The essay title is curious and could be interpreted in a number of ways. Firstly, it invites me to decide whether the essay should be from the perspective of a client, or the therapist, or both. I have chosen to present the essay from the point of view that it is the client who is a member of an ethnic minority group. Perhaps what drew me to this title over the others is of personal significance, being from a multicultural family and having lived and worked in countries in the Far East and West Africa where culture and society is vastly different to that of the UK. Essentially, I have experienced being an ethnic minority member in the opposite context and hence was eager to explore the essay from a clients' perspective in the UK. I chose to focus on depression rather than psychosis, as I was less aware of current research linking ethnicity to depression and felt this would balance out my motivations and be beneficial for my development as a trainee.
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As for the content, I will begin with a discussion on what is meant by an ethnic minority group and by the term depression. I will then present my view of how ethnicity affects the diagnostic process, initiated with a brief 'health warning' about the implications of racial stereotyping. Following this I will focus on presentation of symptoms and the formulation process of depression. The second half of the essay will be about the treatment process, looking closely at the influence of ethnicity on help-seeking behaviour and psychological treatments. Finally I will end the essay with a reflective account containing my thoughts about finishing the essay and a conclusion.
What is an ethnic minority group?
In its original form, the term 'ethnicity' means 'people or tribe' (i.e. ethos; Franklin, 1983). Senior & Bhopal (1994) highlight that is now used as 'a variable to describe health data'. On closer inspection, the concept of ethnicity is not simple or easy to understand. Firstly, ethnic minority status does not account for changes over time and context. There are also many different terms used for groups. McKenzie and Crowcroft (1996) highlight a good example of this:
"â€¦a Black Baptist born in the UK whose parents were born in Jamaica might be called Afro-Caribbean, black British, of Caribbean origin UK born, West Indian, and of course, Jamaican".
Furthermore, ethnic categorization does not inform us of whether the individual is of first or second generation descent, not to mention the migrant status of the individual. Given our multicultural climate, the meaning of ethnicity is a source of continuing debate and is also likely to change with national trends and politics. For example, the Irish have only recently be recognized as an ethnic minority in the UK. Although the National Institute for Mental Health (NIMH, 2001) has advised that ethnicity should be self-identified, this does not always happen in the process of research. McKenzie & Crowcroft (1996) point out that this leaves many researchers in the position of assigning membership of an ethnic minority group on an informal basis in order to have comparable data.
Indeed, defining an ethnic minority group is problematic due to the lack of consensus. Despite these issues it was necessary for me to attach myself to a concrete definition for the purpose of this essay. Furthermore, I have selected a particular ethnic minority group (African-Caribbean's) when specific examples are needed. The definition I am following regarding an ethnic minority group is:
"Those with a cultural heritage distinct from the majority population" (Manthorpe & Hattiaratchy, 1993).
What is Depression?
Depression is a term used both clinically and in everyday discourse (Valente, 1994) to describe a host of unpleasant feelings which people experience, ranging from a low mood to describing a situational feeling (Keller & Nesse, 2005). When depression is considered clinically significant is it quite different from the common experiences just narrated. A person may be diagnosed with clinical depression if they are experiencing depressed mood or loss of interest and pleasure plus at least five other adverse feelings during a two-week period or longer (DSM-IV; American Psychological Association, 1994). When depression is at its worst, it can make people withdraw from ordinary pleasures and concentration may become very poor. Some people with depression report a sense of hopelessness and can experience suicidal feelings or ideations as a result (APA, 1994). Clinical depression can occur alongside different disorders and be multifaceted in its presentation. It is probably fair to say depression does not occur in every country across the world in the way we view it in the West. Other cultures may label it as something different. For example, Kleinman (1980, as cited in Bentall, 2003) found Western depression and a Chinese condition called Neurasthenia to be the same thing, although expressed in different cultural ways. Given this, I question how useful our depression label is. This essay is however, directed by the title and the focus of this essay will therefore follow the DSM-IV definition of depression.
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According to the Office for National Statistics clinical depression is experienced by 10% of the British Population at any one time. Depression is a diagnosis of increasing popularity, and was once referred to as 'the common cold of psychiatry' (Seligman, 1975 as cited in Hawton et al., 2000).
