Community Ment Health J DOI 10.1007/s10597-014-9820-x
BRIEF COMMUNICATION
Attributions of Mental Illness: An Ethnically Diverse Community Perspective Whitney J. Raglin Bignall • Farrah Jacquez Lisa M. Vaughn
•
Received: 4 February 2013 / Accepted: 11 December 2014 Ó Springer Science+Business Media New York 2014
Abstract Although the prevalence of mental illness is similar across ethnic groups, a large disparity exists in the utilization of services. Mental health attributions, causal beliefs regarding the etiology of mental illness, may contribute to this disparity. To understand mental health attributions across diverse ethnic backgrounds, we conducted focus groups with African American (n = 8; 24 %), Asian American (n = 6; 18 %), Latino/Hispanic (n = 9; 26 %), and White (n = 11; 32 %) participants. We solicited attributions about 19 mental health disorders, each representing major sub-categories of the DSM-IV. Using a grounded theory approach, participant responses were categorized into 12 themes: Biological, Normalization, Personal Characteristic, Personal Choice, Just World, Spiritual, Family, Social Other, Environment, Trauma, Stress, and Diagnosis. Results indicate that ethnic minorities are more likely than Whites to mention spirituality and normalization causes. Understanding ethnic minority mental health attributions is critical to promote treatmentseeking behaviors and inform culturally responsive community-based mental health services. Keywords Mental health beliefs Attributions Ethnic minorities Community
W. J. R. Bignall (&) F. Jacquez Department of Psychology, University of Cincinnati, 5121 Edwards Building One, PO Box 2120376, Cincinnati, OH 45221-0376, USA e-mail: [email protected] L. M. Vaughn Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
Introduction Mental health disorders are pervasive, with approximately one in four adults suffering from a diagnosable disorder in a given year (Kessler et al. 2005). Prevalence rates of mental illness diagnoses among ethnic minorities are similar to or less than that of White Americans, with a few specific exceptions (e.g., higher rates of posttraumatic stress disorder and alcoholism among Native Americans and schizophrenia among African Americans; McGuire and Miranda 2008; US Department of Health and Human Services 2001). Although minorities have equitable prevalence of mental health disorders, disparities do exist in the utilization of mental health services, such as ethnic minorities are significantly less likely than Whites to receive treatment when experiencing mental distress (US Department of Health and Human Services 1999, 2001). For example, 25 % of African Americans and 22 % of Hispanics in need of mental health treatment fail to receive such services, as compared to 13 % of Whites (Wells et al. 2001). Given that the prevalence rate of mental illness is similar across ethnic groups, the disparity in mental health utilization is not simply a result of different mental health treatment needs (US Department of Health and Human Services 2001). Cultural practices and beliefs contribute to ethnic differences in help-seeking behaviors. Attributions, or causal explanations used to understand the world, have been shown to influence behavior and decision-making processes (Kelley 1973), particularly regarding health decisions. Health attributions (casual beliefs pertaining to health) form as individuals develop schemas, or cognitive representations about health and mental illness. For example, if a parent attributes their child’s emotional problems to biological causes, they might seek psychiatric
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services for their children (Yeh et al. 2005). However, if the emotional problems are believed to be caused by a spiritual force, parents may be more inclined to seek out guidance from a spiritual leader and forego visiting a mental health professional with their child (Cauce et al. 2002; Cheung and Snowden 1990). Culture including religious and ethnic background, is one of the many factors that influence the development of health schemas (Vaughn et al. 2009). People come to understand mental illness through their cultural beliefs, which can influence their course of action (Helman 1990). For example, Yeh et al. (2005) examined the parental beliefs of the causes of child problems with a sample of at-risk youth and found significant ethnic/racial differences in eight out of eleven different kinds of beliefs regarding the causes of mental health problems. In addition, they found that when parents attributed the cause to something physical or trauma related, it predicted further use of mental health services. A growing body of research indicates that individuals from diverse cultural and ethnic backgrounds can have different attributions about illness, health, and disease (see Vaughn et al. 2009 for a review). For example, Landrine and Klonoff (1994) found that minorities rated supernatural causes for illness as significantly more important in comparison to Whites, and African Americans are more likely than Whites to attribute distress to spiritual or supernatural causes (Gregg and Curry 1994). Similarly, Hispanics are more likely to subscribe to attributions involving personal responsibility and control by ‘‘powerful others’’ than to the behavioral/environmental attributions that are more reflective of western culture (Murguia et al. 2000). Cultural differences in health attributions have major implications for medical professionals because attributions influence behaviors (Helman 1990; Murguia et al. 2000). These ethnic differences are also an important factor sustaining the observed disparities in mental health utilization of and treatment adherence (Cheung and Snowden 1990; US Department of Health and Human Services 2001). For example, Southeast Asian refugees tend to hold the belief that illnesses are inevitable to life, leading them less likely to turn to western medicine for treatment (Uba 1992). To date, mental health attributions have been assessed primarily in three ways. First, researchers have used semistructured interviews to understand causal beliefs. For example, Yeh et al. (2005) had parents of at-risk youth answer yes or no questions to a variety of possible causes for their youth’s behavior. Second, researchers have used surveys with participants ranking causes of mental illness on a Likert scale (Alvidrez 1999; Eisenbruch 1990; Hill and Bale 1980). In this method, researchers often asked the participants to define mental illness before ranking the causal statement (Alvidrez 1999; Eisenbruch 1990). A third
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method involves giving participants vignettes that describe a standard illness, and then asking them what were possible causes for the illness using a Likert scale. There are both strengths and weaknesses to each of the existing methods for measuring health attributions. Semistructured interviews and surveys both allow researchers to determine statistical differences; however, these two methods are limited in their ability to generalize beyond the specific mental disorders included in the prompts. Previous studies using vignettes have focused primarily on a limited number of mental health disorders. For example, Link et al. (1999) only used five vignettes depicting schizophrenia, major depressive disorder, alcohol dependence, cocaine dependence, and a ‘‘troubled’’ person. Like much of the mental health attribution research, the vignette study also failed to examine causal beliefs using a diverse ethnic sample. The lack of diverse samples in previous research is problematic, given that individuals from diverse cultural backgrounds tend to have different attributions about the broad range of mental illnesses. The first wave of attributions research was conducted over a decade ago. However, in light of our nation’s rapidly changing demographics, research is needed which explores attributions among an ethnically diverse sample and gathers information about these attributions across an array of mental health disorders. The purpose of our study was to provide a detailed picture of causes of mental health problems as perceived by community ethnic groups across a range of mental health conditions. Specifically, two research questions guided our work. First, what types of attributions do individuals make about mental health problems? Second, attribute mental illness to different causes? To accomplish our goal, we facilitated ethnically diverse focus groups to brainstorm possible causes of mental illness and used a grounded theory approach to identify attribution themes. This is the first study to assess attributions of a broad range of mental health problems from a diverse ethnic sample.
