M9 - (mental) health

4 health indicators (WHO)

• Life expectancy = the average number of years a person is expected to live form birth. This is affected by available wealth/resources, both across and within countries → because wealth/resources within a country can change, so does life expectancy.

  • The average life expectancy is higher for the ethnic majority compared to the ethnic minority.
    For example, in the U.S., European-American had a life expectancy of 79 years, compared to 75 years for African-Americans. When gender is also considered, the life expectancy for African-American males was only 72 years compared to 81 years for European-American females.

• Infant mortality = the amount of infant (<1 year old) deaths per 1000 live births. Differences in infant mortality rate depend on the general resources of a country (e.g. health care, nutrition, etc.), and can also exist within countries, for example between ethnic groups.

  • Highest infant mortality rates were in Lesotho (42,8), Pakistan (41,2) and the Central African Republic (39,7); lowest infant mortality rates were in San Marino (0,8), Japan (0,8) and Singapore (0,9); the Netherlands has an infant mortality rate of 2,1; the U.S. ranked at 50^th place with a 3,7 rate.

  • There are disparities among ethnic groups; in the U.S. black infants are more than twice as likely to die compared to white infants. This is due to systematic factors (differences in treatment and access to health care).

• Obesity = being extremely overweight → this can lead to health problems such as cardiovascular diseases, diabetes and cancer.

  • This is measured by BMI =  weight of a person : height in meters. A BMI of >25 is overweight, and a BMI of >30 is obese.

  • Countries with the highest BMI are Nauru (61), Cook Islands (55,9), Palau (55,3); countries with the lowest BMI are Cambodia (3,9), India (3,9) and Timor-Leste (3,8). The U.S. scored 12^th highest in the world with a BMI of 36,2; it scored highest compared to economically similar countries. The Netherlands has an average BMI of 13,6.

• Subjective well-being = people’s perceptions and self-judgements of health and well-being. It’s based on a person’s feelings of happiness and life-satisfaction.

  • Subjective well-being is positively related to health; people with higher levels are less susceptible to viruses, have stronger immune systems, fewer heart-attacks and longer life expectancy.

    • This could be because people with higher subjective well-being also engage in healthier lifestyles

  • Subjective well-being was measured by asking people to place themselves on a ladder with steps going from 0 to 10 (10 being the best possible life and 0 the worst).

  • The happiest countries are Finland (7,81/10), then Denmark, Switzerland, Iceland, Norway and the Netherlands. The least happiest countries are the Central African Republic, Rwanda, Zimbabwe, South-Sudan, and Afghanistan (2,57/10).

  • Subjective well-being can be predicted by wealth, autonomy and connection to others.

3 studies on the relationship between culture and health

• A study by Marmot and Simon showed that Japanese-Americans who were more “traditionally” Japanese (they maintained most of their original culture, e.g. they spoke Japanese at home, retained Japanese values/behaviours, etc.) had the lowest incidence of coronary heart disease, whilst the group that was “least” Japanese had a 3-5 times higher incidence rate. These differences could not be accounted for by other coronary risk factors.

• Triandis et al. (1988) examined the relationship between individualism vs collectivism and heart disease across 8 cultural groups. The most individualistic group (European-Americans) had the highest rate of heart attacks; the least individualistic had the lowest.

• Matsumoto and Fletcher (1996) examined associations among Hofstede’s 4 cultural dimensions (individualism/collectivism, power distance, uncertainty avoidance, masculinity-femininity) with mortality rates for 6 medical diseases (infections/parasitic diseases, malignant neoplasms a.k.a. tumors, diseases of the circulatory system, heart diseases, cerebrovascular diseases, respiratory system diseases).

  • High power distance → higher rates of infections/parasitic diseases; lower rates of malignant neoplasms, circulatory diseases and heart diseases.

  • Higher individualism → higher rates of malignant neoplasms and heart diseases; lower rates of infections/parasitic diseases and cerebrovascular diseases.

  • Higher uncertainty avoidance → higher rates of heart diseases; lower rates of cerebrovascular diseases and respiratory diseases.

  • Higher masculinity → higher rates of cerebrovascular diseases.

These differences remained even when they controlled for affluence.

