Cultural Issues in Caring for Patients With Psychosis

SPECIAL REPORT: PSYCHOSIS PART 1

The lifetime prevalence of schizophrenia and related psychotic disorders is approximately 1% of the population.¹ These disorders have clear genetic and biological underpinnings² and generally respond favorably to antipsychotic medication, particularly in reducing the hallmark positive symptoms (eg, delusions, hallucinations).³ However, even with medication, some positive symptoms persist. Furthermore, negative symptoms (eg, asociality, amotivation), which have an even greater detrimental impact on quality of life, are less impacted by medication,⁴ underscoring a need for additional therapeutic interventions for individuals with schizophrenia/psychosis. Sociocultural factors have been shown to impact both the presentation and course of schizophrenia/psychosis. In this article, we use 3 case vignettes to illustrate how cultural factors can be considered in treatment planning and for a more holistic understanding of how to improve outcomes for individuals with schizophrenia/psychosis (Table).

Case 1

“Mr Williams” is a 40-year-old single Black man with a history of schizophrenia, although he notes, “I have been told I have everything: schizophrenia, bipolar disorder, paranoia, you name it.” Mr Williams states he came in at his sister’s request because she noted he was sleeping less and talking to himself more than usual. Mr Williams explains he has been more anxious about the police in his neighborhood. This coincided with a shooting approximately 1 month ago, when a close acquaintance was shot and killed by police about 3 blocks from his home. Mr Williams says he believes the police have bugged his house and he feels energized to solve the issue. “I have been installing a new security system and filling in all the gaps in my house so no radio waves can get through.” He has also been talking more to his grandmother, who died a decade prior. He hears her voice more frequently when he is distressed, and he likes hearing from her.

Mr Williams’ statement about his many diagnoses reflects an unfortunate reality for Black men with experiences of psychosis. It has been shown that Black men tend to to be overdiagnosed with schizophrenia and underdiagnosed with bipolar disorder.⁵ Notably, schizophrenia tends to be more stigmatized than bipolar disorder. This discrepancy in diagnosis has contributed to poorer quality of care, because these 2 diagnoses have key differences in first-line treatment.⁵

Although Mr Williams seems to relay his experiences of disparate diagnoses to his provider as humorous, it should act as a clue to the provider that his existing diagnosis may not be accurate and that Mr Williams may not completely trust the insights of his providers. Potential follow-up questions may be: “What do you think about your diagnosis? Is there a label you prefer that reflects your difficulties with mental health?” Direct questioning about symptomology would also be needed to clarify diagnosis, but these initial questions can help create a shared language between provider and client that prioritizes the client’s understanding of the symptoms. Providers may also reflect this experience back to the client: “That might be frustrating—to be told all these different diagnoses over the years.” Acknowledgements like this can help establish a sense of trust, letting your patients know it is appropriate to acknowledge their challenges with the health care system to their providers.

Mr Williams endorses a belief that the police are recording him inside his house and has acted in response to this delusion. Providers are often told not to reinforce delusions or give them too much airtime beyond what it takes for diagnosis and assessment of severity. Unfortunately, this guidance may be overused such that providers avoid better understanding or seeing the greater context of delusions/hallucinatory symptoms. The presentation and expression of symptoms differs across ethnic groups, often due to differential experiences and environments.^6,7

In the case of Mr Williams, although the police may not be explicitly recording him in his home (although further questioning is warranted), his delusion seems triggered by real-life experiences. Black Americans are proportionally more impacted by police brutality and discrimination and consequently demonstrate greater levels of suspiciousness in general.^8,9 With this cultural consideration in mind, providers need to be especially cautious of rating something as abnormal or delusional when it is a reality for Black individuals (eg, being followed/watched in stores, being targeted for harassment at work, feeling unsafe at home, being wary of police intentions).

