Keywords: acculturation stress, resilience, inequalities, social determinates of health, socio-economic status, social support, depression, anxiety, psychosis, social exclusion, social isolation, social stigma, gender gap, unemployment, forced marriage, family violence, stigmatization, access to healthcare, access to psychological services, service provision, minority groups, ethnic groups, IAPT, transcultural psychology, transcultural psychiatry, individualism, collectivism, emotion regulation, expression of emotion; culture conflict, learned helplessness
I.1. Mental health of ethnic minorities: research topics, gaps and challenges
Immigrants and ethnic minorities, due to various social and cultural reasons, are very vulnerable to psychosocial stress and, as a consequence, to a variety of psychological disorders. Many sources refer to elevated depression, anxiety, personality and psychosomatic disorders as well as higher rates of suicide and psychosis in ethnic minorities compared to the general population (Hashmi, 2011; Kirkbride, 2008). On the other hand, some reports point out higher resilience of some ethnic groups compared to mainstream population (Cooper, 2010). Different factors, including religion, family structure, mentality, social connectedness and support, level of stigmatisation of mental illness, gender roles, social and personal expectations, openness to other culture as well as genetic particularities have been listed as contributing to the extent of psychosocial adaptation of minority groups (Betacourt, 2003). Moreover, different disciplines, including psychology, counselling, linguistics, gender studies, sociology, psychiatry, anthropology as well as educational and medical sciences investigate mental health of minirity populations by applying different discipline-specific research methods. Furthermore, due to complexity and variety of contributing factors and available research methods, it is very difficult to compare and evaluate results of numerous, yet often inconclusive, research publications. Qualitative and quantitative research approaches both provide with data, yet their interpretation is extremely challenging. Statistical reports and population surveys, on the other hand, allow us to estimate the extent of mental health problems in different minority groups; however, due to difficulties in accessing some minority groups, as well as methodological limitations, may lead to confusing or even false statistics with regards to ethnic populations. Illegal immigration represents yet another problem, particularly with regards to access to minority groups statistics. Due to mentality particularities, language barrier, low SES and limited access to health and community care, research is sometimes only fragmentary and does not give justice to the actual situation. Finally, often times research reports are planned, executed and reported by representatives of mainstream cultures, which adds to interpretational bias. Nevertheless, such programmes as IAPT attempt at improving access to psychological services throughout the population, including various ethnic groups, by means of culture-aware practices. The major challenge for counselling and psychotherapy in modern multicultural societies is implementation of flexible programmes and training of clinical specialists capable of dealing with ethnic minorities. Apart from cultural and professional competencies, language skills and openness to other cultures and religions are required from modern counsellors providing services in multicultural environments. This literature review addresses the above-mentioned issues.
1.1. Research question
Immigrant and ethnic minorities groups are vulnerable to stress, and there exist many reports about psychosocial stress, psychological disorders and vulnerabilities of this population. There are however very little amount of references with regards to practicing counselling and psychotherapy in culturally appropriate ways, in particular when working with minority groups. The major challenge of transcultural applications of psychotherapy is to find a balance between mainstream and minority cultures, and give justice to mainstream reality when at the same time explore and use original culture-related resources of clients in order to optimize therapeutic gains. Research question of this study is therefore to identify relevant psychosocial precipitating and protective factors, and ways to address them in everyday psychotherapy practice.
1.2. Research methodology
The present report is based on the results of publication search in various databases including Google Scolar, PubMed, as well as within specific web sites relevant to the topic. The following search keywords were used:
– minority + mental + health
– ethnic + groups + mental + health
– minority + discrimination + inequalities
– depression + anxiety + asian + women
– social + determinants + health
Inclusion/exclusion criteria: the main interest for this review was to find publication reviewing relevant statistics, stressors, psychosocial factors and cultural particularities with regards to minority populations, in particular asian minority groups in UK and the USA.
