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More Than a Pound of Cure, an Ounce of Prevention:
Core Constructs for Reducing Mental Health Disparities
What Do We Know About People of Color?
- They have shorter life spans.
- They have higher rates of heart disease, cancer,
and hypertension.
- They have higher rates of negative effects from
substance abuse and sexually transmitted
diseases (NIH, 2000).
- Chronic physical illness creates higher risk
for psychological distress (e.g., anxiety and depression).
What Do We Know About Race?
- That misdiagnosis of physical and mental health can be
due to clinician bias or racial discrimination.
- Institutional racism is evident in health diagnosis,
treatment, and use of medications with people of Color.
- The SGR (2001) report observed that in regard to mental
health “racial and ethnic disparities .. are likely
the result of racism and discrimination” ( p.32).
(DHHS, 2001)
- Studies link racism to poor mental and physical health.
- Racism and discrimination are stressful events that compromise
the mental health of people of Color
What Do We Know About Culture?
- There is a call for behavioral health care to be culturally
competent (DHHS, 2001).
- Cultural competence means as the SGR report noted that;
(1) clinicians and service providers need to consider the
cultural identity of the patient; (2) service providers
need to be able to explore cultural aspects of illness;
and (3) service providers need to consider environmental
factors that contribute to illness and distress.
- Service providers need to examine cultural factors in
the clinician-patient relationship.
- And use a cultural assessment for diagnosis and care.
What Do We Know About Culture and Mental Health Treatment?
- Mental disorders are determined by use of the DSM and
treated according to its guidelines.
- The focus of cultural knowledge for competence is on
members of historically disenfranchised racial groups usually
in terms of their socio-demographic factors.
- There is a historical legacy in the sciences that views
people of Color not as culturally different but as deprived
or inferior.
- The dominant theories of personality and human development
do not consider race or culture as factors in mental health.
- Racism and discrimination and its effects are not incorporated
into mental health assessment , diagnosis, or treatment.
What Do We Need to Know To Understand Race and Culture?
In my research I have questioned how we understand the experiences
of people of Color and the models we use to explain health
disparities. I think we need to understand;
(A) The role of dominant cultural patterns and how dynamic
cultural conflicts are barriers to cultural competence training
and skill development.
(B) Race as a psychological aspect of culture;
(C )How to create and use broader assessment and diagnostic
criteria for understanding psychological distress, and
(D) How to unpack racism so its effects can be better understood.
Dominant White American Cultural Patterns and American
Society
- Individualism social relations and separation
of professional and personal lives.
- Self-expression as external accomplishments.
- Systems of hierarchical power and verbal communication.
- A future time orientation.
- Judeo-Christian religious system.
- Nuclear family structures.
- European cultural traditions.
American Cultural Patterns and Mental Health
The noted patterns of culture are imbedded in our theories
of human development and personality,
Thus models of mental health treatment operate on the same
cultural assumptions.
We believe strongly in individual responsibility, intrapsychic
processes, talking things out with a stranger or professional.
Working with the individual and not a community or family
system.
We seldom include system level influences in assessment of
mental distress due to our cultural beliefs and historical
notions about people of Color.
Cultural Conflicts Are Barriers to Treatment and Training
Dynamic cultural conflicts are when two cultural styles are
operating at the same time but in contradiction to one another.
Dynamic cultural conflicts should be identified and addressed.
American workers are taught to separate work, professional
and personal lives.
Yet to become culturally competent it is necessary to understand
one’s personal cultural experience. A cultural conflict.
We are not accustom to revealing our selves in professional
settings
The more aware one is of his or her cultural norms, values,
communication styles, the easier it is to consider and grasp
another persons’ culture.
Racial Identity, Culture and Psychological Variation.
In American society race has been and is treated as a marker
for culture. Typically as a socio-demographic characteristic.
Racial groups are identified on the basis of skin-color, physical
features and language.
I advocate a point of view that says - race should to be understood
as racial identity, not “race identity”. Racial
identity ego statuses are psychological orientations to one’s
racial group.
Racial Identity Statuses
For instance, possible racial identity resolutions across
racial groups (e.g., White, Asian, Black) includes:
Color-blind perspectives where race is not salient for self
or others;
Confusion about whether and how race is significant;
Realization of the role of race while working to internalize
the culture of one’s racial group;
Integration of race and its meaning into one’s personality,
world-view and emotional life;
An understanding of one’s race that is positive and
valued as non-oppressive.
Racial Identity
The processes I describe are like the social transformation
of the 1960’s. People today referred to as African-American
transformed their social and cultural identity from an imposed
label of Colored, Negroes’ to people who self-identified
as Black and proud.
Thus, a person may have a distinct psychological resolution
(i.e., racial identity ego status) regarding his or racial
group. The resulting resolutions correspond to different constellations
of thoughts, behaviors, attitudes, values, and emotions.
I contend that a new arena for understanding racial and cultural
factors in the development of health and mental health is
psychological variation in people’s group memberships.
Need for Broader Assessment Criteria
I count myself among other scholars (e.g., Norris,
Herman, Carlson) who argue that DSM-IV-TR diagnostic criteria
is too narrow and limited to adequately or accurately capture
the reactions of people of Color.
Broader and non-pathological categories are need to understand
the life-events and the effects of various aspects of daily
living (i.e., stress) that might contribute to mental health
status and reactions of people of Color.
Need for Broader Assessment Criteria -An Example
I authored a report for DMHAS “Disaster Response to
Communities of Color: Culturally Responsive Interventions”.
(visit the DMHAS website for the report).
- Un it I noted that people of Color both citizens and war
veterans have higher rates of PTSD and traumatic stress
reactions than do Whites.
- And they had prior histories of life-event(s) traumatic
stress.
- Thus, researchers contend that people of Color are confronted
with hostility, neglect and racism that may heighten the
effect of life event crisis.
- Also assessment using strict DSM guidelines underestimate
or do not consider systematic sources of stress that may
lead to trauma
What We Need to Know About Racism?
- We know that it is associated with the poor physical
and mental health for people who are targets of racism.
- I have argued that racism be unpacked by distinguishing
between racial discrimination (avoidance) and racial harassment
(hostility).
- I have found that for people of Color racial discrimination
and harassment are related to symptoms of traumatic stress
as defined broadly (I.e., avoidance, intrusion etc.).
- Moreover, racial harassment was more frequent and related
to more severe psychological and emotional injury than was
discrimination.
In Summary To Prevent Mental Health Disparities
- We need to understand dynamic cultural conflicts as barriers
to training for cultural competence.
- We need to move beyond socio-demographic race and adopt
racial identity ego status models to capture the full complexity
of race and culture for all racial groups.
- We need broader non-pathological diagnostic criteria,
and treatment strategies that are racially-culturally based
and not limited.
- We need to define racism as harassment (hostility) and
discrimination (avoidance) and study there differential
effects on mental health.
- Together I think these preventive steps could increase
equity, access and positive outcome for people of Color.
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