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Defining Mental Health Within a Transcultural Nursing Perspective.

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The World Health Organization (WHO) (2007) proposed: “There is no health without mental health” and the influential organization incorporated mental well-being in their definition of health. According to WHO, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (p. 1). WHO further specified that mental health is “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” (p. 1), and that this understanding of mental health can be interpreted “across cultures” (p. 1). For example, in the Rural Healthy People 2010 Report, survey results of state and local rural leaders indicated that mental health and mental disorders are the fourth most often identified rural health priority (Gamm & Hutchison, 2003). Taking into consideration the WHO definition of mental health, a definition of mental illness would then include one or more of the following: a lack of a sense of well-being in which the individual does not realize his or her own disabilities, is not able to cope with the normal stresses of life, is not able to work productively and fruitfully, and is not able to make a contribution to his or her community. It is important to remember there is a continuum of mental health on one end and mental illness on the extreme other end. An individual can fall on one end of the continuum or the other, or anywhere in between. Individuals’ and communities’ cultural beliefs and values about mental health and mental illness can influence one’s placement on the continuum, as well. It is a daunting task to know all there is to know about each cultural group that mental health nurses care for in their daily practice. Leininger (1991; Leininger & McFarland, 2002) in Culture Care Diversity and Universality: A Theory of Nursing, theorized the importance of identifying what is common and universal among cultures, while at the same time understanding there is individual diversity within cultures. Diversity for transcultural mental health nurses would encompass not only culture and ethnicity, but also gender, sexual orientation, socioeconomic status, age, physical abilities or disabilities, religious beliefs, and political beliefs or other ideologies. Figure 10-1 shows a transcultural nurse working on promoting health and well-being with a patient from a culture different from her own. In this chapter on Transcultural Perspectives in Mental Health Nursing, patterns of values, beliefs, and practices for mental health care are presented and can be used as one “tool” in caring for patients, families, and communities from diverse cultural groups. This is different from simplistic overgeneralizations that can lead to stereotyping a particular culture. Stereotyping can also lead to erroneous misrepresentations of mental health for multiculturally diverse patients. Stereotypes can be used as an underlying rationale to distort mental illness symptoms and misdiagnose multiculturally diverse individuals, families, and communities. Stereotypes can serve to exploit culturally diverse patients, particularly in the area of mental health care, where differences in group norms can sometimes be used to inappropriately label patients with a mental health diagnosis. It is not the intent of this chapter to reduce cultural groups to a limiting set of characteristics, but to identify cultural patterns and norms that can be used to assist the mental health nurse in caring for culturally diverse patients with mental health needs.

Transcultural nurses do not promote stereotyping of patients, families, and communities because of unique characteristics. Stereotyping labels people and is a form of prejudice that is damaging and harmful to any recipient, let alone a patient with a mental illness! Furthermore, stereotyping is generally inaccurate and is often based more on the individual expressing the stereotypical view than the cultural group being targeted. Stereotyping identifies a cultural group or members of that culture as identical and indistinguishable from each other. Some examples of common stereotyping are beliefs that African Americans are “better at sports” and “dancing” than other cultural groups. Other examples of stereotypes are that Irish Americans are “quick tempered,” or Turkish women are “belly dancers.” Identifying people as all looking the same or thinking the same is stereotyping. Transcultural mental health nursing does not promote applying a stereotypical “cookbook” approach to mental health care. One other concept that is important to consider in transcultural mental health nursing is ethnocentrism. In its mildest form, ethnocentrism presents as subconscious disregard for cultural differences; in its most severe form, it presents as authoritarian” (Sutherland, 2002, p. 280). Ethnocentrism can manifest as feelings of superiority or discrimination with respect to one’s own group or culture over another group or culture. For example, ethnocentrism can manifest as a belief that one’s own religious beliefs are superior to another group or culture’s religious beliefs. One’s own health care beliefs and practices are superior to another culture’s health care beliefs and practices. U.S.-educated health care professionals are frequently guilty of the latter ethnocentric assumption. Many cultural groups have distinct patterns of values, beliefs, and practices that can be used as a basis for providing mental health care in a culturally congruent and competent manner. However, many individuals and families belonging to specific cultural groups may have more diverse mental health care needs than those of the cultural group norm. The term “norm” is used to identify patterns of values, beliefs, and practices specific to mental health that have been identified through research and caring for culturally diverse patients, families, and communities.

Population Trends and Mental Health

The U.S. population is projected to increase in age and cultural diversity as we move toward the middle of the century. Given the increasing numbers of elderly in the United States, it is important to understand trends in utilization of mental health care services for older populations of all cultures. Day (1996) in a report developed for The U.S. Bureau of the Census predicts that by 2030, approximately 20% of the total population will be over 65 and those 85 and older will increase fivefold by 2050. By mid-century, African Americans will double in number. Those individuals of Hispanic origin, Asian, and Pacific Islander populations will have the highest rates of increase. By 2030, the non-Hispanic “White” population will be less than 50% of the population under age 18. However, in that same year, this group will comprise 75% of the population aged 65 and over. Native Americans (American Indians and Alaska Natives) will have the lowest number of those aged 65 and older. However, there is evidence of underutilization of mental health services by many minority groups. Community education and outreach programs are needed to increase mental health service utilization in older ethnic minority populations (Jang, Kim, Hansen, & Chiriboga, 2007). Although mental health nurses care for clients of all age groups and all cultural groups, the current and future trends in population projections do have major implications for transcultural nursing and mental health services in the United States. According to Kessler, Chiu, Demler and Walters (2005) approximately 26.2% of Americans 18 years old and older, or 1 in 4 adults, suffer each year from a mental disorder that is defined in the Diagnostic and Statistical Manual, 4th edition (DSM-IV) of the American Psychiatric Association (APA) mental disorders. Of those cases, more than one-third are mild. However, approximately 6%, or 1 in 17 individuals suffer from a “serious mental illness,” including suicide, mental or substance abuse, nonaffective psychosis, bipolar I or II and Mental Health Services Administration (SAMHSA) charged with improving prevention and mental health treatment services in the United States. For 2008, CMHS statistics for utilization of community-based mental health treatment was 19.15%, as compared to treatment in state hospitals and other psychiatric inpatient settings just over 2%. So, not only is the cultural diversity of mental health patients increasing, but also the trends to community-based mental health treatment centers. These statistics can help to guide the direction nursing will take in meeting the needs of mental health patients.disorder, or acts of violence. The institutionalized view of mental health care as portrayed in the movie “One Flew Over the Cuckoo’s Nest” (1975) is no longer the norm for care today. Increasingly, mental health care is moving from state and general “mental” hospitals to community-based service centers. The U.S. Department of Health and Human Services’ Center for Mental Health Services (CMHS) is the Federal agency within the U.S. Substance Abuse.

