Multicultural Counseling

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 approach. 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 disparities. All racial and ethnic groups are highly  heterogeneous, including a diverse mix of people.

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 adversity.  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 particular group.

Heritage includes similar history, language, rituals,  and preferences for music and foods. Culture is a common set of beliefs, norms, and  values. “Cultural identity” refers to the culture with which  someone identifies. 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  health worldwide. Disability is impairment in one or more areas of  functioning at home, work, school, or in the community (American Psychiatric Association [APA], 1994). 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 impairment.

Manifestations of mental disorders and other physical  disorders vary with age, gender, race, ethnicity, and culture.  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 Alaska Natives.  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, and whites. 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, including: ▪ 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 barriers. Render an overall cultural assessment for diagnosis and  care.

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 interventions.  Disseminates successful models (Hamburg, 1998; Mercy et al., 1993).

Public health goals are points on a continuum.  Promotion refers to active steps to enhance  mental health.  Prevention refers to active steps to protect against illness.  Promotion and prevention hinge on the identification of modifiable risk and protective factors.  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.

Individual   Genetic vulnerability  Gender  Low birth weight  Neuropsychological deficits  Language disabilities  Chronic physical illness  Below-average intelligence  Child abuse or neglect

Family   Severe marital discord  Social disadvantage  Overcrowding or large family size  Paternal criminality  Maternal mental disorder  Admission to foster care Community or social   Violence  Poverty  Community disorganization  Inadequate schools  Racism and discrimination

Resilience: the capacity to bounce back  from adversity. Resilient adaptation comes about as a  result of an individual’s situation in interaction with protective factors in the social environment.

10 characteristics of resilient African American families:  1. Strong economic base 2. Achievement orientation 3. Role adaptability 4. Spirituality 5. Extended family bonds 6. Racial pride 7. Respect and love 8. Resourcefulness 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. Thank you.

Individual   Positive temperament  Above-average intelligence  Social competence  Spirituality or religion Family   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  Social cohesion

Traumatic experiences are particularly common  for certain populations:  Veterans  Inner city residents  Immigrants 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 more severe. 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:  Clergy  Traditional healers  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 institutions. Stigma was portrayed as the “most formidable  obstacle to future progress in the arena of mental illness and health” (DHHS, 1999). Stigma   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 arrival.  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 communication. 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 minorities. 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 services. “De facto mental health systems” lack of a single set of  organizing principles. There are four major sectors for receiving mental health  care:  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  metabolized. 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 1. internalized, denigrating individuals’ self-worth and adversely affecting their social and psychological functioning. Racism and discrimination by societal 2. 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 3. that can directly lead to psychological distress (Williams & Williams-Morris, 2000).

Culture influences many aspects of mental illness,  including:  Symptom expression  Coping style  Social supports  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 minorities Mental disorders are highly prevalent across all  populations 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 disorder. 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 help.

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 appropriate care.

African Americans have made great strides in  education, income, and other indicators of social well-being. African Americans have overall rates of distress  symptoms and mental illness similar to those of whites. Many African Americans are found in high-need  populations whose members have high levels of mental illness. 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  alternative therapies. Disparities in access to mental health services are  partly attributable to financial barriers.

Few African American mental health specialists are  available. 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  diagnosed. 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 overrepresented. 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 obtain it.

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 minority groups. Traditional healing practices and spirituality usually  complement, rather than compete with, medical care. 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 1. rapidly. 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 attributable to:  Stigma  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 communities.

The system of mental health services currently in  place fails to provide for the vast majority of Latinos.  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 United States.

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Multicultural Counseling

by Dawn-Elise Snipes

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