Black Americans' and White Americans' Views of the Etiology and Treatment of Mental Health Problems

Transcription

1 Community Mental Health Journal, Vot. 32, No. 3, June 1996 Black Americans' and White Americans' Views of the Etiology and Treatment of Mental Health Problems Peter E. Millet, Ph.D. Bryce E Sullivan, M.A. Andrew I. Schwebel, Ph.D. Linda J. Myers, Ph.D. ABSTRACT: Black Americans, in contrast to White Americans, use the mental health system in different ways. For example, Blacks tend to terminate treatment earlier than Whites. One explanation for the racial differences is that members of the two groups hold different views about mental health problems and their treatment. To test this explanation, subjects read and responded to questions about vignettes describing individuals encountering personal difficulties that ranged from adjustment challenges to severe psychiatric illness. Black American respondents rated spiritual factors as more important in the etiology and treatment of the difficulties than did Whites. The implications of these findings for theory and practice are discussed. Current trends indicate that in 50 years almost 50% of Americans will have distinctly non-european ancestry (U.S. Bureau of Census, 1993). Besides needing to adjust to the stressors associated with everyday life (Serafica, Schwebel, Russell, Isaac, & Myers, 1990), many of these individuals will face additional stressors related to racism, poverty, and acculturation. Their ability to cope with these challenges Peter E. Millet, Ph.D., is affiliated with the Dept. of Psychology, Connecticut College, New London, CT. Bryce F. Sullivan, M.A., and Andrew I. Schwebel, Ph.D., are affiliated with the Dept. of Psychology, The Ohio State University. Linda J. Myers, Ph.D., is affiliated with the Dept. of Black Studies, The Ohio State University. Address correspondence to Andrew I. Schwebel, Ph.D., Department of Psychology, The Ohio State University, 1885 Neff Avenue Mall, Columbus, Ohio Human ~'~e. Pm~, Inc.

2 236 Community Mental Health Journal may depend partly on the degree to which they can effectively take advantage of the resources available to them, including the services provided by mental health workers. At least in some ways, members of minority groups are not taking full advantage of traditional mental health services. Many Black Americans, for example, do not seek outside professional assistance when they initially experience a depressed mood or a sleep disturbance (Raskin, Crook, & Herman, 1975). Rather, they tend to obtain help for depression and other problems later in the disease process, when problems have become more severe (Neighbors & Lumpkin, 1990; Sussman, Robins, & Earle, 1987). Once in treatment, people with ethnic minority backgrounds tend to terminate prematurely, compared to their White counterparts (Sue, 1977; Sue & Zane, 1987; Terrel & Terrel, 1984). Sue, McKinney, Allen, & Hall (1974), who studied the utilization of mental health facilities, also found that half of their minority clients did not return after one session compared to less than one-third of the White clients, a statistically significant difference. Many reasons have been advanced to explain the differences between ethnic minority group members and Whites in their help-seeking. Some suggest that Blacks fear the mental health system (Homma: True, Greene, Lopez, & Trimble, 1993) or obtain assistance from folk healers (Cheung & Snowden, 1990) or other supports, such as the church or family (Henderson & Primeaux, 1981). The present study investigates another possible explanation: that minority group members, in this case Black Americans, hold different views (cognitions) about the etiology and treatment of mental health problems than do white Americans. If it were the case that Blacks held a unique set of mental-health-related cognitions, cognitive-behavioral theorists would maintain that these cognitions, in turn, would lead them to think, feel, and behave differently than white Americans with regard to their own mental health and with regard to their interactions with people who display adjustment or mental health difficulties. Many factors might lead Blacks to hold mental-health-related cognitions that are different from White Americans'. Church teachings, for instance, represent one factor that may have a strong influence on how the large number of church-affiliated Blacks (Snow, 1983) perceive mental disorders, their etiology, and their treatment. Moreover, Black Americans ministers may foster the connection between spirituality and mental health in performing their role in the community, actively counseling persons with mental illness and in crises of other types (Mollica, Streets, Boscarino, & Redlich, 1986). Further, Blacks' cogni-