Healthcare: Racial, Social, and Economic Disparities and Oppression

The fact that racial disparities do exist in the United States is deeply disturbing. Low socioeconomic status contributes to health care disparities, particularly in a society that values monetary success. Social disparities, based on race and economic status are an indication of a society that has failed to integrate its members into a caring and unified protective modality. The United States has a long history of racial discrimination and segregation and this includes health care. What is even more disturbing is that racial disparities in health care are sometimes perpetuated by the health care providers, themselves. If there are racial and economic disparities in health care, then health care providers and those academics and institutions educating the providers are perpetuating a societal disease. (Freire, 1970/1990), over four decades ago, identified the pain of oppression, as a “Pedagogy of the Oppressed,” and discussed the importance of working “with” the oppressed (individuals or peoples) in an “incessant struggle to regain their humanity” (p. 33). Racism and oppression, including internalized oppression (Freire, 1970/1990), are continuous forces that exacerbate destructive behaviors such as suicide, and alcoholism in various oppressed cultural groups (Yellow Horse Brave Heart, & DeBruyn, 1998). Clinical Application Nurses can recognize that patients, families, and communities experience the effects of racial, social, and economic disparities and oppression. Acknowledge that historical grief or cultural pain are very real to those persons who experience them. Transcultural mental health nurses are skilled at caring for and working “with” patients, families, and communities experiencing emotional pain associated with such oppression, disparity and discrimination. Transcultural nurses work with many cultural groups who have experienced racial, social, and economic disparities and oppression. Encouraging patients, families, and communities to assume an active role in their own health care can be empowering.

Immigrant Mental Health Care

There has been extensive debate about immigration policy during the past several years in the United States as well as internationally. In the United States, the debate has become heated politically with both Republicans and Democrats arguing the implications, from their standpoint, of immigration policies. Health care for those immigrants who are not in this country legally has also been extensively debated, again with both sides stating the merits of their views on whether such immigrants, or undocumented workers, have a right to health care in this country. At the same time, however, there has been minimal understanding of these issues from the perspective of the undocumented immigrants and the impact immigration has on their mental health. Setting aside the political debate, transcultural mental health nurses have cared for both documented and undocumented immigrants for many years and are increasingly caring for those immigrants who are feeling the emotional pressures of such a political climate. The term culture shock was coined by the anthropologist Kalervo Oberg (1960) to describe individuals, such as immigrants, who enter a new culture (either legally or illegally). Culture shock is “precipitated by the anxiety that results from losing all our familiar signs and symbols of social intercourse” (p. 177). Oberg suggests that the “signs” or “cues” that people use within a culture-such as the words people speak, customs people follow, and even nonverbal communication such as gestures and facial expressions are not recognized by those who are new to the culture. This leads to feelings of frustration and anxiety even in those persons who would be considered “mentally healthy.” Imagine how these negative feelings would be confounded for an individual who has entered the country illegally and fears arrest, detention, and deportation. The concept of acculturation was initially defined by Redfield, Linton, and Herskovits (1936) as “those phenomena which result when groups of individuals having different cultures come into continuous first-hand contact, with subsequent changes in the original cultural patterns of either or both groups” (p. 149). Acculturation can be a stressful and complex process, particularly for immigrants who experience difficulty adjusting to the new culture. Frequently, children become acculturated sooner than their parents (Boyle, 2008). Some individuals may find themselves unable

to work through the stress of acculturation and have great difficulty in modifying their cultural values, beliefs, or practices and feel isolated from their new culture or even from their culture of origin. Depression is the most common mental health problem among immigrants in the United States and has been associated with the process of acculturation (Al-Omari & Pallikkathayil, 2008; Choi, Miller, & Wilbur 2009). Immigrants and refugees may be fleeing war and other traumatic political environments and may exhibit symptoms of posttraumatic stress disorder as well as depression (Boyle, 2008). Immigration stress can be a result of economic adversity in the new country, language difficulties, loss of support networks, even loss of family members as well as prejudice and discrimination. These difficulties may place immigrants at higher risk for mental health problems. Walsh, Shulman and Maurer (2008) studied immigration distress in young adults immigrating to Israel from Eastern Europe and found young immigrants experienced immigration distress, including feelings of guilt and shame, failure, and incompetence and not feeling wanted, understood, or a sense of belonging. Because of the difficulties faced by immigrant families, their children are at higher risk for depression, anxiety disorders, substance abuse, and other mental health problems. Mental health nurses working with immigrants and their families need to be aware of the risk for mental health problems. Many immigrants may express their anxiety as somatic complaints, so nurses working with immigrant populations need to be aware of the linkages between somatic complaints such as headaches, backaches, and the like, and mental health problems (Lamberg, 2009).

Culture-Bound Syndromes

Various mental health symptoms are experienced by people all over the world. Cultural meanings, beliefs, and practices regarding specific symptoms may vary depending on one’s culture and socioeconomic status within the culture. Although specific identifying terms, manifestations and meanings within different cultures may vary, a diagnosis such as depression is similar around the world. Cultural values, beliefs, and practices also shape how various groups interpret symptoms and identify causality and determine appropriate treatment. In contrast, “Culture-Bound Syndromes,” (also called folk illnesses, culture-specific illnesses, or culture-specific syndromes) often are localized to a particular cultural group. As population trends have indicated, the United States is becoming an increasingly multicultural country and it is necessary, then, for mental health nurses to become familiar with culture-bound syndromes. Mental health nurses will most likely, during their professional practice, encounter patients with symptoms and patterns of behavior that are not commonly observed in the United States and other Western countries, and these symptoms and behaviors have been referred to as culture-bound syndromes. Many mental health nurses must practice within a health care system based on the medical model and use the DSM-IV (2000) of the APA to obtain health insurance reimbursement. In fact, the APA included culture-bound syndromes for the first time in the 2000 DSM-IV edition. This step indicates the extent to which mental health care providers are caring for patients from diverse cultures with unique symptoms that do not fit into the traditional Western diagnostic medical categories. According to APA (2000), culture-bound syndromes are described as recurrent, locality specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category. Many of these patterns are indigenously considered to be “illnesses,” or at least afflictions, and most have local names. Culture-bound syndromes are generally limited to specific societies or culture areas and are localized, diagnostic categories that frame coherent meanings for certain repetitive, patterned, and troubling sets of experience and observations.

