Describe in detail the issue(s) addressed in this reading. Do you  believe it is being addressed in an effective way? Please

One Size Does Not Fit All: Taking Diversity, Culture and Context Seriously

Margarita Alegria, Ph. D.,* Marc Atkins, Ph.D., Elizabeth Farmer, Ph.D., Elaine Slaton, R.N., M.S.A, and Wayne Stelk,

Ph.D.

Introduction

In today’s progressively global world, professional health and mental health care providers are increasingly

required to interact with families whose race, culture, national origin, living circumstances, and family

composition are different from their own. This is particularly true in almost any urban clinic in the U.S., but

especially so in public contexts, where providers routinely encounter multiethnic and multiracial populations.

By the year 2010, immigrant children will comprise 22% of school age children in the U.S. (Connect for Kids,

2006). In contrast to immigrants from Europe during the 19th century, most families that immigrated to the

United States in the last two decades have come from Latin America, the Caribbean, Asia, and Africa (Singer,

2002). These children and families speak different languages and often have skin color that distinguishes them

from the European (majority) culture. According to the National Survey of Children’s Health of 2004, the

primary language spoken at home was far more likely not be English in Latino (60%) and Asian/ Pacific

Islander (41%) households compared with white (1%) children’s households (Flores & Tomany-Korman,

2008).

These populations include families whose notions of mental disorders are totally dissimilar from that of the

clinician in charge of making decisions about their care. Mental illnesses (e.g. defined as any current or past

year psychiatric disorders that result in functional impairment which substantially interfere with the child’s role

or functioning in family, school or community activities) in certain cultures can be largely thought to be

completely incurable, or at least unresponsive to modern medical practices (Desjarlais, 1995; Gureje & Alem,

2000). In Latin America, deeply rooted cultural beliefs can lead to feelings of guilt and shame, distorted help-

seeking patterns, and religious or folk beliefs about the origins of mental disorders (Alarcón, 2003), ideas

reported by immigrants coming to the UK (Cinnirella & Loewenthal, 1999) and the US (Cauce et al., 2002).

Among some immigrant families, there is a great reluctance or delay in seeking appropriate mental health

services, even when health-damaging responses to mental illness can occur (Gureje & Alem, 2000; Razali,

Khan, & Hasanah, 1996; Whyte, 1991). Often times, Western medicine is not considered to be the preferred

treatment for mental disorders in these countries (Alem, Jacobsson, Araya, Kebede, & Kullgren, 1999; Saeed,

Gater, Hussain, & Mubbashar, 2000).

Moreover, ethnic and racial minority families from the US may also differ in their explanations about mental

illness and treatment (Novins et al., 1997), sometimes based on the types of services they historically had

available and not necessarily due to an alternative conception of illness causation (Kirmayer, Groleau, Guzder,

Blake, & Jarvis, 2003). For example, African American and Native American families may have alternative

explanations of mental illness such as supernatural or spiritual forces that lead youth to undesirable behaviors

(Cheung & Snowden, 1990). Ideas of coping with mental illness may also vary, with African American youth

sometimes being encouraged to use will power to “tough out” situations (Browman, 1996) or Asian American

youth being advised to not dwell on uncomfortable thoughts (Cheng, Leong, & Geist, 1993).,

We know that disorder, disease, and healing may manifest differently in different cultures (Kleinman,

Eisenberg, & Good, 2006). The decision to use medications (Snowden & Yamada, 2004) and help-seeking

behaviors (Snowden & Yamada, 2004) are partly driven by culture. We also know that some children can be

misdiagnosed because screening instruments and diagnostic criteria are often developed by (and for) the

majority culture; that is, the culture of the majority of providers and health systems, not necessarily of the

majority of the population in many communities (Dressler & Badger, 1985; Huang, Chung, Kroenke, Delucchi,

& Spitzer, 2006; Vega & Rumbaut, 1991). These facts suggest that cultural differences may play a critical role

in the individual’s recognition of mental illness and the provider’s detection of the mental illness including the

perception and intensity of stigma associated with mental health help-seeking behavior and the understanding of

what might be considered mental health disorder requiring appropriate mental health services.

Multicultural groups are diverse not only in their beliefs and expectations, but also in their assumptions about

what the clinician can do for them (Katz & Alegría, 2009). Individuals seeking help may possess diverse views

of what matters most to them as compared to the provider, which may result in a lack of shared problem

definition between the individual and the provider (Suurmond & Seeleman, 2006), increasing the potential for

misaligned treatment approaches.

