Transcript of Presentation

Hello, and welcome to our training today. Our topic is seeking mental health treatment, a primer for African Americans. Essentially what we will talk about is early information related to cultural competence and working with African American patients. So, this is just very basic information. An outline of what we will be working with is a definition of culture and cultural competence and then we will talk about the potential effects of culture on seeking mental health treatment, the mental health diagnosis, and treatment.

There are several definitions of cultural competence. The socially transmitted behavior patterns and beliefs of a group of people, the thoughts communications actions, customs, and values of a group of people. This is another broad definition. Clinicians should know that in order for a cluster of symptoms to be diagnosed as a kind of mental illness, then they have to found as abnormal within individuals culture. So it’s important for us as clinicians to understand this.

There are some parts of culture that are easy for people from other cultures to get, and these are what are called the objective aspects of culture. They are easily seen, easily understood, and they are expected. They include clothing, food and artifacts. They are fairly easily recognized and they may actually be the basis for stereotypes. However, because they are so objective, very few cross-cultural misunderstandings can occur at this level.

The subjective components of culture are the values, the ideals, the attitudes, the roles, and the norms within a culture. They are less easily understood by people in other cultures, and they are more frequently the basis for misunderstanding. This is where the challenge comes in providing mental health care. It can include things such as whether or not eye contact is appropriate or inappropriate [and other things] along those lines.

The term cross-cultural can derive from multiple factors, from ethnicity, race nationality, regional differences, differences within a group. For example, when I moved from Philadelphia to Virginia, I began to have cross-cultural interactions because people in different regions of the country interact differently with one another. There are differences between groups. Although many people will assume that African Americans are going to act in a certain way, there may be differences in different socio-economic groups. There may be different standards or different expectations for behavior. Religion can be a basis for cross-cultural interaction. Anyone who is raised in the United States as a member of a devalued group could have a cross-cultural interaction. Descriptions of development are based on males who are straight, and so females and gay people may have differences in their development. Deaf people have a culture of their own, so there is a difference between hearing versus deaf and a person of color and a person who is not of color. There are differences in culture. One of things that we say in teaching our trainees at MCV about cross-cultural interactions is that unless someone is raised in your household and is of your gender and your sexual orientation then it’s a cross-cultural interaction.

[Now we are] moving on down the outline to definition of cultural confidence. A therapist can be kind of intellectually aware that there are differences between cultures and can be a bit more aware or have a very strong understanding of the differences between cultures, and this is kind of a continuum of cultural confidence. A person has to be aware--recognize there are some differences. The next step is sensitivity, and the final step is in being culturally confident. That person has a non-judgmental acceptance of cultural differences. One of the things that we will find is that a person does not gain a finite amount of knowledge and become culturally confident. One of the things that we recognize is that people continue to develop their knowledge about different cultures, and that that helps them to become culturally confident and being. Being culturally confident in cultural interactions is an on-going process.

Each mental health specialty, psychology, social work and psychiatry, has expectations that members of that group will work towards being culturally confident and understanding how cultural aspects can affect an individual’s presentation for treatment and how recommendations for treatment are going to be expected. There is a discussion about what is the politically correct term to use in talking about individuals with brown skin in the United States. Most recently this term is ‘African American.’ African Americans are descendents of people who were brought from West Africa as part of the slave trade, and there are people who are descendents of those who were indentured servants before the development of slavery. Africans, however, are people who came directly from Africa and did not have a heritage that relates to that slave trade. African- Caribbean are those whose ancestors came from Africa via the Caribbean, and there are separate cultures within these.

Moving down to Potential Effects of Culture on Seeking Mental Health Treatment, etc. We understand that culture effects what happens when someone comes for mental health evaluation. Let’s look at how people are getting to mental health for evaluation. Does everybody go? No. The percentage of blacks that do not have health insurance is one and half times that of white families. This is because in general African Americans are more likely to have jobs that don’t offer insurance. As a result, they may often end up waiting until symptoms are more severe before they go in for treatment; and so when someone presents for treatment that doesn’t have insurance a result is that they may be sicker or their children may be sicker. Also, as a result of not having insurance, some people may end up using the emergency room as a primary care provider. Because African Americans are over-represented in high need populations because of these insurance concerns, they may end up in more public programs such as community hospitals or community mental health centers for care.

Interestingly, though, insurance is not the most important factor in seeking mental health services for African Americans. If there is insurance with adequate mental health coverage provided, other barriers are still present and African Americans may not end up coming for treatment. Overall only about one-third of all people who need mental health treatment go to get it. The number is lower for African Americans. Overall, blacks are more likely to go see their primary care provider than to go and see a psychiatrist. Whites are only slightly more likely to do so. Only about one-fifth of African Americans who need mental health treatment seek it.

About two and half more times African Americans than white actually fear seeking mental health treatment. Some studies find that African Americans know less about depression or ADHD, for example, than members of other ethnic groups. Once African Americans are involved with a mental health provider, there may significant trust concerns. The question is whether or not the patient feels that the facility understands the person’s experiences as an African American, or are their any providers that are African Americans. People often want to see mental health providers that look like them. The person may not feel that the provider spends enough time with them even if the time span that is allowed for all patients is the same. The most important issue is what is perceived as having enough time spent with one. There was one study that found that African Americans rated their physicians style of interaction as more participatory when they were seeing African American physicians.

If a person feels that the wrong answer is there to any of these questions, then they may leave your facility, leave your agency and end up going to seek treatment elsewhere. Many people feel that going to see a mental health provider is actually counter to their faith. A few Sundays ago, I visited another church and heard a minister say that too many people spending $95 an hour going to a therapist, and all they really need to do is read their bible. That’s something that may cause someone not go and see a mental health provider. Blacks may also be more likely to use home remedies depending on what their family’s cultural tradition is.

