Culture Counts: The Influence of Culture and Society

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

Racism, Discrimination, and Mental Health
Since its inception, America has struggled with its handling of matters related to race, ethnicity, and immigration. The histories of each racial and ethnic minority group attest to long periods of legalized discrimination— and more subtle forms of discrimination — within U.S. borders (Takaki, 1993). Ancestors of many of today’s African Americans were forcibly brought to the United States as slaves. The Indian Removal Act of 1830 forced American Indians off their land and onto reservations in remote areas of the country that lacked natural resources and economic opportunities. The Chinese Exclusion Act of 1882 barred immigration from China to the U.S. and denied citizenship to Chinese Americans until it was repealed in 1952. Over 100,000 Japanese Americans were unconstitutionally incarcerated during World War II, yet none was ever shown to be disloyal. Many Mexican Americans, Puerto Ricans, and Pacific Islanders became U.S. citizens through conquest, not choice. Although racial and ethnic minorities cannot lay claim to being the sole recipients of maltreatment in the United States, legally sanctioned discrimination and exclusion of racial and ethnic minorities have been the rule, rather than the exception, for much of the history of this country. Each of the later chapters of this Supplement describes some of the key historical events that helped shape the contemporary mental health status of each group.

Racism and discrimination are umbrella terms refer-ring to beliefs, attitudes, and practices that denigrate individuals or groups because of phenotypic characteristics (e.g., skin color and facial features) or ethnic group affiliation. Despite improvements over the last three decades, research continues to document racial discrimination in housing rentals and sales (Yinger, 1995) and in hiring practices (Kirschenman & Neckerman, 1991). Racism and discrimination also have been documented in the administration of medical care. They are manifest, for example, in fewer diagnostic and treatment procedures for African Americans versus whites (Giles et al., 1995; Shiefer et al., 2000). More generally, racism and discrimination take forms from demeaning daily insults to more severe events, such as hate crimes and other violence (Krieger et al., 1999). Racism and discrimination can be perpetrated by institutions or individuals, acting intentionally or unintentionally.

Public attitudes underlying discriminatory practices have been studied in several national surveys conducted over many decades. One of the most respected and nationally representative surveys is the General Social Survey, which in 1990 found that a significant percent-age of whites held disparaging stereotypes of African Americans, Hispanics, and Asians. The most extreme findings were that 40 to 56 percent of whites endorsed the view that African Americans and Hispanics “prefer to live off welfare” and “are prone to violence” (Davis & Smith, 1990).

Minority groups commonly report experiences with racism and discrimination, and they consider these experiences to be stressful (Clark et al., 1999). In a national probability sample of minority groups and whites, African Americans and Hispanic Americans reported experiencing higher overall levels of global stress than did whites (Williams, 2000). The differences were greatest for two specific types: financial stress and stress from racial bias. Asian Americans also reported higher overall levels of stress and higher levels of stress from racial bias, but sampling methods did not permit statistical comparisons with other groups. American Indians and Alaska Natives were not studied (Williams, 2000).

Recent studies link the experience of racism to poorer mental and physical health. For example, racial inequalities may be the primary cause of differences in reported quality of life between African Americans and whites (Hughes & Thomas, 1998). Experiences of racism have been linked with hypertension among African Americans (Krieger & Sidney, 1996; Krieger et al., 1999). A study of African Americans found perceived6 discrimination to be associated with psychological distress, lower well-being, self-reported ill health, and number of days confined to bed (Williams et al., 1997; Ren et al., 1999).

A recent, nationally representative telephone survey looked more closely at two overall types of racism, their prevalence, and how they may differentially affect mental health (Kessler et al., 1999). One type of racism was termed “major discrimination” in reference to dramatic events like being “hassled by police” or “fired from a job.” This form of discrimination was reported with a lifetime prevalence of 50 percent of African Americans, in contrast to 31 percent of whites. Major discrimination was associated with psychological distress and major depression in both groups. The other form of discrimination, termed “day-to-day perceived discrimination,” was reported to be experienced “often” by almost 25 percent of African Americans and only 3 percent of whites. This form of discrimination was related to the development of distress and diagnoses of generalized anxiety and depression in African Americans and whites. The magnitude of the association between these two forms of discrimination and poorer mental health was similar to other commonly studied stressful life events, such as death of a loved one, divorce, or job loss.

