Correspondence:
Judy M. Versola-Russo, Psy.D.
29635 Ferry Point Drive
Trappe, MD 21673
jrusso@dhmh.state.md.us
Abstract
Schizophrenia has been described in all cultures and
socioeconomic groups throughout the world. The perception of mental
illness within the cultural dynamics may affect the diagnosis,
treatment, and reintegration of an individual with schizophrenia. As
culture influences the ways individuals communicate and manifest
symptoms of mental illness, style of coping, support system, and
willingness to seek treatment may be affected as well. The role of folk
healing among minority cultures is explored. The purpose of this paper
is to review the illness and to examine the cultural and demographic
factors for schizophrenia.
Key words: culture,
mental health, schizophrenia, treatment
Introduction
Schizophrenia has many effects on a person’s ability to lead a
meaningful life. The disease is found in all cultures throughout
the world. Both genders are equally affected. The age of onset of
schizophrenia appears to be a factor in the presentation of symptoms.
Regardless of its occurrence, whether in Baltimore, Manila, or Rome,
the rates remain the same, one percent of the population. According to
Kaplan, Sadock, and Grebb (1994), about 0.025 to 0.05 percent of the
total population is treated for schizophrenia in any one-year. While
most of those treated require inpatient care, only about half of all
individuals with schizophrenia obtain treatment, in spite of the
severity of the disorder.
Although the manifestations of schizophrenia are varied, the majority
of studies have demonstrated that the symptoms of schizophrenia
typically form into three relatively independent complexes: (1)
positive symptoms (i.e., hallucinations and delusions); (2) negative
symptoms (i.e., blunted affect, anhedonia, poverty of speech,
avolition, and diminished social drive); and (3) disorganized behavior,
including bizarre behavior, and inappropriate affect (Buchanan et al.
1997). These symptoms are not concrete. Not all individuals will
exhibit all or a majority of symptoms.
Perhaps living in a world that is distorted by hallucinations,
delusions, and paranoia may cause people living with schizophrenia to
appear frightened, anxious or even confused. The preoccupation with
hearing voices that others do not may cause an individual to become
distant and detached from others.
Differential diagnoses of schizophrenia
There are many disorders that may mimic schizophrenia, and the disease
varies so greatly in its clinical presentation for different people and
onset. The process of diagnosing schizophrenia is difficult, so several
other disorders must be ruled out before the diagnosis can be made with
a reasonable amount of confidence (Waldinger, 1990).
Mood disorders may be confused with schizophrenia as symptoms of mania
and psychotic depression often present with hallucinations, delusions,
and bizarre behavior. A variety of personality disorders may
present with similar features of schizophrenia. Schizotypal,
schizoid, and borderline personality disorders most closely resemble
the disease. Personality disorders tend to have mild symptoms that are
generally present throughout the person’s life (Kaplan et al. 1994).
Organic mental disorders may look exactly like schizophrenia but may be
attributed to drugs, metabolic disease, neurological condition, or even
infection. A thorough laboratory screening, history, and physical
examination should be documented to rule out medical illness
(Waldinger, 1990).
Disorders such as schizophreniform disorder or delusional disorder may
present with the same symptoms as schizophrenia, with the exception of
duration of symptoms. The symptoms of schizophreniform disorder
have a duration that lasts at least one month but less than six months.
Delusional disorder is an appropriate diagnosis if bizarre delusions
have been present for at least one month in the absence of the other
symptoms of schizophrenia or a mood disorder (Kaplan et al. 1994).
Schizoaffective disorder is the appropriate diagnosis when manic
symptoms or depressive symptoms develop concurrently with the major
symptoms of schizophrenia (Kaplan et al. 1994).
Malingering or factitious disorders may be appropriate diagnoses for
those individuals who may be imitating the symptoms of schizophrenia
but do not actually have the disease. People who are completely in
control of their symptom production maybe given the diagnosis of
malingering. These individuals may be motivated by some secondary gain
(e.g., financial or legal reasons to gain admission into a psychiatric
treatment facility). People who are less in control of their symptoms
may be given a factitious disorder (Kaplan et al. 1994).