Western vs Eastern definition of health (biomedical/biopsychosocial model vs holistic views & homeostasis)

Western countries: health is based on 2 models

• Biomedical model = views health as the lack of disease, which results from a specific, identifiable cause, a genetic/developmental abnormality, or physical damage (e.g. a pathogen).
  Treatment is focused on curing the disease by addressing this underlying biological process.

• Biopsychosocial model = views disease as resulting from biological, social and psychological factors.

Eastern countries: health is based on maintaining balance

• Holistic views = health is when the body is in balance, e.g. Yin and Yang need to be in balance (that is, the positive and negative energies in our bodies need to be in balance). This balance can be disturbed by many things, both within yourself, the environment and the spiritual world.

• Homeostasis = maintaining steady and stable bodily functioning during environmental changes.

cultural fit, stress & health

The cultural fit (how much your own values align with those of your culture) can influence your health, with stress as a mediator:

When your values don’t align with your culture (low fit), you experience stress → this needs more coping → this leads to depression and anxiety → this leads to (physical) diseases.

alameda county study: relationship between (perceived) social support, discrimination, SES & health

The Alameda county (California) study shows the relationship between social support and health. Researches interviewed 7000 people about their social contacts, and then monitored their deaths over 9 years’ time.

• Individuals with the fewest social ties had the highest mortality rate; those with the most social ties had the lowest.

• They controlled for physical health, year of death, SES, and other health-related behaviours (e.g. smoking, alcohol consumption).

It’s important to point out that perceived social support (feeling like you’re supported) matters; some people with few social contacts may not feel lonely, whilst others with many contacts do. Loneliness is linked to many health problems.

Perceived discrimination was also related to a numerous health issues in a study by Pascoe & Richman, such as high blood pressure, higher cardiovascular disease, negative pregnancy outcomes, earlier biological aging, etc.

Social economic status (SES) was consistently associated with health outcomes: people with a higher SES enjoy better health than people of lower SES.

the impact of culture/SES on body image & eating disorders

Culture impacts how people view their own and others’ body shapes → the ideals of body shape and the dissatisfaction stemming from the gap between one’s actual body shape and the ideal, have been linked to eating disorders.

Body dissatisfaction is greater among those who live in affluent countries with a western lifestyle. Body weight standards and dissatisfaction are linked to SES → heavier figures are preferred in lower SES contexts, whilst thinner bodies are preferred in higher SES contexts.

This shows that cultural values, beliefs, and opinions about wealth/beauty/power, impact attitudes towards eating, thinness and obesity.

immigrant paradox + study + factors that explain the immigrant paradox

The immigrant paradox = immigrants are doing better on many health measures, despite the hardships/discrimination they face; they need to adapt to a new cultural environment, and therefore face acculturation issues → this can cause depression, anxiety, and psychosomatic problems. An individual’s level of acculturation (e.g. integration, assimilation, segregation or marginalisation) contributes to the content and expression of distress.

A study on U.S. Latinos showed that immigrant-Latinos (those who moved) were healthier than U.S.-born Latinos; they had lower infant mortality rates, less obesity, longer life-expectancy and fewer psychiatric and substance use disorders.

Factors that could explain the immigrant paradox are:

• Healthy behaviour (better diet, less drug use, etc.).

• Social support (close family and community).

• Immigrant selectivity (the immigrants who are able to migrate, are already healthier and more resilient).

4 ways to measure (ab)normality

• Statistical approach: individual behaviour is defined as abnormal when its occurrence is rare/infrequent.

  • A limitation with this approach is that not al rare/deviant behaviour points towards an disorder, and not al disorder behaviours are rare.

• Impairment/inefficiency: the behaviour makes it hard for the individual to function within society.

  • Not every abnormal behaviour impairs functioning (e.g. people in a manic episode often feel they’re more productive).

• Social norms: behaviour that goes against the social norms, is considered abnormal.

  • Not all socially deviant behaviour, is abnormal.

  • Over time, our ideas of socially deviant behaviour changes.

  • Social norms are subjective (what one may consider deviant, another may accept as normal).

• Subjective distress: behaviour that causes the individual distress, is abnormal.

  • Subjective distress may not be caused by the behaviour itself, but by how others react to the behaviour (if others accept it, they might not experience distress).

absolutist, universalist & relativistic perspective on abnormal behaviour/disease

Absolutist perspective: based on biological models invariant symptoms across cultures.

