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Does Culture Influence the Social and Psychological Impact of Mental Illness?

Does Culture Influence the Social and Psychological Impact of Mental Illness?

Compared to work on the incidence and prevalence of mental illness across cultures, little research has examined how the personal and social impact of mental illness varies across cultures. This is somewhat surprising, given that societal and community responses to mental illness may have the greatest influence on prognosis and may vary the most across cultures. In the WHO study described earlier, Jablensky and colleagues found that patients from ‘‘developing’’ countries had better outcomes 2 and 5 years after the initial onset of schizophrenia than patients from ‘‘developed’’ countries. It is possible that this finding reflects cultural variation in the social and personal impact of schizophrenia.

Although a variety of cultural factors might influence the personal and social consequences of mental illness, we highlight three: (1) the value of social relationships, (2) views of mental illness, and (3) views of the self. The extent to which cultures value social relationships and therefore provide social support to individuals with mental illness may influence psychiatric outcome. For example, having strong family ties reduces the risk of schizophrenic relapse. Therefore, schizophrenia may have a better prognosis in cultures that place greater emphasis on the family unit. In addition, family interaction styles may vary across cultures and may also affect prognosis. In schizophrenia, for example, levels of expressed emotion in the family have been correlated with poor patient prognosis. ‘‘Expressed emotion’’ is comprised of three components: criticism, emotional overinvolvement, and hostility. Although expressed emotion exists across cultures, levels of expressed emotion vary across cultures. For example, compared to American households of schizophrenic patients, Japanese and Indian households demonstrated less, whereas Portuguese-speaking Brazilian households demonstrated more expressed emotion. These differences can be further broken down into the specific components of expressed emotion. Greater levels of expressed emotion in the Brazilian households than in American households were due to greater levels of emotional overinvolvement in Brazilian than in American households. Compared to British and Anglo-American families, Mexican families demonstrate less criticism. Moreover, the content of expressed emotion differs across cultures. Jenkins found that critical Mexican family members were less likely to make negative character attributions about schizophrenic patients’ behavior than Anglo-Americans; instead, they were more critical of disruptive or disrespectful behavior toward the family. These differences may explain why schizophrenic patients who lived in ‘‘developing’’ countries improved more than those who lived in ‘‘developed’’ or industrialized countries. The impact of mental disorder in a particular cultural context may depend on the way that culture views mental illness and those afflicted with mental illness. According to social labeling theory, the way a society responds to patients influences their prognosis. This theory suggests that patients have better prognoses in societies that expect them to recover from mental affliction and return to normalcy rapidly than in societies that view mental illness as a permanent condition and that ostracize and stigmatize patients. For example, in Spanish, the mentally aff licted are described as having ‘‘nervios,’’ a term that elicits sympathy in Mexican culture. In contrast, in English, mental illness connotes biological defects intrinsic to the individual. Social labeling theory predicts that the mentally ill have better prognoses in Mexican culture than in mainstream European-American culture. Few studies examined whether the psychological impact of mental disorders generalizes across cultures. For instance, the impact of mental illness on one’s self concept may depend on cultural views of the self. For example, Estroff  and Fabrega argue that in cultures that value independence and view the self as a stable, context-independent entity, disorders that disorganize or fragment the self (e.g., schizophrenia) may have greater personal consequences than in cultures that view the self as a fluid, dynamic entity. Moreover, the latter cultures may be more accepting of mentally ill individuals’ dependence on caretakers. The impact of mental illness on psychological processes such as cognition and emotion may also vary across cultures.

Unfortunately, few studies have examined this possibility. For instance, several empirical studies demonstrated that depression alters various aspects of emotional processing. Depressed individuals are less sensitive to both positive and negative emotional cues than nondepressed individuals. Depression also alters the behavioral and physiological aspects of emotional response. However, these studies have been conducted primarily on European-American samples. No studies have examined whether the psychological impact of depression generalizes to other cultural contexts. Thus, significantly more research is needed to examine the cultural factors that influence the social and psychological impact of mental illness. Such studies may reveal whether and why the prognosis of specific mental disorders may be better or worse across cultural contexts.

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