1.10.4.9 Ethnic minorities, acculturation and mental health

Ethnicity, race, nationality and culture

• Ethnicity is a self-claimed group identity, expressed as belonging, and it does not rest on biology, appearance or any single cultural component.

• Race, culture and ethnicity also differ in how changeable each is.

• Racism is the belief that races are inherently different, that capacities are largely fixed by race, and that one race is intrinsically superior.

• That belief in race-fixed capacity and superiority is what separates racism from xenophobia, prejudice and ethnocentrism.

• Region, religion, class and generation produce wide variation within any group, so ask the individual rather than assume group beliefs.

Ethnic inequalities in mental health arise from migration, adversity, discrimination, resources and services acting together, not from ethnicity itself.

Minority status and plural society

• Minority status depends on local numbers, recognition and power.

• A plural society keeps distinct cultural, ethnic or religious groups with separate identities inside one political unit, held together by shared law and institutions rather than shared values.

• A plural society describes the structure of the whole society, not a strategy a group adopts.

Acculturation

• Acculturation is the two-way cultural and psychological change that follows sustained contact between cultural groups, and it changes the host community as well as the migrant.

• Acculturation does not require the heritage culture to be given up.

• How hard acculturation is varies with age at migration, and older family members, such as a grandparent, find it hardest.

• Generations acculturate at different speeds, and children who interpret for parents can reverse authority in the family.

Berry's bidimensional model

Berry holds that attitudes to the heritage culture and to the host culture vary independently, giving four strategies.

• Integration tends to support wellbeing, whereas marginalisation is the outcome most often linked with acculturative stress and poorer mental health.

• Strategies are constrained rather than freely chosen: discrimination can force separation, which is then misread as unwillingness to integrate.

• Acculturative stress comes from language barriers, occupational downgrading, lost extended-family support, clashing family and gender expectations, and discrimination.

• Legal security, income and housing are the major modifiable protections, alongside family, community and a valued cultural identity.

What the receiving society imposes

• Segregation is separation imposed by the dominant group, which keeps newcomers apart while leaving their heritage culture intact.

• Separation is chosen by the minority, whereas segregation is imposed on it.

• The melting pot, as a policy of the receiving society, expects newcomers to give up their heritage culture and take on the majority one.

• As a model of cultural dynamics in a country with rising immigration, classically the United States, the melting pot blends incoming and host cultures into a new hybrid culture.

• Total assimilation differs from the melting pot because the non-dominant culture is obliterated rather than blended.

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Migration and psychosis

• Migration is one of the most robustly established environmental risk factors for schizophrenia, with a roughly two-fold or greater excess in first-generation migrants that extends to their children.

• The ÆSOP study found the largest excess in Black Caribbean people, an incidence rate ratio of about nine against White British people, across three English centres.

• In ÆSOP, Black African incidence was raised but lower, and the social adversity markers carried far smaller odds.

• The excess in UK African-Caribbean people is not seen in the Caribbean, where rates are close to White British rates, and their parents' risk matches that of native patients' parents.

• The excess is therefore attributed to social adversity in the host country, not to inheritance, selective migration or imported risk.

• The ethnic density effect is the rise in schizophrenia risk in a migrant group as that group's share of the local population falls.

• Voluntary migrants may at first show a healthy migrant advantage, while refugee outcomes depend on both pre-migration trauma and post-settlement conditions.

Pathways to care

• Black ethnic groups have the highest population rate of compulsory detention under the Mental Health Act in the UK.

• Some Black groups have more crisis and police contact, and expecting coercion delays help-seeking, so a cycle of avoidance, crisis and further coercion builds.

• Institutional discrimination sits in ordinary policy, such as referral routes or interpreter booking, and produces unequal outcomes with no prejudiced individual, so only auditing outcomes finds it.

Culture and psychopathology: Tseng's effects

Culture-bound syndromes

Idioms of distress such as "thinking too much" express suffering without being diagnoses.

Female genital mutilation

• More than 200 million girls and women alive today have undergone female genital mutilation worldwide, most recently estimated at more than 230 million.

Culturally informed assessment

• Kleinman's explanatory models cover what is wrong, why, and what helps, and the clinician's and patient's models should be explored together.

• Explanations steer help-seeking towards faith, family or medicine, and people often use several routes.

• Avoid both errors: diagnosing an accepted cultural experience as psychosis, and dismissing illness as culture.

• The Cultural Formulation Interview structures inquiry into identity, migration, explanations, stresses, discrimination and preferred care.

• Use a professional interpreter when fluency is not enough, avoid family interpreters for risk, abuse or conflict, and never use children.