– to critically assess existing literature about psychosocial adaptation and stress-related psychological disorders of ethnic minorities in the UK, in particular of asian origin. Studies investigating minorities with immigrant background including second-generation immigrants were considered. Such issues as psychological and social adaptation, growing up in another culture, practicing own religion in foreign environments, protective and precipitating factors, social and health inequalities including gender discrimination, as well as service provision to ethnic minorities were of particular interest.
– to critically assess and analyze the current state and future prospects of service provision to ethnic minorities in realities of modern welfare state.
– give recommendation with regards to future psychotherapy research and practice in multinational environments and when working with ethnic minority populations.
2. Critical review of literature
Depression, which often starts as a temporary or reactionary stage of stress adaptation, may lead to severe consequences including suicide (Lester, 2008). Diagnosing and treating depression is a serious issue in primary care, especially in minority and ethnic groups and subpopulations. Low levels of diagnostic identification have been associated with cultural differences in therapist-client relationship style, traditional understanding of health and disease, language barrier, culture-specific attitudes to mental problems, gender and social roles, socio-economic status, social connectedness and support, as well as health-seeking behaviour (Ahmed, 2007). Moreover, different presentations of similar problems in different cultures may represent the same diagnostic entities in different cultural environments. Culture also infulences individual perceptions, societal expectations, as well as therapists’ judgement, therapeutic decisions and ultimately clients’ wellbeing and therapeutic success.
British Asians, particularly females, often suffer from depression, with much higher rates of suicide and cardiovascular disorders; they also have higher average BMI and more often develop obesity, compared to the general population (Hussain, 2004). There are reports, however, indicating that Asian immigrants, on the contrary, have significantly lower rates of depression compared to the maintream white British population (Bhugra, 2004; Nazroo, 1997). This discrepancy may reflect methodological differences of different studies, as well as different acculturation levels and other psychosocial circumstances which are not being controlled for. The difference may also lie in sampling methods as well as ethnic groups studied. Some studies pull all Asian minority groups together, whereas others divide Asian population into subgroups with varying number of subjects.
Gathering adequate statistics on minority groups is a very challenging task, especially because of migrants and ethnic minorities avoiding contacts with counsellors and psychiatrists to improve employment chances or avoid embarassment. Moreover, people of Asian origin are less likely to be diagnosed with depression because of different behavioural patterns and symptoms, demonstrating higher rates of somatisation than other depression symptoms compared to the mainstream population (Ahmed, 2007; Kirmayer, 2001). Interestingly, reduction of somatic symptoms and presentation of more affective symptoms of depression in Asian immigrants has been associated with increased acculturation and changes in the focus of self-attention from somatic (own physical sensation) to affective (emotional reactions to internal and external stimuli; Ahmed, 2007; Chen, 2003).
When comparing first and second immigrant generations, more second-generation Asian clients seek psychological help compared to the first generation group; at the same time, less first-generation Asian immigrants are reported to suffer from mental health problems (Hashmi, 2011). When comparing both generation of Asian immigrants, the first generation seems to more often suffer from depression, whereas the second generation is more often diagnosed with depression (Hashmi, 2011). With respect to psychosis, first-generation Asian immigrants are reported to be at higher risk of non-affective psychoses, compared to the white British population (Coid, 2008); they however did not show higher levels of psychological symptoms compared to the first generation immigrants (Furnham, 1993). Interestingly, first generation imigrants are found to have better stress resilience compared to the second generation, whereas second generation individuals demonstrate better social adaptation which can be partly explained by better social connectedness and language skills in second generation (Berry, 2006; Bhugra, 2004; Sproston, 2002). Still, higher resilience of the first generation immigrants is difficult to explain, and can be argued to reflect experiencing discrimination and poverty during growing up, in realities of double culture, confusing requirements and subtle future for those immigrants born in the UK (Berry, 2006). These differences between generations is not necessarily adequate because higher rates of diagnosis in the second generation may, at least partly, reflect higher rates of seeking help in the second generation, various comorbidities (for instance, depression conciding with psychosis or anxiety) of those seeking help and language barrier of new immigrants compared to those born in the UK (Ahmed, 2007; Hashmi, 2011; Lester, 2008). With regards to elevated suicide rates in this ethnic group, one may explain it by difficulties in social and labor integration as well as religious and cultural adaptation leading to high levels of stress, lower chances of getting fair employment and resulting poverty and frustration (Altug, 1998).