In addition, increased experiences of discrimination are linked to increased paranoia and psychotic experiences in ethnic minorities.¹⁰ For Mr Williams, it would be helpful to acknowledge and reinforce the realities of his experience (“I am so sorry to hear about your friend. I understand why this would make you fearful of the police.”) while guiding him toward relevant solutions (“Have you talked to anyone, like your sister, about what happened? How are the other individuals in your neighborhood coping with this?”). Further conversation may help Mr Williams consider how to get familial/community support and assist him in finding spaces that feel welcoming and safe (eg, support groups, volunteering, reaching out to friends). For some patients in which the delusion is seemingly unconnected to the environment, clinicians may reinforce the patient’s experience (“What I am hearing is that you have been feeling fearful lately.”) and point to emotion-focused coping strategies instead.

In a similar vein, Mr Williams also acknowledged hearing the voice of his late grandmother, but notes that he likes hearing from her. Although hallucinations/voices can be extremely distressing, they are not always so, with some cultures or groups having higher rates of positive or benign experiences.¹¹ In fact, there is a growing movement among those with experiences of hallucinatory voices to integrate them into daily life rather than trying to avoid them completely (ie, Hearing Voices Network), with some evidence of success.¹² Providing quality care therefore involves balancing many considerations (eg, existing symptoms, adverse effects, barriers to adherence), and the distress of current symptoms should not be assumed. Follow-up questions should aim to be neutral (“What is it like to hear your grandmother’s voice? How often does this happen? Are you able to shift your focus when other things need to be done?”) to get a better sense of how it impacts Mr Williams.

Case 2

“Ms Khan” is a 55-year-old divorced Sunni Muslim Pakistani woman on disability, diagnosed with schizophrenia. Outside of 3 relapses triggered by big life changes, Ms Khan mostly struggles with negative symptoms (eg, asociality, low motivation). Ms Khan scheduled a mental health appointment because she has been struggling to get out of bed. She explains, “What is keeping me in bed is a jinn holding me down. It stops me from doing my prayers and makes me lazy. I should do my wudhu and pray, but once I get out of practice, I feel guilty and avoid it.”

Ms Khan endorses a belief that the reason she is struggling to leave bed is the influence of a jinn (ie, a supernatural spirit/demon). A provider unfamiliar with Islam may automatically view this as a sign of pathology. To assess this, however, a clinician should attempt to clarify how common this type of belief is to those who are part of the community. Clinicians may do this by asking questions directly (“I am unfamiliar with jinn. Is this a common experience for other individuals you know?”) but may also need to seek consultation from the patient’s community. In this case, research suggests that many Muslims do indeed believe that physical and mental ailments (eg, sleep paralysis, depression, fever) are caused by jinn¹³ and subsequently endorse religious-based solutions such as wudhu (ie, ablution), prayer, and consulting an imam. However, Muslims and other religious groups tend to endorse multiple models of mental illness, often endorsing biological factors in addition to others (eg, jinn, engaging in sin, God’s will, environmental factors).¹⁴

In developing suggestions, clinicians may gain more traction by acknowledging the patient’s perspective. Clinicians should still provide recommendations within their purview (eg, medication changes, therapy recommendations), while also supporting cultural practice and assisting in problem- solving (“Are there other Muslims you know to whom you can reach out for support?”).

In addition, Ms Khan would likely benefit from greater religious coping, because she indicates that being less engaged with her religious practice leads to more distress. In fact, in the United States, the majority of the general public and individuals with schizophrenia in particular endorse engaging in religious and spiritual practices and report finding these practices highly important to them.^15,16 Religious practice is also broadly associated with better mental health.^16,17 In the case of Ms Khan, if clinicians consider behavioral activation—for example, an emphasis on increased religious practice (eg, prayer and wudhu) and engagement with religious community (eg, going to mosque, finding Quran study groups)—this may be especially beneficial, because it already aligns with the patient’s belief system and desires.

Clinicians should be wary of 2 potential issues. First, not all religious coping is created equal, with some strategies consistently leading to less distress (eg, prayer, belief that God is supportive) and others leading to more distress (eg, believing one’s difficulties are a punishment from God, using religion to avoid problems).¹⁸ Second, emphasis on religion may not be useful if the patient endorses significant religious delusions. In these cases, focusing on other strategies (eg, light exercise, relaxation techniques) and support networks (eg, family, book club) tends to be more beneficial.