It is estimated that there are over 6 million people in England alone who are 'designated' as from minority ethnic groups (Department of Health (DoH), 2003). Much of our current knowledge of depression in UK African-Caribbean people relies on limited research showing inconsistent results. I feel such statistics often lead to misdiagnosis, as clinicians are informed by research and policy. In order to avoid statistical discrimination I have therefore not included any data displaying suggested prevalence rates of depression in this population. Chakraborty (2002) points out that early studies were criticized for methodological problems, but argues that more recent studies have attempted to advocate more rigorous methodology. More recent studies tend to suggest a high prevalence of depression in African-Caribbean populations (e.g. Nazroo, 1997 as cited in Chakraborty, 2002). Interestingly, it is also thought that depression is 'underecognised and undertreated in African-Caribbeans, especially in primary care' (Ahmed & Bhugra, 2006).
To what extent is membership of an ethnic minority group influential in the process of diagnosis of people experiencing depression?
In the recent Inside Outside UK national initiative (Department of Health, 2003) a "well-established link" between health care disparities and ethnicity is claimed and structures are recommended which target this. I question the wider implications of producing such documents as it appears to suggest people should be viewed differently according to their ethnic status. As Lewis-Fernandez (2002) rightly point out, even people who share the same ethnic minority status can differ, as ethnic groups are 'culturally heterogeneous'. As noted above, membership of an ethnic group is not a static thing and there are vast differences within an 'ethnic group' as well as outside of it. I can relate to this as I often have difficulties when completing the ethnic status box on equal opportunities forms. Although I would class myself as 'white-British' my father is Italian-American and my mother is Swiss, hence I have four passports. I normally choose to categorize myself as British however this sometimes changes to 'white-other' or 'white-American' depending on where I have been living. In my experience, I feel the desire to categorize people in society outweighs the usefulness of doing so.
Given the increasingly multicultural climate of the UK it may not always be accurate to state that white people are of the dominant origin however statistically that is currently the case. This means that the relatively recent surge in interest and attention on differences of ethnic groups in mental health is often taken from an essentialist perspective, where differences are observed from 'my' or 'our' perspective. Claims made in research detailing differences between ethnic groups also encourage categorizing of individuals, which simply creates an 'othering' between groups. There is a concern for me that by focusing on the differences between African-Caribbean's and whites, or any other 'ethnic minority' simply serves to reinforce the idea of racial differences and segregation. Institutional racism is a form of discrimination, which stems from the notion that groups should be treated differently according to 'phenotypic difference' (Mckenzie, 1999). It has been suggested that it is widespread in the UK (Modood et al., 1997). It seems to me that if we are to 'eliminate racial disparities in mental health care'; concordant with the aims of the recent Department of Health initiative (2003), we all need to look at the way we are talking and presenting our ideas around this.
For the reasons just discussed I will now attempt to present a view that is balanced and allows disparities of depression in African-Caribbean people to be seen in a relational context. Whilst I will describe potential areas of difference, the aim is not to stereotype people according to their ethnicity.
The bodily styles of experiencing and expressing distress may be different for some people of African-Caribbean origin living in the UK than people from other ethnic backgrounds. Some studies suggest they experience and present more somatic symptoms of depression, e.g. headaches, achy limbs (Comino et al, 2001). Comino and colleagues also suggest idioms of distress 'differ linguistically and can take the form of cultural metaphors'. If clinicians do not recognize these symptoms as signs of distress I imagine some clients may be left feeling quite frustrated.
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For us as therapists this does make the process of diagnosis more complex. An awareness of the possibility of somatic presentations, with a view to enquiring about the clients understanding of them seems helpful. An approach for assessment and understanding of somatic symptoms of depression and idioms of distress has been developed (Lewis-Fernandez & Diaz, 2002). There have also been attempts at identifying the core symptoms of depression across different ethnic groups, although the last one is most probably outdated now. In their large cross-cultural study, Jablensky et al., (1981 as cited in Bhugra & Ayonrinde, 2004) found nine common international symptoms of depression: sadness, joylessness, anxiety, tension, lack of energy, loss of interest, poor concentration and ideas of insufficiency, inadequacy and worthlessness. Perhaps doing more studies like this could help in us developing a more universal approach to symptom recognition.
Despite the evidence, I do believe that symptom presentation of depression can vary for a number of reasons completely unrelated to an individual's ethnic minority status. Children were once considered a difficult and under diagnosed population as they often present with somatic symptoms (e.g. failure to make expected weight gains in very young children; Carson & Cantwell, 1980) which makes it difficult to diagnose. Subsequently, rating scales and measures have been devised which are appropriate for different age groups and enable a conventional diagnosis to be made (Goodyer, 2001). People living with HIV may also present somatic symptoms of depression. Kalichman et al., (2000) suggest available methods for distinguishing 'overlapping symptoms' should be utilised when assessing such individuals. It seems obvious to me that we have to adapt standard methods of recognizing depressive symptoms when dealing with the diversity that naturally occurs in human beings.