Culture-bound syndromes
According to Niehas and others (2004), the term cultural bound
syndrome, refers to any one of a number of recurrent, locality-specific
patterns of aberrant behavior and experiences that appear to fall
outside conventional Western psychiatric diagnostic categories.
Cultural concepts, values, beliefs, influence health-seeking pathways,
and traditional healers play an important role in the management of
disease in many cultures where ‘Western’ medicine is unavailable,
viewed with skepticism, or used in parallel with traditional treatment
methods. Kaplan et al (1994) asserted that Western psychiatrists tend
to view mental illness as culture-free, but certain disorders such as
bulimia nervosa is as shaped by Western culture as koro is by Asian
culture.
Niehas et al. (2004) conducted a study in West Africa and found that
individuals with a family history of either schizophrenia or other
psychiatric disorders were more likely to receive the diagnosis of
ukuthwasa (symptoms include social withdrawal, irritability,
restlessness, and appearing to respond to auditory hallucinations) than
amafufunyana (described as a hysterical condition characterized by
people who speak in a strange muffled voice, cannot be understood, and
have unpredictable behavior. This state is believed to be induced by
sorcery that led to possession by multiple spirits that may then speak
through the individual (‘speaking in tongues’). The authors assert that
not all individuals with ukuthwasa and amafufunyana suffer from
schizophrenia, but may be used as explanatory models in a subset of
schizophrenia sufferers. It may be that families prefer the term
amafufunyana, possibly due to fewer stigmas associated than a diagnosis
of schizophrenia.
Similarly, among unacculturated Mexican-American families, the term
nervios, is used to refer to a wide range of mental illness and
psychological distress. With this condition, the patient is not
considered blameworthy. However, among Anglo-Americans, schizophrenia
is an illness for which the patient’s personal character is implicated.
(Lopez et al. 2004).
Asians who are less Westernized exhibit culture-bound syndromes more
frequently. Early immigrants (40-60 years ago) are strongest believers
in Chinese medicine, newer immigrants (past 20 years) combine both
Chinese medicine and Western medicine; and first and second generation
Chinese Americans are mostly oriented to Western medicine (Lippson,
Dibble, & Minarik, 1996).
However, cultural-bound syndromes occur in European cultures as well.
Kaplan and others (1994) note that in France, bouffée
délirante, is marked by transient psychosis with elements of
trance or dream states. In Spain and Germany, involutional paraphrenia,
refers to a paranoid disorder that occurs in midlife and has features
of, yet is distinct from schizophrenia, paranoid type. Cultural bound
syndromes that share features of schizophrenia include: amok, marked by
a sudden rampage, usually including homicide and suicide, ending with
exhaustion and amnesia (documented in Southeast Asia and Malaysia);
colera, marked by violent outbursts, hallucinations, delusions, and
temper tantrums (documented in Guatemala); and latah, marked by
automatic obedience reaction with echopraxia and echolalia (documented
in Southeast Asia, Malaysia, Bantu of Africa, and Ainu of Japan)
(Kaplan et al. 1994).
Explanatory Models of Illness
As culture influences the ways individuals communicate and manifest
symptoms of mental illness, their style of coping, their support
system, their willingness to seek treatment may be affected as well.
Asian Americans and Pacific Islanders have the lowest rates of
utilization of mental health services of any ethnic population. This
may be attributed to cultural stigmas and financial shortcomings
(Sherer, 2002). Patients may be reluctant to discuss emotional problems
with strangers. Stoicism is a characteristic that is expected among
many Asian Americans. Asian American patients may not express their
emotional pain. Somatic complaints may be expressed instead. This
somatization may be interpreted as a defense mechanism for the guilt
and shame associated with seeking mental health treatment.
In studies examining Asians and Caucasians with schizophrenia, it was
found that both groups had similar inception rates. Bhugra et al.
