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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,
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,
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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