Transcultural Perspectives

in
Mental Health Nursing
Part 3
Mary Rose C. Jontilano, RN,MSN
Compiler
Prayer
Learning Objectives
Asian/Pacific Islander Culture: An Overview of
Mental Health
• For the United States 2010 to 2060 period, Asian Americans and Pacific Islanders are
one of the fastest growing minority groups in the United States, second only to the
Hispanic or Latino cultural groups. The Asian population is projected to more than
double, from 15.9 million in 2012 to 34.4 million in 2060, with its share of nation’s
total population climbing from 5.1% to 8.2% in the same period. The Native
Hawaiian and Other Pacific Islander population is expected to nearly double, from
706,000 to 1.4 million (United States Census Bureau, 2012). Asian Americans and
Pacific Islanders of Asian ancestry represent 43 diverse cultural groups from Korea,
Japan, China, India, Cambodia, Vietnam, Indonesia, Philippines, and Papua New
Guinea, to name only a few (United States Census Bureau, 2012).
• For some Asian Americans and newly arrived immigrants
from China and Japan, stigma related to mental health
problems can be a stumbling block in seeking appropriate
care. For example, a study by Gilbert et al. (2007) focused on
Asian and non-Asian young women’s shame related to mental
health care and identified three components of shame:
external, internal, and reflected. External shame is a belief
that an individual will be viewed negatively for mental
health problems; internal shame is evaluating oneself
negatively; and reflected shame is a belief that having
mentalalth problems could bring shame to an individual’s
family or community.
• Results of this study suggest that Asian women had higher
external and reflected shame beliefs than did non-Asian
women. Asians also expressed concerns about confidentiality
when talking about personal feelings/anxieties. This study
suggests that stigma may play a role in seeking mental health
care and may encourage individuals to seek care only
among friends and family, avoiding professional mental
health services and the risk of bringing shame to themselves
and others.
• Asian Americans’ core cultural values of honor and pride
and patriarchal obligations, particularly with elders, are
important to understanding Asian American culture.
Collective group harmony, including family and kin,
rather than individual concerns, are significant cultural
values (Leininger, 1995). Understanding core cultural
values of the Asian American culture, particularly the
importance of maintaining harmony, will help
transcultural nurses plan care for clients with mental
health problems in a culturally competent manner
• In a study of older Korean Americans exploring cultural attitudes
toward mental health services, Jang et al. (2007) found that individuals
who had been in the United States for a shorter time frame and had more
severe levels of depression were more likely to have negative attitudes
about mental health services. Cultural values and beliefs of older Korean
Americans seemed to have a major influence on whether or not they
viewed mental health services in a negative manner. Those individuals
who identified mental illness with personal weakness or shame held
more negative attitudes about using mental health services. However, if
the individual associated depression as a health condition, then he or she
had a more positive attitude about mental health services. Cultural values
and beliefs about mental illness, including stigma associated with mental
illness, were also found to be influential in individual’s attitudes toward
mental health services.
• Community agencies have often provided mental health
services specifically to Asian Americans. The National
Alliance on Mental Illness (2011) reported deep cuts to state
health care dollar allocations for mental health treatment for
children and adults living with a serious mental illness. Many
of these community agencies have suffered a severe cutback in
services and are unable to provide the level and kinds of care
that they have provided in the past. Recognition of cultural
barriers, such as language, that have a direct effect on
communication between nurses and other health care providers
and clients and their family/significant other(s) can be
preemptive and lead to more positive client outcomes
 Hispanic/Latino Culture: An Overview of
Mental Health Concerns
• Individuals of Hispanic or Latino descent are the fastest growing cultural
group in the United States (United States Census Bureau, 2012). By 2060,
approximately 128 million people, nearly one in three US residents, will
self-identify as Hispanic Americans (United States Census Bureau, 2012).
Hispanic countries include such diverse places as m exico, Puerto Rico,
Cuba, Spain, and the United States; there is tremendous cultural diversity
among the Hispanic/Latino groups.