(1999) found that it there are differences in symptoms manifestations
between Asian and Caucasians and in the mode of onset. The London study
found that Asians were more likely to commit suicide. Auditory
hallucinations were more often reported than in Caucasians. Asians were
more likely to show neglect of activities, lose appetite, and be
irritable. Caucasians were twice as likely to have somatic complaints
and perform violent acts compared to Asians. The study also found that
Caucasians were more likely to suggest that others are responsible for
the onset of the mental illness of the individual compared to Asians
who were more likely to take responsibility for the onset and treatment
of the disorder, suggesting higher pre-morbid functioning (Bhugra, et
al.1999). These findings may reflect the Western cultural expectations
for Asians to be more stoic and controlled than other cultural
groups.
In a longitudinal study by Goater, King, Cole, et al.(1999), it was
found that the incidence rates of schizophrenia and non-affective
psychosis were higher in all ethnic groups compared with Caucasians in
the United Kingdom. The researchers found that members of ethnic
minorities tend to see general practitioners that are more likely
overlook psychological symptoms. This may not only delay the diagnosis
of schizophrenia, but the referral and subsequent treatment (Goater et
al. 1999).
Overall, the inception rates of schizophrenia were similar between
Asians and Caucasians. This may suggest that ethnicity by itself may
not be as strong a factor associated with schizophrenia as previously
hypothesized. Bhugra et al. (1999) concluded that other social factors
might play a more significant role in the onset, diagnosis, and
treatment of schizophrenia in different ethnic groups. The
investigators for both studies concluded that further research is
needed to study the impact of social support systems and family
dynamics on individuals with schizophrenia. Socioeconomic status,
perhaps reflected by level of education, may be a more accurate
indicator of the recognition, diagnosis, and treatment of schizophrenia
in ethnic minorities.
The researchers also noted that among the limitations of their
respective studies was the ambiguity in the term “Asian”. Defining who
is “Asian” may cause a number of problems in the collection and
interpretation of data. Neither study specified if “Asian” referred to
immigrants, or if it included children of immigrants who were not born
in their families’ country of origin.
Some African Americans may view mental illness has a form of punishment
or as "spells" being cast upon wrong doing. The onset and the
subsequent treatment may be perceived as a disgrace and may suggest the
inability to handle responsibilities and threaten an African American
woman’s position/role of mother (Amankwaa, 2003).
McCabe and Priebe (2004) compared explanatory
models of illness that may differ among people with schizophrenia from
four cultural backgrounds (African-Caribbeans, West Africans,
Bangladeshis, and Whites). They found that Whites cited biological
causes more frequently than non-White groups, who cited supernatural
causes more frequently. African-Caribbeans, West Africans, and
Bangladeshis are more likely to have social or supernatural explanatory
model. However, the type of explanatory model does not appear to be
associated with treatment compliance (McCabe & Priebe, 2004).
Folk Healing
Krajewski-Jaime (1991) asserted that folk medicine and modern
scientific practice have coexisted for many years. Folk-healing
interventions that have validity and integrity within the client's
cultural context may be interpreted as ignorance, superstition, or
simply as abuse and/or neglect (Krajewski-Jaime, 1991). Practices and
common elements of folk healers may be misinterpreted or even
pathologized by members of the majority culture (Dana, 1993). New
arrivals are more likely to use indigenous healers. For example, among
Southeast Asians, the Vietnamese might seek out Taoist teachers and
ethnic health practitioners such as Vietnamese physicians, the Khmer
and Lao might use Buddhist monks, and the Hmong might use herbalists
and shamans (Kitano, 1989). Curanderismo, or folk healing, is the
treatment of a variety of ailments with a combination of psychosocial
interventions, mild herbs, and religion (Salimbene, 2000). Some of the
ailments that curanderos focus on are thought to be equivalent to those
treated by mental health professionals. Bean et al. (2001) urges
clinicians to be prepared to collaborate with folk healers when working
with Hispanic Americans, as this cultural factor plays a prominent role
in the delivery of health care services and treatment compliance.