As mental health care is changing to meet the increasing multicultural diversity of the patient population, it is important for mental health nurses to recognize the culture-bound syndromes. As you review the table listing culture-bound syndromes (Table 10-1), keep in mind the cultural context in which the syndromes have evolved. Since values, beliefs, and practices of people are culturally constructed, the syndromes can only be interpreted within the context of the specific culture in which they exist.

Cultural Values, Beliefs, and Practices of Specific Cultural Groups as They Relate to Mental Health Immigration trends have been important factors in the cultural diversity and history of the United States. Nurses have always cared for diverse populations of patients and in particular, community-based nurses have focused on newly arrived immigrant populations. A century ago, nurses and other health professionals were concerned about contagious diseases and malnutrition. Currently, there is a great deal of research being conducted to better understand nursing care for culturally diverse patients and their family members who are seeking care. Many of these studies focus specifically on mental health care, particularly helping patients, families, and communities adjust to life in the United States. In addition, health care services for immigrant communities also place an emphasis on mental health as many current immigrants have experienced war, displacement, and other associated traumas. Nurse researchers and other health-related disciplines have continued to explore the health beliefs and practices of culturally diverse patients specific to mental health. An overview of mental health beliefs and practices of selected cultural groups will be presented in this chapter. The overviews are not intended to stereotype or generalize the specific cultures. They are only intended as a resource for transcultural nurses and others to increase the awareness of patterns of values, beliefs, and practices related to mental health of the selected cultural groups. However, the transcultural nurse is also encouraged to understand the diversity within cultural groups with respect to mental health beliefs and practices. Many patients and families of specific cultural groups may not exhibit traditional patterns of values, beliefs, and practices of any specific cultural group. Transcultural nurses should conduct a thorough history and cultural assessment to ensure competent cultural care for each patient. Transcultural mental health nurses and other mental health care providers want to help patients of all cultures to achieve their optimal level of human functioning. However, it is important to note that an individual’s optimal level of human functioning can have different meanings and expressions based on that individual’s culture (Lopez et al., 2006, p. 224). Current trends on psychologic functioning of individuals from diverse cultures are focused on positive constructs and models (Constantine & Sue, 2006a, 2006b).

The majority of research on psychologic functioning with immigrants, persons from diverse cultures, and people of color has relied on the deficit model. According to the deficit model, hostile environmental factors such as prejudice and inequality in social conditions lead to increased rates of stress among minority populations, which ultimately lead to inferior or self-destructive methods of coping (Kaplan & Sue, 1997). Although the deficit model drew attention to the effects of prejudice and inequality in social conditions, there was a tendency to equate one’s psychologic functioning with negative rather than positive forces. This focus of research—upon the deficit model—has changed in the last few years as researchers now seek more positive frameworks to describe diverse experiences, beliefs, and transitions. This latter approach has emphasized the strengths of immigrants and minority populations. According to Constantine and Sue (2006a, 2006b) an individual’s optimal level of human functioning is dependent upon the cultural context in which it is being defined. In fact, Western goals associated with optimal human functioning, and grounded in a Eurocentric cultural value system such as happiness and self-determination may differ greatly with individuals from diverse cultures. Optimal human functioning of culturally diverse persons may be better understood by studying the values, beliefs, and practices of the cultural group. For example in the United States, optimal level of human functioning for African Americans and Native Americans may include such concepts as collectivism, racial and ethnic pride, spirituality, religion, holistic health, and family/kin and community or tribal importance. In addition, overcoming such adversity as racism may serve as a strength and helps mental health care providers better understand optimal human functioning for diverse cultural groups (Constantine & Sue, 2006a, 2006b). It is important to be flexible, open, and adapt to culturally congruent ways of knowing and doing when working with patients from diverse cultural groups in providing mental health care. Ahnallen, Suyemoto, and Carter (2006) emphasized the importance of health care providers recognizing patterns of self-identification for patients from diverse cultural groups. In addition, health care providers should acknowledge that patients may have varied expressions of either a sense of belonging or feeling excluded in certain situations and contexts and with different social and cultural groups.

Modern medical care may not be viewed the same as traditional health care in reservation or immigrant communities. Native Americans, as well as newly arrived immigrants, may experience some difficulty in trusting modern-day (allopathic) health care providers. For example, some Native Americans may be reluctant to consult professionally educated mental health care workers as they perceive that the mental health professionals are attempting to “brainwash” them into accepting the cultural values, beliefs, and practices of the Western health care system (Gone & Alcantara, 2007, p. 356). It is important for health care providers to be open to the values, beliefs, and practices of patients from diverse cultural groups. That is not to say one must adopt all the cultural values, beliefs, and practices of multiculturally diverse patients, but one should be open to and incorporate when possible, the values, beliefs, and practices of our patients.