• In general, Mexican Americans (American citizens identifying as having Mexican
ancestry) tend to rely on their family and extended family networks. Family and the
extended family members are viewed as a whole and are highly valued. Family
members rely on each other for socialization, support (emotional and monetary), and
childcare, and, often, they expect loyalty from other family members. “Familismo
(loyalty, reciprocity, and solidarity within the immediate and extended family)”
is an important cultural value indicating the importance of the family in the
Hispanic culture (Galanti, 2003).
• Nurses and other health care providers need to consider the importance of the family
when making health care decisions for a client who has entered the American health
care system, where individuality is valued. Mexican Americans have a lower
incidence of mental illness when compared to other diverse cultural groups,
possibly due to strong extended family connections and the role family networks
play in dealing with anxiety and stresses, as well as the role of religion.
• For many Hispanic immigrants, use of mental health services in the
United States is low when compared to use of health care services for
general health concerns. According to a report by the U.S. Department
of Health and Human Services (2009), less than 1 in 11 Hispanic
Americans with a mental health illness contacts a mental health care
provider while less than 1 in 5 contacts a health care provider for a
general health concern. For Hispanic immigrants with a mental health
illness, less than 1 in 20 contacts a mental health care provider while 1 in
10 contacts a health care provider for general health concerns.
According to the American Psychiatric Association (2015), many
Hispanic individuals rely on their extended family, the community,
traditional folk healers known as curanderos or herbalistas, and
churches for help during a health crisis.
• Consequently, many Hispanic individuals with mental
illness often go without seeking professional help for
mental health treatment. One of the main reasons for
failure to seek professional mental health care
services is Hispanics are the largest uninsured
population in the United States. Cultural barriers,
including language and fear of being stigmatized
with a mental health illness, also serve to obstruct
access to seeking professional mental health care.
• In providing mental health care for Mexican Americans, nurses
need to understand the values, beliefs, and practices of the culture
that impact the mental health needs of their clients. The bonds in
the traditional Mexican American family are often very strong,
and the father is the authority figure. Machismo is a term used
in the Latino culture to describe the traditional male gender
role. Machismo has both positive (strength, courage, responsibility)
and negative (aggression, dominance over women and the family)
connotations (Dietrich & Schuett, 2013; Torres, Solberg, &
Carlstrom, 2002). Dietrich and Schuett (2013) described machismo
as the traditional male gender role in the Latino culture.
• Machismo is often viewed by outsiders as “exaggerated male pride.”
However, in the Latino culture, it is a respected position of honor vital to
one’s self-esteem and manhood. The father or oldest male relative is the
power figure in most families and may make health decisions for other
family members. While in private, some women may hold more power,
in public, women show respect for their husbands. The authors also
talked about the importance of what is called “Culture of Honor,” which
encourages women and family members to consider the reputation of the
family. If the woman is abused for violating the honor of the male,
then the abuse may be considered culturally acceptable. For
example, if a married woman flirted with another man, the woman’s
husband would be justified in abusing his wife to maintain the honor
of his family.
• The Latino culture also holds strong expectations for women, with an
emphasis on submissiveness and reverence toward men. The female
role has its roots with the Virgin Mary and is referred to as
marianismo, indicating women should be pure and self-sacrificing
and devote their lives to their family. The traditional Hispanic
cultural values for females may lead to a higher incidence of IPV,
where women are encouraged to be submissive and “obey” their
husbands. Nurses and other health care providers need to be aware
of the importance of modesty for Hispanic women, particularly
older women, and should try to keep them covered during physical
exams (Galanti, 2003).
• Religion is very influential in Hispanic communities and may
play a major role in the mental health illnesses of Hispanic
Americans. Many Hispanic Americans are Roman Catholics,
and faith and church activities are an influential part of their
daily life activities (Kemp, 2005). Some studies have
identified religious and cultural barriers to professional
mental health care as some Hispanic Americans report that
they trust in God, and “if I am sick, it is his will” (Carter-
Pokras et al., 2008). These attitudes often delay appropriate
preventative care as well as treatment of mental health
illnesses.