Universalist perspective: many different disorders have the same symptoms; the underlying structures are the same.

Relativistic perspective: disorders can only be understood within the cultural framework within which they occur.

3 classification systems for mental health disorders

• ICD-11: International Classification of Diseases

• CCMD: Chinese Classification of Mental Disorders → this is closely related to the DSM-IV and the ICD-10 and is a culture-specific approach.

• DSM-V: Diagnostic and Statistical Manual of Mental Disorders → the revision also has a section on cultural differences (cultural concepts of distress)

DSM-V: cultural concepts of distress (CCD) & cultural formulation interview

Cultural concepts of distress (CCD) are a revision on cultural bound syndromes in the DSM-V, consisting of 3 concepts:

• Cultural syndromes of distress = patterns of symptoms that tend to cluster together for individuals in specific cultural groups, communities, and contexts.

• Cultural idioms of distress = the ways that cultural groups and communities communicate and express their distressing thoughts, behaviours, and emotions.

• Cultural explanations of distress = what cultural groups and communities believe is the cause of distress, symptoms or illness.

The DSM-V also includes instructions for a cultural formulation interview (CFI), which is used to ask individuals about their experiences within their specific social/cultural context.

the issue of bias in cross-cultural assessment of psychological disorders & Cild Behaviour Checklist (CBC)

Tools/measurements developed in one culture are based on that specific culture’s definition of normal/abnormal. It may be biased when used in another culture, due to culture-specific expressions of distress (how people show distress) and translation issues (e.g. translating idioms).

This is illustrated by the Child Behaviour Checklist. It is used in diverse cultures to assess behavioural, emotional, and social problems of children/adolescents. Although the scale is reliable and valid across cultures, the clinical cut-off points (when behaviour is still normal and when it’s abnormal) vary a lot by culture. The CBC may also not be able to capture culture-specific dimensions of problematic behaviours.

the issue of test interpretation in cross-cultural assessment of psychological disorders & experiment

Cultural backgrounds of both therapist and client are relevant for the perception and assessment of psychological disorders. A culturally responsive assessment requires an understanding of the cultural background of the client, and your own cultural biases.

For example, Chinese-American clients were rated as more awkward, confused, nervous, depressed, and less socially capable by European-American therapists; the same clients were rated as adaptable, honest and friendly by Chinese-American therapists.

issue of using personality tests to assess psychopathology in cross-cultural research & example of MMPI

Minority worldviews can be considered abnormal/pathology when using large personality inventories (such as the MMPI) that are based on a different culture. Finding a tool that works across all cultures does not mean that it captures all aspects that are relevant for personality in those cultures; it may be missing out on crucial personality aspects of specific cultural groups.

The MMPI was originally developed with a predominantly European-American sample, but it has been used across the world. Whilst the findings of the MMPI are quite reliable and valid across different cultural contexts, the minority worldviews are pathologized more often.

over- vs under-pathologising

Over-pathologising = incorrectly considering behaviour as pathological, when behaviour is a normal variation for that individual’s culture.

Under-pathologising = indiscriminately attributing behaviour to cultural differences, when behaviour actually reflects abnormal psychological response.

somatisation vs psycholigsation + research on Turkish and Belgian people

Somatisation = experiencing more bodily symptomps; this is more common in collectivistic cultures.

Psychologisation = experiencing more mental symptoms; this is more common in individualistic cultures.

Research has shown that Turkish people are more prone to somatisation, and Turkish-Beligians (biculturals) are even more likely to experience somatisation; this could be due to additional acculturation stress the Turkish-Belgian people face.

schizofrenia: (universal) symptoms, ethiological models and effect of family/support network

Schizophrenia is characterised by delusions, hallucinations, lack of motivation, social withdrawal, impaired memory, and dysregulated emotions.

Ethiological models suggest that it may develop in individuals with a genetic/biological disposition once they are exposed to environmental stress.