While this line of research is largely focused on African Americans, there are a few studies of racism’s impact on other racial and ethnic minorities. Perceived discrimination was linked to symptoms of depression in a large sample of 5,000 children of Asian, Latin American, and Caribbean immigrants (Rumbaut, 1994). Two recent studies found that perceived discrimination was highly related to depressive symptoms among adults of Mexican origin (Finch et al., 2000) and among Asians (Noh et al., 1999).

In summary, the findings indicate that racism and discrimination are clearly stressful events (see also Clark et al., 1999). Racism and discrimination adversely affect health and mental health, and they place minorities at risk for mental disorders such as depression and anxiety. Whether racism and discrimination can by themselves cause these disorders is less clear, yet deserves research attention.

These and related findings have prompted researchers to ask how racism may jeopardize the mental health of minorities. Three general ways are proposed:

(1) Racial stereotypes and negative images can be internalized, denigrating individuals’ self-worth and adversely affecting their social and psycho-logical functioning;

(2) Racism and discrimination by societal institutions have resulted in minorities’ lower socioeconomic status and poorer living conditions in which poverty, crime, and violence are persistent stressors that can affect mental health (see next section); and

(3) Racism and discrimination are stressful events that can directly lead to psychological distress and physiological changes affecting mental health (Williams & Williams-Morris, 2000).

Poverty, Marginal Neighborhoods, and Community Violence

Poverty disproportionately affects racial and ethnic minorities. The overall rate of poverty in the United States, 12 percent in 1999, masks great variation. While 8 percent of whites are poor, rates are much higher among racial and ethnic minorities: 11 percent of Asian Americans and Pacific Islanders, 23 percent of Hispanic Americans, 24 percent of African Americans, and 26 percent of American Indians and Alaska Natives (U. S. Census Bureau, 1999). Measured another way, the per capita income for racial and ethnic minority groups is much lower than that for whites (Table 2-2).

measured capita income racial ethnic minority groups whites table 2-2Table 2-2 gives Per Capita Income averages by ethnicity in 1999

For centuries, it has been known that people living in poverty, whatever their race or ethnicity, have the poorest overall health (see reviews by Krieger, 1993; Adler et al., 1994; Yen & Syme, 1999). It comes as no surprise then that poverty is also linked to poorer mental health (Adler et al., 1994). Studies have consistently shown that people in the lowest strata of income, education, and occupation (known as socioeconomic status, or SES) are about two to three times more likely than those in the highest strata to have a mental disorder (Holzer et al., 1986; Regier et al., 1993; Muntaner et al., 1998). They also are more likely to have higher levels of psychological distress (Eaton & Muntaner, 1999).

Poverty in the United States has become concentrated in urban areas (Herbers, 1986). Poor neighborhoods have few resources and suffer from considerable distress and disadvantage in terms of high unemployment rates, homelessness, sub-stance abuse, and crime. A disadvantaged community marked by economic and social flux, high turnover of residents, and low levels of supervision of teenagers and young adults creates an environment conducive to violence. Young racial and ethnic minority men from such environments are often perceived as being especially prone to violent behavior, and indeed they are disproportionately arrested for violent crimes. However, the recent Surgeon General’s Report on Youth Violence cites self-reports of youth from both majority and minority populations that indicate that differences in violent acts committed may not be as large as arrest records suggest. The Report on Youth Violence concludes that race and ethnicity, considered in isolation from other life circumstances, shed little light on a given child’s or adolescent’s propensity for engaging in violence (DHHS, 2001).