• The hot and cold system is one of the most prevalent folk
systems found in Mexican American cultural groups. The hot
and cold system is based on balancing substances in the body
and the outside environment. Various substances including
food, water, and different herbs and medications are considered
hot or cold. Lack of balance is thought to be the cause for
illness: the mind and body are viewed as intertwined, and
balance is sought in all aspects of life (Berry, 2002). Various
diseases are identified as either hot or cold and treated with the
corresponding therapy. Hot diseases are treated with cold and
cold diseases are related to hot.
Arab Muslim Culture: Overview of Mental Health concerns
• There are over 48 countries with at least half of the population
identified as Muslim, or people who practice the Islamic faith,
including Pakistan, Turkey, Egypt, Iran, Afghanistan, Iraq,
Saudi Arabia, Syria, Libya, and Jordan. The Arabic language is
spoken in Arab Muslim countries, and Islam is the main
religion of the people. Islam is growing more rapidly than any
other religion in the world. There are two major religious
orthodoxies of Muslims: the Sunni and the Shi’a (Luna, 2002).
More than a billion Muslims follow the Islamic fundamental
beliefs that are described as “Articles of Faith.”
• Worship in the Islamic faith is known as the “five pillars of
Islam” and consists of the “declaration of faith, prayer, fasting,
charity, and pilgrimage” (Mofty, 2013). Ramadan is the 9th
month of the Islamic calendar and was the month in which the
Koran was revealed to the Prophet Muhammad. During the
month of Ramadan, Muslims are required to abstain from
food and drink from dawn until dusk. Devout Muslims
pray five times each day. Prior to prayer, each person must
perform a cleansing of the body, which signifies a pure
soul.
• There are a number of Islamic religious requirements specific to
men and women such as an unrelated male should not touch
females, including shaking hands; make direct eye contact with
each other; or be alone in a room with one another (Simpson &
Carter, 2008). In the Arab Muslim culture, women are required
to avoid raising their voices so they will not be overheard by
strangers (Abushaikha & Oweis, 2005). Talking in a manner
in which other clients and observers can overhear what is
being communicated would then seem to be incongruent
with the women’s needs of privacy.
• In a study conducted by Simpson and Carter (2008) on Muslim
women’s experiences with health care in the rural United States, one
participant described writing a letter to her physician prior to her health
care appointment to identify her religious needs. She stated: “I don’t
shake hands and I would prefer not to be examined by a male. I don’t
speak with a male unnecessarily either, and conversations with males
will be succinct and to the point” (p. 19). When Arab Muslim women
believed their religious beliefs were violated, they experienced
feelings of guilt and viewed the health care experience as negative;
when no religious beliefs were violated, they viewed their experience
as more positive.
• There are a limited number of psychiatric beds in Arab countries,
ranging from 30 to less than five per 100,000 population. Psychiatric
nurses range from 23 in Bahrain to 0.03 in Somalia per 100,000
population. A number of countries have agreed to integrate mental health
into their current health care delivery system, yet few have actually
integrated the services. Cultural beliefs about being possessed and
sorcery or the “evil eye” affect interpretation of mental health symptoms.
Prior to seeing health care professionals, Arab Muslims may seek
traditional healers for mental health problems. Traditional healers hold
special importance to Arab Muslim people because of their affiliation
and connection to the community. Traditional healers also de deal with
mystical and unknown (Okasha, 2012).
• Seventy to 80% of mental health clients in Arab countries tend to present with
somatic symptoms for psychological issues. There is a stigma about mental health
problems, and the client who presents with somatic complaints is protected from the
stigma of being diagnosed with a mental health illness. However, this creates
difficulties for the client as he or she is treated for physical rather than psychological
problems (Okasha, 2003). Nurses and other health care providers in emergency
departments need to be aware of this phenomenon and assess the client for any
mental health concerns. The subordinate position of Arab women places them at risk
for developing mental health disorders such as depression, anxiety, and suicidal
behaviors (Douki, Ben Xineb, Nacef, & Halbreich, 2007). For individuals from Arab
communities, stigma associated with mental illness is considered a major barrier to
accessing mental health services related to the shame associated with disclosing
personal and family iss es to outsiders (Ciftci, Jones, & Corrigan, 2013).