One implication of folk medicine has to do with the strong ties with
the extended family in many minority cultures. It is noted that when a
person is ill, many of the family members are involved in deciding if
indeed the patient or client is ill in the first place, and the extent
of the illness, the treatment to be given, and by whom
(Krajewski-Jaime, 1991). Rather than viewing folk healing as a barrier,
it should be viewed upon as a strength and resource. Doing so may also
help the worker to build rapport with the client. Folk healers may be
consulted as a first opinion, because he or she has known the family
intimately for many years, speaks their language, and does not dictate
orders for care but makes suggestions, leaving the ultimate decision up
to the patient and family (Krajewski-Jaime, 1991).
Use of herbs common may be a common practice among Asian American
patients. However, this practice may interfere with the efficacy of
psychotropic medications. Fundamental Asian health beliefs that may
impact mental health treatment include imbalance of the yin and yang,
and the corresponding conditions of “hot” and “cold”. Illness may be
attributed to an upset in this balance of forces (Salimbene,
2000). Braswell and Wong (1994)
notes that Native American healing practices are those which may
involve traditional medicine practitioners, such as medicine men and
women, herbalists, and shamen, to restore an individual to a healthy
state using traditional medicines, such as healing and purification
ceremonies, teas, herbs, special foods, and special activities such as
therapeutic sings, prayers, chants, dancing, and sand painting.
Traditional healers may be combined with use of Western medicine. As
many as two-thirds of this population continue to use traditional
healers, sometimes in combination with mental health care providers
(Galanti, 2004).
Native American beliefs hold that the individual is ultimately
responsible for his own wellness (Dana, 1993). Wellness implies harmony
in spirit, mind, and body, while unwellness, comes from natural causes
of violations of taboos. This is supported by the Trimble and Hayes
(1984) who stated that mental illness is the result of living beyond
the rules of right living in which a shaman can be helpful. This is
contrary to the mainstream White population in the United States, which
views mental illness as the result of trauma and external stressors, a
chemical imbalance, or a pathological process within the individual
that can be relieved through medication and personal efforts toward
behavior change (Trimble & Hayes, 1984).
Onset of schizophrenia
For many people, the symptoms of schizophrenia can be frightening and
tragic. Confusing changes in behavior, complex delusional belief
systems, and cold detachment from otherwise engaging members of
families may tragically withdraw from society, unable to cope with the
manifestations of a chronic and persistent debilitating illness.
Individuals who are just entering adulthood are often struck down by
the symptoms of schizophrenia. While it is generally regarded that this
illness has an onset in late adolescence, a significant amount of
people first manifest symptoms of schizophrenia in middle or even old
age.
The type of onset is significant in the analysis of an individual with
schizophrenia. Adolescent onset may be considered the age range
from 10 to 17 years. Early-adult onset may be considered from 18
to 30 years of age. Middle-age onset may occur between the ages
of 30 to 45 years. Late-onset may be considered after 45 years of
age (Hollis, 2000). But the exact determination of the onset can
be very difficult, as the illness does not suddenly “strike”.
More obvious psychotic symptoms are preceded by more ambiguous
behaviors. Misdiagnosis may often occur as the symptoms of other
disorders overlap with schizophrenia.
According to a study by Howard et al. (2000), it was found that
categorization by specific age at onset ranges is relatively arbitrary.
The peak period of onset seems to be from 15 years up to 30 years. They
found that early and late onset cases are more similar than different
in terms of positive symptoms. Furthermore, no difference in type of
cognitive deficits appears in early versus late onset cases. The
researchers did note, however, that among cases involving later onset
of schizophrenia, somewhat milder cognitive deficits might exist,
especially in the areas of learning and abstraction.