African Americans:

An Overview of Some Mental Health Concerns Individuals of African descent comprise 12.8% of the total U.S. population (U.S. Census Bureau, 2008). The concept of African Americans as a distinct group in the United States is grounded historically in their shared social and environmental contexts, historical events, as well as family and kin memories of those experiences. Bell and Peterson (1992) noted that slavery, segregation, and institutionalized racism created a climate that resulted in health disparities, structural inequalities, marginalization, and cultural pain for African Americans. Acknowledging and understanding this cultural context is an important first step prior to providing transcultural mental health care to African American individuals, families, and communities. Although numerous health disparities are of great concern in the African American population, mental health issues have often gone unnoticed, taking a back seat to other health concerns. While there is an equal percentage of Black and White males who suffer from depression, Black men experience a higher rate of suicide (NPR: Recognizing Depression and Suicide Risk in Black Men, 2005). Black men, in particular, often are uninsured and have little or no access to mental health care. They may receive a poorer quality of care even if they are able to access the mental health system. Furthermore, minorities are underrepresented in mental health research (USDHHS, 2001a, 2001b, 2001c). Over time, all of these factors lead to more untreated depression and eventually to higher rates of suicide. In addition, there has been little outreach to the Black community about the availability of mental health care and education about what mental health is and what depression is all about, as well as targeted education about other kinds of mental disorders. Many in the Black community, especially young Black males, may believe that depression is not really an illness or that it is a sign of weakness, so they tend not to seek help. There is a notion that is prevalent among young Black men (as well as others) that because of machismo, being macho or tough … then Black men cannot be suicidal. It is one of the most pervasive and damaging falsehoods within and outside of the African American community. Some studies have shown that that some African Americans believe that depression is a personal weakness and the result of improper lifestyles (e.g., too much worry, working too hard, not being religious enough) (Shellman & Mokel, 2010).

Black men, as in other diverse cultural groups, often express their depression through bodily symptoms, that is, headaches, stomach aches, pains, and so on. Within the Black community, there can be considerable stigma about mental illnesses. Prevention of depression and suicide is extremely important and education is the key to early prevention. Although the Black church has traditionally viewed suicide as a sin, many religious organizations are now starting to create mental health programs. The Black church is a major institution in the community and pastors can be educated to recognize signs of depression among parishioners and refer troubled individuals to the proper professionals (Taliaferro, 2006). In addition, mental health providers need to be attuned and realize that depression occurs in Blacks, particularly young men. It can often be overlooked, but sometimes cultural insensitivity to what Black people are trying to say or how they might say it leads health care providers to overlook symptoms of depression.

Native Americans:

An Overview of Some Mental Health Concerns Native Americans (American Indians and Alaska Natives) comprise 1.0% of the total population in the United States (U.S. Census Bureau, 2008). There are 562 Federally Recognized Native American Tribes and Nations in the United States (Federally Recognized Indian Tribes. Federal Register: July 12, 2002). The need to improve care for Native Americans has been known for some time. The U.S. DHHS received a 9% increase from Congress in 2001 to boost the budget of the Indian Health Services (IHS) to $2.6 billion. Funds for diabetes and improved living quarters were included in the increase. There was also an increase in mental health services to increase the overall health of Native Americans (USDHHS, 2001a, 2001b, 2001c). Still, much work remains to be accomplished in the overall health care for Native Americans. The Native American culture believes in holistic health care and generally has a holistic outlook in all aspects of their lives. Holism is a belief that the physical, mental, emotional, and spiritual dimensions of an individual are perceived as one. Native Americans, as a cultural group, are also perceived as one, although bear in mind that each tribe may have unique characteristics. The mind–body separation of Western health care is not present in the Native American culture (Yurkovich & Lattergrass, 2008). Traditional peoples bring cultures together in contemporary life in many ways. Ideally, individuals with more than one cultural affiliation can bring parts of each culture together without conflict. Figure 10-3 shows tipis at a Lakota Nation Powwow, Pine Ridge, South Dakota. For Native Americans, acknowledging positive cultural strengths such as spirituality in all aspects of their lives, resiliency and positive identity are necessary for healing within a cultural care perspective (Yurkovich & Lattergrass, 2008). It is important for nurses working with Native American patients to focus on such strengths as spirituality, resiliency and positive identity to help patients in the healing process. Gone (2009) conducted a study on the legacy of Native American historical trauma with staff and patients in a Native American Healing Lodge. Findings suggested connecting evidence-based and culturally sensitive treatment options with indigenous programs, to create culturally sensitive interventions congruent with community values and norms. Program staff identified the importance of embracing the Native American indigenous heritage, identity, and spirituality in order to begin healing the detrimental effects of historical trauma and colonization. In order to provide culturally competent care, health care professionals should work closely with native healers to integrate spirituality and other indigenous beliefs into treatment processes (Yurkovich & Lattergrass, 2008). Many minority and underrepresented cultural groups have experienced what is called “Historical Unresolved Grief” or “Historical Trauma.” Nurses can help specific cultural groups grieve the past traumatic event(s) and resolve some of the past pain associated with such grief and trauma (Evidence-Based Practice 10-5). FIGURE 10-3 Traditional peoples bring cultures together in contemporary life in many ways. Ideally, individuals with more than one cultural affiliation can bring parts of each culture together without conflict. Tipis at a Lakota Nation Powwow, Pine Ridge, South Dakota.

Alcohol has had an overwhelming impact on the mental health of Native Americans. Forced into a harsh reservation system, Native Americans were forced to give up their native lands and ways of life. Yellow Horse Brave Heart and DeBruyn (1998) suggest that, for many individuals, the resulting anger and oppression are acted out upon oneself and others like the self, such as members of one’s group. Native Americans have repeatedly suffered losses of family and community members to alcoholrelated accidents, homicides, and suicide. Abuse, such as domestic violence and child abuse are leading mental health concerns among Native American communities throughout the country. “These layers of present losses in addition to the major traumas of the past fuel the anguish, psychologic numbing, and destructive coping mechanisms related to disenfranchised grief and historical trauma” suffered by Native Americans (Yellow Horse Brave Heart, & DeBruyn, 1998, pp. 68–69). Kasl (1992) observed an anniversary celebration of a Native American healing center. She suggested that the Native Americans in attendance drew from several belief systems and referred to this phenomena as an “integrated faith.” Other examples of integrated faith may be an informal Catholic mass integrating Native American wisdom and then followed by an Alcoholics Anonymous (AA) meeting. Many Native American tribes have developed their own mental health centers, including those that specifically treat chemical dependencies (alcohol and drugs). These treatment centers (both inpatient and outpatient) are fully accredited by appropriate accreditation agencies and employ certified and licensed counselors, who are often Native Americans themselves. The services combine traditional beliefs with professional treatment. The services focus on wellness and healing; they may include spiritual retreats, talking circles, sweats, burning sage, smudge, and other practices that are specific to the patients’ tribes.