3 Peter E. Millet, Ph.D., et al. 237 tions about mental health and illness would likely be affected by the extent to which they hold an Afro-centric world view, a perspective which has spirituality as a central feature (Myers, 1988). Building on these issues, the authors asked Blacks and Whites questions designed to assess their cognitions about the etiology and treatment of mental illness. Whereas the participants were expected to have views that were similar in many ways, some differences were expected. Subjects METHOD To partially fulfill the requirements of an introductory psychology course at a large midwestern university, 67 Black and 78 White undergraduates participated in the study. They ranged from 19 to 41 years of age (M = 21.3, SD = 4.15). Of this number, 91 were women, 52 were men, and 2 did not report their gender. Instruments The Mental Illness Vignettes Instrument (MIVI) consists of 11 vignettes. It was developed from a pool of 39 vignettes which described a diverse set of target persons (TPs). These TPs manifest a wide range of typical and atypical behaviors and are described as facing problems that range in severity from adjustment difficulties to severe mental illness. The description of the TPs in the vignettes were independently evaluated by three graduate students in clinical psychology. Given the information available, they were asked to rate whether or not each TP had characteristics of a DSM-III-R diagnosis. From the group of vignettes on which all three agreed, 11 were chosen for the MIVI. The selection process was designed to provide diversity in terms both of target behaviors and of the characteristics 0fthe TPs, such as gender and age. Nine of the vignettes selected described TPs who met the DSM-III-R criteria for the following: major depression; alcohol dependence; bipolar disorder; bulimia nervosa; paranoid personality disorder; panic disorder with agoraphobia; schizophrenia, paranoid type; borderline personality disorder; and schizophrenia, undifferentiated type. The other two vignettes described TPs facing significant difficulties in meeting the challenges of life, but difficulties that did not have DSM-III-R-like symptoms. An example of one of the vignettes follows: Phil is a 43 year old male. While always a heavy drinker, recently he has been drinking to the point where he either blacks out or becomes forgetful and has trouble remembering things. When drunk he typically becomes both verbally and physically abusive, resulting in him being beaten up several times and losing contact with many of his friends. He has become very socially alienated and bitter about his life. Drinking appears to be his answer for all of the problems in his life.

4 238 Community Mental Health Journal Each vignette on the MM was followed by the same 11 questions that assessed three types of information: Two questions measured respondents' assessments of the nature and level of severity of the TP's problems. Four questions measured respondents' assessments of the etiology (organic/biological; personal/moral weakness; spiritual/mystical forces; environmental circumstances) of the TP's problems. Finally, five questions measured respondents' assessments of the potential effectiveness of various treatment approaches (self-help programs, jail term or placement in a correctional facility, medical treatment, psychological treatment, spiritual/religious help). RESULTS First, a multivariate analysis of variance (MANOVA) was conducted that used race as the independent variable and responses to the 11 questions that followed the vignettes (collapsed across all 11 vignettes) as the dependent variables. Given that the MANOVA was significant (Wilks' Lambda =.79; F [11, 133] = 3.44, p <.001), univariate analysis of variances (ANOVAs) were conducted. First, two one-way ANOVAS were conducted with ratings of the severity and abnormality of the TP's behavior as the dependent variables. Next, two two-way ANOVAs were conducted with race as the between-subject factor and the summed scores from ratings of etiology or treatment variables as the within-subject factors. The two one-way ANOVAs indicated that there were no significant differences in how "normal" or how "severe" the Blacks and the Whites rated the TPs' behavior. On a scale from 0-9, the mean rating of the severity given by Black respondents was 6.52 compared to the mean of 6.65 for Whites; the mean rating of abnormality given by Blacks was 6.92 compared to the mean of 7.03 provided by White respondents (after recoding reverse-keyed items, larger numbers indicate that respondents evaluated the behavior as more abnormal or more severe). The two-way ANOVA, with race as the between subject factor and type of etiological variable as the within subject factor, used the summed etiological responses across vignettes (organic, moral, spiritual, environmental) as the dependent measures. This ANOVA revealed an interaction between race and the type of etiological factor, F (1, 3) = 9.91, p <.001, (Greenhouse-Geisser corrected). After recoding reverse-keyed items on the 10-point scale, 0 indicated a rating of no effect and 9 indicated a rating of major effect. On the organic, moral,