Another significant means of support is the utilization of other people in the community such as family, friends, neighbors, volunteer groups, and members of the church in order to help in times of need. There will be families that have an extended kinship network and these can play brother, play sisters, play uncles, play aunts and they can be used as a support.

Let’s look at some of the—for those folks in the audience who are not in mental health—let’s look at some of the things that are part of the psychiatric evaluation. There are times when this information is being gathered that a parent if you’re working with children or the patient may look at you and say, “That’s my personal business. Why is it that you are asking me this information? That does relate to the particular reason why I came into see you.” It will be important at these times to explain what the purpose is for these particular questions so that the patient can understand that this is part of the comprehensive evaluation that we need to provide. Part of the psychiatric evaluation is finding out why the person is there in the first place for treatment, and then gathering all the information related to that illness. We need to know about a person’s past psychiatric history—if there’s been any psychiatric treatment that they’ve had before, if there’s been any medications that they have had before, if they have been seen in the hospital before. This will help us to understand the severity of the illness and anything that has not been successful in the past. Similarly, it is important to know about a family’s psychiatric history because there are many mental illnesses that are hereditary—that run in families. Because of this, it is helpful for the provider to have this information.

We need the past medical history because there are some illnesses that have a mental health component or some illnesses that can be exacerbated or worsened by medication that may be used for psychiatric purposes. Family medical history is similarly important. The social history, understanding about school, how school may be helping the child or may be causing a problem for the child, the interaction between the school and various members of the family is helpful. It may be necessary to explain again why we are asking for this information to make sure we are getting a full history and that we have everything that we need. Finally, the mental status exam gives us information about whether or not the person is psychotic or depressed and thinking about suicide.

Those are the parts of the social history that we talked about again as you would imagine that a substance abuse history is very important in differentiating different forms of psychosis and understanding whether or not the person has any history of traumatisation or witnessing any violence in the community is equally important because there are significant psychiatric symptoms that can develop there.

One of the things that is very important in evaluating members of another ethnic group, and we’re talking about African Americans today, is understanding how people are supposed to be interacting with one another and what kind of expectations there is for dress and for behavior. One of the things particularly that can happen with African Americans is that in the assessment of affect is that some people have found (and this seems to happen more in the South than in the North) that it is protective to not show a lot of one’s emotions on one’s face. That can lead to what we in mental health call a flat affect. People in the African American culture have learned that this can be a survival mechanism because if someone doesn’t understand what you are thinking then they can’t over-react to what you are thinking. This has led to over diagnosis of schizophrenia in many African Americans. If someone is over diagnosed with schizophrenia then, of course, they are going to have an inappropriate treatment for that; and we can have people who are treated with anti-psychotics when that is inappropriate.

We’re all aware of the stereotype of fearfulness of black males. Although I have not seen this diagnosed in literature, I have seen in my clinical experience that aggressive children are very easily given the diagnosis of conduct disorder. A person with conduct disorder is really someone who willfully decides to violate the rights of others. There are many instances in which a complete history may not be obtained; and as a result, a misdiagnosis is given. This is something as mental health providers if we have a young person who has the history of aggression not to over react but to find out more about what it is that is precipitating the aggression. I have met many children who have become aggressive related to symptoms due to post-traumatic stress disorder. They are having flashbacks re-experiencing some kind of traumatic experience; they develop some kind of hair trigger; and then they may become aggressive. They will come in to see a mental health provider, and they are immediately given an anti-psychotic to try and get rid of their aggression. Or someone may ask them if they ever hear things or see things that other people can’t hear or see, they’ll say yes; but they are not explaining that what they are seeing is a flashback to a previous bad experience. The medication treatment for such a person is different that for a person who is psychotic.

Under-diagnosis: One of the things that has been found is that African Americans may be more likely to experience hallucinations with depression. This has led to an over-diagnosis of schizophrenia in addition to the flat affect that may be seen some individuals. That is one reason that the schizophrenia can be over-diagnosed and affected disorders are under-diagnosed.

A person who is experiencing alcohol hallucinosis or some kind of withdrawal from alcohol can also be agitated and have hallucinations just like a person has with schizophrenia, and that can lead to an over-diagnosis of schizophrenia. If an adequate substance abuse history is not obtained, then the relationship with alcohol abuse or other substance use symptoms is not going to be elicited.

It is important as clinicians that we understand any cultural biases that we may have been raised with that we don’t have purposefully but that may just be present because we have been raised in America. It is important as clinicians for us to recognize any personal biases that we may have.

There are some medications that are more or less likely to be effective in working with black people. This seems to be related to the way that the body metabolizes or breaks down the medication. Young black males seem to respond to lower anti-psychotic medication; and as a result, they may be more likely to experience side effects from these medicines. African Americans may respond more quickly to the older antidepressants or to the benzodiazepines like adavan. We may end up having higher levels of lithium to the same dose, and we might be less likely to respond to Prozac. This study of results of members of various ethnic groups to medications if ongoing, and there are not a lot of definitive answers regarding to this; but what is most important for providers to consider is that there may be some ethnic differences and racial difference in responses to psychotropic medications.

The surgeon general did a report called Mental Health, Culture, Race and Ethnicity, which is available on the Internet. It reviews information about various ethnic groups and African Americans are included in this. It can be very helpful for the clinician who wants to understand the history of any racial or ethnic group in America and how these factors might effect their presentation for mental health as well as their response to treatment.