Method Participants Thirty-four participants participated in one of seven focus groups. Each focus group contained three to eleven participants of similar racial/ethnic origin. The total sample was ethnically diverse and consisted of eight African American (24 %), six Asian American (18 %), nine Hispanics (26 %), and 11 White (32 %) participants. The sample was predominantly female (82 %). The participants were all over the age of 18 and were members of
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community (49 %) and campus (51 %) ethnically focused groups. Measures Participants were each given a packet that contained 19 case scenarios, with each case scenario on an individual sheet of paper. The 19 case scenarios were created by the authors to represent a disorder from one of the major categories in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; e.g. Depression, Substance Abuse, and Autism). Case scenarios were designed to represent various ages and ethnic groups. An example of one of the case Scenarios: ‘‘A high school freshman is failing in school because the teachers says he can’t seem to keep track of his work, forgets things, has trouble paying attention in class, and is always fidgeting. His mom says he has always been like this’’. Procedure A licensed clinical psychologist trained the research team on group facilitation and research ethics prior to focus groups. Ten culturally/ethnically diverse community and campus organizations were approached for recruitment purposes and were targeted based on membership to a specific racial/ethnic community. All organizations were recruited through email, and members 18 years of age or older were invited to participate. A total of seven focus groups were conducted. Focus groups were held in community settings (e.g. ethnic cultural center, hospital setting, and coffee shop) designated by partnering community organizations. All focus groups were audio recorded. Throughout the focus groups, note takers recorded the participants’ responses and later notes were crosschecked with the audio recordings for accuracy. After obtaining written consent for participation, participants were presented with the packet of case scenarios. The focus groups began with the moderator informing participants that different case scenarios would be discussed among the group. Participants would then be asked to provide what they believed or what other people in their community may have believed caused each scenario. Each case scenario was read aloud as participants followed along. After reading each case scenario, participants were asked to provide explanations for the behaviors of the characters in the case scenarios. Each participant generated several responses for each case scenario. The responses often lead to a discussion, in which others in the focus group would either confirm the person’s attribution or give further elaboration. Order of case scenario presentation differed by group to address order effects. The institutional review board approved this project before research commenced.
Data Analysis Focus group data was analyzed to identify themes of attributions provided by participants. In order to identify themes of attributions, we used qualitative data analysis techniques based on grounded theory (Strauss and Corbin 1998). First, the three authors each independently conducted a thematic analysis of the notes and identified possible themes of attributions. Second, the three authors came together as a group to gain consensus about and condense the themes they had identified individually. Third, the original notes were coded into one of the agreed upon themes. The authors coded each attribution provided by participants; each author coded a set of attributions they had not worked with in the previous theme development step. An inter-rater reliability of .84 (Cohen’s Kappa) indicated high inter-rater agreement. A total number of attributions (the responses given by the participants) were tallied for each theme and percentages were calculated representing the frequency the themes were reported.
Results Question #1: What Types of Attributions do Individuals Make About Mental Health Problems? Using the full sample of 34 participants from seven focus groups, 12 attribution themes were identified and labeled: Biological, Normalization, Personal Characteristic, Personal Choice, Just World, God/spiritual, Family, Social Other, Environment, Trauma, Stress, and Diagnosis. Each of the themes represented a category of responses that explained the participants’ attributions of mental illness. For instance, normalization represents responses in which participants are labeling the behaviors described in the case scenarios as normal, or a normal part of life (e.g. ‘‘that just how people are’’). Another example is Just World, in which the response represents participants labeling the cause as being something deserved or karma (e.g. ‘‘that what he deserved’’). A total of 831 attributions were recorded and tallied across the 19 case scenarios. Overall, the top five themes (excluding diagnosis) were (in order from highest to lowest): Personal Characteristics (169, 20.3 %), Family (91, 11.0 %), Normalization (66, 7.9 %), Spiritual (64, 7.7 %) and Biological (52, 6.3 %). We excluded the Diagnosis theme from our results and discussion because the responses found within this theme do not represent attributions but rather labeling of mental health problems; therefore, these responses do not relate to our specific research questions. We have highlighted the top five attributions because excluding Diagnosis, the top
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five themes comprise more than 50 % of the attributions made by participants. Question 2: Do Ethnic Groups Attribute Mental Illness to Different Causes? To understand patterns in attributions by ethnicity, we calculated the frequency of each theme by ethnic group. Several key patterns are noteworthy regarding mental health attributions by ethnicity. First, ethnic minority participants consistently endorsed Spirituality and Normalization whereas Whites participants rarely did so. Minority participants, particularly Hispanics tended to mention spiritual reasons more frequently than White participants (11–3.0 % respectively). Normalization was particularly common among Hispanic and Asian American participants (10.4–11.6 % respectively). White participants also attributed Trauma (8.5 %) more often than other ethnic groups (5.9 % for African Americans, 2.4 % for Hispanics, 1.7 % for Asians) within the top five attributions. Asian American participants tended to make Personal Characteristic, Family, Normalization, Social Other, and Environmental attributions relatively equally (each category represented 11.6 % of the attributions generated by them). In other words, whereas all other ethnic groups tended to favor one or two particular attribution themes, Asian American participants described many different types of causes of mental illness.
