Cultural Variables in Psychiatry
Cultural Variables in Psychiatry
Several recent national reports indicate that people from racial and ethnic minority groups in the United States face severe difficulties accessing mental health care services. When they do obtain services, they often face further challenging obstacles in obtaining adequate care. At the 2001 fall component meetings of the American Psychiatric Association, then-U.S. Surgeon General David Satcher, M.D., presented his newly published report "Mental Health: Culture, Race, and Ethnicity." The report pointed out that there are significant disparities in the availability and access to mental health care services disproportionately affecting racial and cultural minority populations. In order to respond to the report and to provide guidance to the Board and Assembly, the then-President of the APA, Richard K. Harding, M.D., appointed a Steering Committee to Reduce Disparities in Access to Psychiatric Care. The Steering Committee's report will soon be published.
In the meantime, President Bush's New Freedom Commission on Mental Health has published its own recommendations for steps that can be taken at national, state and local levels to improve access to mental health care services and supports for all people afflicted with psychiatric disorders. Recognizing the severity of these discrepancies, the Accreditation Council for Graduate Medical Education (ACGME) established new training standards for all residency programs that include cultural competency. It is obvious that the major factors involved in creating and perpetuating disparities that Satcher, the New Freedom Commission and many other sources have recognized involve the consequences of national economic and social forces such as poverty, discrimination, violence and crime.
Psychiatrists might wonder what we as professionals can do about this other than be politically involved, responsible citizens. Until political solutions are eventually found, the Group for the Advancement of Psychiatry (GAP) Committee on Cultural Psychiatry believes that there are many clinical interventions that psychiatrists can adapt to their practices that enhance outcomes in mental health care to minority patients.
To begin with, psychiatrists should become familiar with the Cultural Formulation (Appendix I) in the DSM-IV-TR, which recommends that the clinician assess the patient's self-perception of their ethnic identity. This is an important procedure in the diagnostic process and is also helpful in designing the treatment and management interactions that follow. The first step is to ask the patient about cultural and religious backgrounds. People who live in multicultural societies may have several ethnic traditions from which much of their identity is derived. Although patients may be able to articulate some cultural influences with full awareness, others may be so automatic and taken for granted that they are discovered only by studied self-reflection and inference. Giving the patient the opportunity to reflect on personal cultural identification may allow for expressions that affirm the self and inform the clinician.
Despite the lack of precision and clarity with respect to race, the subject has assumed particular significance in the United States with linkage of stereotyped concepts and stigmata. The potentially problematic interaction between different racial groups is a significant element in practically every facet of life. In psychiatric practice, race can have significant consequences for the diagnostic process for treatment decisions. Studies have found that whites and Asians more often received the diagnoses of major affective disorders than African-Americans or Hispanics and that African-Americans and Asians received the diagnoses of schizophrenia and other psychoses more often than whites. These studies concluded that biases in diagnosis may be related to factors of race and ethnicity (Flaskerud and Hu, 1992).
The DSM-IV-TR also discusses gender in the context of culture as a variable in the prevalence and the clinical presentation of disorders preceding the consideration of diagnosis. Although gender as a cultural variable may determine the epidemiological prevalence of certain diagnostic categories, there are also differences in prevalence in clinical samples. This may be the result of culturally determined gender differences in acknowledgment or denial of symptoms, in differential treatment-seeking behaviors, or biases in diagnosing. For example, whereas Hispanic men have somewhat higher rates of alcohol abuse and dependence than white or African-American men, Hispanic women have lower rates of these disorders than women from any other ethnic group.
It is important to be aware of issues that are culturally significant in patients' psychology and how these issues influence their concepts of self and their relationships with others. Despite individual endowments, capacities or achievements, women in Western countries are more motivated by emotional connectedness and relationships than are men (Comas-D'az and Greene, 1994). As Clower (1991) and others have suggested, the vicissitudes in the psychological development of females lead to some very positive capabilities: flexibility in adaptive regression, identification, empathy, affiliation and close intimacy. On the other hand, females may have liabilities: low self-esteem, inhibition of independence and self-assertion, and a proclivity to endure less than satisfying relationships.
As is the case with gender, age interacts with the other components of cultural identity to influence developmental issues, as well as psychiatric assessment and treatment. The APA Task Force on Ethnic Minority Elderly has presented specific outlines for clinical care of the elderly from ethnic minority groups. In all groups, elderly people feel the impact of immigration more keenly than other age groups and are handicapped by a lesser ability to acculturate and a higher risk of culture shock (Sakauye, 1992). Elderly people are also more likely to manifest culture-bound syndromes, which create difficulties in diagnosis. Also confounding the diagnostic process is the fact that many speak only their native languages. Ethnic minority elderly people may also feel displaced in Western societies, in which aged people may be abandoned or placed in nursing homes.