Language is also thought to be a potential barrier (Mentality, 2004) in the diagnostic process of depression. African-Caribbean people may not always speak clear English but speak multiple local languages or with an accent. Whilst I know this happens, I could not find any research investigating the percentages of African-Caribbean people in the UK and their language abilities. This so-called barrier could therefore be perceived rather than actual; however I will briefly discuss methods to work with this in the clinical context. As stated in the aforementioned Inside Outside document (2003) mental health services now aim to be 'culturally capable', which includes tackling difficulties with language. There is no doubt in my mind that communication is a key element in diagnosis, and I know from personal experience that not being able to communicate in a locally understood language can cause people to feel isolated. Thus, ensuring language access for people who speak a language other than English through appropriate interpreting/translating services is crucial. However, I do feel that this parallels a need for people who have other difficulties with language. For example, I am sure it can be difficult to identify depression in individuals who have suffered severely dehabilitating strokes or physical injuries where speech is severely impaired. My point is that there are an array of factors which influence the way people talk about their difficulties and how they are understood by clinicians. Not being able to speak the English language in a clear English accent is simply one of those factors. I feel the issue raised here is more related to how we work with diversity rather than how we work with ethnicity.
As a trainee clinical psychologist involved in the diagnostic process of depression I am also concerned with the formulation process and how this is affected. The beliefs people have about the nature and causes of depression do differ between cultures. For example, Bhugra et al., (1997) found in some African and Asian cultures depression is seen as 'part of life's ups and downs and it is not thought of as a 'treatable' condition. From this perspective, many psychological models which aid us in understanding depression can account for the differing beliefs and experiences of people. For example, the Cognitive model of depression (Beck, 1967, 1976) suggests that people's early experiences lead people to form beliefs or schemata about themselves and the world. These assumptions are thought to cause negative automatic thoughts which perpetuate symptoms of depression on five different levels; behavioural, motivational, affective, cognitive and somatic. Despite this model being quite flexible at face value, however, the 'negative cognitive triad' (Beck, 1979) is directed by the beliefs and experiences of the individual. This may not fit in with those from more collectivist cultures. Indeed, we know that social networks often play an important part in the belief systems of ethnic minority members (Bhugra & Ayonrinde, 2004). Therefore thinking more systemically may be particularly useful when considering individuals from ethnic minority groups.
However, we do need to be cautious in making assumptions about what beliefs people from ethnic minorities have. There is a danger that in doing so, we may be able to formulate quicker but may also cause considerable distress to the client. I recently attended a mental health awareness course as part of my placement where an African Caribbean service user came to talk to us about her experiences of being in the mental health system. She described her first traumatic admission to hospital after a close suicide attempt at the age of nineteen. She told us it was persistently assumed by mental health staff that she had attempted suicide because she did not understand or fit in with the predominantly white community in her area. She told us how upset and misunderstood this made her feel, as this was not the case at all. On reflection, this highlights the importance of service-user feedback in clinical practice.
The question I see appearing with regards is how we as clinicians in the UK can best explore the beliefs, experiences and background of the multicultural population we are working with in order to diagnose appropriately. As Fernandez & Diaz rightly point out, to do this "we need a systematic method for eliciting and evaluating cultural information in the clinical encounter" (Fernandez & Diaz, 2002). There is a paucity of information debating ways to take this forward and models to encapsulate these ideas are currently being developed and tested in the USA. One such model is the Cultural Formulation model (Lewis-Fernandez & Diaz, 2002), which is an expansion on the depression guidelines, published in the DSM-IV. The innovative model consists of five components; assessing cultural identity, cultural explanations of the illness, cultural factors related to the psychosocial environment and levels of functioning, cultural elements of the clinician-client relationship and the overall impact of culture on diagnosis and care. I find this model very inclusive as it can still elicit very useful information about culturally-based norms, values and behaviours even when there is no ethnic difference between the clinician and the client. Whilst cultural differences exist within an ethnic group, they are not necessarily ethnicity-bound. For example, they can equally be associated with an individual's age, gender, socioeconomic status, educational background, family status and wider social network (Ahmed and Bhugra, 2006). If this is the case, then I would say that it is important for clinicians to have a very exploratory and curious approach when assessing and diagnosing an individual in a mental health service, whether they are from an ethnic minority or not.