Studies of the childhood histories of adult schizophrenic patients have
suggested that some early patterns of developmental difference from
children who did not become schizophrenic in their adulthood (Lewis,
1996). Children who subsequently develop the disorders have been noted
to demonstrate premorbid patterns of behavior such as conduct problems,
attentional deficits, or avoidant behaviors. Lewis (1996) reports that
onset of disturbance appears to follow at least three general patterns:
insidious onset, with a gradual deterioration in functioning; acute,
without premorbid signs of disturbance; and insidious onset with acute
exacerbation of disturbance. It is further reported that, as in
adults, males appear to have an earlier onset of the disorder than
females during childhood (Lewis, 1996). Generally, it appears that
children who later developed schizophrenia demonstrate a significant
delay in achieving developmental milestones by the first two years of
life. By age two, they were less likely to reach such milestones such
as sitting, standing, walking, and talking. Walker, Savoie, and Davis
(1994) found that children who later developed schizophrenia
demonstrated poor motor skills and had a higher rate of neuromotor
abnormalities compared to their healthy siblings. They also reported
that abnormalities were predominantly seen on the left side of the
body.
In terms of symptomatology, late onset schizophrenia may have a higher
proportion of women than early onset illness. Symptom variables such as
emotional expressiveness and social activity, gender may play a factor
in assessment. Research by Lindmer, Mohr, Caligiuri, and Jeste (2001)
indicates that differences exist between patients who manifest
schizophrenia for the first time after age 45 (late-onset
schizophrenia, LOS) than those with early-onset schizophrenia
(EOS). They found that patients with LOS are more likely to be
female, with less negative symptoms, and have a significantly lower
duration of illness than other patients.
Avila, Thaker, and Adami (2001) hypothesized that according to
evolutionary theory, in the case of schizophrenia, lower rates of
reproduction constitute a negative selection factor reduce genes in the
population associated with the expression of the illness. In effect,
this hypothesis predicts the decrease in the prevalence of
schizophrenia. Yet, the rates continue to appear a stable one percent
across different geographic locations. Their findings are consistent
with a model of reproductive fitness in that the more siblings there
are of schizophrenic patients, more genetic material necessary for
expression of the disease is maintained. This finding provides some
insight to why the prevalence rates remain stable despite lower
reproductive rates among individuals with schizophrenia (Avila, Thaker,
& Adami, 2001). The risk for the general population is
approximately one percent. This is a figure that is consistent in other
countries as well.
Gender differences in schizophrenia
While it appears that schizophrenia is equally prevalent in men and
women, the two genders show several differences in onset and course of
illness. Kaplan et al. (1994) describe differences such as peak ages of
onset. Men seem to have the onset of schizophrenia from ages 15 to 25
years. The peak ages of onset for women are from 25 to 35 years. The
mean age of onset for men was 31.2 years for men and 41.1 years for
women. It appears that studies overwhelmingly support an earlier age of
onset in males by 3 to 5 years, regardless of culture. Females have
several peaks of onset, first in their twenties, one in middle age, and
another over age 65 years (Kaplan et al. 1994).
Differences in symptomatology exist between the genders. Studies have
found that while men tend to display more negative symptoms,
schizophrenic women tend to display more affective symptoms such as
dysphoria, depression, irritability, hostility, inappropriate affect,
impulsivity, sexually inappropriate or bizarre behaviors, and sexual
delusions. Szymanski, Lieberman, Alvir, Mayerhoff, Loebel, and Geisler
(1995) found that females displayed significantly less illogical
thinking, but more anxiety, inappropriate affect and bizarre behavior.
The study reports that women were diagnosed more frequently with
paranoid and disorganized subtypes of schizophrenia than men.
Females were found to be more likely than males to express persecutory
delusions (Szymanski et al. 1995).
Pre-morbid functioning tends to be better in women than men. Perhaps
this is based on more opportunities for women to be more socially
adjusted and having greater chances of finding partners and starting
families of their own before becoming ill. This may be reflected in the
later onset of illness for women. In a study conducted by Rasanen,
Nieminen, and Isohanni (1999), it was found that in Finland, men with
serious psychiatric illness often stay home with their parents and fail
to progress towards higher education, work, or marriage. This is
consistent with other findings that may be attributed to the later
onset of schizophrenia in women.
