Race, Class, and Power

The hidden assumptions about mental health and its treatment

Cultural Influences on Mental Health

1. The assumptions of the DSM

2. Should we focus on race, class, and culture in therapy?

3. Cross-cultural research

a. Two causal models of cultural influence

b. A research example: Jamaica vs. U.S.

4. Implications for psychotherapy

The assumptions of the DSM

Four basic psychological paradigms Psychodynamic Cognitive-Behavioral Humanistic Biological

What assumptions do they share about the etiology of abnormal behavior and mental health problems?

The assumptions of the DSM (cont.)

Assumption 1: The problem is in the person (or family)

Assumption 2: The appropriate intervention is to treat the person (or his/her family)

Why might this be problematic?

Four steps to “blaming the victim”

1. Identify a social problem

2. Study those affected by the problem to discover how they are different from those who are not affected by the problem.

3. Define the difference as the cause of the problem itself

4. Create a humanitarian action (social service) program to correct the differences (from #2)

Four steps to blaming the victim: Steps 1 and 2

1. Identify a social problem

Risky behaviors, including illegal drug and tobacco use, violence, and early sexual activity, are among the top causes of disease and early death among youth.

2. Study those affected by the problem to discover how they are different from those who are not affected by the problem.

Boys often begin to fall behind girls in elementary school, which leads to higher dropout rates and juvenile delinquency, and they often show signs of behavioral problems early in life.

Youth who fall behind in reading have a greater chance of dropping out of high school altogether.

Each year, there are approximately 15 million new STD cases in the U.S., and about one-quarter of these are teenagers.

Half of all new HIV infections affect those 24 and younger, and almost 900,000 women under the age of 19 become pregnant every year.

Injury and violence is the leading cause of death among youth aged 5-19: Motor vehicle crashes account for 31% of all deaths among youth aged 5-19, and alcohol and other drug use is a factor in approximately 41% of all deaths from motor vehicle crashes.

Statistics show boys are at greater risk than girls for developing learning disabilities, illiteracy, dropping out of school, substance-abuse problems, violence, juvenile arrest, and early death caused by violent behavior. As boys grow older, risky behaviors, such as alcohol and drug abuse, become more prevalent, and gang involvement increases.

3. Define the difference as the cause of the problem itself

The President and Mrs. Bush believe parents and family are the first and most important influence in every child's life, providing a foundation of love and support.

[Implication: Children who develop problems receive poor or inadequate parenting]

4. Create a humanitarian action (social service) program to correct the differences (from #2)

An appropriate social program would be an educational program that stresses good decision making, especially in the context of drug use and sex (see the Laura Bush youth initiative at http://www.whitehouse.gov/news/releases/2005/03/20050307-5.html)

Four steps to blaming the victim: Steps 3 and 4

Therapeutic implications of “blaming the victim”

Implication 1: Environmental factors are often ignored or minimized in assessment and treatment

Implication 2: Some individuals are more likely to be negative affected by implication 1 than others

Who is likely to be disproportionally affected?

Urie Bronfenbrenner

Alternative Approach:

Attend to environmental aspects in both assessment and intervention

Often misrepresented

Urie Bronfenbrenner

The original model

Ecology from Ecos: House (Greek)

Ecology: A House in Biological Terms - A system of interacting organisms

The role of culture

Zeitgeist Drapetomania (out) Homosexuality (out) Pathological gambling (in)

Cultural relativity (emic vs etic)

Cultural influences on prevalence

Cross-Cultural Research Methodology

Etic perspective

•Emphasis on universals among human beings by using examination and comparison of many cultures from a position outside those cultures.

•The usual etic imposed is white, middle-class, Anglo-American.

•The original norms on the original MMPI (1972) described a 35-year-old white, married, semi-skilled man with an 8th-grade education

Emic Perspective

Examines behavior from within a culture, using culture-specific criteria

Causal Models of Cultural Influence (Weisz, 1987)

Problem Suppression-Facilitation Model

• Culture suppresses (via punishment) some behaviors

• Culture facilitates (via modeling, reinforcement) other behaviors

Adult-Distress-Threshold Model

• Culture determines adult thresholds for different types of child problems

A research example: Jamaica vs. U.S.