To what extent is membership of an ethnic minority group influential in the process of treatment of people experiencing depression?
Some people with depression get better without any treatment. However, living with depression can be challenging as it impacts many areas of an individuals' life including relationships, employment, and their physical health. Therefore, many people with depression do try some form of treatment. This process usually begins at primary care level and then a collaborative decision is made between the patient and the clinician as to what treatment suits them best. It has been suggested that Africa-Caribbean people are less likely than whites to tolerate antidepressant medication (Cooper et al, 1993). Therefore this section of this essay will focus on the process of psychological treatments of depression. Treatments vary and have altered radically with the growing use of Cognitive Behavioural Therapy (CBT), which is based on the 'scientist-practitioner model and routinely offers outcome data' (Whitfield, 2003). In CBT, and in the majority of other talking therapies, treatment usually involves seeing a therapist for a number of sessions on a regular basis.
There appear to be two main potential barriers when it comes to the treatment of depressed clients from ethnic minorities. Firstly, the help-seeking behaviours of African-Caribbean and other ethnic minority groups have attracted considerable attention in the research domain. Members of the African-Caribbean population are thought to be less likely to seek professional treatment for depression.
Whilst reading a mountain of papers listing reasons why the help-seeking behaviour of people from ethnic minorities is so 'different', a few ideas sprung to my mind. From my own experience when people are very depressed they may struggle to get motivated and make less use of the support available to them. Moreover, I wonder whether one it is a possibility that African-Caribbean's do not approach services as much because of negative experiences of the UK mental health system. I recall seeing an elderly Jamaican gentleman for an assessment last year whilst working as an Assistant in a Clinical Health department. Following the very limited referral information I had, I elicited his ideas about what brought him to our service. He told me that he had felt unable to cope with his low mood and intrusive thoughts for some while, however he did not feel able to seek help because a family member of his had been treated unfairly by mental health staff before. Perhaps the reasons for people not accessing treatment are simpler than we think. In their study of reasons for exclusion of African-Caribbean people in mental health services, Mclean et al., (2003) found the types of interactions between staff and patients strongly associated with disparities in treatment. They encourage positive, non-judgmental interactions as the first step on the path to social inclusion of mental health services (Mclean et al., 2003). Their study reminded me of a report I read recently on placement about the "Circles of Fear" (Salisbury Centre for Mental Health, 2002). Essentially, this report stipulates that people from ethnic minorities tend to have a more negative experience of the mental health system. People may then fear the consequences of becoming involved with it and avoid contact. This leads me to believe that we (the health service) are very much part of the reason why such individuals may not seek help.
Geography may also be a reason for varying help-seeking behaviour. People living in rural areas are thought to be at risk of facing isolation and experiencing discrimination in mental health treatment (Barry et al, 2000). I do think there is something valuable about looking at populations which services are not reaching. However, it has just struck me that writing about the help-seeking behaviour of people can come across as quite blaming and puts the responsibility very much with the individual. Whatever the reason, if minority members are less likely to get appropriate care, I feel the focus should be on how to engage different members of society in effective care for depression. Fortunately, depressed people who fail to seek help for treatment can often be identified and treated in general medical settings (Shulberg et al, 1999). One study also suggests that the majority of people who are depressed do want help, regardless of their ethnicity (Brody et al, 1997). What I find particularly interesting is that the desire for help seems to be related to the severity of the depression in precedence of their ethnic minority status. Thus it appears that ethnicity, severity of depression, geographical location, previous experiences with the mental health system and beliefs about what help is available all influence help-seeking behaviour.
The second claimed difficulty in the treatment of African-Caribbean people who are depressed is poor attendance rates and incompletion of treatment (Bhugra & Ayonrinde, 2004). There are also claims that African-Caribbean people are more likely to experience a poorer outcome from treatment. Given that the search for a biological cause for disparities in treatment success rates has not been fruitful we must turn our focus to other explanations. Given that the relationship between the therapist and client is a key component of treatment outcome, I am going to focus on those which link to the therapeutic alliance.
