What does a clinician need to know about the delivery of mental health services to African Americans? What kinds of information and knowledge does the clinician need to know about African Americans, other than general, sociocul-tural, and demographic patterns obtained from group data? How do general sociocultural and demographic factors relate to the delivery of mental health services for African Americans? Does separating African American patients into ethnic or cultural groups contribute to treating them? These and other questions and concerns will be addressed below specifically for African Americans while at the same time providing guidance in applying multicultural assessment practices with African Americans.
1. Does multicultural assessment and treatment of mental health problems and disorders in African Americans in any way discredit traditional therapies? The answer is no. Traditional therapies including psychodynamic, behavior therapies, psychotropic therapies, group therapies, insight-oriented, supportive, or behavior-modifying therapies that are used with European American patients also can be used with African Americans. The problem is that traditional approaches sometimes do not seem to work as well for most African Americans as they do for most European Americans. Sometimes traditional approaches have to be modified in some manner or form in order to improve their acceptability and effectiveness. Could it be that systems and therapies are more appropriate in some ways for some consumers than for others? Psychotherapy is not for everybody, it appears to be more effective with more verbal, insightful, and reflective people. Behavior therapies are not for everybody either. Systematic desensitization is appropriate for some problems but not for others. Individuals with different problems respond better to specific therapies. This is nothing new. This is, however, an important clinical skill to learn (i.e., to know what kinds of problems respond best to which therapies). The point here is that African Americans may have very different problems than persons from other groups. Many problems will be in common with all groups, but many problems also are unique onto themselves. It is good for the clinician to have some idea as to the kind of life, psychosocial stressors, problems, burdens, trials, world-views, and the like that characterize the life of their client.
At the beginning of the 20th century, it was recognized that psychiatric and psychological care entails communicating with the patient, and the appreciation for the importance of detailed knowledge of the influences the particular culture exerts over the individual. (Also see Marselle, chapter 1, this volume, for a more detailed history of the "struggle" to include the role of culture as a determinant of behavior). Early writers and psychiatrists such as Emil Kraepelin
(1904), Erich Fromm, Wilhelm Reich, Harry Stack Sullivan, and John Dollard (Homey, 1936) recognized the importance of cultural factors as a determining influence in psychological conditions. A physical problem like a broken leg can be treated by anyone trained to treat a broken leg. The racial and ethnic background of the physician or healer doesn't matter, neither does the racial, ethnic, linguistic, or cultural group the patient belongs to for treatment of the patient's broken leg. However, these factors do matter in the provision of mental health care. Assessment of mental status entails sophisticated, structured, nonstruc-tured, standardized, and nonstandardized observations, communication, and testing of the patient in order to assess, among other cognitions and feelings, orientation, reasoning, conceptualization, motivation, thought processes, insight, intelligence, mood, and personality. Often such an assessment has to be conducted within limited time constraints, sometimes limited by reimbursement sources and other times by the setting. An inpatient hospital consultation may need to be accomplished within a 30- or 50-minute period of time. There is a lot to be learned about the patient, and there are many opportunities for miscommunication. Even when the same word is used by two people there can be miscommunication as to meaning.
Miscommunication is exacerbated when expressions of speech, dialects, phrases, metaphors, and the like are used with common meaning between the provider and the consumer of mental health care. The greater the cultural differences existing between the provider and the consumer of mental health care, including socioeconomic, gender, ethnic, language, and worldviews, the greater is the likelihood of misdiagnosis, inappropriate care, or noncompliance with treatment.
The notion that one needs to walk in someone else's shoes to really understand that person has much appeal to many people because it makes intuitive sense. Of course, it is not literally necessary for a professional mental health worker to actually walk in their client's shoes to understand and provide appropriate care and therapy. But if the professional did walk a day, for example, in their patient's shoes, whatever knowledge gained from this act should augment the quality of therapy rendered, and should not in any way discredit the professional's knowledge, skills, and/or training. Communication, empathy, compassion, appreciation, affection, insight, and comprehension increase commensurate with greater knowledge of others.
Traditional therapies have valued directive approaches, individual responsibility, looking inward, self-understanding, personal growth, and improvement in social and occupational functioning, resolution of dependency needs, verbal and emotional expressiveness, and thinking through problems. These same therapies can be used with African Americans; however, some African Americans will respond even more favorably if therapy efforts are directed toward the environment or toward working with the extended family or toward spirtualistic and/or religious interventions, or toward strengthening interdependence giving direct advice, and to special symbolic approaches.