Regardless of who is perpetrating violence, it disproportionately affects the lives of racial and ethnic minorities. The rate of victimization for crimes of violence is higher for African Americans than for any other ethnic or racial group (Maguire & Pastore, 1999). More than 40 percent of inner city young people have seen someone shot or stabbed (Schwab-Stone et al., 1995). Exposure to community violence, as victim or witness, leaves immediate and sometimes long-term effects on mental health, especially for youth (Bell & Jenkins, 1993; Gorman-Smith & Tolan, 1998; Miller et al., 1999).

How is poverty so clearly related to poorer mental health? This question can be answered in two ways. People who are poor are more likely to be exposed to stressful social environments (e.g., violence and unemployment) and to be cushioned less by social or material resources (Dohrenwend, 1973; McLeod & Kessler, 1990). In this way, poverty among whites and nonwhites is a risk factor for poor mental health. Also, having a mental disorder, such as schizophrenia, takes such a toll on individual functioning and productivity that it can lead to poverty. In this way, poverty is a consequence of mental illness (Dohrenwend et al., 1992). Both are plausible explanations for the robust relationship between poverty and mental illness (DHHS, 1999).

Scholars have debated whether low SES alone can explain cultural differences in health or health care utilization (e.g. Lillie-Blanton et al., 1996; Williams, 1996; Stolley, 1999, 2000; LaVeist, 2000; Krieger, 2000). Most scholars agree that poverty and socioeconomic status do play a strong role, but the question is whether they play an exclusive role. The answer to this question is “no.” Evidence contained within this Supplement is clearly contrary to the simple assertion that lower SES by itself explains ethnic and racial disparities. An excellent example is presented in Chapter 6. Mexican American immigrants to the United States, although quite impoverished, enjoy excellent mental health (Vega et al., 1998). In this study, immigrants’ culture was interpreted as protecting them against the impact of poverty. In other studies of African Americans and Hispanics (cited in Chapters 3 and 6), more generous mental health coverage for minorities did not eliminate disparities in their utilization of mental health services. Minorities of the same SES as whites still used fewer mental health services, despite good access.

The debate separates poverty from other factors that might influence the outcome — such as experiences with racism, help-seeking behavior, or attitudes — as if they were isolated or independent from one another. In fact, poverty is caused in part by a historical legacy of racism and discrimination against minorities. And minority groups have developed coping skills to help them endure generations of poverty. In other words, poverty and other factors are overlapping and interdependent for different ethnic groups and different individuals. As but one example, the experience of poverty for immigrants who previously had been wealthy in their homeland cannot be equated with the experience of poverty for immigrants coming from economically disadvantaged backgrounds.

An important caveat in reviewing this evidence is that while most researchers measure and control for SES they do not carefully define and measure aspects of culture. Many studies report the ethnic or racial back-grounds of study participants as a shorthand for their culture, without systematically examining more specific information about their living circumstances, social class, attitudes, beliefs, and behavior. In the future, defining and measuring different aspects of culture will strengthen our understanding ethnic differences that occur, beyond those explained by poverty and socioeconomic status.

6 Perceived discrimination” is the term used by researchers in reference to the self-reports of individuals about being the target of discrimination or racism. The term is not meant to imply that racism did not take place.

Demographic Trends
The United States is undergoing a major demographic transformation in racial and ethnic composition of its population. In 1990, 23 percent of U.S. adults and 31 percent of children were from racial and ethnic minority groups (Hollmann, 1993). In 25 years, it is projected that about 40 percent of adults and 48 percent of children will be from racial and ethnic minority groups (U.S. Census Bureau, 2000; Lewit & Baker, 1994). While these changes bring with them the enormous richness of diverse cultures, significant changes are needed in the mental health system to meet the associated challenges, a topic addressed in Chapter 7.