To improve health-seeking rates and therapeutic gains in ethnic groups, interpreters and specially trained practitioners can be used; this however requires planning and investment thus changes in NHS service provision. In the past years, various attempts have been made to improve access to psychological services and provide culturally-ajusted therapies in the UK. Yet, compared to such countries as New Zealand or Australia, very little effort has been made in providing psychological services in other languages than English or at least providing hospital intrepreting services. On the other hand, clients’ cultural and religious particularities are very rarely taken into account, and clinicians are rarely prepared to adequately address problems of minority groups. Moreover, diagnostic challenges are mostly connected to underdetection due to unwillingness of minority individuals to seek help and masked or confusing symptoms, as well as using an inadequate explanatory model. As recommendation, we may suggest training bilingual therapists and clinical interpreters, as well as providing cultural competency training for clinical personnel (Ahmed, 2007; Betacourt, 2003; Brach, 2000).
Clearly, ethnic minorities represent some kind of hybrid mentalities, which require development of more intuitive and flexible approaches to healthcare provision. Firstly, clients from non-Western cultures cannot be diagnosed and treated according to standard ¨western¨ clinical protocols due to differences in clinical presentations and preferrable treatment methods. Furthermore, clinicians should learn to apply truly holistic approach when taking into account particularities and boundaries of race, culture, social standing and mentality of their clients. Moreover, minorities face totally different stressors and may have very different protective factors compared to the mainstream population; those factors should also be taken into consideration. Finally, differentiation among various diagnoses according to the DSM classification manual does not necessarily help treatment process, especially when clinical pictures vary with culture.
It is understandable that therapists cannot speak all the languages and be aware of all cultural particularities and mentalities of their clients. However, it is in their power to attend to each client individually, and work with them towards the ultimate goal of psychological therapies: wellbeing of their clients. I argue that rather than providing ethnic-specific (Cinnirella, 1999) or trauma-focused (Pumariega,2005) care, therapeutic gains may be maximized when looking at each human being more from a continuum and holistic point of view (Handwerker, 1999). This will not only improve therapeutic results, but also reduce ethnic-related bias and improve willingness of ethnic minorities to seek help (Lepiece, 2014).
To conclude, one needs to emphasize both the importance and difficulty of studying minority groups in the UK. The major difficulty is to find fair samples for ethnic groups which is not an easy task indeed due to differences in mentality and adaptation strategies of first-and second-generations of immigrant populations. Another problem is comparing across different studies which all differ methodologically, being it methodology of participant recruitment or instruments used. Those limitations clearly do not allow for a perfect comparison. Despite numerous attempts at describing the phenomenon and linking it to stress, resilience and mental health, there is no consensus as to what immigration actually does to human mind, habits and life perspectives from the holistic point of view. Future research will show how stress and resilience affect mental health of migrants who became an integral part of our society.
Ahmed, K., & Bhugra, D. (2007). Depression across ethnic minority cultures: Diagnostic issues. World Cultural Psychiatry Research Review, 47-56.
Allen, R. (1990). Psychophysiology of the Human Stress Response. University of Maryland, College Park.
Altug, S., & Miller, R. (1998). The effect of work experience on female wages and labout supply. Review of Economic Studies, 65: 45-85.
Atkinson, T. (2002). Income inequality and the welfare state in a global era. Queen’s University lecture series, School of Policy Studies.
Beltfield, C., Cribb, J., Hood, A., & Joice, R. (2014). Living standards, poverty and inequality in the UK. Institute for Fiscal Studies Report..
Berry, J. W., Phinney, J. S., Sam, D. L., & Vedder, P. (2006). Immigrant Youth: Acculturation, identitiy, and adaptation. Applied Psychology: An International Review, 55(3): 303-332.
Betacourt, J. R. (2003). Cross-cultural medical education: Conceptual approaches and frameworks for evaluation. Academic Medicine, 78: 560-569.
