Her present depression was a result of cumulative losses: the death of her husband and son two years earlier and the loss of her part-time work after a car accident in which she also lost her car. Shortly after, she noticed that she became more forgetful, more conscious of her health and developed a fear of falling. She became more helpless after her stroke and placement into the nursing home.
Although Mrs. H undeniably suffers from depression, many cultural features influence the working alliance and presentation of elderly African-American patients and other minority patients. Regarding the interview process, it is important to realize that patients often do not view current symptoms as depression. Excess physical disability from depression is often attributed to health problems. This lack of insight becomes a major problem in establishing compliance with medical treatment for depression.
It is important to realize that latent cultural issues (e.g., skin color, feelings of inferiority) do not surface immediately. Issues like those described in this case emerge only after a relationship is established, rarely on the first session, and often must be interpreted or confronted directly.
Extended family networks are clearly important when family size is small or when the immediate family is not cohesive, or lacks money or resources, as may occur in poor minority families. Compensatory relationships may be one key to successful aging. This is probably the reason why Vaillant and Mukamal (2001) found no correlation between successful aging and warmth of parental experiences, contrary to the stereotype. In this case, compensatory positive relationships can come from extended family or especially the church for African-Americans. Both lead to growth and development.
Social supports and a sense of mastery over one's situation are often viewed as major buffers against stress. Although universal issues, this seems especially important for minority individuals. Kleinman (1988), in his landmark book, summarized life event changes perceived as stressful in the presence of inadequate social support and ineffective coping responses casually contributing to the onset of medical and mental disorders. In the case of Mrs. H, her cumulative losses all proved catastrophic, especially in the absence of social supports.
The underlying thread in this and many other minority cases is that low self-esteem caused by racism, not a personality disorder, influences treatment. "Disconfirming cultural labels foster ruinous cycles of generalized hopelessness that undermine one's identity," Kleinman (1988) wrote. It is clear that this concept about color and the unconscious devaluation of darker skin exists even within a minority community. If being poor makes one second class, being a minority makes one third class, being dark-skinned and a woman may make one feel below third class. Stigmatizing labels induce feelings of guilt, worthlessness and negative self-identity conducing to despair (Dressler, 1985). Cultural labels act as self-fulfilling prophecy in mental disease. African-Americans are recognized by their physical features and are treated accordingly (U.S. Department of Health and Human Services, 2001).
How does one understand why people like Mrs. H do not attribute or link their low self-esteem directly to racism despite the inextricable relationship between the two? The answer is that the personal experiences of the individual seem overshadowed by the collective experience of the race. Patients like Mrs. H take racism for granted and seem unaware of its existence, despite its ever-present status. Sue and Sue (1999) confirmed, "African Americans differ significantly in their family and individual experiences." For some, like Mrs. H, the experience as a dark-skinned person of color played a large role in her identity but was perceived as an expectable aspect of being an African-American in the United States. Kleinman (1988) summarized: "Mental illnesses are the outcome of the creation of experience by physical stuff interacting with symbolic meaning å the experience of illness (or distress) is always a culturally shaped phenomenon."