Discussion The purpose of the current study was to provide a detailed picture of mental health attributions held by ethnic minority communities across a range of mental health conditions. Three major findings emerged. First, across all ethnic groups, we identified themes in attributions that are consistent with several of those identified in the existing literature. Second, our qualitative analysis uncovered ‘‘Normalization’’ as an attribution theme more commonly held by ethnic minorities than by Whites. Third, our study adds further evidence for the increased tendency of ethnic minorities to attribute mental illness to spiritual causes in comparison to Whites. Each of these findings will be discussed and implications for community mental health will be explored. Many of the themes we identified showed some overlap with previous research. Across our focus groups, ‘‘Personal Characteristics,’’ or an individual’s traits (e.g. ‘‘he’s lazy’’), were the most often identified attribution theme for mental disorders. We suspect that the pervasiveness of the Personal Characteristics theme was influenced by the welldocumented phenomenon of correspondence bias, the
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tendency for individuals to attribute another person’s behavior to internal dispositional causes rather than external situational factors (Gilbert and Malone 1995). White, African American, and Hispanic participants used personal characteristic attributions definitively more than any other type of attribution. Previous research has shown that correspondence bias exists across diverse cultures (Krull et al. 1999); our study provides further evidence that correspondence bias is pervasive across ethnicities in providing explanations of mental illness. Several other themes are consistent with those identified by previous researchers investigating mental health attributions. The ‘‘Biological,’’ ‘‘Spiritual’’ and ‘‘Stress’’ categories identified through our thematic analysis are similar to the biological, religious/ supernatural, and balance factors identified by Alvindrez (1999), as well as the stress, Western physiological, nonWestern physiological, and supernatural categories identified by Eisenbruch’s survey (1990). Similar to Eisenbruch (1990), other studies have differentiated categories based on Western or non-Western ideas (Sheikh and Furnham 2000; Yeh et al. 2005). In our thematic analysis, we did not specifically differentiate between Western and non-Western ideas, but several of our themes tended to be more Westernized (e.g. biological and stress), while other themes could be viewed as non-Western (e.g. spirituality). Our thematic analysis also revealed the importance of environmental causes (e.g. Family, Environment, and Social other categories) similar to the interactive dimension found in a survey study by Hill and Bale (1980). Qualitative analysis of themes generated by ethnically diverse focus groups identified ‘‘Normalization’’ as a frequent attribution—a theme not previously described in health attributions research. In our study, White participants were least likely to use ‘‘Normalization’’ attributions, suggesting that minority populations are more likely to attribute mental health problems to normal behavior (e.g. ‘‘he’s just getting old’’). Specifically, Asian American and Hispanic respondents were more likely to provide attributions that normalized the behaviors in the case scenarios. The tendency to normalize mental health problems could help explain the underutilization of mental health treatment services by Asian Americans and Hispanics. We hypothesize that the tendency to normalize may be explained by the abundance of mental health stigmas in many minority communities and a lack of knowledge regarding mental health disorders. Beliefs about the causes of mental illness can contribute to an understanding of shame and stigma which have been linked to mental health help-seeking and recovery (Knifton et al. 2010). Further research is needed to investigate if those that normalize behaviors are doing so in order to avoid the shame or stigma, or if it is simply a lack of mental health literacy. Nevertheless, our study’s findings support the deliberate promotion of help-seeking
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behaviors within minority populations by increasing mental health literacy (Jorm et al. 1997). The promotion of mental health literacy within minority communities could help this population better identify when those whose behaviors were once considered normal would benefit from appropriate mental health treatment. In general, health professionals should continue to work toward eliminating stigmas using community approaches (i.e. community workshops), which have been shown to be more effective than top-down public education (Knifton et al. 2010). Although existing literature has discussed the increased likelihood for ethnic minorities to attribute illness to spiritual causes in comparison to Whites (Landrine and Klonoff 1994) and for African Americans to specifically attribute mental illness to spiritual causes (Alvidrez 1999); our study confirmed the importance of spiritual causes in all ethnic minority groups, with Hispanic participants most likely to make spirituality-based attributions. Spirituality has been identified as a key component in help-seeking behaviors for those with mental illnesses. A review examining the relationship of social support, religion, and help-seeking behaviors found that religion impacted several factors: (1) the etiological beliefs held about a particular disorder, (2) which individuals sought treatment, with many choosing spiritual leaders before seeking professional mental health practitioners, and (3) how they coped, finding their religious beliefs and those associated as social support (Smolak et al. 2012). Our study has several keys strengths. First, by using a qualitative approach to understand mental health attributions, our study was not limited to attributions described in previous quantitative research or to those attributions that the research team identified as important. Instead, participants in seven separate focus groups were given descriptions of mental health case scenarios and had the opportunity to generate an exhaustive list of possible attributions. Second, participants reacted to nineteen different case scenarios representing each major category in the DSM-IV-TR. By including a diverse array of prompts, we were able to examine core attributions about mental health and avoided making conclusions based on popular opinion or stigmas associated with a particular mental illness. Third, our study included not only African American and Hispanic participants, but also Asian American participants, an understudied ethnic minority group (Sue 1977), shedding light on how ethnically diverse populations understand mental illnesses. Finally, we were able to examine ethnic differences in attribution, without having to homogenize all ethnic minorities into a single group (e.g. White vs. minority attribution differences). The results of this study have several implications for mental health professionals. First, in order to promote treatment-seeking behavior among ethnic minorities and to