• Jadalla and Lee (2012) conducted a study on the relationship
between acculturation and health status for Arab Americans
living in southern California to assess the physical and mental
health of the participants. The researchers found that
acculturation was an important factor when assessing the well-
being of Arab Americans, particularly their mental health. The
results indicated that the Arab American participants who had a
higher assimilation into the American culture were associated
with significantly better mental health.
• While acculturation has been shown to be beneficial, Arab
Americans moving to the United States can experience
great stress associated with acculturation difficulties. There
is evidence to suggest that the experience of prejudice,
intolerance, and hostility toward Arab Americans has
increased in the United States following the terrorist attacks
on 9/11. Arab Americans have been victims of racism,
aggression, insulting speech, and discrimination on the basis
of their cultural religious beliefs and practices and national
origin (Kulwicki, Khalifa, & Moore, 2008).
 Culturally Competent Mental Health Care
• Frequently, behavior can be misinterpreted and/or distorted if
health care providers are not knowledgeable about caring for
clients from diverse cultural groups. Particularly with mental
health, diagnoses applied to clients based on certain behaviors
may be inaccurate; if the same behavior were understood
and interpreted within the context of the client’s culture, a
different diagnosis might be made, with different
treatment, or no diagnosis at all.
Making incorrect diagnoses of mental disorders can be
emotionally damaging to our patients because being labeled with
such disorders has a negative impact on an individual and his/her
family for years. Consider the stigma the patient (and his family)
will suffer because of an inaccurate diagnosis of a mental
disorder.
Communication and cultural knowledge, leading to cultural
competency, can have a positive impact on the mental health
care that is provided to clients of diverse cultural groups and lead
to positive experiences for both clients and the nurses
providing the care.
 Developing Cultural Competence

• 1) develop a trusting relationship with participants

• By being more patient and by giving words of
encouragement are needed to gain trust
• understanding the client’s culture increases the likelihood
of improved health outcomes.
• 2) move beyond being “sensitive” to competency-based
cultural care, instead nurses should see themselves as
becoming culturally competent rather than being culturally
competent”
• 3) nurses need to be aware of the phenomenon of cultural
blind spot/cultural blindness because of the unintended
influence it can have on the care of diverse populations of
mental health clients.
• “cultural blind spot,” sometimes referred to as cultural blindness, to describe
the assumption that if a person is similar in appearance and behaviors to the care
provider, then there are no perceived cultural differences or potential barriers to
giving appropriate care. The cultural blind spot supports people’s beliefs that
they understand the culture and have had similar cultural encounters. Thus, a
person could conclude he or she has culturally competent skills.
• The nurses is blinded with the belief that she/he is culturally competent because
she has similar cultural encounters with his her client.
• 4)Conducta personal inventory of one’s culture to remove
personal cultural bias, ethnocentrism, and prejudice—
intrapersonal reflection
• nurses to explore their personal prejudices and biases
toward people from diverse cultures and peel away and
expose stereotypes that impede caring for culturally
diverse clients.
Important Factors to Consider in Transcultural
Mental Health Nursing
• Three important factors that need to be considered when
discussing transcultural mental health nursing are:
• communication and language,
• spirituality, and
• experiences of pain.
 Communication and Language
• Communication, both verbal and nonverbal, is one of the most
important skills for mental health nurses. Communication is
even more important with culturally diverse mental health
clients, where language may serve as a barrier and make the
process of communication more difficult. Interpersonal
communication helps mental health nurses assess each
client’s values, beliefs, and practices about their mental health
care. Communicating with each client is important in caring
for clients in a culturally congruent and competent manner.
• Communication between the mental health nurse and the
client and family generally brings together the exchange of
two diverse cultures, that of the nurse and that of the
client. Therefore, it is also important for nurses to have an
understanding of their own cultural values, beliefs, and
practices, so they can better understand the diversity between
their own cultural values, beliefs, and practices and those of
the client and family, particularly as these phenomena relate to
mental health care.
• Culture influences each interaction nurses have with clients.