Asian/Pacific Islander Cultural Groups:

An Overview of Some Mental Health Concerns Asian Americans and Pacific Islanders are one of the fastest growing minority groups in the United States, second only to the Hispanic or Latino cultural groups. Individuals of Asian ancestry are 4.5% of the total U.S. population (U.S. Census Bureau, 2008). Asian Americans and Pacific Islanders of Asian ancestry represent 43 diverse cultural groups from Korea, Japan, China, India, Cambodia, Vietnam, Indonesia, Philippines, and Papua New Guinea to name only a few (U.S. Census Bureau, 2008). In some Asian Americans and newly arrived immigrants from China and Japan, stigma related to mental health problems can be a stumbling block in seeking appropriate care. For example, a study by Gilbert et al. (2007) focused on Asian and non-Asian young women’s shame related to mental health care and identified three components of shame. They were external shame or a belief that an individual will be viewed negatively for mental health problems; internal shame that is evaluating oneself negatively; and reflected shame, a belief that having mental health problems could bring shame to an individual’s family or community. Results of this study suggest that Asian women had higher external and reflected shame beliefs than non-Asian women. Asians also expressed concerns about confidentiality when talking about personal feelings/anxieties. This study suggests that stigma may play a role in seeking mental health care and may encourage individuals to seek care among friends and family. These same individuals may not seek professional mental health services at all, as they would risk feelings of shame for themselves and others if mental health services were utilized. Asian Americans’ core cultural values of honor and pride and patriarchal obligations, particularly with elders, are important to understanding the Asian American culture. Collective group harmony, including family and kin, rather than individual concerns are significant cultural values (Leininger, 1995). Understanding core cultural values of the Asian American culture, particularly the importance of maintaining harmony, will help transcultural nurses plan care for patients with mental health problems in a culturally competent manner. In a study of older Korean Americans exploring cultural attitudes toward mental health services, Jang et al. (2007) found that individuals who had been in the United States for a shorter time frame and had more severe levels of depression were more likely to have negative attitudes about mental health services. Cultural values and beliefs of older Korean Americans seemed to have a major influence on whether or not they viewed mental health services in a negative manner. Those individuals who identified mental illness with personal weakness or shame held more negative attitudes about utilizing mental health services. However, if the individual associated depression as a health condition, then he or she had a more positive attitude about mental health services. Cultural values and beliefs about mental illness, including stigma associated with mental illness were also found to be influential in individual’s attitudes toward mental health services. Community agencies have often provided mental health services specifically to Asian Americans. With recent cuts in funding for health care, many of these community agencies have suffered a severe cut-back in services and are unable to provide the level and kinds of care that they have provided in the past. Recognition of cultural barriers such as language that has a direct effect on communication between nurses and other health care providers and patients and their family/ significant other(s) can be preemptive and lead to more positive patient outcomes (Evidence-Based Practice 10-6).

Hispanic/Latino Cultural Groups:

An Overview of Some Mental Health Concerns Individuals of Hispanic or Latino descent are the fastest growing cultural group in the United States and make up 15.4% of the total population of the United States (U.S. Census Bureau, 2008). By 2050 approximately 97 million people, or one-fourth of the U.S. population, will self-identify as Hispanic Americans (U.S. Department of Health and Human Services, 2009). Hispanic countries include such diverse places as Mexico, Puerto Rico, Cuba, South and Central America, Spain, and various states in the United States. It is important to keep in mind that Hispanic/Latino groups may contain tremendous cultural diversity. In general, Mexican Americans (those who have traditionally lived within the U.S. borders or who have immigrated to the United States from Mexico) tend to rely on their family and extended family networks. Family and the extended family members are viewed as a whole and are highly valued. Family members rely on each other for socialization, support (emotional and monetary), childcare and often, they expect loyalty from other members. Mexican Americans have a lower incidence of mental illness, possibly due to strong extended family connections and the role family networks play in dealing with anxiety and stresses as well as the role of religion (Leininger, 1995).

Arab Muslim Cultural Groups:

An Overview of Mental Health Concerns There are over 48 countries, where at least 50% of the population is Muslim including Pakistan, Turkey, Egypt, Iran, Afghanistan, Iraq, Saudi Arabia, Syria, Libya, and Jordan to name only a few. The Arabic language is spoken in Arab Muslim countries and Islam is the main religion of the people. Islam is growing more rapidly than any other religion in the world. Those who practice the Islamic faith are considered Muslim. There are two major religious orthodoxies of Muslims, the Sunni and the Shi’a (Luna, 2002). Ramadan is the ninth month of the Islamic calendar and was the month in which the Koran was revealed to the Prophet Muhammad. During the month of Ramadan, Muslims are required to abstain from food and drink from dawn until dusk. Devout Muslims pray five times each day. Prior to prayer, each person must perform a cleansing of the body, which signifies a pure soul. In some Muslim countries, there is a preference for male children and it has been documented that female children may receive inferior care from birth (Douki, Ben Xineb, Nacef, & Halbreich, 2007). There are a number of Islam religious requirements specific to men and women such as an unrelated male should not touch females, including shaking hands, make direct eye contact with each other, or be alone in a room with one another (Simpson, 2008). In the Arab Muslim culture, women are required to avoid raising their voices so they will not be overheard by strangers (Abushaikha & Oweis, 2005). Talking in a manner in which other patients and observers can overhear what is being communicated would then seem to be incongruent with the women’s needs of privacy. In a study conducted by Simpson and Carter (2008), on Muslim women’s experiences with health care in the rural United States, one participant described writing a letter to her physician prior to her health care appointment to identify her religious needs. She stated: “I don’t shake hands and I would prefer not to be examined by a male. I don’t speak with a male unnecessarily either, and conversations with males will be succinct and to the point” (p. 19). When Arab Muslim women believed their religious beliefs were violated, they experienced feelings of guilt and viewed the health care experience as negative and when no religious beliefs were violated, they viewed their experience as more positive. However, the women also expressed an understanding that it is difficult for health care providers outside of their culture to understand all of their cultural beliefs and practices. Several women identified being treated differently by health care providers because they wore the Islamic head covering (hijab) (Simpson & Carter, 2008).