Case 3

“Mr Baker” is a 60-year-old White retired male veteran who received a diagnosis of schizophrenia and lives with his long-term girlfriend. Over the past year, he has struggled to keep up with chores and relies on his girlfriend to make most of his meals. This has led to fights that escalate into his girlfriend threatening to leave him due to his “laziness, lack of caring, and craziness.” Mr Baker feels like a burden on his girlfriend and is also afraid to tell others how much he struggles with his mental health. “I always prided myself, especially with my veterans group, that I was dependable and logical. If I admit to them that I have heard voices and had to go to the hospital, I will have to admit I am a screwed-up person.”

Mr Baker has internalized the idea that mental illness is shameful, which is more common among men.¹⁹ Unfortunately, self-stigma is linked to marked increases in distress and to greater risk of suicide.²⁰ His noted feelings of burdensomeness, therefore, could warrant a suicide risk assessment. Although psychoeducation can reduce stigma, engaging with individuals openly about their experience with mental illness tends to be most effective.²¹ Mr Baker would likely benefit from a referral to support groups of other veterans with serious mental illness. Providers may begin suggesting these referrals by highlighting the effectiveness of therapy for others, because focusing directly on Mr Baker’s need for support may lead to defensiveness or denial: “I find a lot of veterans in your situation have really enjoyed this outpatient group we have.” Keeping it low stakes may also prove helpful: “Hey, this is a good way to get out of the house and meet some new individuals.”

There is also a high level of criticism and hostility (ie, expressed emotion) in Mr Baker’s household, which research indicates is related to higher rates of relapse for individuals with serious mental illness.²² Hostility and criticism occur in some ethnic groups at higher rates (eg, White families) than others (eg, Latinos).²³ Mr Baker and his girlfriend may benefit from psychoeducation such that they can recognize that many of Mr Baker’s symptoms are related to a mental illness. This could help reduce some of the girlfriend’s frustration by shifting the blame away from her partner. This couple might also benefit from developing strategies to meet their household needs and demands in tandem with each other. Culturally informed therapy for schizophrenia (CIT-S) is a family intervention that emphasizes the family unit’s shared values, engages in psychoeducation with culture in mind, reinforces positive religious coping, and guides the family unit through communication and problem-solving techniques.²⁴ Rather than solely focusing on Mr Baker, it equally acknowledges the needs of his girlfriend and guides both individuals through their shared difficulties.

Concluding Thoughts

Practices like CIT-S also highlight an important message across all 3 cases. Clinicians often see the individual (identified patient) arriving at a session as the sole therapy target. However, there is an untapped but extremely important social support network integral to the lives and well-being of individuals with schizophrenia/psychosis. It may be a family member who suggested they visit a doctor (case 1), a larger religious community that provides meaning (case 2), or a partner who provides resources (case 3). In addition to employing the aforementioned strategies and being mindful of cultural distinctions, providers benefit from relying on these social structures (eg, consultation) and encouraging their patients to be more engaged in these social supports, which ultimately could be an invaluable resource in improving the lives of patients with schizophrenia/psychosis.

Ms McLaughlin is a predoctoral psychology trainee at the University of Miami in Florida. Dr Weisman de Mamani is a professor of psychology at the University of Miami.

References

1. Saha S, Chant D, Welham J, McGrath J. A systematic review of the prevalence of schizophrenia. PLoS Med. 2005;2(5):e141.

2. Tsuang MT, Stone WS, Faraone SV. Genes, environment and schizophrenia. Br J Psychiatry Suppl. 2001;178(40):s18-s24.

3. Mizuno Y, McCutcheon RA, Brugger SP, Howes OD. Heterogeneity and efficacy of antipsychotic treatment for schizophrenia with or without treatment resistance: a meta-analysis. Neuropsychopharmacology. 2020;45(4):622-631.

