources of care such as:
Family and friends
Mistrust is a major barrier to the receipt of mental
health treatment by minorities.
Mistrust toward health care providers can be inferred
from a group’s attitudes toward government-operated
Stigma was portrayed as the “most formidable
obstacle to future progress in the arena of mental
illness and health” (DHHS, 1999).
a cluster of negative attitudes and beliefs that
motivate the general public to fear, reject, avoid, and
discriminate against people with mental illness
(Corrigan & Penn, 1999).
Migration can influence mental health.
Acculturative stress occurs while adapting to a new
culture (Berry et al., 1987).
Refugees who leave because of extreme threat
experience more trauma than do voluntary immigrants.
The psychological stress associated with immigration
tends to be concentrated in the first three years after
An initial euphoria often characterizes the first year,
followed by a strong disenchantment and demoralization
reaction during the second year.
The third year includes a gradual return to well-being.
Chinese immigrants who have been here less than
one year have fewer symptoms of distress than those
here for several years.
The emphasis on verbal communication is
unique to the mental health field.
Diagnosis and treatment of mental disorders
depend to a large extent on verbal
The emphasis on verbal communication
yields greater potential for miscommunication
when clinician and patient come from
different cultural backgrounds, even if they
speak the same language.
Misdiagnosis can arise from clinician bias
and stereotyping of ethnic and racial
Clinicians often reflect the attitudes and
discriminatory practices of their society.
Every society influences mental health treatment by how
it organizes, delivers, and pays for mental health
“De facto mental health systems” lack of a single set of
There are four major sectors for receiving mental health
The specialty mental health sector
The general medical and primary care sector
The human services sector which is made up of social
welfare (housing, transportation, and employment), criminal
justice, educational, religious, and charitable services.
The voluntary support network
How aware are you of your personal attitudes
about cultural differences? How about
societal influences? How do you practice
awareness and find balance? We would love
for you to share your responses in the
discussion forum. Thank you.
Subtle genetic differences impact how medications are
Lifestyle factors including diet, rates of smoking, alcohol
consumption, and use of alternative or complementary
treatments can interact with medications.
Ethnopsychopharmacology investigates ethnic
variations that affect medication dosing.
African Americans and Asians are more likely to be slow
metabolizers of several medications for psychosis and
depression (Lin et al., 1997).
Clinicians who are unaware of these differences may
prescribe doses that are too high for minority patients
by giving them the dose normally prescribed for whites.
How racism jeopardizes the mental health of
minorities. Three general ways are proposed:
Racial stereotypes and negative images can be
internalized, denigrating individuals’ self-worth
and adversely affecting their social and psycho-
Racism and discrimination by societal
institutions have resulted in minorities’ lower
socioeconomic status in which poverty, crime,
and violence are persistent stressors that can
affect mental health.
Racism and discrimination are stressful events
that can directly lead to psychological distress
(Williams & Williams-Morris, 2000).
Culture influences many aspects of mental illness,
Willingness to seek treatment
The cultures of the clinician and the service system
influence diagnosis, treatment, and service delivery.
Cultural/social influences are not the only determinants
of mental illness and patterns of service utilization for
Mental disorders are highly prevalent across all
Cultural and social factors contribute to the causation of
mental illness, yet that contribution varies by disorder.
Mental illness is the product of a complex
interaction among biological, psychological, social,
and cultural factors.
The role of any one of these major factors can be
stronger or weaker depending on the specific
Within the United States, overall rates of mental
disorders for most minority groups are largely
similar to those for whites.
Ethnic and racial minorities in the United States
face a social and economic environment of
inequality that takes a toll on mental health.
Living in poverty has the most measurable impact
on rates of mental illness.
People who are impoverished are about two to
three times more likely than those in the highest
stratum to have a mental disorder.
Racism and discrimination are stressful events that
adversely affect health and mental health.
They place minorities at risk for mental disorders
such as depression and anxiety.
Stigma discourages major segments of the
population, majority and minority alike, from seeking
Concerning clients who live in poverty, have you noted a
difference in their response to treatment? How do you
adapt their treatment plan to meet their needs? Please
take a moment to share your responses in the discussion
forum. Thank you.
Attitudes toward mental illness held by minorities
are as unfavorable as attitudes held by whites.
Mistrust of mental health services is an important
reason deterring minorities from seeking treatment.
The cultures of ethnic and racial minorities alter the
types of mental health services they use.
Cultural misunderstandings or communication
problems between patients and clinicians may
prevent minorities from using services and receiving
African Americans have made great strides in
education, income, and other indicators of social
African Americans have overall rates of distress
symptoms and mental illness similar to those of
Many African Americans are found in high-need
populations whose members have high levels of
3.5 times as many African Americans as white
Americans are homeless. None of them are
included in community surveys.
The mental health problems of persons in high-
need populations are especially likely to occur
jointly with substance abuse problems, as well as
with HIV infection or AIDS.
African Americans may be more likely to use
Disparities in access to mental health services are
partly attributable to financial barriers.
Few African American mental health specialists are
African Americans are overrepresented in areas
where few providers choose to practice.
African Americans with mental health needs are
unlikely to receive treatment.
African Americans are more likely to be incorrectly
They are more likely to be diagnosed as suffering
from schizophrenia and less likely to be diagnosed
as suffering from an affective disorder.
American Indian and Alaska Native youth and
adults suffer a disproportionate burden of mental
health problems compared with other Americans.
Indian and Native people who are homeless,
incarcerated, and victims of trauma are
There is significant co-morbidity in regard to mental
and substance abuse disorders.
Little is known about either the use of mental health
services by American Indians and Alaska Natives,
or whether those who need treatment actually
Major changes in the financing and organization of
mental health care are underway in American Indian
and Alaska Native communities.
The knowledge base underpinning treatment
guidelines for mental health care has been built with
little specific analysis of the benefit to ethnic
Traditional healing practices and spirituality usually
complement, rather than compete with, medical
Preventive and promotive approaches are favored
in these communities.
Interventions are needed to promote the strengths,
resiliencies, and other psychosocial resources.
Asian Americans and Pacific Islanders can be
characterized in four important ways:
Their population in the U.S. is increasing
2. They are diverse, with some subgroups
experiencing higher rates of social, health,
and mental health problems.
3. AA/PIs may collectively exhibit a wide range of
strengths and risk factors.
4. Very little national data is available that
describe the prevalence of mental disorders
using standardized DSM criteria.
Overall prevalence of disorders does not significantly
differ from that of other Americans, although the
distribution of disorders may be different.
AA/PIs have the lowest rates of utilization of mental
health services among ethnic populations.
The low utilization of mental health services is
Lack of financial resources
Conceptions of health and treatment that differ from those
under-lying Western mental health services
Cultural inappropriateness of services
The use of alternative resources within the AA/PI
The system of mental health services currently in
place fails to provide for the vast majority of
Latino youth are at a significantly high risk for poor
mental health outcomes.
Resilience is indicated by the lower rates of
mental disorders for Mexican-born adults and
children and island-born Puerto Rican adults
compared with the rates for those born in the