Mental Health and Multiculturalism
Mental Health and Multiculturalism
The concept of mental illness is relatively new. Westernized nations like the Canada, the United States of America and European nations are where the majority of research on the subject is being conducted. In fact, there was a time when mental illness did not exist in western society (Thornicroft, 2006). Throughout history there have been observation and historical documentation of people who have had mental health issues whom were portrayed as deviant or psychotic. With increasing social conscience which occurred in the 18th century, the mentally ill were given what was considered appropriate refuge in asylums, where residents were isolated and in large part gratefully forgotten by society, receiving little more than shelter (Callaway, 2007). Prior to the past century the general reaction ranged from being tolerated, pitied, shunned, or punished, sometimes they lived out their years or died (Andrews & Boyle, 1999; Callaway, 2007). Persons defined as “mad” were more likely to be viewed as fools, or possessed rather than being viewed as suffering from legitimate illness (Andrews & Boyle, 1999).
Societal perceptions of the mentally ill have changed vastly in recent decades with increased research and attention paid to proper care of those suffering form mental illness Today’s mentally ill are more integrated in the community, which encourages an emphasis on primary and preventative care as well as increased attention to crisis intervention and care management that is specific to client needs (Andrews & Boyle, 1999). Perhaps in current years the problems faced by human beings globally are far more numerous in terms of experiencing severe stress, violence, anxiety, anger, mood disturbances, confusion, and substance abuse. In Canada today the incidence of mental illness is further complicated by global movement of world populations, meaning that multiculturalism in the nation, although celebrated and important as creating a cultural mosaic, is often not adequately addressed inpatient healthcare treatment settings, especially mental illness.
The Role of Multiculturalism in Inpatient Mental Health Nursing
I work as nurse in a psychiatric unit at the University of British Columbia hospital. The unit I work on is a concurrent disorders unit. There is a diverse population in the catchment area because all ages, genders, socioeconomic classes and ethnicities access these two major Vancouver hospitals. Primarily the patient populations being treated suffers from mental illness combined with addictions with the majority of patients I encounter suffer from multiple life stressors coupled with the fact that they are in acute psychiatric distress. On a daily basis I see firsthand how each patient has difficulties managing their mental illness and addictions issues as marginalized group, many living in poverty with no fixed address.
The unit is a short stay unit, opened a little over two years ago designed to manage the overflow of addictions patients from the emergency rooms in both Vancouver General Hospital and from St. Paul’s Hospital. Many of the patients on our unit are certified, meaning that they are there under legal order because they are in acute psychiatric distress warranting a medically ordered hospital stay. The inpatient unit houses fifteen patients at capacity and more often seventeen patients because there are two overcapacity beds. The patients are typically in acute psychiatric crisis because they have stopped taking their medications and are using illegal drugs or alcohol exacerbating their symptoms. Common behaviours encountered are agitation/aggression due to withdrawal, delusions or paranoia, suicidal/homicidal ideation and self harm beahviours.
I have encountered and cared for patients of many cultural groups and ethnicities such as Aboriginal descent, East Indian, Asian, South American and Eastern European. Some of the ethnic populations are immigrants and some are domestically born second or third generation Canadians. On a regular basis I find that there are many learning experiences fostered from working with a multicultural population, as I am allowed to probe into many aspects of each patient’s lives through assessment and therapeutic conversation in order to provide excellent nursing care in a team approach. However, there are also many challenges presented from working with cultural groups with cultural beliefs, practices and norms that are not familiar to me or my health care teammates.
Challenges of Work with Multicultural Patient Populations
Currently four fifths of the global population lives in non-Western countries, yet interestingly most psychiatric recourses are found in western societies (Andrews & Boyle, 1999). The schizophrenias, manic-depressive disorders, major depressions, and anxiety disorders are thought to occur throughout the world yet much of the research towards treatment is conducted in English speaking, westernized nations perhaps showing only part of how they are manifested in different patient populations. Depression anxieties and somatoform disorders are likely more prevalent in the non-Western world then are infectious diseases (Andrews & Boyle, 1999). However, despite international epidemiological and research efforts, there are presently few international centres focused on mental health treatment programs comparable to, for example, the World Health Organization (Andrews & Boyle, 1999).