Diversity within Racial and Ethnic Groups

The four most recognized racial and ethnic minority groups are themselves quite diverse. For instance, Asian Americans and Pacific Islanders include at least 43 separate subgroups who speak over 100 languages. Hispanics are of Mexican, Puerto Rican, Cuban, Central and South American, or other Hispanic heritage (U.S. Census Bureau, 2000). American Indian/Alaskan Natives consist of more than 500 tribes with different cultural traditions, languages, and ancestry. Even among African Americans, diversity has recently increased as black immigrants arrive from the Caribbean, South America, and Africa. Some members of these subgroups have largely acculturated or assimilated into mainstream U.S. culture, whereas others speak English with difficulty and interact almost exclusively with members of their own ethnic group.

Growth Rates

African Americans had long been the country’s largest ethnic minority group. However, over the past decade, they have grown by just 13 percent to 34.7 million people. In contrast, higher birth and immigration rates led Hispanics to grow by 56 percent, to 35.3 million people, while the whites grew just 1 percent from 209 million to 212 million. According to 2000 census figures, Hispanics have replaced African Americans as the second largest ethnic group after whites (U.S. Census Bureau, 2001).

Hispanics grew faster than any other ethnic minority group in terms of the actual number of individuals and the rate of population growth. The group with the second highest rate of population growth was Asian Americans, who in the 2000 census were counted separately from Native Hawaiians and Other Pacific Islanders. Because of immigration, the Asian American population grew 40.7 percent to 10.6 million people, and this growth is projected to continue throughout the century (U.S. Census Bureau, 2001).

American Indians and Alaska Natives surged between 38 and 50 percent over each of the decades from the 1960s through the 1980s. However, during the 1990s, the rate of growth was slightly slower (19%). Even so, the rate is still greater than that for the general population. One factor accounting for this higher-than-average growth rate is an increase in the number of people who now identify themselves as American Indian or Alaska Native. The current size of the American Indian and Alaska Native population is just under 1 percent of the total U.S. population, or about 2.5 million people. This number nearly doubles, however, when including individuals who identify as being American Indian and Alaska Native as well as one or more other races (U.S. Census Bureau, 2001).

The numbers of ethnic minority children and youth are increasing most rapidly. Between 1995 and 2015, the numbers of black youth are expected to increase by 19 percent, American Indian and Alaska Native youth by 17 percent, Hispanic youth by 59 percent, and Asian and Pacific Islander youth by 74 percent. During the same period, the white youth population is expected to increase by 3 percent (Snyder & Sickmund, 1999).

Geographic Distribution

Until the 1960s, American Indians, Asian Americans, and Hispanic Americans were geographically isolated. Before then, American Indians lived primarily on reservations to which the government assigned them. Few Asian Americans lived outside California, Hawaii, Washington, and New York City. Latinos resided primarily in the southwestern border States, New York City, and a few midwestern industrial cities (Harrison & Bennett, 1995).

Today, although they are not evenly distributed, members of each of the four major racial and ethnic minority groups reside throughout the United States. The western States are the most ethnically diverse in the United States, and they are home to many Latinos, Asian Americans, and American Indians. In the Midwest, which is less ethnically diverse, over 85 percent of the population is white, and most of the remainder is black. This proportion has remained relatively unchanged since the 1970s.

Although the Nation as a whole is becoming more ethnically diverse, this diversity remains relatively concentrated in a few States and large metropolitan areas. In general, minorities are more likely than whites to live in urban areas. In 1997, 88 percent of minorities lived in cities and their surrounding areas, compared to 77 percent of whites. American Indians/Alaska Natives and African Americans are the only minority groups with any consider-able rural population. (U.S. Census Bureau, 1999).

Impact of Immigration Laws

During the last century, U.S. immigration laws alternately closed and opened the doors of immigration to different foreign populations. For example, the 1924 Immigration Act established the National Origins System, which restricted annual immigration from any foreign country to 2 percent of that country’s population living in the United States, as counted in the census of 1890. Since most of the foreign-born counted in the 1890 census were from northern and western European countries, the 1924 Immigration Act reinforced patterns of white immigration and staved off immigration from other areas, including Asia, Latin America, and Africa.