In general, the outcome for women who have schizophrenia is better than
the outcome for men who have the illness. It appears that women are
more likely to seek treatment. Diagnostic criteria have been found to
be a factor in gender differences in schizophrenia. Seeman (1985) has
observed that the more stringent the diagnostic criteria for
schizophrenia are, the more females are excluded. Seeman (1985) further
states that gender differences may be attributed to more severe roles
stresses on males and social protective factors in females.
Estrogen hypothesis
The presence of estrogen has been hypothesized to protect women from
the early onset of the severe symptoms of schizophrenia. As the start
of puberty brings on hormonal changes, estrogen may serve to protect a
woman against an earlier onset of the illness. Female hormones act on
the developing brain to protect its integrity and delay the expression
of psychosis.
Epidemiological studies have shown that women with schizophrenia
present about five years later than men with the disorder (Kulkarnia,
Riedel, deCastella, Fitzgerald, Rolfe, Taffe, & Burger, 2001).
Life-cycle studies have suggested that women are more vulnerable for a
first episode of psychosis or relapse of an existing illness during two
major periods of hormonal change, the post-partum period, and the
menopausal period (Kulkarnia et al. 2001). These findings are
consistent with the hypothesis that estrogen may reduce dopamine
concentration, which can then affect acute psychotic symptoms and
general health status (Riecher-Rossler & Hafner,1993).
In a study by Howard et al. (2000), it was found that patients with
late onset schizophrenia tend to have somewhat subnormal pre-morbid
functioning and generally have a chronic course of illness without full
remission. In a similar study by Cohen, Seeman, Gotowiec, and Kopala
(1999), findings suggest that there may be an association between
pubertal hormones and delayed age of onset of schizophrenia.
Upon an extensive review of the literature, Palmer, McClure, and Jeste
(2001) conclude that although there may be a link between menopause and
the onset of schizophrenia, as estrogen may act as an endogenous
anti-psychotic, masking symptoms of schizophrenia in women who are
otherwise predisposed to developing the disorder at some point in their
lives. Psychosocial factors, the environment, and other influences may
combine to serve as protectors or inhibitors of the disorder. Based on
this estrogen hypothesis, investigators have begun exploring the
possibility of estrogen replacement therapy as an effective supplement
to antipsychotic medication in an effort to control the psychotic
symptoms of postmenopausal women with schizophrenia (Palmer et al.
2001).
Hochman and Lewine (2004) investigated if this hormone, indeed, serves
as a protective factor in the development of schizophrenia and posited
that the earlier the age of menarche, the later the onset of
schizophrenia. Although the results of their study suggest that an
earlier age at menarche might predict improved clinical outcome after
schizophrenia onset (in support of the estrogen hypothesis), the
authors could not conclude that a causal relationship exists between
age at menarche, and the timing of the onset of the disorder.
While it has been determined that schizophrenia affects men and women
in equal frequency, there are some gender differences that occur, in
terms of manifestations of symptoms. No cultures or ethnic groups are
excluded from the illness, which is often misunderstood. Some cultural
expectations may influence the interpretation of symptoms. But as
symptoms of this disorder rarely present themselves in a sudden manner,
onset of illness can be difficult to determine.
Socioeconomic factors
Socioeconomic reasons may become a barrier if treatment cannot be
afforded. The cost of psychotropic medications and adverse side effects
may result in treatment non-compliance or self-medication. However,
there are community and state resources available for those uninsured
who are in need of treatment. If symptoms progress and interfere with
the individual’s ability to function, involuntary commitment and/or
forensic involvement become likely.
Tsuang, Stone, and Faraone (2001) modified the description of the term
schizotaxia, which is the liability produced by schizophrenia genes, by
incorporating biological and psychosocial factors. This concept may
provide a basis for development of treatment strategies in
non-psychotic individuals who may vulnerable to developing
schizophrenia. The disorder appears to be more prevalent in groups that
are considered lower socioeconomic class within urban areas. Perhaps
this may be due to the relationship between downward mobility and the
debilitating effects of the illness. At this time the relationship is
unclear, but researchers continue to investigate the effects of stress
and development of the illness. Poorer educational achievement is
associated in individuals with schizophrenia. However, this may be
attributed to attentional deficit, learning disabilities, major
neurological conditions, or onset of schizophrenia before the age of 18
years (Tsuang et al. 2001).