There are few empirical studies which explore how ethnic differences affect the therapeutic alliance and these have consisted mostly of client preferences. Cultural unfamiliarity may act as interference to some African-Caribbean people staying in psychological treatment (Davidson, 1987). In their study of secondary school students, Uhlemann et al (2004) looked at how being an ethnic minority therapist affected relationships in a counselling setting. They found ethnic minority counsellors were perceived more favorably than white-Caucasian counsellors. Most students believed therapists were less able to understand or empathize with them if the therapist was ethnically different. In another study Coleman et al., (1995) surveyed studies comparing ethnic minority clients' preferences of therapists, being ethnically similar or ethnically dissimilar. They found that in most cases clients preferred therapists of similar ethnic background, particularly those with strong cultural attachments. I acknowledge that this may be something to be aware of as a therapist; however I do not think this in itself would put people off psychological treatment. It might be useful for us as therapists to address this issue and to do so early on in the treatment process. One way of doing this could be to address any obvious ethnic differences and explore together how it may affect the given relationship. This may also help the process of understanding which is deemed very important in strengthening the therapeutic alliance.
Whilst this is something I will try and be aware of in my practice, I also feel it is important to present this discussion in a realistic and in context. From my experience as a trainee, the age and amount of experience a therapist is far more valuable and influential than the ethnic status of a therapist. One lady I saw recently had difficulty accepting me as her therapist for the simple fact that she worried about how much I would be able to help her in comparison to a qualified clinical psychologist. There was also an ethnic difference between us but this was did not cause her concern. Similarly, Coleman et al (1995) asked clients individuals in their study to list the characteristics of a competent therapist in order of importance. Sure enough, they found that people placed ethnic similarity below that of other characteristics such as educational ability, maturity, gender, personality and attitude. I think this illuminates just how important it is for us to tailor the treatment process to the individual needs and concerns of the client.
Is a more holistic approach to psychological treatment of depression the answer? I do wonder whether CBT, the current preferred model of treatment, will soon lose its popularity. The somewhat prescriptive nature of CBT for depression may mean the varying needs of people in our multicultural climate are not being met. Rather than creating new and separate treatment models or services for ethnic minority clients, perhaps we should be embracing ones which encourage clients to lead the treatment. One model I find demonstrates this is the Recovery model. Recovery from mental illness is seen as a personal journey and the unique experiences of each individual are valued and explored (Jacobson & Greenley, 2001). Treatment using this model works around helping the client gain hope, a secure base, supportive relationships, empowerment, social inclusion, coping skills, and finding meaning to their experiences. Although used more with individuals experiencing major mental health problems, I think the principles are very inclusive and useful for the treatment of any mental health problem, including depression. Of course, I have only touched upon one model and there are many more which embrace individual differences.
As a current trainee on my adult mental health placement, I cannot pretend that I am able to provide an objective nor extensively experienced view. I am also aware that I am at the beginning of my placement, in a service which very much promotes recovery from mental illness through understanding the individual rather than categorically through their 'psychiatric label'. Whilst this may have had an influence over my stance towards the essay topic, I have witnessed the positive effects in my clinical work of not categorizing people and feel that this has indicated some valid concerns. Upon finishing this essay it came to mind that that the buoyancy of the essay may be a reflection of the ideas and questions I have been grappling with as part of my practice on placement. However, these ideas are by no means a closed deal and I continue to work with them in an applied context.
Furthermore, I acknowledge that had I chosen to present this essay assuming that it was the therapist who was a member of an ethnic minority, my essay and conclusions may be very different.
How will writing this essay affect my practice as a Trainee Clinical psychologist? I do feel we are in a contentious situation. If we treat people differently according to any issue of diversity we run the risk of perpetuating institutional racism. Ion the other side of the coin, if we work with everybody in exactly the same way and try and fit people in to Eurocentric systems then we run the risk of ignoring important cultural differences. What I will take from this is the importance of being sensitive to people's backgrounds and experiences and investigation of what makes them who they are. I will definitely attempt to bring more flexibility, curiosity and receptiveness to my practice and acknowledge when there is a noticeable difference between myself and the client in the therapeutic setting.
In conclusion, membership of an ethnic minority group may influence the diagnosis and treatment process in how people experience depression, present to services and possibly how they proceed with psychological treatments. If we are to diagnose and treat depression through a Euro centric lens, we should be embracing the use of models which allow for cultural diversity in the diagnosis and treatment of depression.
However, as I hope I have demonstrated in my writing, no two people in a therapeutic setting will ever be exactly the same. So how useful is it to continually focus on ethnic differences when they are just one drop in the ocean of diversity? Perhaps instead we need a shift in the dominant discourses surrounding ethnic differences in mental health? The real challenge I think we face is understanding how the identity of the individual contributes to the diagnosis and treatment of depression.