In the 1970s the WHO conducted a large international study on schizophrenia in 9 countries. They identified a set of symptoms that seem to be present across all cultures:

• Lack of insight

• Auditory and verbal hallucinations

• Ideas of reference

In Western countries, when the family and support network show increased hostility, criticism and over-involvement, this may trigger a schizophrenia relapse. This is not always found in other cultures, but that could be because these concepts differ per culture (when is someone “over-involved”?).

schizofrenia: cultural differences & experiment by Luhrrmann et al. on voice-hearing experiences

The course of the illness was more positive for patients in developing countries than in highly industrialised countries, which was also concluded in a follow-up study.

• This has been attributed to the extended kin network, community support, marriage and other social factors that are often better in developing countries.

Symptom expression also differed across cultures: patients in the U.S. were less likely to demonstrate lack of insight and auditory hallucinations than Danish or Nigerian patients.

• This may be because insight and self-awareness are highly regarded in the U.S., but less in other countries.

Luhrrmann et al. looked at schizophrenia in relation to 3 cultural contexts: San Mateo (U.S.), Accra (Ghana) and Ghennai (India). They looked at voice-hearing experiences: how many voices people have heard, how often, and whether they experienced these hallucinations in other sensory modalities.

• Some of the voice-hearing experiences were similar in all 3 cultural settings: they reported good and bad voices, conversations with the voices, voices that whispered/hissed/weren’t very audible, conversations with God, hating their voices and considering them assault.

• There were differences in the quality of the voice-hearing experience, particularly the quality of the relationship with the speaker of the voice:

  • Many Ghennai and Accra participants viewed that their predominant experience of the voices was positive, but not a single San Mateo participant reported that it was positive.

  • Many Ghennai and Accra participants experienced voices of people they had a relationship with in real life (e.g. a brother, friend, neighbour, etc.), whilst this was less typical for San Mateo participants (only 1 person).

    • More than half of the Ghennai sample heard the voices of family → they gave guidance, but also scolded them.

  • In the Accra culture, the social world accepts that there are human-like, non-embodied spirits that can talk; in the U.S. hearing voices feels like an intrusion into one’s private world. The fact that the voices could not be controlled, upset American participants greatly.

depression (universal symptoms/characteristics & cultural differences)

Depression is characterised by physical, motivational, emotional and behavioural changes.

Universal symptoms are:

• Sadness and joylessness

• Anxiety

• Tension

• Lack of energy

There are also symptoms that differ across cultures due to variations in stress sources and coping mechanisms. Women are more likely to develop depression than men, although prevalence rates differ substantially across cultures (higher in Brazil and the U.S., lower in Germany and Japan).

cultural differences in depression

In China, there is a higher prevalence of somatisation. People also reported that their relationships with others were affected and that insomnia was the cause of depression (rather than the other way around).

Another study showed that depressed European-Americans displayed fewer emotions than non-depressed European-Americans, whereas depressed Asian Americans displayed more emotions than non-depressed Asian Americans.

This demonstrates that there are cross-cultural differences in the expression of depression, but also that, in both cultures, emotions are expressed differently than social norms dictate.

ADHD: gender & cultural variations

Across various cultures, boys are diagnosed with ADHD more frequently than girls.

Research shows that variations in the prevalence of ADHD are largely attributable to methodology rather than culture. Cultural differences are primarily found regarding causes and treatment.

amok (culture-specific disorder / cultural distress syndrome)

Amok = disorder that exists in several (Asian) countries and that is characterised by sudden rage and homicidal aggression, divided into different stages.

Causes are thought to be stress, sleep deprivation, personal loss, or alcohol consumption. It has primarily been observed among men.

Zar (culture-specific disorder / cultural distress syndrome)

Zar = altered state of consciousness observed among Ethiopian immigrants to Israel; this is rooted in the belief of possession by Zar spirits which are common in Africa.

Symptoms are involuntary movements, mutism and incomprehensible language.

Ataque de nervios (culture-specific disorder / cultural distress syndrome)

Ataque de nervios = disorder among Puerto Rican and Caribbean individuals.

Symptomes include feeling out of control, trembling, uncontrollable shouting, intense crying, heat in the chest rising to the head, and dizziness.

• It is more common among women and tends to arise during stressful family events.

• It has similarities with panic attacks as described in the DSM-V.

• A study on Latinas in the U.S. showed that people with this disorder were more likely to also reported other illnesses.