Seventy to 80% of mental health patients in Arab countries tend to present with somatic symptoms for psychologic issues. There is a stigma about mental health problems and the patient who presents with somatic complaints is protected from the stigma of being diagnosed with a mental health illness. However, this creates difficulties for the patient as they are treated for physical rather than psychologic problems (Okasha, 2003). Nurses and other health care providers in emergency departments need to be aware of this phenomenon and assess the patient for any mental health concerns. The subordinate position of Arab women places them at risk for developing mental health disorders such as depression, anxiety, and suicidal behaviors (Douki et al., 2007). Prior to seeing health care professionals, Arab Muslims may seek traditional healers for mental health problems. Traditional healers hold special importance to Arab Muslim people because of their affiliation and connection to the community. Traditional healers also deal with the “‘mystical,’ the ‘superstitious,’ and the ‘unknown,’ all of which are still powerful cognitive constructions” in Arab Muslim countries (Okasha, 2003). Following the terrorist attacks on 9/11, there is evidence to suggest that the experience of prejudice, intolerance, and hostility toward Arab Americans has increased in the United States. Arab Americans have been victims of racism, aggression, insulting speech, and discrimination on the basis of their cultural religious beliefs and practices and national origin (Kulwicki, Khalifa, & Moore, 2008). Arab American nurses in Detroit participated in a study to explore the influence of the terrorist attacks on 9/11 on their profession as nurses. Overall, the Arab American nurses had not experienced hate crimes or major work-related retaliation, such as termination. The discrimination the nurses did experience was in the form of verbal insults about their cultural and religious practices such as wearing a hijab, the traditional head covering worn by Muslim women. One in seven of the nurse participants had experienced a situation wherein patients and their families refused their care (Kulwicki et al., 2008).

Culturally Competent Mental Health Care

The interpretation of behavior generally transpires within the context of the specific culture in which it occurs. However, when patients and families from diverse cultural groups come to institutions of the dominant culture, the behavior is identified and interpreted by the dominant culture. Frequently, that interpretation can be misinterpreted and/or distorted if health care providers are not competent in caring for patients from diverse cultural groups. Particularly with mental health, diagnoses can be applied to patients that may be inaccurate and if the cultural behavior were understood and interpreted within the context of the specific culture, a different diagnosis might be made with different treatment or no diagnosis at all. Inaccurate mental health labels can be applied that will have a negative impact on an individual and family for years and may not be congruent with the values, beliefs, practices, and norms of the patient’s culture.

Process of Cultural Competence (Cultural Awareness, Cultural Sensitivity, and Cultural Knowledge) .

Most nurses understand that developing a mutually trusting relationship with patients improves plans of care and increases the likelihood of more optimal health outcomes. Developing a trusting relationship with patients is particularly important in mental health nursing care. Because of difficult experiences with past family and other relationships, it may be difficult for some patients with mental health needs to trust others, including health care providers. An understanding of the patient’s culture increases the likelihood of improved health outcomes. As one’s culture shapes an individual’s health care values, meanings, expressions, beliefs, practices and experiences, or cultural norms, it becomes difficult to separate health care from culture. The shared values, beliefs, and practices, including how one perceives mental health, are determined to a great extent by one’s culture. Nurses are increasingly caring for patients from diverse cultures and are expected to have a broad understanding of culture in order to provide culturally competent mental health care. Culturally competent nursing care for patients from diverse cultures becomes crucial in caring for patients with mental health needs. Some questions that nurses may be asking are what exactly does culturally congruent care mean? How can a transcultural mental health nurse understand the cultural values, beliefs, and practices of all the culturally diverse patients a nurse will care for over the lifetime of his or her career? Well, one answer may be that, of course, you cannot understand the values, beliefs, and practices of all of the patients you will care for in your career. However, nurses can become familiar with the values, beliefs, and practices of the culturally diverse groups to whom they do provide care. This will enable them to acknowledge and recognize common cultural needs of all patients with mental health care needs. Because of the need to understand the values, beliefs, and practices of patients with mental health care needs, a number of theories and models of culturally competent care have been developed. One of the most prominent culture-specific nursing theory is Leininger’s (1991) Culture Care Diversity and Universality Theory of Nursing. Leininger theorized that understanding the patient’s social structure factors (technological, religious

and philosophical, kinship and social, cultural values and lifeways, political and legal, economic and educational) in addition to generic or folk systems could lead to nursing care decisions and actions that would facilitate culturally congruent nursing care and improved health and wellbeing of patients. Leininger (1967, 1991) identified cultural congruent care was “care that was congruent with people’s lifeways” (p. 41). Nurses have identified the importance of culturally sensitive care. Although learning to be sensitive to patient’s cultural values, beliefs, and practices is important, it has became obvious that transcultural nurses needed to move beyond being “sensitive” to competency-based cultural care. Cultural competence is defined as a process in which nurses strive to work successfully within the cultural context of individuals, families, and communities (Andrews & Boyle, 1997; Campinha-Bacote, 2002). Campinha-Bacote (2009) identified that cultural competency “requires nurses to see themselves as becoming culturally competent rather than being culturally competent” (p. 49). Buchwald et al. (1994) used the term “cultural blind spot,” sometimes referred to as cultural blindness to describe the assumption that if a person is similar in appearance and behaviors as the care provider, then there are no perceived cultural differences or potential barriers to giving appropriate care. The cultural blind spot supports people’s beliefs that they understand the culture and have had similar cultural encounters. Thus, a person could conclude he or she has culturally competent skills. However, it is this lack of awareness of differences that creates the cultural blind spot. Transcultural mental health nurses need to be aware of the phenomenon of cultural blind spot/cultural blindness because of the unintended influence it can have on care of diverse populations of mental health patients.