Cognitive therapy for depression can be used as an example. The basic principles of cognitive therapy are the same for individuals suffering from depression regardless of their racial and ethnic background. It is a traditional form of psychological therapy appropriate for African Americans as it is for Hispanics, Asian Americans, American Indians, Native Americans, and European Americans. An example of the way in which cognitive therapy could be applied across diverse populations from a multicultural perspective is that individual explanatory models are linked to the cultural background of the person. For example, in culture "A," needs for achievement, individual responsibility, and guilt may be intricately tied to a patient's explanatory model, whereas in culture "B," needs for acceptance, interdependence, and fatalistic beliefs may be linked to their explanatory model. An individual clinical assessment in the development of a cognitive therapy plan that does not identify such cultural differences between a patient for culture "A" and "B" would most likely not lead to effectual treatment.
2. Does multicultural assessment and treatment of mental health problems and disorders in African Americans presume that most practitioners are racist? The answer is no. Multicultural Therapy understands the reality that people with racist attitudes exist in the real world. It also recognizes that people have biases and that people harbor negative stereotypes. What Multicultural Therapy stresses is that whenever working cross-culturally with individuals from racial/ ethnic/cultural groups different from oneself, it is essential to routinely ask oneself, "Do I have any conflicting values with this consumer?" Some people who have racist attitudes are not consciously aware of their racism while others are. Some people who are not racist, nonetheless, have strong conflicting values with their consumers. There is no presumption of racism in multicultural therapies and interventions. For the therapist to ask himself or herself if they hold any racist, discriminating, or prejudicial attitudes toward members of their client's ethnic and racial group is not to presume racism. It is a healthy question for all therapists to ask of themselves. Questions such as, "Would I view this client differently if they were from my own ethnic group?" These questions do not presume that the therapist is racist. What they do presume is that everybody is human and we all hold biases from time to time. Furthermore, it is important for therapists to be in touch with their own feelings, attitudes, and values held with respect to their own culture and other ethnic group(s). Most therapists are not racist, as racism strives to oppress people, whereas mental health strives to empower people, the same goal of psychotherapy. Oppression and empowerment are incompatible goals. However, trainees are people and like many people may come into their training programs with prejudicial and racist attitudes toward other groups. It is not a minor point that multicultural sensitivity training is promoted by the American Psychological Association, the American Psychiatric Association, and other mental health professional organizations and associations. It is not because of a presumption of racism but a presumption of need for some kinds of cultural training when assessing and treating people from different ethnocultural groups. It cannot even be presumed that because a trainee is from a given racial or ethnic cultural group that they do not require knowledge or training with that group.
A multicultural therapist, like a good psychotherapist requires knowledge of self in order to provide appropriate help for others. Multicultural therapy practices emphasize the importance of learning about self and others. Like other good scientific practices, it requires objectivity, stepping back, reflecting, relating, and integrating formal practice knowledge with applied experiential knowledge.
3. Does multicultural assessment and treatment of mental health problems and disorders in African Americans require the acceptance of stereotypes as the basis of therapy? The answer is no. A frequently heard criticism of multicultural psychotherapy and related professional practices is that it requires the acceptance of blatant ethnic stereotypes as the basis for psychological treatment. Paniagua (1998) in his book on Assessing and Treating Culturally Diverse Clients is careful to warn the reader in the Preface that descriptions of cultural variables reflect generalizations. They don't apply to everyone who is a member of that group, and they represent heterogeneous constructs that vary both within and across groups. Paniagua indicates that for any group there are cultural commonalities with other cultural groups as well as cultural differences reflected in diversity. These generalizations about a group are not stereotypes. Stereotypes are "something conforming to a fixed or general pattern" according to Webster's Ninth New Collegiate Dictionary (Webster, 1991). These general descriptions, like the ones provided at the beginning of this chapter, about African Americans are acknowledged to be nonfixed descriptions and clearly do not characterize all members of that group. Cultural descriptions obtained from multicultural approaches do not impose a one-size-fits-all cultural diagnosis to be used with all persons from that group. Neither do they establish rigid rules of treatment based on groupthink.
Group-based generalizations represent knoweldge used as cultural variables to better understand members of that group. Group-based generalizations when obtained using sound scientific methods should represent relative truths. Knowing, for example, that historical hostility is a pattern of responses (rage, violence, crime, and substance abuse) found in many African Americans (Vontress & Epp, 1997) is important clinical information to know. If this information were used as a stereotype, the clinician would think and behave according to that stereotype, and would treat each African American client as though he or she automatically had "historical hostility." The way that information about "historical hostility" can be used constructively is to prepare therapeutic techniques or strategies that break through this defense, or stance, if historical hostility is or becomes a therapeutic barrier during assessment and treatment. From a preventive perspective, historical hostility could be studied. It would be of interest to research its etiology and development in African Americans: who has it worse, how it is learned or taught, and how is it dysfunction, and how can it be channeled into positive, proactive growth and development?