Bhardwaj, A. (2001). Growing up young, asian and female in Britain: A report on self-harm and suicide. Feminist Review, 68: 52-67.
Bhugra, D., Gupta, S., Kamaldeep, B. et al. (2011). WPA guidance on mental health and mental health care in migrants. World Psychiatry, 10(1): 2-10.
Bhugra, D., & Ayonrinde, O. (2004). Depression in migrants and ethnic minorities. Advances in Psychiatric Treatment, 10: 13-17.
Blebuyk, J. F. (1990). The metabolic response to stress: An overview and update. Anesthesiology, 75, 308-327.
Blundell, R., Crawford, C., & Jin, W. (2014). What can wages and unemployment tell us about the UK’s productivity puzzle? Economic Journal, 124: 377-407.
Brach, C., & Fraser, I. (2000). Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Medical Care Research Review, 57: 181-217.
Chen, H., Guarnaccia, P. J., & Chung, H. (2003). Self-attention as a mediator of cultural influences on depression. International Journal of Social Psychiatry, 49: 192-203.
Coid, J. W., Kirkbride, J. B., Barker, D. et al. (2008). Raised incidence rates of all psychoses among migrant groups: Findings from the East London first episode psychosis study. Archives of General Psychiatry, 65: 1250-1258.
Cristiansen, N. F. (2006). The Nordic model of welfare.
Cinnirella, M., & Loewenthal, K. M. (1999). Religious and ethnic group influences on beliefs about mental illness: A qualitative interview study. British Journal of Medical Psychology, 72: 505-524.
Cohen, S., Janicki-Deverts, D., & Miller, G. (2007). Psychological stress and disease. JAMA, 298(14): 1685-1687.
Cooper, J., Murphy, E., Webb, R.. et al (2010). Ethnic differences in self-harm, rates, characteristics and service provision: Thre-city cohort study. The British Journal of Psychiatry, 197, 212-218.
Enfield Health and Wellbeing (2015). Diabetes. http://www.enfield.gov.uk/healthandwellbeing
Eisenck, H.J., & Eysenck, M. W. (1985). Personality and individual differences: A natural science approach. New York: Plenum.
Fitzpatrick, R. M., Hopkins, A. Ap., & Howard-Watts, O. (1983). Social dimensions of healing. Social Science and Medicine, 17: 501-510.
Furnham, A., & Shikh, S. (1993). Gender, generational and social support correlates of mental health in Asian immigrants. International Journal of Social Psychiatry, 39: 22-33.
Handler, J. F., & Hasenfeki, Y. (2007). Blame welfare, ignore poverty and inequality. Cambridge: Cambridge University Press.
Handwerker, W. P. (1999). Cultural diversity, stress, and depression: Working women in the Americas. Journal of Women’s Health & Gender-Based Medicine, 8(10): 1303-1311.
Hashmi, A., Halder, N. & Aslam, Y. (2011). Characteritics of first and second generation Asian mental health patients in Bolton, UK. World Cultural Psychiatry Research Review, 95-101.
Hills, J., Brewer, M., Jenkins, S. et al. (2010). An anatomy of economic inequality in the UK: Report of the National Equality Panel. London: Government Equalities Office.
Holden, K., McGregor, B., Thandi, P. et al. (2014). Toward culturally centered integrative care for addressing mental health disparities among ethnic minorities. Psychological Services, 11(4): 357-368.
Holen, A. (1989). A longitudinal study of the occurence and persistance of posttraumatic health problems in disaster survivers. Stress Medicine, 7: 11-17.
Horowitz, M. J. (1986). Stress response syndromes. New York: Jason Aronson.
Hussain, F., & Cochrane, R. (2004). Depression in Sout Asian women living in the UK: A review of the literature with implications for service provision. Transcultural Psychiatry, 41(2): 253-270.
Jolie, G. (2011). Inequalities in health. http://jolieblogz.blogspot.ch/2010/12/inequalities-in-health.html
Kawachi, I., Kennedy, P., & Glass, R. (1999). Social capital and self-rated health: a contextual analysis. American Journal of Public Health, 89: 1187-1194.