Lefley (1990) researched insights from Third World cultures and
suggested that patients may function better in developing countries
because more kinship networks, buffering mechanisms, and apparently
greater respect to tolerance of difficult behaviors may exist within
social dynamics. For individuals with schizophrenia, there are also
more opportunities for low-stress, non-competitive productive roles in
communal societies and agrarian economics. It is possible that Lefley’s
(1990) comments may be applicable to the parallel conditions that exist
in the rural setting.
Lefley (1990) further opined that the two-tiered system of care exists
in the United States, private and public, in other words, for the
“rich” and “not-rich” (including middle-class America). The author
notes that astronomical costs of psychiatric care together with limits
on private insurance can insure that ultimately, almost all chronic
patients will end up in the public sector (Lefley, 1990). Almost all
community support services are in the public sector, including
psychosocial rehabilitation programs.
The presence of community support programs does not, however, insure
their utility. Galanti (2004) reported that per capita income for
Hispanic Americans is among the lowest of the minority groups in the
US. This group is the least likely ethnic group to have health
insurance, which impacts the delivery of health services. Limited
access to mental health services among many Hispanic Americans is
related to their lack of health insurance. Locke (1992) notes the
cultural group with the lowest average income, least educated, and
lowest standard of living, is the Native American population. This
group represents the most economically disadvantaged and underserved
group in the U.S. Geographical isolation has resulted in a lack of
transportation, lack of employment, lack of skilled labor, and absence
of capital. Therefore, the mental health problems of uninsured Hispanic
Americans and Native Americans often go undetected and untreated
because of the low rates of contact with, and access to, health care
providers (Gonzalez, 1997).
In a study by Sullivan, Jackson and Spritzer (1996), clinical
characteristics and service uses patterns were examined between
individuals with schizophrenia who live in rural areas of one state and
those who live in non-rural areas of the same state. The researchers
found that rural subjects were more likely to live with family members.
It was noted rural subjects were less likely to receive opportunities
for psychosocial rehabilitation. A similar study by Sorgaard, Hansson,
Heikkila, Vinding and Bjarnason (2001) found that while rural regions
are said to be better arranged and have more well-functioning social
networks, urban areas tend to offer better chances to establish
voluntary relationships, resulting in greater satisfaction with
emotional relations. The Sorgaard et al. (2001) concluded that women
with schizophrenia generally function better socially than men, but
this can be attributed to the later onset and development of family
dynamics. Sullivan et al. (1996) report that their findings should not
be generalized because rural populations across the U.S. differ in
levels of poverty, percentage of minority clients, and quality of care
provided by local mental health systems.
Seeking Treatment
An understanding of cultural themes is important as they may
predominate and less self-disclosure may lead to disjointed
information. The difference in health beliefs between the predominant
culture provider and the minority client may result in an inappropriate
assessment. If practitioners do not understand or respect a client’s
traditional health beliefs and find ways to incorporate their beliefs
into their treatment, their clients may not participate or become
non-compliant with treatment.
Barnes (2004) suggests several factors that may be associated with an
over-diagnosis of schizophrenia in African Americans. These include:
diagnostic bias of clinicians, lack of cultural understanding between
clinicians and minority clients, racial differences in the presentation
of psychiatric symptoms. African-Americans may not immediately seek
mental health service for a variety of reasons. Not recognizing the
need for treatment certainly is a barrier. The onset of psychotic
and/or affective symptoms may lead to consultation with spiritual and
folk healers, members of clergy, or family members. Perhaps some turn
to self-medication via drugs/alcohol. Pugh and Mudd (1971) found that
African-American women ranked their mothers, female friends, family
physician, and minister as primary sources of help, while
African-American men ranked their mothers and their minister, followed
by their wife and father. The strong religious and spiritual aspects of
African-American culture can be an important part of mental health
treatment.