Since an important part of mental health care is
communicating and providing counseling for clients with
mental health illnesses, if nurses are not knowledgeable
about the cultural context in which their communication is
being interpreted, there is a possibility that the message can
be misunderstood.
• Rosenberg (2003) described how cultural conditioning, a
socialization process that influences how we think and
behave, has a major impact on each of us. Becoming
consciously aware of our individual cultural conditioning is key
to lessening the effect it has on us.
• Communication is crucial when nurses are caring for
culturally diverse clients with such mental health problems as
schizophrenia, bipolar disorder, or major depression, where
clients and their family or kin may be confused or even fear a
health care system in which they have no previous experience.
Effective cross-cultural communication skills are particularly
important when caring for mental health clients. Developing
lasting meaningful relationships across potential social
barriers such as ethnicity and culture contributes to improved
communication.
• Mental health nurses understand the importance of developing
trust with clients and their family/kin networks. Sometimes,
health care providers can become irritated that clients and
family members do not speak the dominant English language.
When there is a possibility of having a certified
translator/interpreter serve as an interpreter, that is the ideal
choice rather than using family members or other staff who
may not understand complex health situations. Family
members should be encouraged to offer family support rather
than serve as an interpreter.
• People who do not speak English identify care as than do
those individuals who do speak English (Simpson & Carter,
2008). Whenever possible, a translator is preferred for
barriers in communicating the language between care
provider and clients seeking treatment, particularly for mental
health care..
• Caregivers are more confident when a translator is present
and interprets the client’s words verbatim whenever possible,
in order to maintain accuracy and reduce translation bias
(Olivares & Altarriba, 2009). The attitude of the care
provider is instrumental in helping the client be open to
treatment options.
• Communicating an understanding of cultural diversity helps
facilitate the client–nurse relationship. On the other hand,
authoritarian care providers have a negative impact on
treatment compliance
• Bowes and Domokos (1995) make a distinction between
language and communication, suggesting that language has
more to do with the technical aspect of speech, while
communication consists of both verbal and nonverbal
elements, including the provider’s attitude. For a number of
culturally diverse clients and their families/kin, there are
cultural values that influence what subjects are appropriate to
discuss with health care providers. Some topics (e.g., sexual
activities) may be considered inappropriate to discuss with
health care providers.
• Even in conducting a health history and assessment, what are
culturally acceptable questions to ask in the United States may
not be acceptable in other countries and cultures. There are
other factors that may have a profound influence on the
communication between clients and health care providers.
Undocumented migrants may fear that health care providers
would turn them into the authorities if providers learned that
their clients were in the United States illegally (Carter-Pokras
et al., 2008).
• Empathy is one of the most important communication skills
that transcultural mental health nurses and other health care
providers can use with clients from diverse cultural
backgrounds. In using empathy in communicating with
clients, health care providers are attempting to understand
what a client is experiencing or has experienced—trying to
put themselves in the client’s place and feel and experience
what the client is going through ng—and then
communicating that understanding back to the individual
client.
Empathic communication helps the health care provider to better
understand the situation or context of the client as well as the
cultural norms and values that structure that context and influence
the client. For example, if a client was sitting in his or her hospital
room crying, the nurse would know to further explore that client’s
feelings. the ability to use “ethnocultural empathy” has become
crucial for health care providers in their interactions with clients
(Rasoal, Jungert, Hau, Stwine, and Andersson, 2009). It is
important to communicate back to the client and family your
understanding of their experience so they may clarify whether
you have accurately identified the client’s perception of a
particular experience (Egan, 2014).
• Empathy becomes very important in trying to
understand the experience and feelings of mental health
clients and their families. Attempting to understand the
experience of abuse, schizophrenia, depression, bipolar
disorders, and other mental health issues is crucial to
understand the perspectives of the client and family
(Figure 10-7).
• For transcultural mental health care providers, empathy needs
to be communicated, taking into consideration the beliefs,
values, and practices, or in other words the “norms,” of a
culture. When communicating with clients from other
cultures, particularly for those who do not speak English or
for whom English is a second language, there is an increased
risk of miscommunication.