offer culturally-responsive mental health services within the community, it is critical for health professionals to better understand why individuals believe mental illness occurs. Our study found that ethnic minorities were more likely to report the behavior seen in mental health disorders to be normal. If such behavior is deemed to be normal, it is less likely for them to seek treatment. We recommend that health professionals actively engage with community organizations to improve mental health literacy and utilize cultural competence when addressing mental health disorders with their patients and clients (Knifton et al. 2010). Second, our study highlights that in order to address the disparity of underutilization and retention of ethnic minorities in the mental health system, health professionals should continue to work ardently to incorporate spirituality when appropriate into therapy (e.g. in their case conceptualizations and work with clients who believe spirituality cause mental illness). In addition, clinicians should wherever possible and appropriate incorporate spiritual leaders in the process of connecting ethnic minority clients with the mental health treatments they need. Recent research has demonstrated that traditional services alone are inadequately meeting the needs of these individuals (Sue and Zane 2009). Incorporating spirituality could be one way to treat ethnic minority mental health needs in a culturally sensitive manner. Although our study was able to provide a detailed picture of how individuals attribute mental illness, it does have several limitations. The first limitation is the relatively small sample size for each ethnic group and the overrepresentation of women. Due to sample restrictions, our findings might not be generalized across an entire ethnic group, particularly regarding male perspectives of mental illness. Second, due to the qualitative nature of this study, we were unable to use inferential statistics to test the significant differences between ethnic groups on the identified themes, and therefore additional research is needed to incorporate the identified themes into a measure to test group differences. Third, because our study focuses on the impact of racial and ethnic cultural factors, we did not investigate the many other potential influences on attributions (e.g., social class, individual experiences with mental illness). Future research on racial and ethnic differences in attributions should include multiple cultural influences to more fully understand the dynamic process of making mental health attributions. Finally, further research is needed to examine the relationship between the identified themes and actual help-seeking behaviors. We speculate that individuals who tend to make normalizing, spiritual, and ‘‘just world’’ mental health attributions will be less likely to seek out mental health services than those who believe ‘‘Biology,’’ ‘‘Personal Choices,’’ or ‘‘Trauma’’ causes mental illness; however, further research that
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includes measurements of help-seeking behaviors are needed to explore these relations. Further research is also needed to test the ethnic differences of beliefs using a measure based on our identified themes. In summary, our study was the first to use a diverse sample and a qualitative approach to assess the attributions of mental illness across a wide spectrum of disorders. Our findings indicated that there is great variability in causal beliefs of individuals regarding different mental disorders, and that ethnic minorities attributed the cause of certain mental disorders to be a normal part of life or a spiritual etiology more than Whites. Mental health professionals should work to understand their clients’ mental health attributions in order to provide more effective treatment to ethnic minorities. Our findings suggest that there are significant opportunities for community agencies and health providers to impact the mental health of minorities by providing education regarding mental illness in order to break down stigmas and increase mental health literacy.
References Alvidrez, J. (1999). Ethnic variations in mental health attitudes and service use among low-income African American, Latina, and European American young woman. Community Mental Health Journal, 35, 515–530. Cauce, A. M., Paradise, M., Rodriguez, M. D., Cohran, B. N., Shea, J. M., Srebnik, D., & Baydar, N. (2002). Cultural and contextual influences in mental health help seeking: A focus on ethnic minority youth. Journal of Consulting and Clinical Psychology, 70, 44–55. doi:10.1037//0022-006X.70.1.44. Cheung, F. K., & Snowden, L. R. (1990). Community mental health and ethnic minority populations. Community Mental Health Journal, 26, 277–291. doi:10.1007/BF00752778. Eisenbruch, M. (1990). Classification of natural and supernatural causes of mental distress: Development of a mental distress explanatory model questionnaire. The Journal of Nervous and Mental Disease, 178, 712–719. doi:10.1097/00005053-19901 1000-00007. Gilbert, D. T., & Malone, P. S. (1995). The correspondence bias. Psychological Bulletin, 117(1), 21. Gregg, J., & Curry, R. H. (1994). Explanatory models for cancer among African American women at two Atlanta neighborhood health centers: The implications for a cancer screening program. Social Science Medicine, 39, 519–526. doi:10.1016/02779536(94)90094-9. Helman, C. G. (1990). Culture, health and illness: An introduction for health professionals. London: Wright. Hill, D. J., & Bale, R. M. (1980). Development of the mental health locus of control and mental health locus of origin scales. Journal of Personality Assessment, 44, 148–156. Jorm, A. F., Korten, A. E., Jacomb, P. A., Christensen, H., Rodgers, B., & Pollitt, P. (1997). Mental health literacy: A survey of the public’s ability to recognize mental disorders and their beliefs about the effectiveness of treatment. Medical Journal of Australia, 166(4), 182–186. Kelley, H. (1973). The process of causal attribution. The American Psychologist. doi:10.1037/h0034225.