Personally, I can see that there is a lack of attention focused on how certain patient’s cultural values and beliefs bear implications on their treatment because there is a tendency to rely on models and theories that are researched and found effective among generalized data from North American populations. As health care professionals we are often quick to assume that our ways are the best ways because they are empirically researched and represent the general population yet we often fail to acknowledge that every society has systems of beliefs and practices related to health care, and specific persons trained as healers. For example, I recall caring for an Aboriginal patient earlier this year. This patient participated extensively in rites and rituals of her particular cultural group, some of which us as outsiders considered dangerous and perhaps contributors to her state of psychosis. We made these judgments based on North American sets of medical assumptions, treating the patient accordingly but failed to recognize the important significance of the patient’s cultural practices and even the experience of what we construed as psychosis in the context of her culture.
There is currently no access to traditional healers to consult on such matters. Interestingly I also find that the use of spiritual care is often ignored or underutilized in patient treatment for fear that it conflicts with prescribed treatment plans. There are many places where biomedicine is not widely available and most people depend on traditional healers, although they also exist in modern westernized societies. Whereas shamans and traditional healers are often not very effective in treating chronic mental disorders, the outcome for some conditions tends to be more positive in those societies where clients are not negatively stigmatized and are not alone with their problems (Andrews & Boyle, 1999). Where persons with mental illness are devalued, they are more likely to be demoralized and isolated, to feel dehumanized, and to curtail the development of potential support systems. Individualism and self-reliance further reinforce a tendency toward social isolation and alienation. Additionally, many individuals cross cultures, which requires special psychosocial resilience and adaptation.
The division of illnesses into physical and mental categories is Western, although every society labels some behaviours as abnormal. The cultural assumption that mind and body are somehow separate, which is now increasingly challenged in terms of relationships between healing and the mind has several centuries strongly swayed Western ideas about normality and abnormality. What is considered “normal” and what is “abnormal” is always based on cultural perspective. Culture influences expression, presentation, recognition, labeling, explanations for and distributions of mental illnesses.
Mental health and mental illnesses are more difficult than physical disorders to delineate because of the lack of readily observable, discrete, and organic phenomena. The symptoms of mental illness, dependent as they are on behavioural expression, vary because they depend on social definitions rather than physical measures. Assessment is based on the appropriateness of bahaviours that lack fixed standards and depend upon context and social relationships to differentiate what is considered normal from what is viewed as abnormal.
Outward expression of symptoms and outsider perceptions and treatment of them varies widely dependent on treatment plan. Although psychotic disorders occur in every society and the primary symptoms occurs across cultures, the secondary of these disorders are highly influenced by culture. For example, in some groups, guilt and suicidal ideation do not accompany depression; in others they frequently do. In some societies, suicide is an acceptable escape from problems ranging from marital dissension, illness, sorcery, loneliness, and hopeless to criticism fro others.
In some groups somatic rather than psychological symptoms are prominent among depressed individuals; in others such as middle class European Americans, psychological “blues” prevail. Somatization pertains to a preoccupation with physical symptoms that are thought to have ea psychological rather than physical cause. Somatic symptoms that express psychological distress occur at high rates, for example, among clients who are Hispanic or Chinese. It is not unusual for nurses to encounter clients who deny being depressed but complain of headaches, backaches, stomach ahces and other physical phenomena prompted by sorrow and suffering.
Multicultural Patient Populations and the Issues with Role and Relationship Literature
Conceptions of social roles as well as current research literature on relationships are highlighted as two areas significant to the patient populations that I encounter. Social roles are the expected behaviours and attitudes that come with one’s position in society. Bjorkland and Bee (2008) highlight the concept of gender roles indicated the significance in Canadian society. Gender roles are culturally defined, shifting as the culture shifts. Every society is thought to have some form of gender roles. For example, in Western cultures, it is part of the female prescribed gender role to be the primary caregiver for both children and aging adult parents. The challenges that arise with the issue of roles are that in other cultures there may be more rigid gender roles. According to the textbooks there are definitive times when children are expected to leave home to pursue becoming independent adults. There is brief discussion that those from single parents families make this transition earlier while African-Americans are found to move out of the parental home later. Marriage is seen as a major step in the transition to adulthood.
Joys
The joys are that there is the opportunity to learn about the differences in gender roles. Also a joy is to be able to provide the opportunity to educate about the differences in culture.
Strengths
The strengths of the literature are that they present the perspective from the point of view of
Limitations
The limitations with the literature are that the roles may not be representative of other cultures. There are intricacies such as
Modifications
Modifications to this could be more about the different roles in other cultures.
