CHAPTER 2

Culture Counts: The Influence of Culture and Society on Mental Health, Mental Illness

Culture of the Clinician

As noted earlier, a group of professionals can be said to have a “culture” in the sense that they have a shared set of beliefs, norms, and values. This culture is reflected in the jargon members of a group use, in the orientation and emphasis in their textbooks, and in their mindset, or way of looking at the world.

Health professionals in the United States, and the institutions in which they train and practice, are rooted in Western medicine. The culture of Western medicine, launched in ancient Greece, emphasizes the primacy of the human body in disease.² Further, Western medicine emphasizes the acquisition of knowledge through scientific and empirical methods, which hold objectivity para-mount. Through these methods, Western medicine strives to uncover universal truths about disease, its causation, diagnosis, and treatment.

Around 1900, Western medicine started to conceptualize disease as affected by social, as well as by biological phenomena. Its scope began to incorporate wider questions of income, lifestyle, diet, employment, and family structure, thereby ushering in the broader field of public health (Porter, 1997; see also Chapter 1).

Mental health professionals trace their roots to Western medicine and, more particularly, to two major European milestones — the first forms of biological psychiatry in the mid-19th century and the advent of psychotherapy (or “talk therapy”) near the end of that century (Shorter, 1997). The earliest forms of biological psychiatry primed the path for more than a century of advances in pharmacological therapy, or drug treatment, for mental illness. The original psychotherapy, known as psychoanalysis, was founded in Vienna by Sigmund Freud. While many forms of psychotherapy are available today, with vastly different orientations, all emphasize verbal communication between patient and therapist as the basis of treatment. Today's treatments for specific mental disorders also may combine pharmacological therapy and psychotherapy; this approach is known as multimodal therapy. These two types of treatment and the intellectual and scientific traditions that galvanized their development are an outgrowth of Western medicine.

To say that physicians or mental health professionals have their own culture does not detract from the universal truths discovered by their fields. Rather, it means that most clinicians share a worldview about the interrelationship among body, mind, and environment, informed by knowledge acquired through the scientific method. It also means that clinicians view symptoms, diagnoses, and treatments in a manner that sometimes diverges from their patients. “[Clinicians’] conceptions of disease and [their] responses to it unquestionably show the imprint of [a] particular culture, especially its individualist and activist therapeutic mentality,” writes sociologist of medicine Paul Starr (1982).

Because of the professional culture of the clinician, some degree of distance between clinician and patient always exists, regardless of the ethnicity of each (Burkett, 1991). Clinicians also bring to the therapeutic setting their own personal cultures (Hunt, 1995; Porter, 1997). Thus, when clinician and patient do not come from the same ethnic or cultural background, there is greater potential for cultural differences to emerge. Clinicians may be more likely to ignore symptoms that the patient deems important, or less likely to understand the patient’s fears, concerns, and needs. The clinician and the patient also may harbor different assumptions about what a clinician is supposed to do, how a patient should act, what causes the illness, and what treatments are available. For these reasons, DSM-IV exhorts clinicians to understand how their relationship with the patient is affected by cultural differences (Chapter 1).

Communication

The emphasis on verbal communication is a distinguishing feature of the mental health field. The diagnosis and treatment of mental disorders depend to a large extent on verbal communication between patient and clinician about symptoms, their nature, intensity, and impact on functioning (Chapter 1). While many mental health professionals strive to deliver treatment that is sensitive to the culture of the patient, problems can occur.

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. Overt and subtle forms of miscommunication and misunderstanding can lead to misdiagnosis, conflicts over treatment, and poor adherence to a treatment plan. But when patient and clinician do not speak the same language, these problems intensify. The importance of cross-cultural communication in establishing trusting relationships between clinician and patient is just beginning to be explored through research in family practice (Cooper-Patrick et al., 1999) and mental health (see later section on “Culturally Competent Services”).