Similarly, changing family structures and the diverse context of childrearing may be challenging for clinicians

whose personal experience with family and neighborhood is very different from those of their diverse

multicultural clients (Burkard, Ponterotto, Reynolds, & Alfonso, 1999). Children and youth today live in varied

family arrangements and contextual environments, each with its own distinct cultural milieu. For example, 26

percent of US children in 2000 resided in single-parent households and 15 percent lived in blended families

(Kreider & Fields, 2005), signaling a significant shift in the living arrangements of children since the 1970s.

Children live in the context of their families — even those who are in foster care, institutionalized, or otherwise

physically separated from their original families — and their communities. For too many this context also

includes involvement with child welfare and the juvenile justice system (Freudenberg & Ruglis,

2007; Lauritsen, 2005). Consequently, the context in which these families live, and even the definition of

families, has been dramatically altered in the last three decades.

Yet, the context of childrearing has a profound impact on well being and risk for illness. A child’s resilience is

dependent upon numerous contextual factors, not the least of which includes a reliable and supportive adult who

cares about them (Cicchetti & Rizley, 2006; Oades-Sese & Esquivel, 2006). There is noteworthy cross-cultural

work (Draper & Harpending, 1982) suggesting that children might be particularly reactive and susceptible to the

context of early childrearing that is closely linked to their living arrangements. Childrearing differences also

appear to influence the child’s prospective bonding and psychological development. The development of

optimal behavioral strategies, thus, appears dependent on the social and physical environmental cues that

regulate interpersonal and behavioral development (Belsky, Steinberg, & Draper, 1991) in these contexts. These

cues vary by the childrearing patterns occurring in different family arrangements.

Because children spend a significant portion of time outside their homes, neighborhoods and schools also play a

critical role in their mental health outcomes. Furstenberg’s ethnographic studies (Furstenberg & Hughes, 1997)

pinpointed how families living in high-risk neighborhoods might select strategies of childrearing (i.e. protection

and insulation from risk) that differ from those living in low-risk neighborhoods, constraining opportunities for

social interaction and increasing isolation from peers and socialization activities. Environments in which ethnic

and racial minority children live are characterized by residential segregation (Logan, Stults, & Farley, 2004),

poor quality housing (Simmons, 2001), limited resources, exposure to violence (Jaycox et al., 2002) and fewer

institutional and community support systems (Hoberman, 1992). There is evidence showing how neighborhood

safety relates to risk for mental illness (Alegria, Sribney, Woo, Torres, & Guarnaccia, 2007) and how

neighborhood socioeconomic conditions correlate with suicide rates, violence, adolescent well-being, and

behavioral and emotional problems in children and youth (Baker & Taylor, 1997; Ferrada-Noli,

1997; Furstenberg & Hughes, 1997; Sampson, Raudenbush, & Earls, 1997). The work of Sampson and

colleagues (1997) underscores how the ability of adults in the neighborhood to regulate social behavior, as

evidenced by high levels of collective efficacy, is associated with neighborhood levels of violence and personal

victimization. These data underscore the importance of the neighborhood environment to children’s mental

health. For clinicians serving diverse children and youth populations in marginalized and segregated

communities, understanding neighborhood conditions and community supports may be paramount. A better

understanding of the context of childrens’ and families’ lives may allow them to identify what precipitates a

child’s negative behaviors and increases their chances of developing mental illness.

In addition to living in neighborhoods with high levels of environmental stress, ethnic and racial minority youth

are disproportionally more likely to have interactions with the juvenile justice system (Freudenberg & Ruglis,

2007; Lauritsen, 2005), or to have relatives involved in the criminal justice system as compared to their white

peers. As a consequence, these minority youth may expect greater injustice from formal institutions (Woolard,

Cleary, Harvell, & Chen, 2008). Persistent exposure to discrimination and racial profiling (Rousseau et al.,

2009) can also impact their ability to trust and collaborate with mental health providers. Community, religious,

and social agencies are therefore more typically trusted as resources to confront the hardships and stressors

associated with their own and/or their family’s living circumstances (Alegria et al., 2002). Expectations of

misunderstanding and/or coercion within traditional institutional services (e.g. schools, police, and government

services) tend to discourage minority youth and families from seeking professional mental health care

(Takeuchi, Bui, & Kim, 1993). As a result, there is a larger gap between the mental health service system’s

offerings in contrast to the negative expectations and unmet needs of diverse children and youth.