Important Factors to Consider in Transcultural Mental Health Nursing

Communication and Language As most mental health nurses know, both verbal and nonverbal communications are some of the most important skills used with patients. Communication is even more important with multiculturally diverse mental health patients, where language may serve as a barrier and make the process of communication more difficult. Interpersonal communication helps mental health nurses assess each patient’s values, beliefs, and practices about their mental health care. Communicating with each patient is important in caring for clients in a culturally congruent and competent manner. Communication between the mental health nurse and the patient and family generally brings together the exchange of two diverse cultures, that of the nurse and that of the patient. Therefore, it is also important for nurses to have an understanding of their own cultural values, beliefs, and practices, so they can better understand the diversity between their own cultural values, beliefs, and practices and those of the patient and family, particularly as these phenomena relate to mental health care. Culture influences each interaction we, as nurses, have with our patients. If we are not knowledgeable about the cultural context in which our communication is being interpreted, there is a possibility that our message can be misunderstood. Rosenberg (2003) described how cultural conditioning, a socialization process that influences how we think and behave, has a major impact on each of us. Becoming consciously aware of our individual cultural conditioning is a key to lessening the effect it has on us. Communication is crucial when nurses are caring for culturally diverse patients with such mental health problems as schizophrenia, bipolar disorder, or major depression, where patients and their family or kin may be confused or even fear a health care system in which they have no previous experience. Effective transcultural communication skills are particularly important when caring for mental health patients (Figure 104). Developing lasting meaningful relationships across potential social barriers such as ethnicity and culture contributes to improved communication. Mental health nurses understand the importance of developing trust with

patients and their family/kin networks. Taking time to develop trust with patients who do not speak English or minimal English can be very challenging, particularly given the increasingly culturally diverse population seeking mental health care. Sometimes health care providers can become irritated that patients and family members do not speak the dominant English language. When there is a possibility to have a certified translator/interpreter serve as an interpreter, that is the ideal choice rather than use family members or other staff who may not understand complex health situations. Family members should be encouraged to offer family support rather than serve as an interpreter.

People who do not speak English identify care as less supportive and more rushed than those individuals who do speak English (Simpson & Carter, 2008). However, Bowes and Domokos (1995) found that speaking the same language, while important, is not the most important element in communicating with patients from diverse cultural backgrounds. The attitude of the care provider is instrumental in helping the patient be open to treatment options. Communicating an understanding of cultural diversity helps facilitate the patient–nurse relationship. On the other hand, authoritarian care providers have a negative impact on treatment services. Bowes and Domokos (1995) make a distinction between language and communication suggesting that language has more to do with the technical aspect of speech, while communication consists of both verbal and nonverbal elements, including the provider’s attitude. For a number of culturally diverse patients and their families/kin, there are cultural values that influence what subjects are appropriate to discuss with health care providers. Some topics (sexual activities, for example) may be considered inappropriate to discuss with health care providers. Other topics that most of us consider appropriate to discuss with a health care provider in the United States are not necessarily viewed that way by persons from different cultures. For example, in Asian and Latino cultures, individuals would not communicate dissatisfaction with services. In a study on Latino health disparities, one nurse participant in the study stated “If someone does not like the doctor or does not agree, they will not speak up or say anything because they are taught that it is rude to do this” (Carter-Pokras et al., 2008, p. 163). Even in conducting a health history and assessment, what are culturally acceptable questions to ask in the United States may not be acceptable in other countries and cultures. There are other factors that may have a profound influence on the communication between patients and health care providers. Undocumented migrants may fear that health care providers would turn them in to the authorities if providers learned that their patients were in the United States illegally (Carter-Pokras et al., 2008). Empathy is one of the most important communication skills that transcultural mental health nurses and other health care providers can use with patients from diverse cultural backgrounds. In using empathy in communicating with patients, health care providers are attempting to understand what a patient is experiencing or has experienced. You are trying to put yourself in the patient’s place and feel and experience what they are feeling and experiencing. You are then communicating that understanding back to the individual patient (Egan, 2009). Empathic communication helps the health care provider to better understand the situation or context of the patient as well as the cultural norms and values that structure that context and influence the patient. For example, if a patient was sitting in his or her hospital room crying, the nurse would know to further explore that patient’s feelings. According to Rasoal, Jungert, Hau, Stwine, and Andersson (2009) the ability to use “ethnocultural empathy” (p. 300) has become crucial for health care providers in their interactions with patients. It is important to communicate back to the patient and family your understanding of their experience so they may clarify whether you have accurately identified the patient’s perception of a particular experience (Egan, 2009). Empathy becomes very important in trying to understand the experience and feelings of mental health patients and their families. Attempting to understand the experience of abuse, schizophrenia, depression, bipolar disorders, and other mental health issues is crucial to understand the perspectives of the patient and family. In communicating with patients from diverse cultures, perceptions of both the nurse and patient specific to “time, space, distance, touch, modesty, and other factors” are necessary (Andrews, 2008, p. 21). When communicating with patients from other cultures, particularly for those who do not speak English or English is a second language, there is an increased risk of miscommunication (Andrews, 2008).

Transcultural Mental Health Nursing and Spirituality Sometimes people tend to have some difficulty differentiating spirituality and religion. In fact, frequently the terms spirituality and religion are used interchangeably. Spirituality tends to refer to a broad sense of the inner experience of the self and a search for meaning. Religion generally involves an institution with a given set of rules and observances involving devotion and ritual (see Chapter 13, Religion, Culture, and Nursing, pages 351–402). There are many spiritual and religious themes to mental health disorders such as schizophrenia, bipolar disorder, psychosis, hallucinations, and delusions. Transcultural mental health nurses care for patients who have diverse cultural values, beliefs, meanings, and practices many of which are grounded in spiritual and religious beliefs. At times, an individual’s religious and spiritual beliefs may be difficult to separate from their cultural values, beliefs, meanings, expressions, and practices. This applies to patients and families from all of the world’s major religious systems, Jewish, Christian, Islam, and others. A phenomenological research study attempted to answer the question with Australian mental health patients from a community mental health center: “What does spirituality mean for people with a mental illness?” (Wilding, Muir-Cochrane, & May, 2006, p. 144). Patients were not recruited to the study if they were experiencing psychosis or exacerbation of symptoms. Findings indicated that spirituality became increasingly important in patient’s lives after being diagnosed with a mental illness. Spiritual experiences of the patients could be interpreted as signs and symptoms of mental illness, depending on who was interpreting the experiences. Patients expressed a fear that mental health nurses would label them as mentally ill when their spiritual beliefs and experiences were similar to symptoms of mental illness. As we have previously discussed, the interpretation of one’s cultural values, beliefs, and practices takes place within the dominant culture or power structure in which the situation or event occurs. Therefore, it is quite likely that within a mental health setting, values, beliefs and practices would be interpreted according to the mental health professional’s views rather than those of the patient. Spirituality and religious practices can play a very influential role in enhancing mental health and emotional stability. For example, many African Americans view their church as the focal point of their lives.

