Provided by David Satcher, M.D., Ph.D.
Surgeon General of the United States of America
Chapter 2
Overview of Cultural Diversity and Mental Health Services
Coping Styles
Cultural differences can be reflected in differences in preferred styles of
coping with day-to-day problems. Consistent with a cultural emphasis on
restraint, certain Asian American groups, for example, encourage a tendency not
to dwell on morbid or upsetting thoughts, believing that avoidance of troubling
internal events is warranted more than recognition and outward expression (Leong
& Lau, 1998). They have little willingness to behave in a fashion that might
disrupt social harmony (Uba, 1994). Their emphasis on willpower is similar to
the tendency documented among African Americans to minimize the significance of
stress and, relatedly, to try to prevail in the face of adversity through
increased striving (Broman, 1996).
Culturally rooted traditions of religious beliefs and practices carry important
consequences for willingness to seek mental health services. In many traditional
societies, mental health problems can be viewed as spiritual concerns and as
occasions to renew one’s commitment to a religious or spiritual system of belief
and to engage in prescribed religious or spiritual forms of practice. African
Americans (Broman, 1996) and a number of ethnic groups (Lu et al., 1995), when
faced with personal difficulties, have been shown to seek guidance from
religious figures.23
Many people of all racial and ethnic backgrounds believe that religion and
spirituality favorably impact upon their lives and that well-being, good health,
and religious commitment or faith are integrally intertwined (Taylor, 1986;
Priest, 1991; Bacote, 1994; Pargament, 1997). Religion and spirituality are
deemed important because they can provide comfort, joy, pleasure, and meaning to
life as well as be means to deal with death, suffering, pain, injustice,
tragedy, and stressful experiences in the life of an individual or family (Pargament,
1997). In the family/community-centered perception of mental illness held by
Asians and Hispanics, religious organizations are viewed as an enhancement or
substitute when the family is unable to cope or assist with the problem (Acosta
et al., 1982; Comas-Diaz, 1989; Cook & Timberlake, 1989; Meadows, 1997).
Culture also imprints mental health by influencing whether and how individuals
experience the discomfort associated with mental illness. When conveyed by
tradition and sanctioned by cultural norms, characteristic modes of expressing
suffering are sometimes called “idioms of distress” (Lu et al., 1995). Idioms of
distress often reflect values and themes found in the societies in which they
originate.
One of the most common idioms of distress is somatization, the expression of
mental distress in terms of physical suffering. Somatization occurs widely and
is believed to be especially prevalent among persons from a number of ethnic
minority backgrounds (Lu et al., 1995). Epidemiological studies have confirmed
that there are relatively high rates of somatization among African Americans
(Zhang & Snowden, in press). Indeed, somatization resembles an African American
folk disorder identified in ethnographic research and is linked to seeking
treatment (Snowden, 1998).
A number of idioms of distress are well recognized as culture-bound syndromes
and have been included in an appendix to DSM-IV. Among culture-bound syndromes
found among some Latino psychiatric patients is ataque de nervios, a syndrome of
“uncontrollable shouting, crying, trembling, and aggression typically triggered
by a stressful event involving family. . . ” (Lu et al., 1995, p. 489). A
Japanese culture-bound syndrome has appeared in that country’s clinical
modification of ICD-10 (WHO International Classification of Diseases, 10th
edition, 1993). Taijin kyofusho is an intense fear that one’s body or bodily
functions give offense to others. Culture-bound syndromes sometimes reflect
comprehensive systems of belief, typically emphasizing a need for a balance
between opposing forces (e.g., yin/yang, “hot-cold” theory) or the power of
supernatural forces (Cheung & Snowden, 1990). Belief in indigenous disorders and
adherence to culturally rooted coping practices are more common among older
adults and among persons who are less acculturated. It is not well known how
applicable DSM-IV diagnostic criteria are to culturally specific symptom
expression and culture-bound syndromes.
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