Beyond Just a “Phase:” Acknowledging the Role of Diversity and Culture in Mental Health

By Tara Earl, PhD, MSW

Overall, my childhood wasn’t terribly remarkable. I have four older siblings from my dad’s first marriage. Technically, they are my half- brothers and sisters, but those descriptions were not used in our home. Family is family. I spent the most time with my twin brothers, mostly because we are the closest in age. My summers were equally filled with sibling play, love, and rivalry.

However, things changed in my early 20’s. One of my brothers started telling us that he “didn’t feel right.” He became withdrawn and got into more trouble than what was “normal” for him. I didn’t understand this at the time, but his behavior was the onset of what we now know — many years later — as schizophrenia. In our eyes, he was just a young adult going through a “phase.” I recall my grandmother saying that he was “smelling himself.” The concept of mental illness was as foreign to my family as “half-brother or half-sister.” We simply did not understand what was going on; and we certainly didn’t know what we were supposed to do.

My family’s response — or lack thereof — stayed with me for many years. In fact, when my colleagues and I published an article in 2015 (see Earl, Fortuna, Gao, Williams, Takeuchi, Neighbors, and Alegría, 2015[1]), my brother’s experience influenced much of my thinking and motivation. I had questions that I couldn’t find in the extant literature. In general, I wanted to know how my family’s experience related to others. I wanted to better understand what people experience, and how that information could be (mis)understood. In the article, we explored how psychotic-like symptoms were experienced, endorsed, and understood by a sample of African Americans, Asians, Caribbean Blacks, and Latinos.

While reviewing the data and reading several articles, I quickly realized that “abnormal” symptom presentation of mental illness was just as destructive for an individual as delayed treatment or limited access to care. As found in our work, attributions of psychotic-like symptoms varied significantly by race and ethnicity, and were commonly associated with culturally-bound beliefs, practices or personal or familial distress (e.g., death). Diagnostic criteria for psychosis that are based on Western standards may not account for the potential depth and breadth of the ways in which race, ethnicity, and culture can mediate and/or sanction the expression of what might otherwise be considered psychotic-like experiences.

Despite mental health parity, remarkable progress in expanding mental health coverage, and a rise in global awareness, we are still challenged with understanding and accurately assessing this class of disorders. Each year, approximately 1 in 5, or 44 million, Americans are affected by mental illness. Mental disorders like schizophrenia affect about 100,000 people per year. They can be debilitating and often alter a person’s ability to think, communicate, and function properly. As I think about my own family’s experience, I still try to imagine what it’s like for others. Although my brother was eventually diagnosed with schizophrenia, for many others, that may not be accurate or appropriate.

As we move towards building a holistic Culture of Health, we must not forget to include mental health. We must also intentionally acknowledge the role of diversity and culture. In order to be successful in this endeavor, we need to have a shared understanding about what is required to deliver the right type of care to the right people at the right time. We should also be realistic about the shortcomings, committed to establishing favorable population-wide strategies for improvement, and steadfast in our plan to create a society where everyone, regardless of their culture and background, is equipped with the knowledge, services, and support to lead healthy lives.

Dr. Tara Earl

[1] Earl, T.R., Fortuna, L.R., Gao, S., Williams, D.R., Takeuchi, D.T., Neighbors, H.W., & Alegría, M.A. (2015). An exploration of how psychotic-like symptoms are experienced, endorsed, and understood from the National Latino and Asian American Study and National Survey of American Life, Ethnicity and Health, 20(3), 273–292. doi: 10.1080/13557858.2014.921888.

Tara Earl, PhD, MSW, is an Associate with Abt Associates.