5 Peter E. Millet, Ph.D., et al. 239 spiritual, and environmental etiological ratings, Blacks had means of 4.98, 5.96, 3.74, and The White respondents had means of 5.27, 5.70, 2.48, and 4.45, respectively. As hypothesized, the Black Americans put significantly more emphasis on spiritual etiological factors that the white respondents. Tukey HSD tests (p <.05) indicated that Blacks rated spiritual or mystical forces as more responsible for the TPs' behavior than did whites. There were no other significant differences between groups. A second two-way ANOVA, with race as the between subject factor and type of treatment variable as the within subject factor, used the summed treatment responses across vignettes (self-help, jail term, medical treatment, psychological treatment, spiritual/religious help) as the dependent measures. This ANOVA revealed an interaction between race and the type of treatment, F (1, 4) = 5.22, p <.001 (Greenhouse-Geisser corrected). After recoding reverse-keyed items on the 10-point scale, 0 indicated a rating of definitely not beneficial and 9 indicated a rating of definitely beneficial. On the treatment factors of self-help, jails, medical treatment, psychological treatment, and spiritual/religious, Black respondents had means of 5.98, 2.06, 5.28, 6.77, and 5.97, The Whites had means of 5.83, 1.60, 5.56, 7.00, and 4.91, respectively. As hypothesized, Tukey HSD tests (p <.05) indicated that Blacks rated spiritual or religious help as significantly more beneficial than did Whites. There were no other significant differences between groups. DISCUSSION These results suggest that Black and White college students make different assessments about the etiology and treatment of various kinds of adjustment challenges and psychiatric disorders. Specifically, Black, in contrast to White, Americans attribute much more importance to spirituality in treating and in understanding the cause of mental health difficulties. These findings have value to scholars, practitioners, and those who develop social policy. Cognitive behavioral theory suggests that individuals' cognitions shape how they think, feel and behave (Schwebel & Fine, 1994). This theory, applied in the area of mental health, indicates that the specific cognitions people hold about what is "abnormal" behavior shape how they perceive and assess their own behavior and that of others, when individuals identify problems with their behavior or others', their cog-

6 240 Community Mental Health Journal nitions lead them to conclude what caused the abnormality and how it could best be treated. Because they hold different cognitions with regard to the etiology and treatment of mental health problems, Black and White Americans should be expected to think, feel, and act differently when experiencing what is commonly thought of as mental health problems, either in themselves or in others. Also because of these differences, when confronted with a mental health problem, they would likely seek help at different points in its course, turn to different sets of resource people, and, to match their cognitions, expect success from different forms of assistance. Clients who seek professional treatment may find that the assistance they receive does not match their expectations or does not appear to them to be helpful with their problem. Individuals might make such assessments if they hold mental-health-related cognitions that stress the importance of spirituality and receive traditional mental health services. As Levine (1974) suggests, when the treatment does not mesh with the clients' expectations, the mismatch may lead to termination early in treatment. In this connection, Terrel and Terrel (1984) found that 43% of the Black clients seeing a White therapist did not return to treatment, compared to 25% of the Black clients seeing same race therapists. Jackson and Hayes (1993) stated that to be effective help-givers for individuals from culturally different backgrounds, professionals need to be aware of how they and their clients differ in: philosophy of life, reasoning and problem-solving strategies, and communication style. The results of this study suggest that knowledge of the clients' mental health related cognitions should also be included in this list. Practitioners and planners who understand the importance of spirituality in the mental health-related cognitions of many Black Americans are better equipped to develop programs that meet their Black clients' needs. This knowledge can help practitioners and program planners develop a better match between services provided and their clients' mental health cognitions. Mental health planners and providers can create this match in at least two ways: First, by offering treatment and other services that mesh with their clients' beliefs about spirituality; second, by providing an educational component designed to expand clients' views about the etiology and treatment of mental health problems. Specifically, to help them better understand the rationale for these services, clients can be taught about the value of time-tested and theoretically-sound, traditional services. This