4. Does multicultural assessment and treatment of mental health problems and disorders in African Americans excuse dysfunctional behavior as misunderstood cultural behavior? The answer is no. A frequently used example of multi-culturalism excusing dysfunctional behavior is the concept of "healthy paranoia." An African American client having paranoid ideation (feelings and thoughts that others are conspiring to do one harm) is seen as expressing defensive behavior in response to discrimination or racism. By relabeling paranoia as defensive behavior, this excuses important symptoms of mental disorder. Another manner in which multicultural approaches are supposed to excuse dysfunctional behavior is to label it as "cultural" and thus acceptable. For example, because it is normal in some neighborhoods for juveniles to steal does not mean that stealing is acceptable. These are examples of how multicultural perspectives change the meaning or relative importance of cultural elements and the role they exert on behavior. This is not meant to minimize the clinical importance of certain behaviors, but rather to arrive at a more comprehensive, and perhaps more balanced perspective on matters. There are, however, also many examples of multicultural practices identifying unhealthy patterns, attitudes, cultural practices, morals, and beliefs that have adverse consequences or are maladaptive for a specific group. The identification of high rates of substance abuse/dependence, poverty, mental illness, criminal behavior, violence, and other unhealthy and maladaptive behaviors patterns in African Americans does not excuse these patterns. On the contrary, their identification helps to target resources, advocacy efforts, policies, programs, services, and interventions aimed at their reduction, correction or modification, and elimination where possible.
Multicultural mental health helps to develop a body of knowledge about diverse populations and to use that body of knowledge in constructive ways to improve psychological, social, and occupational functioning. Multiculturalism does not excuse dysfunctional behavior. On the contrary, multicultural theory and practices are concerned with the identification of factors related to high levels of personal, social, and occupational functioning within and across contexts. Multiculturalism actually expands the role of mental health systems to include many forms of dysfunctional and maladaptive behavior.
Mental health, like physical health, is not defined simply by the absence of symptoms. Mental health requires the presence of a healthy environment that promotes health and well-being. Mental health and multiculturalism, like science, aim to control, maximally, features of the physical or cultural environment that have adverse impacts on growth and development. Thus, behaviors such as (a) dropping out of school before completion, (b) refusing to work for a living, (c) violence to self or others, (d) criminal behavior, (e) substance abuse and dependence, and other behaviors including (f) inability to financially support self or to take responsibility for self are examples of behaviors that indicate there is a dysfunction, a failure to adapt to either the environment, the culture, or its institutions, specifically those designed to promote growth and well-being. Spiritual development and moral development are also included when mental health is defined broadly.
Broadly defined, mental health includes such behaviors as violence, criminal behavior, substance abuse, and irresponsibility. These behaviors when found to exist in relative high rates in any group become indicators of mental health needs. Behaviors such as violence and criminal behavior result from interactional conflicts between the self and the environment. In interactional problems, sometimes the individual is to blame (i.e., the responsibility lies with the self), whereas at other times it is not the individual's fault at all (i.e., fault lies with the environment, physical and/or cultural, and at other times, neither the individual nor the environment can be singularly blamed (i.e., responsibility lies with both to some varying degree, as neither people nor their cultures are perfect). Interactional behaviors, by their very nature, involve to some extent dynamism. For some reason, the concept of shared responsibility is very threatening to those persons who adhere to the belief that the individual is solely responsible for his or her behavior. The few exceptions to individual responsibility generally allowed for in U.S. culture are (a) insanity or mental illness, (b) extreme youth, and (c) physical disease or other organic illness.