Primary Care

Primary care is a critical portal to mental health treatment for ethnic and racial minorities. Minorities are more likely to seek help in primary care as opposed to specialty care, and cross-cultural problems may surface in either setting (Cooper-Patrick et al., 1999). Primary care providers, particularly under the constraints of man-aged care, may not have the time or capacity to recognize and diagnose mental disorders or to treat them adequately, especially if patients have co-existing physical disorders (Rost et al., 2000). Some estimates suggest that about one–third to one–half of patients with mental disorders go undiagnosed in primary care settings (Higgins, 1994; Williams et al., 1999). Minority patients are among those at greatest risk of nondetection of mental disorders in primary care (Borowsky et al., 2000). Missed or incorrect diagnoses carry severe consequences if patients are given inappropriate or possibly harmful treatments, while their underlying mental disorder is left untreated.

Clinician Bias and Stereotyping

Misdiagnosis also can arise from clinician bias and stereotyping of ethnic and racial minorities. Clinicians often reflect the attitudes and discriminatory practices of their society (Whaley, 1998). This institutional racism was evident over a century ago with the establishment of a separate, completely segregated mental hospital in Virginia for African American patients (Prudhomme & Musto, 1973). While racism and discrimination have certainly diminished over time, there are traces today which are manifest in less overt medical practices concerning diagnosis, treatment, prescribing medications, and referrals (Giles et al., 1995; Shiefer, Escarce, & Schulman, 2000). One study from the mental health field found that African American youth were four times more likely than whites to be physically restrained after acting in similarly aggressive ways, suggesting that racial stereotypes of blacks as violent motivated the professional judgment to have them restrained (Bond et al., 1988). Another study found that white therapists rated a videotape of an African American client with depression more negatively than they did a white patient with identical symptoms (Jenkins-Hall & Sacco, 1991).

There is ample documentation provided in Chapter 3 that African American patients are subject to overdiagnosis of schizophrenia. African Americans are also underdiagnosed for bipolar disorder (Bell et al., 1980, 1981; Mukherjee, et al., 1983), depression, and, possibly, anxiety (Neal-Barnett & Smith, 1997; Baker & Bell, 1999; Borowsky et al., 2000). The problems extend beyond African Americans. Widely held stereotypes of Asian Americans as “problem free” may prompt clinicians to overlook their mental health problems (Takeuchi & Uehara, 1996).

The following chapters of this Supplement each cover diagnostic errors and inappropriate treatment in greater detail. They also address the extent to which each racial or ethnic minority group utilizes services or receives treatment in conformance with treatment guide-lines developed from controlled clinical trials. For example, minority patients are less likely than whites to receive the best available treatments for depression and anxiety (Wang et al., 2000; Young et al., 2001).

To infer a role for bias and stereotyping by clinicians does not prove that it is actually occurring, nor does it indicate the extent to which it explains disparities in mental health services. Some of the racial and ethnic disparities described in this Supplement are likely the result of racism³ and discrimination by white clinicians; how-ever, the limited research on this topic suggests that the issue is more complex. A large study of cardiac patients could not attribute African Americans’ lower utilization of a cardiac procedure to the race of the physician. Lower utilization by African American versus white patients was independent of whether patients were treated by white or black physicians (Chen et al., 2001). The study authors suggested the possibility that institutional factors and attitudes that were common to black and white physicians contributed to lower rates of utilization by black patients. Some have suggested that what appears to be racial bias by clinicians might instead reflect biases of their socioeconomic status or their professional culture (Epstein & Ayanian, 2001). These biases, whether intentional or unintentional, may be more powerful influences on care than the influence of the clinician’s own race or ethnicity.

² In very general terms, most other healing systems throughout history conceived of sickness and health in the context of understanding relations of human beings to the cosmos, including planets, stars, mountains, rivers, deities, spirits, and ancestors (Porter 1997).

³ Defined in the next section of this chapter as “beliefs, attitudes, and practices that denigrate individuals or groups because of phenotypic characteristics or ethnic group affilliation...[which] can be perpetrated by institutions or individuals, acting intentionally or unintentionally.”