Jamaican Society:

• Descendants from British-owned slaves from West Africa (became fully independent state in 1962).

• Cultural customs reflect a combination of• British values (e.g., respect for authority)• African values (e.g., respect for elders)

• Child-rearing often done by extended family

• Non-related adults have “permission” to address a child’s behavior

U.S. Society:•

•

Externalizing disorders: problems in conforming to expected norms; often cause problems for others.

Rule violations Negativity, anger & aggression Impulsivity Hyperactivity Deficits in attention

Internalizing disorders: experience of subjective distress; others often unaware of their difficulties.

Separation anxiety Depression Phobias

Two types of childhood disorders

Cultural Differences in Child Behaviors

Given your basic knowledge of

• how the Jamaican and U.S. societies are different

• the two major categories of child problems• Internalizing

• Externalizing

Can you make any predictions about how the prevalence of these two types of problems may differ in Jamaican vs. U.S. children?

02468

10

U.S. Jamaica

Ext *

Int *

Parents’ reports of boys ages 6-11

02468

10

U.S. Jamaica

Ext *

Int *

Parents’ reports of boys ages 12-18

Lambert & Lyubansky, 1999

02468

10

U.S. Jamaica

Ext *

Int

02468

10

U.S. Jamaica

Ext

Int *

Parents’ reports of girls ages 6-11

Parents’ reports of girls ages 12-18

Lambert & Lyubansky, 1999

048

121620

U.S. Jamaica

Ext *

Int *

048

121620

U.S. Jamaica

Ext

Int *

Self-reports of boys ages 11-18

Self-reports of girls ages 11-18

Lambert & Lyubansky, 1999

00.5

11.5

2

U.S. Jamaica

Ext

Int

Presenting problems of clinic-referred African-American and Jamaican youths, ages 4 to 18

Lambert et al., 1999

Research Conclusions

1. The data indicate that there are, in fact, cultural influences in child problems, lending support to the two models of cultural influence.

2. Jamaican children tend to have more internalizing problems and U.S. children tend to have more externalizing problems, regardless of age, gender, or reporter.

3. Adolescents report more internalizing problems than parents, regardless of their gender or culture. Do we know why?

4. Understanding cultural differences is necessary to a) understand human behavior and b) to work effectively with people

5. Cultural differences exist, and are likely to become more pronounced with age, as the effects of socialization become more ingrained.

Should we focus on race, class, and culture in therapy?

Two “good” arguments not to:

1. We are all fundamentally the same

2. Each of us is a unique person with unique life experiences

Clinical Implications

Clinical Implications

Consider all clients as individuals first, but recognize that a person’s racial/ethnic group membership is often part of his/her personal identity. Note separately the degree of involvement with both the culture of origin and the new culture.

Never assume that a person's race/ethnicity tells you anything about his or her cultural values or patterns of behavior (see Cross article on Black racial identity).

Treat all "facts" you have ever heard or read about cultural values and traits as hypotheses, to be tested anew with each client. Turn “facts” into questions.

Remember that all members of racial/ethnic minority groups in this society are bicultural. The percentage may be 90-10 (in either direction), but they still have had the task of integrating two value systems that may be in conflict. The conflicts involved in being bicultural may override any specific cultural content.

Clinical implications (continued)

Do not prejudge which aspects of a client's cultural history, values, and lifestyle are relevant to your work with the client. Engage your client actively in the process of learning what cultural content should be considered.

Identify strengths in the client's cultural orientation which can be built upon. Assist the client in identifying areas that create social or psychological conflict related to bi-culturalism and seek to reduce dissonance in those areas.

Know your own attitudes about cultural pluralism, and whether you tend to promote assimilation into the dominant society or stress the maintenance of traditional cultural beliefs and practices.

Identify cultural explanations for the individual’s illness. Also, identify the associated beliefs and attitudes regarding the illness (e.g., temporary vs. permanent)

Be aware of cultural elements in the clinician-client relationship