Kirkbride, J. B., Barker, D., Cowden, F. et al. (2008). Psychoses, ethnicity and socio-economic status. The British Journal of Psychiatry, 193: 18-24.
Kirmayer, L. J. (2001). Cultural variations in the clinical presentation of depression and anxiety: Implications for diagnosis and treatment. Journal of Clinical Psychiatry, 62(13): 22-28.
Lang. P. J. (1977). Imagery in therapy: An information processing analysis of fear. Behavior Therapy, 8: 862-886.
Lazarus, R. S. (2000). Evolution of a model of stress, coping and discrete emotions. In V. H. Rice (Ed.), Handbook of stress, coping, and health: Implications for nursing research, theory, and practice. Thousand Oaks, CA: Sage.
Lepiece, B., Zdanowicz, N., Jaque, D. et al. (2014). Review of disparities in the mental health care of ethnic minorities patients. Psychiatria Danubina, 26(1): 43-47.
Luthar, S. S., Cicchetti, D., & Becker, B. (2000). The construct of resilience: A critical evaluation and guidelines for future work. Child Development, 71(3): 543-562.
Lester, D. (2008). Suicide and culture. World Cultural Psychiatry Research Review, 51-68.
Luthams, F., Avey, J. B., & Patera, J. L. (2008). Experimental analysis of a web-based training intervention to develop positive psychological capital. Academy of Management Learning and Education, 7(2), 209-221.
Mandel, H., & SHalev, M. (2009). How welfare states shape the gender gap: A theoretical and comparative analysis. Social Forces, 87(4): 1873-1911.
McDermott, J. (2014). No more ignorance about inequality. http://blogs.ft.com
Mental Health Reform (2014). Ethnic minorities and mental health: A position paper. Dublin: Mental Health Reform.
Nazroo, J. (1997). Ethnicity and mental health. London: PSI.
Patterson, J. M. (2002). Integrating family resilience and family stress theory. Journal of Marriage and Faily, 64: 349-360.
Psoinos, M., Hatzidimitriadou, E., Butler, C., & Barn, R. (2011). Ethnic monitoring in healthcare services in the UK as a mechanism to address health disparities: A narrative review. London: South West London Academic Network.
Pumariega, A., Rothe, E., & Pumariega, J. B, (2005). Community Mental Health Journal, 41(5): 581-597.
Sapolsky, R. M. (1994). Individual differences and the stress response. Seminars in the Neurosciences, 6: 261-269.
Selye, H. (1976). Stress in health and disease. Boston: Butterworth.
Schmitz, K. (2013). ENAR Shadow Report: Racism and related discriminatory practices in the UK. European Network Against Racism.
Sproston, K., & Nazroo, J. (2002). EMPIRIC Report: Survey Carried out on Behalf of the Deparment of Health by the National Centre for Social Research. Retrieved from: http://www.doh.gov.uk
Stansfield, S. (1999). Social support and social cohesion. In: Marmot M., Wiklinson R. (Eds.). Social determinants of health. Oxford University Press, Oxford.
Stevens, G. W. J. M., & Vollebergh, W. A. M. (2008). Mental health in migrant children. Journal of Child Psychology and Psychiatry, 49(3), 276-294.
The Migration Observatory (2015). Characteristics and outcomes of migrants in the UK labour market. http://www.migrationobservatory.ox.ac.uk/briefings/characteristics-and-outcomes-migrants-uk-labour-market
Triandis, H. C., Bontempo, R., & Villareal, M. J. (1988). Individualism and collectivism: Cross-cultural perspectives on self-ingroup relationships. Journal of Personality and Social Psychology, 54(2), 323-338.
Wagstaff, A., & Doorslaer, E. (2000). Income inequality and health: What does the literature tell us? Review of Public Health, 22, 543-567.
Wilkinson, R., & Marmot, M. (Eds.) (1998). Social determinants of health: the solid facts. WHO Regional Office for Europe.