• Mental health nurses need to practice culturally competent
communication skills to improve care for an ever-increasing
population of culturally diverse mental health clients. In
addition, basic verbal and nonverbal communication skills
such as tone of voice, use of probes and clarification,
listening, empathy, facial expressions, and body gestures,
for both the nurses themselves and for the clients and
family members, will help to improve overall
communication and culturally competent mental health care
 Spirituality
• Spirituality refers to a broad sense of the inner experience of the
self and a search for meaning while religion generally involves
an institution with a given set of rules and observances
involving devotion and ritual. There are many spiritual and
religious themes to mental health disorders such as
schizophrenia, bipolar disorder, psychosis, hallucinations, and
delusions. Transcultural mental health nurses care for clients
who have diverse cultural values, beliefs, meanings, and
practices, many of which are grounded in spiritual and religious
beliefs.
• Findings indicated that spirituality became increasingly
important in clients’ lives after being diagnosed with a
mental illness. The spiritual experiences of the clients
could be interpreted as signs and symptoms of mental
illness, depending on who was interpreting the
experiences. Clients expressed a fear that mental health
nurses would label them as mentally ill when their
spiritual beliefs and experiences were similar to
symptoms of mental illness.
• Spirituality and religious practices can play an influential role
in enhancing mental health and emotional stability. Given this
important role the African American church plays in the lives
of parishioners, the churches may be uniquely positioned to
overcome barriers such as stigma, distrust, and limited access
that contribute to racial disparities in professional mental
health care and service utilization (Hankerson & Weissman,
2012). In addition, health care providers could partner
with churches and develop culturally congruent
interventions to improve care for African Americans
connected to various churches.
• Church leaders could also begin to develop
relationships with professional mental health care
providers to refer parishioners needing more acute
mental health care services. Listening was stressed as
the most important skill a pastor can use with
someone seeking emotional support.
 Experiences of Pain

• In mental health nursing, the client’s experience of pain

can be manifested in many different ways. Unlike other
somatic symptoms frequently associated with mental
health issues, pain has a component that includes
emotional elements. Psychosocial factors have been
found to influence pain.
• In a study by Palmer et al. (2008) on somatic
complaints, mood, and self-rated health as predictors of
arm pain, mental health was found to be a strong
predictor of complaints of arm pain in adults from a
British community. Beliefs about causation and
prognosis of arm pain were also associated with
persistence of symptoms.
• There is increasing evidence to suggest that pain can be a
physical symptom of depression and that pain and depression
are common comorbidities. According to Hall-Flavin (2013),
depression can lead to pain and vice versa. In fact, pain and
depression may create a “vicious cycle in which pain worsens
symptoms of depression, and then the resulting depression
worsens feelings of pain.” It seems to be extremely difficult to
separate the somatic, physical component of pain from the
psychological component of pain.
• In a study conducted by Bonnewyn et al. (2009),
researchers found that chronic pain and mood disorders
were common in elderly populations. Elderly
individuals with a 12-month major depressive episode
were more likely to have painful physical symptoms
than were those persons without major depression.
• There is the concept of psychosomatic pain, or pain with
psychological components, and this pain is expressed
differently by cultural groups. One of the distinct types of
depression with Haitian women is “douluer de corps (pain in
the body)” (Nicholas et al., 2007, p. 87). Barkwell (2005)
studied Native Americans (Ojibwa) with cancer pain. They
described their pain as “all that was most painful in life” and
included the following properties in their description of cancer
pain: “physical sensation, threatening cognitions, emotional,
social and spiritual anguish, and intuitive sensing” .
• Lee, Kleinman, and Kleinman (2007) have suggested that
knowledge about depression and other mental illnesses is
based on research conducted with Western populations. In a
study with Chinese clients in Guangzhou (Canton), China, in
an outpatient mental health service, clients experiencing
symptoms of depression identified numerous affective
symptoms, including sadness, preverbal pain, social
disharmony, and sleeplessness. The authors emphasized how
important it is to study depression cross-culturally, in order
to be more sensitive and appropriate with culturally
diverse populations.
The end.