In what ways does culture impact treatments of depression? This case study follows the progress of "Mrs. H," a 77-year-old African-American female.
Different psychiatric themes and problems in treatment present themselves for U.S.-born versus immigrant minority patients. Language barriers, culture-bound syndromes, and differences in customs and culture are often pronounced for immigrants and the basis for adaptation problems and stress. Problems are often more subtle for U.S. born minorities of color such as African-Americans who have lived in the United States for many generations (American Psychiatric Association Task Force on Ethnic Minority Elderly, 1994). The psychological sequelae of longstanding experiences of prejudice and marginalization may be profound for minority individuals. Ingrained feelings of bitterness and resentment over prejudicial treatment and attitudes may last a lifetime, although, in theory, this is put into perspective as one matures. Internalization of prejudicial views is an issue for minority patients that can be a lifelong influence on self-esteem. This cannot be viewed as a personality disorder in the usual sense, although culturally insensitive therapists might misdiagnose it as such. The phenomenon has several faces. It leads to an "external locus of control" in which things in life are viewed as chance occurrence. It can engender either strong adherence to, or rejection of, social hierarchies. It can affect the treatment alliance, even if the patient's therapist is of the same race.
"Mrs. H" is a 77-year-old African-American female who resided in a long-term care facility after suffering a cerebrovascular accident five months earlier, leaving her with a left hemiparesis. She also required management of insulin-dependent diabetes mellitus and atrial fibrillation. Mrs. H's primary care physician referred her to the psychiatry department because of a personality change over the past few months, when she became more irritable and withdrawn. She denied depression but several staff members found her unusually tearful and easily insulted. According to Mrs. H, a member of the staff noticed that she rarely smiled and was not herself for several months. She found herself in tears and in nostalgic contemplation more often than not. Mrs. H blamed an initial 26-pound weight loss over the past few months on distaste for food in the facility, but she was not losing further weight. She denied sleep disturbance and showed no suicidal ruminations, delusions or hallucinations. Mrs. H had never been diagnosed with or treated for depression.
She was taciturn and concrete with doctors, leading many caregivers to think she was mildly demented from her stroke (which later turned out to be false). An attempt to improve the reliability of the evaluation was made by assigning a same-race student doctor to interview her over an extended period of time. It is important to note that the student was a fair-skinned African-American, unlike the patient, who was dark-skinned. The patient did not even begin to talk openly until the fourth visit, when she first began to allude to a lifelong feeling of inferiority. She opened up only after direct inquiry into the impact of race on her life.
She was intimidated by whites and light-skinned African-Americans, and had felt this way all of her life. She even attributed her tendency to help others as a way of "pleasing people." She grew up in an era when African-Americans were not afforded the same rights and privileges as their white counterparts. She had white neighbors that she could not befriend, although she often wanted to out of curiosity, knowing in her heart that she was "just like them." Mrs. H felt that being African-American hindered her in life--she never felt like she was "good enough."
Mrs. H's maternal family was lighter than she was, and they would make every attempt to make it painfully obvious that she was the darkest person in the family. Her mother only said negative things to remind her of her shortcomings. She did not feel loved at home, and was "never built up to think that she was somebody." She felt that the white nuns at her parochial school treated her and the other darker-skinned students worse. As a child, she believed that the fair-skinned children were smarter than she was. Mrs. H lived life without many expectations, accepted the way others treated her and internalized their racial negativity.
She found compensatory relationships in a maternal aunt, her husband and the extended support network through the church. Although she grew up in a devoutly Baptist family, she could not gather enough courage or confidence to participate in church functions. Having a child forced her to get involved and become active in the community and their local church; church became central to her. She became a deaconess and used the church for support. These experiences were not only reinforcing to her worth as a person, being a good mother and spouse, but she found herself becoming active in areas that she would have normally shied away from.
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 the experience of illness (or distress) is always a culturally shaped phenomenon."
Non-minority caregivers need to believe that it is not just political correctness to guard against racial stereotyping. Dealing with cultural issues becomes a therapeutic issue that must be discussed openly and uncritically. There is no best way to address it, but it will not become manifest unless confronted gently. One must be more attentive to structural issues in therapy such as scheduling enough time to avoid rushing the patient, avoiding excessively long silences, and providing feedback in the form of repeating how one has understood what was just said. When the patient feels safe to express feelings and believes the therapist genuinely wants to understand, treatment begins.
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