Baksbat (culture-specific disorder / cultural distress syndrome)

Baksbat = disorder that’s prevalent in Cambodia and related to cultural trauma.

Symptoms include extreme fear, being overly submissive, mutism, mistrusting others (people and spirits).

susto (culture-specific disorder / cultural distress syndrome)

Susto = sadness, sleep problems, eating problems, anxiety, social limitations.

This occurs in Mexico, Central America and South America.

Latah (culture-specific disorder / cultural distress syndrome)

Latah = extreme startle reaction combined with uncontrollable behavior, such as repeating others' words, and occurs primarily among Malasian (Malay) women.

Koro (culture-specific disorder / cultural distress syndrome)

Koro = extreme anxiety that the genitals will shrink or the body will contract.

This occurs in Men in China, Indonesia and Malaysia.

refugees vs immigrants on PTSD, depression & anxiety (dose-effect & post-migration factors)

Refugees show higher rates of PTSD, depression and anxiety, contrary to immigrants. This is caused by the traumatic experiences that most refugees have gone through.

There is a dose-effect = a greater severity (“dose”) of trauma is associated with a higher likelihood of psychological disorders.

However, post-migration factors (like isolation, loss of community, loss of life projects) are equally important in predicting a refugee’s emotional distress.

rates of major depressive disorder (MDD) and panic disorder of African-Americans compared to others

African-Americans report lower lifetime and 12-month prevalence rates of major depressive disorder and panic disorder → this is due to protective factors against mental illness (such as family bonds, community, religious networks).

client-centered approach (Rogers)

Freud’s theory caught the attention of Carl Rogers in the U.S., who developed a client-centred approach: instead of the therapist being an interpreter of the patient’s troubles, the client themselves drives the progress, whilst the therapist remains sensitive to their feelings and emotions.

characteristics of western psychotherapy; individualistic focus

Traditional psychotherapy has its roots in Western Europe (Freud, Jung, Adler, etc.). The assumption that underlies western therapies is that changing our thinking changes our behaviour, and vice versa.

For this to be true, there needs to be a separation between thought and behaviours. The emphasis lies on deep self-awareness and introspection → this is a very individualistic focus.

Psychotherapy generally encourages individuals to express their private emotions, thoughts and feelings, to engage in self-reflection and self-disclosure and to arrive at insights in their own behavioural and cognitive patterns.

why (western) psychotherapy is less effective for non-Europeans: cultural frame of reference

Psychotherapy is less effective for people of non-European descent, because it wasn’t developed in those cultural contexts.

Reasons for less effectiveness are differences in cultural frame of reference:

• Abnormality is defined and expressed in different ways across cultures.

• Self-concept differs across cultures; this has important implications for self-concentrated therapies.

  • People from collectivistic cultures may find the focus on the self/individual in psychotherapy very unusual/uncomfortable. A treatment that involves the family/community and acknowledges that the unit of analysis and intervention is the individual in relation to others, might work better for collectivistic cultures.

• The ability of the therapist to assess is based on their knowledge, understanding and appreciation of the cultural context of the client.

• The goal of psychotherapy is to help people become more functional within their society → “functionality” differs across cultures and is therefore culturally determined.

  • For example, being assertive may be considered functional within a competitive context, but maladaptive within a collaborative context. Psychotherapy CANNOT be cultural/value free.

cultural modified psychotherapy

Cultural modified psychotherapy tries to make psychotherapy more culturally diverse.

Psychologists have implemented elements of their culture into therapy, like integrating local language, religions, remedies, cultural meaningful stories/symbols/idiom.

This seems more effective than non-modified psychotherapy, and can also be applied to minority groups within a cultural setting.

between country differences & within country differences in who receive (mental) health treatment

Between country differences: people from lower-income countries are less likely to receive treatment than those from countries with high economic resources.

Within-country differences: mental health hospitalisation and length of treatment differ by racial/ethnic groups (e.g. white Americans use mental health services the most).

6 barriers to seeking mental health services as a minority group

• Language barriers

  • A study reviewing mental health services in 16 European countries showed that difficulty with the mainstream language of the country was the most prominent barrier to seeking mental health services.

  • Evidence from the U.S. showed that those with limited English proficiency are less likely to use mental health services.