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Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the national comorbidity survey replication (NCSR). Archives of General Psychiatry, 62, 617–627. Knifton, L., Gervais, M., Newbigging, K., Mirza, N., Quinn, N., Wilson, N., & Hunkins-Hutchison, E. (2010). Community conversation addressing mental health stigma with ethnic minority communities. Social Psychiatry Epidemiology, 45, 497–504. doi:10.10007/s00127-009-0095-4. Krull, D. S., Loy, M. H. M., Lin, J., Wang, C. F., Chen, S., & Zhao, X. (1999). The fundamental fundamental attribution error: Correspondence bias in individualist and collectivist cultures. Personality and Social Psychology Bulletin, 25(10), 1208–1219. doi:10.1177/0146167299258003. Landrine, H., & Klonoff, F. A. (1994). Cultural diversity in causal attributions for illness: The role of the supernatural. Journal of Behavioral Medicine, 17, 181–193. doi:10.1007/BF01858104. Link, B. G., Plelan, J. C., Bresnahan, M., Stueve, A., & Pescosolido, B. A. (1999). Public conceptions of mental illness: Labels, causes, dangerousness, and social distance. American Journal of Public Health, 89, 1328–1333. doi:10.2105/AJPH.89.9.1328. McGuire, T. G., & Miranda, J. (2008). New evidence regarding racial and ethnic disparities in mental health: Policy implications. Health Affairs, 27(2), 393–403. doi:10.1377/hlthaff.27.2.393. Murguia, A., Zea, M. C., Reisen, C. A., & Peterson, R. A. (2000). The development of the cultural health attributions questionnaire. Cultural Diversity and Ethnic Minority Psychology, 6, 268–283. doi:10.1037/1099-9809.6.3.268. Sheikh, S., & Furnham, A. (2000). A cross-cultural study of mental health beliefs and attitudes toward seeking professional help. Social Psychiatry and Psychiatric Epidemiology, 35, 326–334. doi:10.1007/s001270050246. Smolak, A., Gearing, R. E., Alonzo, D., Baldwin, S., Harmon, S., & McHugh, K. (2012). Social support and religion: Mental health service use and treatment of schizophrenia. Community Mental Health Journal, 49, 1–7. Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Grounded theory procedures and techniques (2nd ed.). Thousand Oaks: Sage. Sue, S. (1977). Community mental health services to minority groups: Some optimism, some pessimism. American Psychologist, 32, 616–624. doi:10.1037//0003-066X.32.8.616. Sue, S., & Zane, N. (2009). The role of culture and cultural techniques in psychotherapy: A critique and reformulation. Asian American Journal of Psychology, S(1), 3–14. doi:10.1037/1948-1985.s.1.3. Uba, L. (1992). Cultural barriers to health care to Southeast Asian refugees. Public Health Report, 107, 544–548. US Department of Health and Human Services. (1999). Mental health: A report of the Surgeon General. Rockville: Author. US Department of Health and Human Services. (2001). Mental health: Culture, race, and ethnicity: A report of the Surgeon General. Rockville: Author. Vaughn, L., Jacquez, F., & Baker, R. C. (2009). Cultural health attributions, beliefs, and practices: Effects on healthcare and medical education. The Open Medical Education Journal, 2, 64–74. Wells, K., Klap, R., Koike, A., & Sherbourne, C. (2001). Ethnic disparities in unmet need for alcoholism, drug abuse, and mental health care. American Journal of Psychiatry, 158, 2027–2032. doi:10.1176/appi.ajp.158.12.2027. Yeh, M., McCabe, K., Hough, R. L., Lau, A., Fakhry, F., & Garland, A. (2005). Why bother with beliefs? Examining relationships between race/ethnicity, parental beliefs about causes of child problems, and mental health service use. Journal of Consulting and Clinical Psychology, 73, 800–807. doi:10.1037/0022-006X. 73.5.800.
BRIEF COMMUNICATION
Attributions of Mental Illness: An Ethnically Diverse Community Perspective Whitney J. Raglin Bignall • Farrah Jacquez Lisa M. Vaughn
•
Received: 4 February 2013 / Accepted: 11 December 2014 Ó Springer Science+Business Media New York 2014
Abstract Although the prevalence of mental illness is similar across ethnic groups, a large disparity exists in the utilization of services. Mental health attributions, causal beliefs regarding the etiology of mental illness, may contribute to this disparity. To understand mental health attributions across diverse ethnic backgrounds, we conducted focus groups with African American (n = 8; 24 %), Asian American (n = 6; 18 %), Latino/Hispanic (n = 9; 26 %), and White (n = 11; 32 %) participants. We solicited attributions about 19 mental health disorders, each representing major sub-categories of the DSM-IV. Using a grounded theory approach, participant responses were categorized into 12 themes: Biological, Normalization, Personal Characteristic, Personal Choice, Just World, Spiritual, Family, Social Other, Environment, Trauma, Stress, and Diagnosis. Results indicate that ethnic minorities are more likely than Whites to mention spirituality and normalization causes. Understanding ethnic minority mental health attributions is critical to promote treatmentseeking behaviors and inform culturally responsive community-based mental health services. Keywords Mental health beliefs Attributions Ethnic minorities Community
W. J. R. Bignall (&) F. Jacquez Department of Psychology, University of Cincinnati, 5121 Edwards Building One, PO Box 2120376, Cincinnati, OH 45221-0376, USA e-mail: [email protected] L. M. Vaughn Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
Introduction Mental health disorders are pervasive, with approximately one in four adults suffering from a diagnosable disorder in a given year (Kessler et al. 2005). Prevalence rates of mental illness diagnoses among ethnic minorities are similar to or less than that of White Americans, with a few specific exceptions (e.g., higher rates of posttraumatic stress disorder and alcoholism among Native Americans and schizophrenia among African Americans; McGuire and Miranda 2008; US Department of Health and Human Services 2001). Although minorities have equitable prevalence of mental health disorders, disparities do exist in the utilization of mental health services, such as ethnic minorities are significantly less likely than Whites to receive treatment when experiencing mental distress (US Department of Health and Human Services 1999, 2001). For example, 25 % of African Americans and 22 % of Hispanics in need of mental health treatment fail to receive such services, as compared to 13 % of Whites (Wells et al. 2001). Given that the prevalence rate of mental illness is similar across ethnic groups, the disparity in mental health utilization is not simply a result of different mental health treatment needs (US Department of Health and Human Services 2001). Cultural practices and beliefs contribute to ethnic differences in help-seeking behaviors. Attributions, or causal explanations used to understand the world, have been shown to influence behavior and decision-making processes (Kelley 1973), particularly regarding health decisions. Health attributions (casual beliefs pertaining to health) form as individuals develop schemas, or cognitive representations about health and mental illness. For example, if a parent attributes their child’s emotional problems to biological causes, they might seek psychiatric
