By Gordon Nagayama Hall, PhD (Professor of Psychology, University of Oregon)
If you had a cold, with a stuffy nose, sore throat, and headache, would you want a medicine that treated all the symptoms or just the stuffy nose? Most people would want the medicine that treated all the symptoms. A decongestant can make you feel better but a medicine that treats all three symptoms can get you well. Yet, when it comes to mental health problems, such as depression and anxiety, standard mental health treatments do not necessarily address all the issues involved, particularly cultural issues. Standard mental health treatments make many people better and even well, but does everyone get well?
Jennifer was a successful 29-year-old Chinese American computer engineer in the Silicon Valley with one apparent weakness; she was indecisive (Should I bake cookies for my co-workers? Should I take on this project at work?) and needed repeated reassurance from her family that her decisions were correct. After experiencing heart palpitations, she went to a doctor who could not find a medical reason for the heart palpitations and sent her to psychologist. The psychologist told her that her heart palpitations were caused by anxiety associated with her dependence on her family and diagnosed her with obsessive-compulsive disorder and dependent personality disorder. The goals of treatment prescribed by the psychologist were for Jennifer to become more independent: (a) set personal boundaries with her family; (b) stop seeking their assurance and advice; and (c) stop second-guessing her own decisions. Jennifer tried not to contact her family for two weeks and she felt relieved and less anxious but began to miss her family and the heart palpitations resumed occasionally. She was better but not completely well. A Chinese American coworker of Jennifer’s noticed that she seemed preoccupied and asked what was going on. Jennifer told her about seeing a psychologist and having mixed feelings on the attempts to set boundaries with her family. The coworker told Jennifer about a Japanese American psychologist who seemed to understand Asian American cultures. Jennifer decided to leave the first psychologist and try the Japanese American psychologist. The treatment began with controlled breathing exercises and Jennifer noticed that her heart palpitations became less frequent. The psychologist observed that seeking her family’s advice kept Jennifer connected with her family, who were concerned about “losing her” as she became more involved in her career. Similar to the first psychologist, this psychologist encouraged Jennifer to stop second-guessing her own decisions. But rather than stopping contact with her family, the psychologist had Jennifer meet once a week, not for unnecessary advice but to go grocery shopping together. Her heart palpitations stopped, she became more confident in her decisions, and she felt good about her relationship with her family. In other words, she got well.
The first psychologist offered the standard treatment – be your own person, make your own decisions, don’t rely on others. Jennifer began to feel better but this treatment didn’t help her relationships with her family or her heart palpitations. Wellness for Jennifer meant: (a) reduced heart palpitations; (b) making her own decisions; and (c) staying in touch with her family. The second psychologist offered a culturally-adapted treatment that promoted wellness by:
addressing physical health complaints which are an important component of distress for many Asian Americans and other cultural groups (Hunter & Schmidt, 2010; Ryder et al., 2008)
combining independence and interdependence, which are both important for many Asian Americans and other cultural groups (Nguyen & Benet-Martínez, 2007; Oyserman, Coon, & Kemmelmeier, 2002)
Science tells us that paying attention to culture can improve the effectiveness of mental health treatments. In a recent meta-analysis of 78 studies of nearly 14,000 people worldwide that will be published in the 50th Anniversary Issue of Behavior Therapy, culturally-adapted mental health treatments were more effective in reducing mental health problems than standard treatments that did not incorporate the client’s culture (Hall et al., 2016). A meta-analysis is a statistical analysis that combines the results of multiple studies to determine the overall effectiveness of a treatment. People with African, Arab, Asian, Latino/a, and Native American ancestries in these 78 studies all benefitted from attention to their cultures.
Nearly 40% of the people in the United States are not White and the majority of children under age 5 are not White (U.S. Census Bureau, 2014). These are people who stand to benefit from culturally-adapted treatments. Yet, critics of cultural adaptations argue that they are more costly and complicated than standard treatments. Such criticisms have impeded research and development of culturally-adapted treatments. But the costs in not developing culturally-adapted treatments include unaddressed suffering for a large number of people and in some cases suicide. Standard mental health treatments help people get better, but incorporating culture into mental health treatments can help many people get well.
Hall, G. C. N., Ibaraki, A. Y., Huang, E. R., Marti, C. N., & Stice, E. (2016). A meta-analysis of cultural adaptations of psychological interventions. Behavior Therapy. (Online version available here: http://www.sciencedirect.com/science/article/pii/S0005789416300806)
Hunter, L. R., & Schmidt, N. B. (2010). Anxiety psychopathology in African American adults: Literature review and development of an empirically informed sociocultural model. Psychological Bulletin, 136, 211-235. doi: 10.1037/a0018133
Nguyen, A. D., & Benet-Martínez, V. (2007). Biculturalism unpacked: Components, measurement, individual differences, and outcomes. Social and Personality Psychology Compass, 1, 101-114. doi: 10.1111/j.1751-9004.2007.00029.x
Oyserman, D., Coon, H., & Kemmelmeier, M. (2002). Rethinking individualism and collectivism: Evaluation of theoretical assumptions and meta-analyses. Psychological Bulletin, 128, 3–73. doi: 10.1037/0033-2909.128.1.3
Ryder, A. G., Yang, J., Zhu, X., Yao, S., Yi, J., Heine, S. J., & Bagby, R. M. (2008). The cultural shaping of depression: Somatic symptoms in China, psychological symptoms in North America? Journal of Abnormal Psychology, 117, 300-313. doi: 10.1037/0021-843X.117.2.300
U.S. Census Bureau (2014). A more diverse nation. Retrieved 9/20/16 from https://www.census.gov/content/dam/Census/newsroom/releases/2015/cb15-113_graphic.pdf
Gordon C. Nagayama Hall, PhD, is a Professor of Psychology at the University of Oregon. He has authored over 100 publications on topics including Asian Americans and mental health. Dr. Hall is Past President of the Asian American Psychological Association and of the Society for the Study of Culture, Ethnicity, and Race.