Module 7: Cultural Perspectives on Mental Health

Stigma, Discrimination, and Mental Health

Mental illness stigma is defined as the “devaluing, disgracing, and disfavoring by the general public of individuals with mental illnesses”.(1) Stigma often leads to discrimination, or the inequitable treatment of individuals and the denial of the “rights and responsibilities that accompany full citizenship”.(2) Stigmatization can cause individual discrimination, which occurs when a stigmatized person is directly denied a resource (e.g. access to housing or a job), and structural discrimination, which describes disadvantages stigmatized people experience at the economic, social, legal, and institutional levels.(3) In addition, stigma can prevent mentally ill individuals from seeking treatment, adhering to treatment regimens, finding employment, and living successfully in community settings. In 2001, the World Health Organization (WHO) identified stigma and discrimination towards mentally ill individuals as “the single most important barrier to overcome in the community”, and the WHO’s Mental Health Global Action Programme (mhGAP) cited advocacy against stigma and discrimination as one of its four core strategies for improving the state of global mental health.(4)(5)

Cultural Perspectives on Mental Illness

Attitudes toward mental illness vary among individuals, families, ethnicities, cultures, and countries. Cultural and religious teachings often influence beliefs about the origins and nature of mental illness, and shape attitudes towards the mentally ill. In addition to influencing whether mentally ill individuals experience social stigma, beliefs about mental illness can affect patients’ readiness and willingness to seek and adhere to treatment.(6) Therefore, understanding individual and cultural beliefs about mental illness is essential for the implementation of effective approaches to mental health care. Although each individual’s experience with mental illness is unique, the following studies offer a sample of cultural perspectives on mental illness.

A review of ethnocultural beliefs and mental illness stigma by Abdullah et al. (2011) highlights the wide range of cultural beliefs surrounding mental health. For instance, while some American Indian tribes do not stigmatize mental illness, others stigmatize only some mental illnesses, and other tribes stigmatize all mental illnesses. In Asia, where many cultures value “conformity to norms, emotional self-control, [and] family recognition through achievement”, mental illnesses are often stigmatized and seen as a source of shame.(7) However, the stigmatization of mental illness can be influenced by other factors, such as the perceived cause of the illness. In a 2003 study, Chinese Americans and European Americans were presented with a vignette in which an individual was diagnosed with schizophrenia or a major depressive disorder. Participants were then told that experts had concluded that the individual’s illness was “genetic”, “partly genetic”, or “not genetic” in origin, and participants were asked to rate how they would feel if one of their children dated, married, or reproduced with the subject of the vignette. Genetic attribution of mental illness significantly reduced unwillingness to marry and reproduce among Chinese Americans, but it increased the same measures among European Americans, supporting previous findings of cultural variations in patterns of mental illness stigmatization.(8)

Many studies have reported other significant differences in attitudes towards mental illness among ethnic groups in the United States. Carpenter-Song et al. (2010) conducted an intensive 18-month observation-based ethnographic study of 25 severely mentally ill individuals living in inner city Hartford, Connecticut. The European American participants frequently sought care from mental health professionals and tended to express beliefs about mental illness that were aligned with biomedical perspectives on disease. In contrast, African American and Latino participants were more likely to emphasize “non-biomedical interpretations” of mental illness symptoms. Although participants of all three ethnic groups reported experiencing stigma due to their mental health, stigma was a core component of the African Americans’ responses but was not highly emphasized by the European Americans. While European Americans tended to view psychiatric medications as “central and necessary” aspects of treatment, African American participants reported frustration over mental health professionals’ focus on medication. Furthermore, Latino participants often viewed clinical diagnoses as “potentially very socially damaging”, preferring to describe their mental health conditions more generally as nervios, which was perceived to hold less stigma. Because African Americans and Latinos in the U.S. are significantly less likely to seek and receive mental health care compared to European Americans, investigating possible cultural contributions to this usage pattern may help efforts to increase uptake of mental health care services.(9)  

Bailey et al. (2011) also report negative attitudes toward health care professionals among many African Americans, noting that stigma, religious beliefs, distrust of the medical profession, and communication barriers may contribute to African Americans’ wariness of mental health services.(10) In a 2007 study, approximately 63% of African Americans viewed depression as a “personal weakness”, 30% reported that they would deal with depression themselves, and only one-third reported that they would accept medication for depression if prescribed by a medical professional.(11) Because African Americans are less likely to receive proper diagnosis and treatment for depression and are more likely to have depression for longer periods, African Americans’ perceptions of mental illness and the medical profession should be taken into account in efforts to improve mental health care access.(12) 