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services for their children (Yeh et al. 2005). However, if the emotional problems are believed to be caused by a spiritual force, parents may be more inclined to seek out guidance from a spiritual leader and forego visiting a mental health professional with their child (Cauce et al. 2002; Cheung and Snowden 1990). Culture including religious and ethnic background, is one of the many factors that influence the development of health schemas (Vaughn et al. 2009). People come to understand mental illness through their cultural beliefs, which can influence their course of action (Helman 1990). For example, Yeh et al. (2005) examined the parental beliefs of the causes of child problems with a sample of at-risk youth and found significant ethnic/racial differences in eight out of eleven different kinds of beliefs regarding the causes of mental health problems. In addition, they found that when parents attributed the cause to something physical or trauma related, it predicted further use of mental health services. A growing body of research indicates that individuals from diverse cultural and ethnic backgrounds can have different attributions about illness, health, and disease (see Vaughn et al. 2009 for a review). For example, Landrine and Klonoff (1994) found that minorities rated supernatural causes for illness as significantly more important in comparison to Whites, and African Americans are more likely than Whites to attribute distress to spiritual or supernatural causes (Gregg and Curry 1994). Similarly, Hispanics are more likely to subscribe to attributions involving personal responsibility and control by ‘‘powerful others’’ than to the behavioral/environmental attributions that are more reflective of western culture (Murguia et al. 2000). Cultural differences in health attributions have major implications for medical professionals because attributions influence behaviors (Helman 1990; Murguia et al. 2000). These ethnic differences are also an important factor sustaining the observed disparities in mental health utilization of and treatment adherence (Cheung and Snowden 1990; US Department of Health and Human Services 2001). For example, Southeast Asian refugees tend to hold the belief that illnesses are inevitable to life, leading them less likely to turn to western medicine for treatment (Uba 1992). To date, mental health attributions have been assessed primarily in three ways. First, researchers have used semistructured interviews to understand causal beliefs. For example, Yeh et al. (2005) had parents of at-risk youth answer yes or no questions to a variety of possible causes for their youth’s behavior. Second, researchers have used surveys with participants ranking causes of mental illness on a Likert scale (Alvidrez 1999; Eisenbruch 1990; Hill and Bale 1980). In this method, researchers often asked the participants to define mental illness before ranking the causal statement (Alvidrez 1999; Eisenbruch 1990). A third
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method involves giving participants vignettes that describe a standard illness, and then asking them what were possible causes for the illness using a Likert scale. There are both strengths and weaknesses to each of the existing methods for measuring health attributions. Semistructured interviews and surveys both allow researchers to determine statistical differences; however, these two methods are limited in their ability to generalize beyond the specific mental disorders included in the prompts. Previous studies using vignettes have focused primarily on a limited number of mental health disorders. For example, Link et al. (1999) only used five vignettes depicting schizophrenia, major depressive disorder, alcohol dependence, cocaine dependence, and a ‘‘troubled’’ person. Like much of the mental health attribution research, the vignette study also failed to examine causal beliefs using a diverse ethnic sample. The lack of diverse samples in previous research is problematic, given that individuals from diverse cultural backgrounds tend to have different attributions about the broad range of mental illnesses. The first wave of attributions research was conducted over a decade ago. However, in light of our nation’s rapidly changing demographics, research is needed which explores attributions among an ethnically diverse sample and gathers information about these attributions across an array of mental health disorders. The purpose of our study was to provide a detailed picture of causes of mental health problems as perceived by community ethnic groups across a range of mental health conditions. Specifically, two research questions guided our work. First, what types of attributions do individuals make about mental health problems? Second, attribute mental illness to different causes? To accomplish our goal, we facilitated ethnically diverse focus groups to brainstorm possible causes of mental illness and used a grounded theory approach to identify attribution themes. This is the first study to assess attributions of a broad range of mental health problems from a diverse ethnic sample.
Method Participants Thirty-four participants participated in one of seven focus groups. Each focus group contained three to eleven participants of similar racial/ethnic origin. The total sample was ethnically diverse and consisted of eight African American (24 %), six Asian American (18 %), nine Hispanics (26 %), and 11 White (32 %) participants. The sample was predominantly female (82 %). The participants were all over the age of 18 and were members of
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community (49 %) and campus (51 %) ethnically focused groups. Measures Participants were each given a packet that contained 19 case scenarios, with each case scenario on an individual sheet of paper. The 19 case scenarios were created by the authors to represent a disorder from one of the major categories in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; e.g. Depression, Substance Abuse, and Autism). Case scenarios were designed to represent various ages and ethnic groups. An example of one of the case Scenarios: ‘‘A high school freshman is failing in school because the teachers says he can’t seem to keep track of his work, forgets things, has trouble paying attention in class, and is always fidgeting. His mom says he has always been like this’’. Procedure A licensed clinical psychologist trained the research team on group facilitation and research ethics prior to focus groups. Ten culturally/ethnically diverse community and campus organizations were approached for recruitment purposes and were targeted based on membership to a specific racial/ethnic community. All organizations were recruited through email, and members 18 years of age or older were invited to participate. A total of seven focus groups were conducted. Focus groups were held in community settings (e.g. ethnic cultural center, hospital setting, and coffee shop) designated by partnering community organizations. All focus groups were audio recorded. Throughout the focus groups, note takers recorded the participants’ responses and later notes were crosschecked with the audio recordings for accuracy. After obtaining written consent for participation, participants were presented with the packet of case scenarios. The focus groups began with the moderator informing participants that different case scenarios would be discussed among the group. Participants would then be asked to provide what they believed or what other people in their community may have believed caused each scenario. Each case scenario was read aloud as participants followed along. After reading each case scenario, participants were asked to provide explanations for the behaviors of the characters in the case scenarios. Each participant generated several responses for each case scenario. The responses often lead to a discussion, in which others in the focus group would either confirm the person’s attribution or give further elaboration. Order of case scenario presentation differed by group to address order effects. The institutional review board approved this project before research commenced.