Relying on a traditional clinical approach, the mental health system is often ill prepared to serve a diverse

clientele. Differences in culture, language, family composition, living arrangements, and neighborhoods lead

multicultural youth and their families to have different expectations of clinical services. Mental health systems

must now meet the needs of children (Williams & Collins, 2001) that are very distinct from those that the

system was developed to serve. Unfortunately, traditional practice models appear unresponsive to the special

needs and the most pressing concerns of multicultural youth and their families. This may leave them without

care, or it may cause them to prematurely drop out of care.

A Failing Children-Adolescent Mental Health Service System

While children on average are often underserved by mental health care in the United States, ethnic and racial

minority children receive an average of half as many counseling sessions (Pumariega, Glover, Holzer, &

Nguyen, 1998) than their white counterparts. As compared to non-Latino whites, both Latino and African-

American youth exhibit lower rates of mental health service use (Kataoka, Zhang, & Wells, 2002; Yeh,

McCabe, Hough, Dupuis, & Hazen, 2003), make fewer office visits for treating their attention deficit

hyperactivity disorder (ADHD) and depression (Olfson, Gameroff, Marcus, & Jensen, 2003; Olfson, Gameroff,

Marcus, & Waslick, 2003), and enter care later. Ethnic and racial minority youth are also less likely to receive

multimodality treatments for their ADHD (Bussing, Schoenberg, & Perwien, 1998) or formal services for their

suicide attempts (Freedenthal, 2007), in contrast to their white counterparts. Thus, the evidence suggests that the

mental health system is failing many minority children and families as indicated by low rates of entry into care,

high rates of drop out, and greater rates of unmet need for mental health services. As described above, one

potential explanation for the system’s failure might be the inattention paid to the culture, context and diversity

of multicultural children and families.

The Role of Culture and Context: Why it Matters

Culture, in its simplest definition, is a set of shared understandings, a view of “how we do things around here”

(Glisson & James, 2002; Hofstede, 1998) that is socially constructed and evolving. Those who write about

culture refer to it as “contextual, emergent, improvisational, transformational, and political (Laird, 1998),” so

that a group's cultural identity can evolve over time or in reaction to the environment or retrench toward some

core values, given certain stresses. As such, it exists at all levels in a society – individuals come from a “cultural

milieu” that they carry with them. As they join together with others (in communities, schools, or organizations),

a shared set of beliefs and understanding emerges. As this suggests, culture is always dynamic and emergent in

social interactions. When cultural elements (i.e., beliefs, values, routines) align across levels (e.g. family, peers,

neighborhood), it is almost invisible. In this scenario, cultural competence is rarely an issue. However, in our

multi-cultural, complex society, with a host of “cross-cutting parameters,” culture is often visible – in different

assumptions, ways of interacting, values, and goals. It is this complexity of people attempting to survive and

thrive in multiple cultures that makes current concepts of “cultural competence” and “diversity” essential to the

delivery of culturally relevant and effective mental health treatment (Bigby & Perez-Stable, 2004). For the

clinician who has innate biases and assumptions about behavior and child development given the mainstream

culture becoming “culturally competent” to an evolving and dynamic culture of diverse patients becomes a

challenge, possibly a myth (Dean, 2001). Acquiring awareness of these biases, developing cultural humility and

reflection, and attempting to address these biases is a process that proceeds in stages, so that being culturally

"naive" is not a fault but a starting place.

At its most basic level, “mental health” is a cultural construct – our society has, via cultural agents (i.e.,

psychiatrists, psychologists, DSM-IV, legal system), defined mental health and mental illness in a way that

corresponds to our underlying Western-majority culture. Our society has a long-standing and uneasy cultural

view of where the boundaries of mental illness should lie – e.g., the “bad vs. mad” distinction has long been

debated. Hence, even the focus of mental health treatment, itself, is NOT self-evident – rather what’s seen as

“normal” is shaped by views, assumptions, and orientations that are, at their core, cultural judgments (Erikson,

1966; Goffman, 1963).

Therefore, it is not surprising that when a complex and diverse society, such as ours, faces these essential

questions of acceptable vs. unacceptable behavior, treatment vs. punishment,

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