Although the reasons for stigmatization are not consistent across communities or cultures, perceived stigma by individuals living with mental illness is reported internationally. For instance, the World Mental Health Surveys showed that stigma was closely associated with anxiety and mood disorders among adults reporting significant disability. The survey data, which included responses from 16 countries in the Americas, Europe, the Middle East, Africa, Asia, and the South Pacific, showed that 22.1% of participants from developing countries and 11.7% of participants from developed countries experienced embarrassment and discrimination due to their mental illness. However, the authors note that these figures likely underestimate the extent of stigma associated with mental illness since they only evaluated data on anxiety and mood disorders.(13)

Finally, presenting mental health care services in culturally-sensitive ways may be essential to increasing access to and usage of mental health care services, as local beliefs about mental health often differ from the Western biomedical perspective on mental illness. For example, one study comparing Indian and American attitudes toward mental illness surveyed students at a university in the Himalayan region of Northern India and at a university in the Rocky Mountain region of the United States. The Indian students were more likely to view depression as arising from personally controllable causes (e.g. failure to achieve goals) and to “endorse social support and spiritual reflection or relaxation” as ways to deal with depression. The authors report that “conceptualizations and treatments” for depression should take into account diverse perspectives on mental illness in order to maximize the effectiveness of mental health care delivery programs.(14)

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Footnotes

(1) Abdullah, T., Brown, T.L. (2011). Mental illness stigma and ethnocultural beliefs, values, and norms: an integrative review. Clinical Psychology Review, 31: 934-948.

(2) Stuart, H. (2005). Fighting stigma and discrimination in fighting for mental health. Canadian Public Policy, 31: S21-28.

(3) Ibid.

(4) World Health Organization. 2003. “Investing in mental health”. Retrieved 7/2/2012.

(5) World Health Organization. (2001). The World Health Report 2011. Mental Health: New Understanding, New Hope. Geneva: World Health Organization.

(6) Nieuwsma, J.A., Pepper, C.M., Maack, D.J., Birgenheir, D.G. (2011). Indigenous perspectives on depression in rural regions of India and the United States. Transcultural Psychiatry, 48(5): 539-568.

(7) Abdullah, T., Brown, T.L. (2011). Mental illness stigma and ethnocultural beliefs, values, and norms: an integrative review. Clinical Psychology Review, 31: 934-948.

(8) WonPat-Borja, A.J., Yang, L.H., Link, B.G., Phelan, J.C. (2012). Eugenics, genetics, and mental illness stigma in Chinese Americans. Soc Psychiatry Psychiatr Epidemiol., 47(1): 145-156.

(9) Carpenter-Song, E., Chu, E., Drake, R.E., Ritsema, M., Smith, B., Alverson, H. (2010). Ethno-cultural variations in the experience and meaning of mental illness and treatment: implications for access and utilization. Transcultural Psychiatry, 47(2): 224-251.

(10) Bailey, R.K., Milapkumar, P., Barker, N.C., Ali, S., Jabeen, S. (2011). Major depressive disorder in the African American population. J Natl Med Assoc., 103: 548-557.

(11) National Mental Health Association. “What you need to know Clinical Depression and African Americans.” As cited in Bailey, R.K., Milapkumar, P., Barker, N.C., Ali, S., Jabeen, S. (2011). Major depressive disorder in the African American population. J Natl Med Assoc., 103: 548-557.

(12) Bailey, R.K., Milapkumar, P., Barker, N.C., Ali, S., Jabeen, S. (2011). Major depressive disorder in the African American population. J Natl Med Assoc., 103: 548-557.

(13) Alonso, J., Buron, A., Bruffaerts, R., He, Y., Posada-Villa, J., Lepine, J-P., Angermeyer, M.C., Levinson, D., Girolamo, G., Tahimori, H., Mneimneh, Z.N., Medina-Mora, M.E., Ormel, J., Scott, K.M., Gureje, O., Haro, J.M., Gluzman, S., Lee, S., Vilagut, G., R.C. Kessler, Von Korff, M. (2008). Association of perceived stigma and mood and anxiety disorders: results from the World Mental Health Surveys. Acta Psychiatr Scand, 118: 305-314.

(14) Nieuwsma, J.A., Pepper, C.M., Maack, D.J., Birgenheir, D.G. (2011). Indigenous perspectives on depression in rural regions of India and the United States. Transcultural Psychiatry, 48(5): 539-568.