Personality
Challenges
Psychologists studying persistency of personality are most often asking whether each individual’s relative position on some constant measure has remained the same over time. The interest is in personality traits and personality trait structure. The strongest evidence for personality consistency in adulthood comes from the work of Costa and McCrae (1997) who identified five major dimensions of personality that have come to be accepted by most personality researchers. Behaviour geneticists estimate that between 30 and 50 percent of the variation in personality, as measured by the typical self-report instruments used in these studies, can be accounted for by genetic differences.
Joys
Strengths
Limitations
The limitations within the research may include the lack of current study that includes populations that do not fit in with the generalizations that have been studied. For example, with regard to recent immigrants I would imagine this is a life changing event where one is taken out of the culture and way of life that they are familiar with and placed into another culture. For example, being a doctor in one’s homeland and coming to Canada and finding that the only employment opportunity available is labour work may be a blow to one’s self esteem.
The population that I work with is in acute psychiatric distress. There are patients that have major depression or schizophrenia, as mentioned previously many have addictions issues. Many of the patients I encounter do not have fixed addresses, they are homeless, living in shelters, if they are lucky enough they live in supported housing. It is incredible unfortunate but many of the patients I encounter have destroyed many of the ties they have with family. Many of the patients have abused those supportive relationships or feel to embarrassed to access these types of social support. Often when there are patients of different origin the families do not have good understanding of the mental illness. Sometimes there are language barriers on the part of the family because there is not the same type of understanding about mental illness in other cultures. Sometimes there is social isolation because patients of different cultures have family in other countries.
Joys
It is good when I see patients of different cultures because sometimes there is a large social support network that they can access and there are those opportunities to provide teaching to not only patients but also their families.
Strengths
The strength of the research on the area of relationships is that there is a large body of research. The concept of attachment has been studied extensively since the 1960s. Research has showed that adult romantic relationships styles are reflections of attachment the adults had with their parents in childhood.
Limitations
Limitations include the fact that perhaps relationships are different in normative Canadian society than globally. For example, Bjorkland and Bee (2008) discuss extensively the concept of love. They explain that during the past few decades there has been in increased interest in the concept of love. There is the differentiation between the concept of liking and loving as well as a discussion such as the work of Hatfield (1988) discussing the difference between passionate and compassionate love. Further, Sternberg’s theory of love describes the connection between intimacy, passion, and commitment. Concepts such as love may be different in different types of cultures. For example, some cultures use arranged marriage. Perhaps they have different conceptions of love. In discussion of intimate partnerships the research is based on a North American perspective in which the concept of free choice is seemingly utilized. I imagine it must be quite difficult when immigrants move to Canada where conceptions of what marriage is are quite different. Bjorkland and Bee (2008) concede that there is a need for more longitudinal research of couple relationships fro any theoretical framework. Perhaps there needs to be study on conception of marriage in different cultural groups as well as research into how those marriage partners are chosen.
In terms of friendship relationships are difficult to define because of different relationships
Modifications
Perhaps there should be more research on sibling relationships in multicultural populations within the realm of mental health.
A balance of cultural sensitivity, knowledge, and skills allows nurses to link awareness and sensitivity with knowledge of typical, expectable group patterns. Sensitivity and knowledge, in combination with cultural assessment, communication, and other mental health nursing skills, can produce respectful, culturally acceptable and effective nursing interventions for diverse peoples in specific, individual situations.
However, limiting attention to sensitivity leaves the sensitive nurse powerless, as he or she still lacks the knowledge and skills required to act knowingly on the issue. Knowledge of expectable cultural patterns provides starting places against which the reality of a given situation can be tested. Such knowledge differs from stereotypes which lock out real evidence through acknowledgement of only that which was expected. Lack of sensitivity, knowledge, and skill may be involved when people are labeled “noncompliant,” “problem patients,” or too resistant or defensive to benefit from treatments or to recognize the value of the care being offered. Might it be that the client’s ideas about care and caring simply differ from those of the nurse?
There is probably more variation among etiological beliefs of mental health care professionals than is commonly acknowledged, but belief in relatively impersonal, environmental, and natural causation generally prevails. For a variety of reasons or simply by chance, parts, systems, families, or individuals take on characteristics that are assessed as dysfunctional. In contrast, members of many cultural groups believe illness is caused by supernatural being, a nonhuman being, or another human being. The sick person in such as case is viewed as a victim who is not responsible for his or her condition or its resolution. Some peoples have no concept of accident or spontaneous internal disease processes, so every phenomenon is accounted for as the result of intent by an outside force.
Conclusion
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