Data Analysis Focus group data was analyzed to identify themes of attributions provided by participants. In order to identify themes of attributions, we used qualitative data analysis techniques based on grounded theory (Strauss and Corbin 1998). First, the three authors each independently conducted a thematic analysis of the notes and identified possible themes of attributions. Second, the three authors came together as a group to gain consensus about and condense the themes they had identified individually. Third, the original notes were coded into one of the agreed upon themes. The authors coded each attribution provided by participants; each author coded a set of attributions they had not worked with in the previous theme development step. An inter-rater reliability of .84 (Cohen’s Kappa) indicated high inter-rater agreement. A total number of attributions (the responses given by the participants) were tallied for each theme and percentages were calculated representing the frequency the themes were reported.
Results Question #1: What Types of Attributions do Individuals Make About Mental Health Problems? Using the full sample of 34 participants from seven focus groups, 12 attribution themes were identified and labeled: Biological, Normalization, Personal Characteristic, Personal Choice, Just World, God/spiritual, Family, Social Other, Environment, Trauma, Stress, and Diagnosis. Each of the themes represented a category of responses that explained the participants’ attributions of mental illness. For instance, normalization represents responses in which participants are labeling the behaviors described in the case scenarios as normal, or a normal part of life (e.g. ‘‘that just how people are’’). Another example is Just World, in which the response represents participants labeling the cause as being something deserved or karma (e.g. ‘‘that what he deserved’’). A total of 831 attributions were recorded and tallied across the 19 case scenarios. Overall, the top five themes (excluding diagnosis) were (in order from highest to lowest): Personal Characteristics (169, 20.3 %), Family (91, 11.0 %), Normalization (66, 7.9 %), Spiritual (64, 7.7 %) and Biological (52, 6.3 %). We excluded the Diagnosis theme from our results and discussion because the responses found within this theme do not represent attributions but rather labeling of mental health problems; therefore, these responses do not relate to our specific research questions. We have highlighted the top five attributions because excluding Diagnosis, the top
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five themes comprise more than 50 % of the attributions made by participants. Question 2: Do Ethnic Groups Attribute Mental Illness to Different Causes? To understand patterns in attributions by ethnicity, we calculated the frequency of each theme by ethnic group. Several key patterns are noteworthy regarding mental health attributions by ethnicity. First, ethnic minority participants consistently endorsed Spirituality and Normalization whereas Whites participants rarely did so. Minority participants, particularly Hispanics tended to mention spiritual reasons more frequently than White participants (11–3.0 % respectively). Normalization was particularly common among Hispanic and Asian American participants (10.4–11.6 % respectively). White participants also attributed Trauma (8.5 %) more often than other ethnic groups (5.9 % for African Americans, 2.4 % for Hispanics, 1.7 % for Asians) within the top five attributions. Asian American participants tended to make Personal Characteristic, Family, Normalization, Social Other, and Environmental attributions relatively equally (each category represented 11.6 % of the attributions generated by them). In other words, whereas all other ethnic groups tended to favor one or two particular attribution themes, Asian American participants described many different types of causes of mental illness.
Discussion The purpose of the current study was to provide a detailed picture of mental health attributions held by ethnic minority communities across a range of mental health conditions. Three major findings emerged. First, across all ethnic groups, we identified themes in attributions that are consistent with several of those identified in the existing literature. Second, our qualitative analysis uncovered ‘‘Normalization’’ as an attribution theme more commonly held by ethnic minorities than by Whites. Third, our study adds further evidence for the increased tendency of ethnic minorities to attribute mental illness to spiritual causes in comparison to Whites. Each of these findings will be discussed and implications for community mental health will be explored. Many of the themes we identified showed some overlap with previous research. Across our focus groups, ‘‘Personal Characteristics,’’ or an individual’s traits (e.g. ‘‘he’s lazy’’), were the most often identified attribution theme for mental disorders. We suspect that the pervasiveness of the Personal Characteristics theme was influenced by the welldocumented phenomenon of correspondence bias, the
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tendency for individuals to attribute another person’s behavior to internal dispositional causes rather than external situational factors (Gilbert and Malone 1995). White, African American, and Hispanic participants used personal characteristic attributions definitively more than any other type of attribution. Previous research has shown that correspondence bias exists across diverse cultures (Krull et al. 1999); our study provides further evidence that correspondence bias is pervasive across ethnicities in providing explanations of mental illness. Several other themes are consistent with those identified by previous researchers investigating mental health attributions. The ‘‘Biological,’’ ‘‘Spiritual’’ and ‘‘Stress’’ categories identified through our thematic analysis are similar to the biological, religious/ supernatural, and balance factors identified by Alvindrez (1999), as well as the stress, Western physiological, nonWestern physiological, and supernatural categories identified by Eisenbruch’s survey (1990). Similar to Eisenbruch (1990), other studies have differentiated categories based on Western or non-Western ideas (Sheikh and Furnham 2000; Yeh et al. 2005). In our thematic analysis, we did not specifically differentiate between Western and non-Western ideas, but several of our themes tended to be more Westernized (e.g. biological and stress), while other themes could be viewed as non-Western (e.g. spirituality). Our thematic analysis also revealed the importance of environmental causes (e.g. Family, Environment, and Social other categories) similar to the interactive dimension found in a survey study by Hill and Bale (1980). Qualitative analysis of themes generated by ethnically diverse focus groups identified ‘‘Normalization’’ as a frequent attribution—a theme not previously described in health attributions research. In our study, White participants were least likely to use ‘‘Normalization’’ attributions, suggesting that minority populations are more likely to attribute mental health problems to normal behavior (e.g. ‘‘he’s just getting old’’). Specifically, Asian American and Hispanic respondents were more likely to provide attributions that normalized the behaviors in the case scenarios. The tendency to normalize mental health problems could help explain the underutilization of mental health treatment services by Asian Americans and Hispanics. We hypothesize that the tendency to normalize may be explained by the abundance of mental health stigmas in many minority communities and a lack of knowledge regarding mental health disorders. Beliefs about the causes of mental illness can contribute to an understanding of shame and stigma which have been linked to mental health help-seeking and recovery (Knifton et al. 2010). Further research is needed to investigate if those that normalize behaviors are doing so in order to avoid the shame or stigma, or if it is simply a lack of mental health literacy. Nevertheless, our study’s findings support the deliberate promotion of help-seeking