An important feature of multicultural approaches is that culture and personenvironment interactions are taken into consideration in explaining behavior. Regression analyses conducted in the social sciences are frequently used to empirically demonstrate the relative contribution of various factors, variables, or predictors on some criterion variable(s). Cultural variables such as acculturation and ethnic identity have been empirically demonstrated in numerous studies to make significant contributions and influences on a variety of behaviors (Dana, 1993, 1998; Paniagua, 1998). Although this is far from saying that cultural variables cause behavior, the evidence shows there are strong empirically demonstrated relations among cultural variables and many behaviors. Because multiculturalism at times finds fault with both the environment and the individual, this does not mean it excuses or diminishes personal or individual responsibility. Criminal behavior, for example, may result from both individual or psychological dysfunction and sociocultural dysfunction. Macro- and meso-level system failures can generate individual dysfunctional behavior, as when a family system fails to instill moral behavior. The problem is that some systems work well for most individuals but do not work well for all individuals. Not all systems function perfectly for all. It appears that most systems (educational, health, criminal justice, economic, etc.) work best for defined cultural groups, and even so not for all from any given cultural group. When a system that works well for most persons from a specific cultural group doesn't work well for a specific individual, is it always the fault of the individual? Because individual differences are, generally, normally distributed in any given population, there will always be some persons who don't seem to fit into any given system. Take the educational system, for example, early on at the turn of the century, around 1905, Alfred Binet and others saw the need to identify persons with special needs (mental deficiency) in order to devise special educational systems for them. This concept of identifying subgroups with special needs has now been expanded for other special education populations, and lately is being used to assign special educational settings for those who exhibit behavioral problems in school (e.g., Alternative Behavior Schools/programs). In the Criminal Justice System there are continuums of security facilities with restrictions of individual liberties, depending on the nature and severity of the crime. Not everyone is treated the same. Economic systems do not market the same product to everybody. Stores provide a variety of prices, goods, and services. The food and entertainment industry likewise tailor their products to special groups because they know that not everybody has the same likes and needs. If a widget doesn't sell it is not always the consumer who is to blame. Likewise, mental health system interventions and therapies need to be tailored to the diverse needs and problems of that population. Does the automobile blame the consumer when a particular vehicle doesn't do well in the marketplace? Why should the mental health field assume that all its traditional therapies should work equally well for all consumers of mental health care regardless of the consumer's cultural background? The truth is that some traditional therapies (i.e., psychoanalysis, Adlerian, analytical, person-centered, rational-emotive, behavioral, etc.) work well for all persons, others not so well for some, and not at all for others. It is part of a good clinician's repertoire of skills to know what works best for what kinds of problems across what kinds of settings and populations. The general tendency initially is to blame the individual or victim for failures to comply, engage, and benefit from system interventions. Mental health is a system intervention as well as an individual intervention. Objective functional analyses of the mental health, social, and other problems of African Americans clearly reveal system as well as individual failings in most cases of noncompliance and mismatching of needs.
5. Does multicultural assessment and treatment of mental health problems and disorders in African Americans undermine serious discussion? The answer again is no. The shortcomings of the established mental health service delivery systems, training programs, and models are at times highlighted in discussions of treatment of African Americans and other racial or ethnic minorities. For example, there are some professionals with strong opinions that certain racial and ethnically diverse groups in the United States are not being served adequately (i.e., are underserved or inappropriately served). There is also evidence as noted in the introduction of this chapter that African Americans are being disproportionately misdiagnosed. Some professionals would like to revamp many service and training programs to include specialist training in multiculturalism.
When opposing views are expressed, multicultural practitioners examine the scientific evidence in support of the differing views. Practitioners certainly do not automatically reject traditional scientific practices. Debate over the issue of the role of culture gets at the very heart of multicultural practices. To what extent does the environment and our culture influence who we are, what we believe in, and what we do? This is an ongoing discussion in the fields of psychology, sociology, psychiatry, and other behavioral sciences. There are those that believe that we are human beings not "cultural puppets," and that we are responsible for our own actions not the environment or our culture. Efforts that blame the environment lessen or overlook responsibility that rightfully belongs with the individual. Furthermore, they warn that disavowing individual responsibility is a dangerous and disastrous road to take. Multiculturalism does not run from this debate and in no way supports the lessening of individual responsibility. It promotes the application of scientific practices and analysis as the basis for determining the most appropriate, efficient, and effective ways to treat mental illness in any given population. It promotes the use of scientific methods to arrive at the truth of these and other matters.
In the early 1970s it was not unusual for a supervisor to instruct their trainee to delete the label Black as a description of the patient from the psychological report. This rationale often had to do with labeling. By labeling the client as Black you could be found guilty, or accused, of discriminating against him or her. You could also be accused of placing an unacceptable label on the client, the very person to whom services and help are being directed. To some extent this is still true today. How to label people from different racial and ethnic groups has always been problematic, and there seldom is any clear consensus. There are risks involved in labeling, particularly mislabeling people.
Dr. Richard H. Dana's book, Understanding Cultural Identity in Intervention and Assessment (1998) makes a strong case for assessing ethnic identity, cultural identity, and other cultural variables in professional practices. His point is that the failure to assess ethnic identity and cultural identity in our patients is to leave out much about who our patients are as human beings. Dana and others believe that one's sense of self is formulated from our experiences, our cultural upbringing, membership in racial and ethnic groups, as well as other commitments and ideologies. Ethnic identity is more salient for some people than others. It is particularly salient for some racial/ethnic groups (Phinney & Ali-puria, 1990), and is an important part of the psychological makeup of all human beings.
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