BY SARAH POLIQUIN
In a paper by Dr. Harriet Lefley, a psychologist at the University of Miami, states that 37 percent of schizophrenia patients in industrialized countries have full remission and are nearly three times as likely to have impaired functioning compared to less developed places, in which the remission rate averages 63 percent. Family care has a lot to do with this discrepancy. While the focus on deinstitutionalization has forced families in the US to take on a more active role in caring for mental patients, only 34 percent of people with schizophrenia live with their families, compared to 88 percent in India and 90 percent in China. Ethnicity also plays an important role in the US — European Americans are much less likely to take care of a mentally ill family member at home, compared to any other ethnic group.
Dr. Amy Weisman, from the psychology department at the University of Miami, has been fascinated by culture’s influence on psychological disorders since 1989. She said the reason for these variances comes down to the difference between individualistic and collectivist cultures. Individualistic cultures, of which Anglo-America is a prime example, place great emphasis on independence and individual responsibility. A person is expected to do all things themselves and should not rely on others, because the outcome of nearly anything — good or bad — is believed to be within the individual’s control. Collectivist cultures, on the other hand, view individuals as part of a whole. One’s family members are an extension of themselves, there is responsibility towards others, and — importantly — people are willing to receive aid. When a person develops a mental illness, especially a severe one such as schizophrenia, they are likely to become more dependent on others. Lefley wrote, “In individualistic cultures, the realization that one is unable to perform former functions,that one needs help from others, is a critical issue in all disabilities.” Additionally, collectivist cultures are more likely to attribute mental illness to external sources such as the supernatural to avoid harming the reputation of the family.
Collectivist cultures, which include East Asians and Hispanics, are more likely to have a close-knit extended family, in contrast to the Western nuclear family. A large family that emphasizes support for each other not only provides more care for a person suffering from a mental illness but also tends to provide care that is more positive. Psychologists use a variable called “expressed emotion,” or EE, which refers to the way that primary caregivers speak to the patient. High EE means that the family tends to express their frustration with the person, lay blame on them, see them as a burden and otherwise speak negatively. Families with low EE, meanwhile, either do not have as many of these sorts of thoughts or do not voice them (though repressing those emotions can be harmful as well). In general, individualistic cultures have higher EE — possibly due to the increased responsibility on the fewer caretakers in addition to the expectations of the culture — and this negativity and viewing themselves as a burden can stress patients. Stress is one of the main predictors of the outcome of psychological disorders, with higher stress being correlated with poorer outcomes.
Relatedly, the way in which society perceives people with mental illnesses affects development and recovery. In some cultures, there is “less pressure for performance and more tolerance for subtle deviance,” Weisman said. If a person acts a little out of the ordinary and claims to talk to spirits, it may not be considered worrisome and even might be taken as a sign of otherworldly favor in some cultures. Acceptance allows people with illnesses to maintain their involvement in the community as much as possible, while also experiencing a wider range of suitable contributions; they are not being pressured to live alone and get an office job. Community involvement is beneficial for many mental illnesses — especially for schizophrenia, because most symptoms are negative in the sense that normal behaviors decrease, in contrast to development of new behaviors, which is known as positive symptoms. Importantly, the violence rate of people with schizophrenia is negligibly higher than that of the general population.
All of these factors are brought into consideration by culturally informed treatment, a method of psychotherapy that Weisman said massages cultural beliefs and tries to incorporate characteristics of traditional cultures. The therapist talks to the entire family and helps them adjust their pre-existing views and values to most benefit the patient and the family. Weisman related an example of a Cuban family who was struggling because their son had schizophrenia and was withdrawing from activities. Before the onset of the disease, the father and son used to love playing chess together, so the therapist encouraged that the family resume that tradition and then continue with other involvements, which helped the son to go into remission.
Though industrialized countries have better access to mental health resources, people with mental illnesses surprisingly often fare worse than in developing countries. This is because mental health is heavily influenced by societal values and family care. Culturally informed therapy considers the factors that are related to the most success and attempts to bring these ideas into the treatments used in developed countries.