4. Rabinowitz J, Levine SZ, Garibaldi G, et al. Negative symptoms have greater impact on functioning than positive symptoms in schizophrenia: analysis of CATIE data. Schizophr Res. 2012;137(1-3):147-150.

5. Akinhanmi MO, Biernacka JM, Strakowski SM, et al. Racial disparities in bipolar disorder treatment and research: a call to action. Bipolar Disord. 2018;20(6):506-514.

6. Barrio C, Yamada AM, Atuel H, et al. A tri-ethnic examination of symptom expression on the positive and negative syndrome scale in schizophrenia spectrum disorders. Schizophr Res. 2003;60(2-3):259-269.

7. Weisman AG, López SR, Ventura J, et al. A comparison of psychiatric symptoms between Anglo-Americans and Mexican-Americans with schizophrenia. Schizophr Bull. 2000;26(4):817-824.

8. McLeod MN, Heller D, Manze MG, Echeverria SE. Police interactions and the mental health of Black Americans: a systematic review. J Racial Ethn Health Disparities. 2020;7(1):10-27.

9. Wolny J, Moussa-Tooks AB, Bailey AJ, et al. Race and self-reported paranoia: increased item endorsement on subscales of the SPQ. Schizophr Res. Published online December 9, 2021.

10. Bardol O, Grot S, Oh H, et al. Perceived ethnic discrimination as a risk factor for psychotic symptoms: a systematic review and meta-analysis. Psychol Med. 2020;50(7):1077-1089.

11. Larøi F, Luhrmann TM, Bell V, et al. Culture and hallucinations: overview and future directions. Schizophr Bull. 2014;40(suppl 4):S213-S220.

12. Longden E, Read J, Dillon J. Assessing the impact and effectiveness of Hearing Voices Network self-help groups. Community Ment Health J. 2018;54(2):184-188.

13. Khalifa N, Hardie T, Latif S, et al. Beliefs about Jinn, black magic and the evil eye among Muslims: age, gender and first language influences. Int J Cult Ment. 2011;4(1):68-77.

14. Bagasra A, Mackinem M. An exploratory study of American Muslim conceptions of mental illness. J Muslim Ment Health. 2014;8(1):57-76.

15. Carlson KM, González-Prendes AA. Cognitive behavioral therapy with religious and spiritual clients: a critical perspective. J Spiritual Ment Health. 2016;18(4):253-282.

16. Mohr S, Borras L, Nolan J, et al. Spirituality and religion in outpatients with schizophrenia: a multi-site comparative study of Switzerland, Canada, and the United States. Int J Psychiatry Med. 2012;44(1):29-52.

17. Koenig HG. Religion, spirituality, and health: a review and update. Adv Mind Body Med. 2015;29(3):19-26.

18. Ano GG, Vasconcelles EB. Religious coping and psychological adjustment to stress: a meta‐analysis. J Clin Psychol. 2005;61(4):461-480.

19. Corrigan PW, Watson AC. The stigma of psychiatric disorders and the gender, ethnicity, and education of the perceiver. Community Ment Health J. 2007;43(5):439-458.

20. Oexle N, Rüsch N, Viering S, et al. Self-stigma and suicidality: a longitudinal study. Eur Arch Psychiatry Clin Neurosci. 2017;267(4):359-361.

21. Mittal D, Corrigan P, Drummond KL, et al. Provider opinions regarding the development of a stigma-reduction intervention tailored for providers. Health Educ Behav. 2016;43(5):577-583.

22. Hooley JM. Expressed emotion and relapse of psychopathology. Annu Rev Clin Psychol. 2007;3:329-352.

23. Kymalainen JA, Weisman de Mamani AG. Expressed emotion, communication deviance, and culture in families of patients with schizophrenia: a review of the literature. Cultur Divers Ethnic Minor Psychol. 2008;14(2):85-91.

24. Weisman de Mamani A, McLaughlin M, Altamirano O, et al. Culturally Informed Therapy for Schizophrenia: A Family-Focused Cognitive Behavioral Approach, Clinician Guide. Oxford University Press; 2021. ❒