• Stigmas and mistrust: different cultural groups may attach different stigmas to seeking mental help, and some communities may be mistrustful towards mental health professionals.

  • In Europe, level of education plays a role in whether or not people seek mental help; among working-class groups, seeking help can be highly stigmatised.

  • For minorities, seeking mental health services may lead to feelings of shame/loss of face (Asian-Americans), or shame/weakness of character/disgrace (Hispanic-Americans).

  • Seeking mental help may be damaging to the prospect of marriage for women of Arab origin.

  • The historical contexts of some minority groups can explain why some groups are mistrustful towards western psychotherapy. For example, in the U.S. the national health services actively experimented on African-Americans: Tuskegee-syphilis-experiment. African-American men who were infected with syphilis were told that they would receive free health care and treatment. In reality, they were not told they had syphilis and were not treated, even though treatment was readily available. The purpose of the experiment was to document the “natural course” of the disease.

• Beliefs about health and illness: depending on cultural norms/values, people may want to “though it out”, or they’d rather seek help from religious/folklore persons instead of formal services.

• Social validity: the perception of the social importance and acceptability of an intervention by a cultural group → does the cultural group think the intervention works?

• Lack of available services: for example in rural areas (also in the U.S.) there are not many services, and there may be an even bigger lack of culturally-appropriate services.

• Financial factors: for example insurance (minority groups are less likely to be insured).

indigenous/traditional remedies, alternative therapies & complementary treatment

Indigenous/traditional medicine = helping people through treatment beliefs and practices derived from their own culture.

Alternative therapies = treatments that are indigenous in other cultures.

Complementary treatment = treatment that has not been specifically developed within one culture.

ways to remove barriers for minority groups to acces mental health services

To remove barriers to treatment, we must:

• Learn how the barriers interact with racial/ethnic backgrounds, immigration status, and socioeconomic status.

• Hire more bilingual staff (and preferably bicultural staff) and make sure there are enough practitioners available who can work with different cultural groups.

• Focus on outreach and visibility in the community.

• Allow clients to visit at flexible hours

  • This is because many people from minority groups have to deal with long working hours and minimal wages, so they may not have access to health care during regular working hours.

• Reduce stigma surrounding mental health care.

treatment challenges when there’s a cultural mismatch between client & therapist

• Different ways of thinking and expressing thoughts about illness (differences in cultural idioms of distress).

• Language differences.

• Variations in communication patterns.

• Cultural variations in the importance of hierarchy in interpersonal relationships (e.g. the therapist is seen as an authority figure, or the age of the therapist relates to hierarchy).

• Differences in treatment expectations between cultures (e.g. whether the therapist is a “doctor” who cures you, or you cure yourself under guidance of the therapist, or differences in goals).

• Involving (extended) family can be hard.

• Reputational downgrade for the client; they may “lose face”.

culturally informed services; US COVID-19 example

Being culturally informed can help improve metal health services for minority groups; culturally informed services = health services that involve understanding and respecting the histories, traditions and value systems of various cultural groups.

During the COVID-19 pandemic, the Centre for Disease in the U.S. was conscious of the fact that it would be hard to advertise COVID-19 vaccinations to African-Americans, since because of the historical context of slavery, exploitation and discrimination, they had a lot of mistrust. They therefore ran campaigns through religious organisations (e.g. churches), which are sources of trust and community for this ethnic group → this helped in reducing mistrust and increasing compliance with vaccination.

match between client & therapist: cultural & cognitive

Matching cultural, ethnic and racial aspects in therapists and clients can help ethnic minorities reach health care (although effect sizes were small).

Cultural matching refers to similarities in worldviews, cognitive styles, and language between client and therapist.

Cognitive matching refers to client and therapist having the same perspective on how the therapy should look like and what the result should be.

intercultural competence (3 aspects)

Intercultural competence: the therapists must be culturally competent in the following aspects:

• Cultural awareness and beliefs: counsellors are sensitive to their personal values and biases and how these may influence perceptions of clients, the clients’ problems and counselling relationships.

• Cultural knowledge: counsellors must have knowledge of the clients’ culture, their worldviews and expectations of counselling relationships.

• Cultural skills: counsellors need to have the ability to intervene in a manner that is culturally sensitive and relevant.