7 Peter E. Millet, Ph.D., et al. 241 knowledge, in turn, should help clients make more effective use of available, traditional services. The value of the present findings would be enhanced if the study were replicated and extended by using community samples of varying ages and socio-economic backgrounds. The current sample and results lack the generalizability that such community samples would provide. The authors expect that in community samples, age-related differences would emerge and the gap between Black and White respondents in the area of spirituality would be larger than those reported here. In particular, Black Americans from the community would probably place a greater emphasis on spirituality than Black respondents enrolled in a college course that stressed the scientific foundations of behavior and described the role of biological and environmental factors in mental health. REFERENCES Cheung, G.K., & Snowden, L.R. (1990). Community mental health and ethnic minority populations. Community Mental Health Journal, 26, Henderson, G. & Primeaux, M. (1981). The importance of folk medicine. In G. Henderson, & M. Primeaux (Eds.), Transcultural health care (pp ). Menlo Park, CA: Addison-Wesley Publishing. Homma-True, R., Greene, B., Lopez, S.R., & Trimble, J.E. (1993). Ethnocultural diversity in clinical psychology. The Clinical Psychologist, 46, Jackson, D.N., & Hayes, D.H. (1993). Multicultural issues in consultation. Journal of Counseling & Development, 72, Levine, M. (1974). Some postulates of community psychology practice. In F. Kaplan & S. Sarason (Eds.). The psychoeducational clinic papers and research studies, Vol. 4 (pp ). Boston: Massachusetts Department of Mental Health Monographs. Lopez, S.R. (1989). Patient variable biases in clinical judgment: Conceptual overview and methodological considerations. Psychological Bulletin, 106, Mollica, R.F., Streets, F.J., Boscarino, J., & Redlich, F.C. (1986). A community study of formal pastoral counseling activities of the clergy. American Journal of Psychiatry, 143, Myers, L.J. (1988). Understanding an Afrocentric world view: Introduction to an optimal psychology. Dubuque, IA: Kendall/Hunt. Neighbors, N.W., & Lumpkin, S. (1990). The epidemiology of mental disorders in the black population. In D. Ruiz (Ed.), Handbook of mental health and mental disorder among black Americans (pp ). New York: Greenwood Press. Raskin, A., Crook, T.H., & Herman, K.D. (1975). Psychiatric history and symptom differences in black and white depressed inpatients. Journal of Consulting and Clinical Psychology, 43, Schwebel, A.I., & Fine, M.A. (1994). Understanding and helping families: A cognitive behavioral approach. Hitlsdale, NJ: LEA Press. Serafica, F., Schwebel, A.I, Russell, R., Isaac, P., & James-Myers, L. (1990). Mental Health of Ethnic Minorities. New York: Praeger Press. Snow, L.F. (1983). Traditional health beliefs and practices among lower class Black Americans. The Western Journal of Medicine, 139, Sue, S. (1977). Community mental health services to minority groups: Some optimism, some pessimism. American Psychologist, 32, Sue, S., McKinney, H., Allen, D. & Hall, J. (1974). Delivery of community mental health services to black and white clients. Journal of Consulting and Clinical Psychology, 42,

8 242 Community Mental Health Journal Sue, S., & Zane, N. (1987). The role of culture and cultural techniques in psychotherapy: A critique and reformulation. American Psychologist, 42, Sussman, L.I~, Robins, L.N., & Earls, F. (1987). Treatment-seeking for depression by blacks and white Americans. Social Science and Medicine, 24, Terrel, F., & Terrel, S. (1984). Race of counselor, client sex, cultural mistrust level, and premature termination from counseling among black clients. Journal of Counseling Psychology, 31, U.S. Bureau of the Census (1993). Population profile of the United States: 1993 (Current Population Reports, Series P23-185). Washington, DC: U.S. Government Printing Office.