Until the 1960s, approximately two–thirds of all legal immigrants to the United States were from Europe and Canada. The Immigration Act of 1965 replaced the National Origins System and allowed an annual immigration quota of 20,000 individuals from each country in the Eastern Hemisphere. The Act also gave preference to individuals in certain occupations. The effect was striking: Immigration from Asia skyrocketed from 6 percent of all immigrants in the 1950s to 37 percent by the 1980s. Yet another provision of the Act supported family reunification and gave preference to people with relatives in the United States, one factor behind the growth in immigration from Mexico and other Latin American countries (U.S. Census Bureau, 1999). Over this same period of time, the percentage of immigrants from Europe and Canada fell from 68 percent to 12 percent (U.S. Immigration and Naturalization Service, 1999).

In the past 20 years, immigration has led to a shift in the racial and ethnic composition of the United States not witnessed since the late 17th century, when black slaves became part of the labor force in the South (Muller, 1993). Though this wave of immigration is similar to the surge of immigration that occurred in the early part of this century, a critical difference is in the countries of origin. In the early 1900s, immigrants primarily came from Europe and Canada, while recent immigration is primarily from Asian and Latin American countries.

Overall, the racial and ethnic makeup of the United States has changed more rapidly since 1965 than during any other period in history. The reform in immigration policy in 1965, the increase in self-identification by ethnic minorities, and the slowing of the country’s birth rates, especially among non-Hispanic white Americans, have all led to an increasing, and increasingly diverse, racial and ethnic minority population in the United States.

1. Culture influences many aspects of mental illness, including how patients from a given culture express and manifest their symptoms, their style of coping, their family and community supports, and their willingness to seek treatment. Likewise, the cultures of the clinician and the service system influence diagnosis, treatment, and service delivery. Cultural and social influences are not the only determinants of mental illness and patterns of service utilization for racial and ethnic minorities, but they do play important roles.

2. Mental disorders are highly prevalent across all populations, regardless of race or ethnicity. Cultural and social factors contribute to the causation of mental illness, yet that contribution varies by disorder. Mental illness is considered the product of a complex interaction among biological, psychological, social, and cultural factors. The role of any one of these major factors can be stronger or weaker depending on the specific disorder.

3. Within the United States, overall rates of mental disorders for most minority groups are largely similar to those for whites. This general conclusion does not apply to vulnerable, high-need sub-groups, who have higher rates and are often not captured in community surveys. The overall rates of mental disorder for many smaller racial and ethnic groups, most notably American Indians, Alaska Natives, Asian Americans and Pacific Islanders are not sufficiently studied to permit definitive conclusions.

4. Ethnic and racial minorities in the United States face a social and economic environment of inequality that includes greater exposure to racism and discrimination, violence, and poverty, all of which take a toll on mental health. Living in poverty has the most measurable impact on rates of mental illness. People in the lowest stratum of income, education, and occupation are about two to three times more likely than those in the highest stratum to have a mental disorder.

5. Racism and discrimination are stressful events that adversely affect health and mental health. They place minorities at risk for mental disorders such as depression and anxiety. Whether racism and discrimination can by themselves cause these disorders is less clear, yet deserves research attention.

6. Stigma discourages major segments of the population, majority and minority alike, from seeking help. Attitudes toward mental illness held by minorities are as unfavorable, or even more unfavorable, than attitudes held by whites.

7. Mistrust of mental health services is an important reason deterring minorities from seeking treatment. Their concerns are reinforced by evidence, both direct and indirect, of clinician bias and stereotyping. The extent to which clinician bias and stereotyping explain disparities in mental health services is not known.

8. The cultures of ethnic and racial minorities alter the types of mental health services they use. Cultural misunderstandings or communication problems between patients and clinicians may prevent minorities from using services and receiving appropriate care.

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