Within the African American church emotions can be released that cannot be expressed in many other social situations and friendships established that last throughout a lifetime. The African American church functions in promoting a high level of self-esteem, particularly for those individuals and communities in poverty-stricken environments. The role of the African American church “as a cornerstone for optimal health care cannot be emphasized enough” (Geiger, Appel, Davidhizar, & Davis, 2008, p. 382). The church can often connect the African American and health care communities and play an integral role in increasing positive health outcomes for African Americans even those who do not attend church on a regular basis. In fact, the important role the African American church plays in the lives of parishioners is a clue for health care providers to partner with churches and develop culturally congruent interventions to improve care for a particular church population. Blank, Mahmood, Fox, and Guterbock (2002) found that African American churches offered more mental health services than did more mainline or European American churches. Findings also indicated that African American churches played a key role in mental health service referrals. Bonifield (2009) in a report for CNN about African American churches fighting mental health “demons” described how African American church leaders were taking a lead in reaching out to those who need mental health services. In an effort to change attitudes about mental illness, concerned Black clergy of Atlanta established a connection with the National Alliance on Mental Illness to educate their church members about the signs and symptoms of mental illness. The church leaders suggested that it may be helpful for an individual to go to a church pastor if he or she was experiencing minor depression. Pastors were trained to recognize early signs and symptoms of depression and how to refer parishioners with major depression to mental health facilities. In another example, the Tennessee Department of Mental Health and Magellan Health Services, in collaboration with African American churches in various Tennessee communities, initiated “Emotional Fitness Centers” to screen for signs and symptoms of mental illness with parishioners seeking emotional support. Listening was stressed as the most important skill a pastor can use with someone seeking emotional support. Mental health nurses need to practice culturally competent communication skills to improve care for an ever-increasing population of culturally diverse mental health patients. Becoming aware of the importance of communication is key to caring for this patient population.

Taking into account the cultural values, beliefs, meanings, practices, expressions, and cultural norms of specific cultures takes knowledge, experience, and patience in acquiring these skills. In addition, basic verbal and nonverbal communication skills such as tone of voice, use of probes and clarification, listening, empathy, facial expressions and body gestures, for both the nurses themselves and for the patients and family members will help to improve overall communication and patient care.

Intrapersonal Reflection

Several transcultural nursing leaders identified the importance of conducting a personal inventory of one’s own cultural values, beliefs, and practices to begin to identify, understand, and remove personal cultural bias, ethnocentrism, and prejudice (Andrews & Boyle, 1997; Leininger, 2000). It is important for nurses to explore and reflect on their own cultural values, beliefs, practices, expressions, meanings, and own cultural norms in order to identify and begin to understand personal biases, prejudices, and other barriers to caring for patients in a culturally congruent and competent manner. Although tolerance may be the opposite of prejudice, it is clearly an inadequate benchmark in caring for patients in a culturally competent manner. Nurses and other health care providers need to celebrate diversity and recognize the challenge to continually explore areas within themselves or others that may block or serve as barriers to caring for patients in a culturally competent manner. Each nurse needs to explore his or her own personal values, beliefs, and practices in order to recognize areas of prejudice, bias, stereotyping, and ethnocentrism of culturally diverse individuals, families, and communities. Gordijn, Koomen, and Stapel (2001) studied whether an individual’s level of knowledge of cultural stereotypes about minority groups was universal or whether that knowledge was influenced by that individual’s level of prejudice. Findings indicated that an individual’s level of prejudice was related to that individual’s level of knowledge about cultural stereotypes with minorities. Findings such as these should encourage transcultural mental health nurses to explore their personal prejudices and biases toward people from diverse cultures and peel away and expose stereotypes that impede caring for culturally diverse patients.

Transcultural Mental Health Experiences of Pain

In mental health nursing, the patient’s experience of pain can be manifested in many different ways. Unlike other somatic symptoms frequently associated with mental health issues, pain has a component that includes emotional elements. Psychosocial factors have been found to influence pain. In a study by Palmer et al. (2008) on somatic complaints, mood and self-rated health as predictors of arm pain, mental health was found to be a strong predictor of complaints of arm pain in adults from a British community. Beliefs about causation and prognosis of arm pain were also associated with persistence of symptoms. There is increasing evidence to suggest that pain can be a physical symptom of depression and that pain and depression are common comorbidities (Williams, Jacka, Pasco, Dodd, & Berk, 2006). It seems to be extremely difficult to separate the somatic, physical component of pain from the psychologic component of pain. In a study conducted by Bonnewyn et al. (2009) researchers found that chronic pain and mood disorders were common in elderly populations. Elderly individuals with a 12-month major depressive episode were more likely to have painful physical symptoms than those persons without major depression. There is the concept of psychosomatic pain or pain with psychologic components and this pain is expressed differently by cultural groups. One of the distinct types of depression with Haitian women is “Douluer de Corps (pain in the body)” (Nicholas et al., 2007, p. 87). Barkwell (2005) studied Native Americans (Ojibwa) with cancer pain; they described their pain as “all that was most painful in life” and included the following properties in their description of cancer pain: “physical sensation, threatening cognitions, emotional, social and spiritual anguish, and intuitive sensing” (p. 454). In a study to differentiate somatic versus psychologic symptoms as a cultural expression of depression, Chinese outpatients reported more somatic symptoms compared to EuroCanadians, who reported more psychologic symptoms specific to the diagnosis of depression (Ryder et al., 2008). Lee, Kleinman, and Kleinman (2007) have suggested that current knowledge about depression and other mental illnesses is based on research conducted with Western populations. In a study with Chinese patients in Guangzhou (Canton), China, in an outpatient mental health service, patients experiencing symptoms of depression identified numerous affective symptoms, including sadness, preverbal pain, social disharmony, and sleeplessness. The authors emphasized how important it is to study depression transculturally, in order to be more sensitive and appropriate with culturally diverse populations.

SUMMARY

This chapter has explored perspectives on transcultural mental health nursing care. The goal is to help nurses provide culturally competent care that improves the health and well-being of culturally diverse mental health patients. Nurses can increase their competency by understanding cultural values, beliefs, practices, meanings, expressions, and cultural norms of diverse cultures specific to the mental health and well-being of individuals, families/kin, and communities. Competency-based transcultural knowledge is essential in today’s complex mental health environment

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