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behaviors within minority populations by increasing mental health literacy (Jorm et al. 1997). The promotion of mental health literacy within minority communities could help this population better identify when those whose behaviors were once considered normal would benefit from appropriate mental health treatment. In general, health professionals should continue to work toward eliminating stigmas using community approaches (i.e. community workshops), which have been shown to be more effective than top-down public education (Knifton et al. 2010). Although existing literature has discussed the increased likelihood for ethnic minorities to attribute illness to spiritual causes in comparison to Whites (Landrine and Klonoff 1994) and for African Americans to specifically attribute mental illness to spiritual causes (Alvidrez 1999); our study confirmed the importance of spiritual causes in all ethnic minority groups, with Hispanic participants most likely to make spirituality-based attributions. Spirituality has been identified as a key component in help-seeking behaviors for those with mental illnesses. A review examining the relationship of social support, religion, and help-seeking behaviors found that religion impacted several factors: (1) the etiological beliefs held about a particular disorder, (2) which individuals sought treatment, with many choosing spiritual leaders before seeking professional mental health practitioners, and (3) how they coped, finding their religious beliefs and those associated as social support (Smolak et al. 2012). Our study has several keys strengths. First, by using a qualitative approach to understand mental health attributions, our study was not limited to attributions described in previous quantitative research or to those attributions that the research team identified as important. Instead, participants in seven separate focus groups were given descriptions of mental health case scenarios and had the opportunity to generate an exhaustive list of possible attributions. Second, participants reacted to nineteen different case scenarios representing each major category in the DSM-IV-TR. By including a diverse array of prompts, we were able to examine core attributions about mental health and avoided making conclusions based on popular opinion or stigmas associated with a particular mental illness. Third, our study included not only African American and Hispanic participants, but also Asian American participants, an understudied ethnic minority group (Sue 1977), shedding light on how ethnically diverse populations understand mental illnesses. Finally, we were able to examine ethnic differences in attribution, without having to homogenize all ethnic minorities into a single group (e.g. White vs. minority attribution differences). The results of this study have several implications for mental health professionals. First, in order to promote treatment-seeking behavior among ethnic minorities and to
offer culturally-responsive mental health services within the community, it is critical for health professionals to better understand why individuals believe mental illness occurs. Our study found that ethnic minorities were more likely to report the behavior seen in mental health disorders to be normal. If such behavior is deemed to be normal, it is less likely for them to seek treatment. We recommend that health professionals actively engage with community organizations to improve mental health literacy and utilize cultural competence when addressing mental health disorders with their patients and clients (Knifton et al. 2010). Second, our study highlights that in order to address the disparity of underutilization and retention of ethnic minorities in the mental health system, health professionals should continue to work ardently to incorporate spirituality when appropriate into therapy (e.g. in their case conceptualizations and work with clients who believe spirituality cause mental illness). In addition, clinicians should wherever possible and appropriate incorporate spiritual leaders in the process of connecting ethnic minority clients with the mental health treatments they need. Recent research has demonstrated that traditional services alone are inadequately meeting the needs of these individuals (Sue and Zane 2009). Incorporating spirituality could be one way to treat ethnic minority mental health needs in a culturally sensitive manner. Although our study was able to provide a detailed picture of how individuals attribute mental illness, it does have several limitations. The first limitation is the relatively small sample size for each ethnic group and the overrepresentation of women. Due to sample restrictions, our findings might not be generalized across an entire ethnic group, particularly regarding male perspectives of mental illness. Second, due to the qualitative nature of this study, we were unable to use inferential statistics to test the significant differences between ethnic groups on the identified themes, and therefore additional research is needed to incorporate the identified themes into a measure to test group differences. Third, because our study focuses on the impact of racial and ethnic cultural factors, we did not investigate the many other potential influences on attributions (e.g., social class, individual experiences with mental illness). Future research on racial and ethnic differences in attributions should include multiple cultural influences to more fully understand the dynamic process of making mental health attributions. Finally, further research is needed to examine the relationship between the identified themes and actual help-seeking behaviors. We speculate that individuals who tend to make normalizing, spiritual, and ‘‘just world’’ mental health attributions will be less likely to seek out mental health services than those who believe ‘‘Biology,’’ ‘‘Personal Choices,’’ or ‘‘Trauma’’ causes mental illness; however, further research that
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includes measurements of help-seeking behaviors are needed to explore these relations. Further research is also needed to test the ethnic differences of beliefs using a measure based on our identified themes. In summary, our study was the first to use a diverse sample and a qualitative approach to assess the attributions of mental illness across a wide spectrum of disorders. Our findings indicated that there is great variability in causal beliefs of individuals regarding different mental disorders, and that ethnic minorities attributed the cause of certain mental disorders to be a normal part of life or a spiritual etiology more than Whites. Mental health professionals should work to understand their clients’ mental health attributions in order to provide more effective treatment to ethnic minorities. Our findings suggest that there are significant opportunities for community agencies and health providers to impact the mental health of minorities by providing education regarding mental illness in order to break down stigmas and increase mental health literacy.
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