Communication styles may become issues during treatment. A client who
has cultural values, beliefs, and customs different from the provider
might not only connote a different meaning to symptoms but also express
it in a way that can be misunderstood. Out of respect for authority
figures, eye contact may not be made when discussing personal issues.
Again, out of respect, a patient may turn down an offer to receive
services or for further assistance. Several attempts may be made before
the patient accepts. Wait time during interaction may be perceived by
the therapist as defensiveness or unwillingness to engage, when it may
actually be out of respect for authority.
Delivery service style with Hispanic American clients should be
sensitive to implications of respeto, personalismo, and platicando, in
which informal, individualized attention and how they affect the
therapeutic alliance (Santiago-Rivera, 1995).
Kim, Bean, and Harper (2004) present eleven specific guidelines when
working with Asian Americans: Assess support systems; assess
immigration history; establish professional credibility; provide role
induction; facilitate "saving face"; accept somatic complaints; be
present/problem focused; be directive; respect family structure; be
non-confrontational; and provide positive reframes.
It is important to be aware of fundamental observations when
considering the different approaches to the treatment of schizophrenia.
Kaplan et al. (1994) propose three observations. First, schizophrenia
occurs in a person who possesses unique strengths and limitations.
Treatment should be tailored to capitalize on those strengths while
corresponding to how the person is affected by the disorder. Second,
the fact that numerous studies have suggested that the cause of
schizophrenia is probably due to the genetic, environmental, and
psychological factors leads clinicians to utilize pharmacological
agents to address biological issues while using non-pharmacological
strategies to address non-biological issues. Third, just as
schizophrenia is a most complex disorder, the individual is also both
complex and unique. Limiting the individual to one therapeutic approach
rarely, if ever, seems appropriate in addressing this multi-faceted
disorder (Kaplan et al. 1994).
Family Support
Culture shapes the way in which families construe schizophrenia. An
understanding of a client's cultural heritage can improve the quality
of the relationship between the mental health professional and client.
Family education and ongoing support is beneficial in order to maximize
the support the family network can provide the individual. This is
especially critical when the individual with the disorder is under the
direct care of the family. This is noteworthy in the treatment of
males, whose onset occurs earlier than females, and are often still
living in the family home. The extended family is important, and any
illness concerns the entire family. Mental health professionals should
be mindful that decision-making varies with kinship structure.
In Asian cultures, like many other cultures, family members generally
do not institutionalize members. They care for them in the home.
According to Bae and Brekke (2002), Asian families are more likely to
accompany the schizophrenic patient on clinic visits and to actively
participate in treatment decisions. The authors reviewed the literature
regarding participation in treatment among Asians, They found that it
is possible that variation such as geographical location, acculturation
levels, and diagnostic criteria may account for different findings in
the literature. Also, the combining of Asian-Americans into one group
may have limited external validity (Bae & Brekke, 2002).
Therefore, the family may be involved in decision-making with the
patient. Galanti (2004) recommends that family members be included to
allow them to fulfill their familial duty by spending as much time with
the patient as possible.
Sociocentric individuals with collectivistic cultural orientation tend
to emphasize family integrity, harmonious relationships, and
sociability. Bae and Brekke (2002) note the importance of incorporating
cultural characteristics into the intervention process. Interventions
that are designed to involve families in a collaborative effort may be
more appropriate for minority members because of the interdependent
nature of their family dynamics.
Conclusion
Schizophrenia is a severe and persistent mental illness that crosses
all racial, ethnic, cultural, and demographic lines. The influence of
class status, ethnic and cultural identity in relation to the
presentation and the reporting of schizophrenia must be considered.
Communication, coping styles, support system, and willingness to seek
treatment are also affected. The factors discussed influence beliefs,
attitudes, and behaviors regarding the identification of illness and
health and in the process of treatment and recovery. The lack of
educational and financial resources may create a barrier, in terms of
utilization of services and compliance with treatment. Understanding
how psychosocial factors within the cultural dynamics of this
population would promote more culturally relevant care.
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