CHAPTER 2

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

Introduction

To better understand what happens inside the clinical setting, this chapter looks outside. It reveals the diverse effects of culture and society on mental health, mental illness, and mental health services. This understanding is key to developing mental health services that are more responsive to the cultural and social contexts of racial and ethnic minorities.

With a seemingly endless range of subgroups and individual variations, culture is important because it bears upon what all people bring to the clinical setting. It can account for minor variations in how people communicate their symptoms and which ones they report. Some aspects of culture may also underlie culture-bound syndromes — sets of symptoms much more common in some societies than in others. More often, culture bears on whether people even seek help in the first place, what types of help they seek, what types of coping styles and social supports they have, and how much stigma they attach to mental illness. Culture also influences the meanings that people impart to their illness. Consumers of mental health services, whose cultures vary both between and within groups, naturally carry this diversity directly to the service setting.

The cultures of the clinician and the service system also factor into the clinical equation. Those cultures most visibly shape the interaction with the mental health consumer through diagnosis, treatment, and organization and financing of services. It is all too easy to lose sight of the importance of culture — until one leaves the country. Travelers from the United States, while visiting some distant frontier, may find themselves stranded in miscommunications and seemingly unorthodox treatments if they seek care for a sudden deterioration in their mental health.

Health and mental health care in the United States are embedded in Western science and medicine, which emphasize scientific inquiry and objective evidence. The self-correcting features of modern science — new methods, peer review, and openness to scrutiny through publication in professional journals — ensure that as knowledge is developed, it builds on, refines, and often replaces older theories and discoveries. The achievements of Western medicine have become the cornerstone of health care worldwide.

What follows are numerous examples of the ways in which culture influences mental health, mental illness, and mental health services. This chapter is meant to be illustrative, not exhaustive. It looks at the culture of the patient, the culture of the clinician, and the specialty in which the clinician works. With respect to the context of mental health services, the chapter deals with the organization, delivery, and financing of services, as well as with broader social issues — racism, discrimination, and poverty — which affect mental health.

Culture refers to a groups shared set of beliefs, norms, and values (Chapter 1). Because common social groupings (e.g., people who share a religion, youth who participate in the same sport, or adults trained in the same profession) have their own cultures, this chapter has separate sections on the culture of the patient as well as the culture of the clinician. Where cultural influences end and larger societal influences begin, there are contours not easily demarcated by social scientists. This chapter takes a broad view about the importance of both culture and society, yet recognizes that they overlap in ways that are difficult to disentangle through research.

What becomes clear is that culture and social contexts, while not the only determinants, shape the mental health of minorities and alter the types of mental health services they use. Cultural misunderstandings between patient and clinician, clinician bias, and the fragmentation of mental health services deter minorities from accessing and utilizing care and prevent them from receiving appropriate care. These possibilities intensify with the demographic trends highlighted at the end of the chapter.