CHAPTER 2

Culture Counts: The Influence of Culture and Society on Mental Health, Mental Illness

Racism, Discrimination, and Mental Health

Since its inception, America has struggled with its handling of matters related to race, ethnicity, and immigration. The histories of each racial and ethnic minority group attest to long periods of legalized discrimination— and more subtle forms of discrimination — within U.S. borders (Takaki, 1993). Ancestors of many of today’s African Americans were forcibly brought to the United States as slaves. The Indian Removal Act of 1830 forced American Indians off their land and onto reservations in remote areas of the country that lacked natural resources and economic opportunities. The Chinese Exclusion Act of 1882 barred immigration from China to the U.S. and denied citizenship to Chinese Americans until it was repealed in 1952. Over 100,000 Japanese Americans were unconstitutionally incarcerated during World War II, yet none was ever shown to be disloyal. Many Mexican Americans, Puerto Ricans, and Pacific Islanders became U.S. citizens through conquest, not choice. Although racial and ethnic minorities cannot lay claim to being the sole recipients of maltreatment in the United States, legally sanctioned discrimination and exclusion of racial and ethnic minorities have been the rule, rather than the exception, for much of the history of this country. Each of the later chapters of this Supplement describes some of the key historical events that helped shape the contemporary mental health status of each group.

Racism and discrimination are umbrella terms refer-ring to beliefs, attitudes, and practices that denigrate individuals or groups because of phenotypic characteristics (e.g., skin color and facial features) or ethnic group affiliation. Despite improvements over the last three decades, research continues to document racial discrimination in housing rentals and sales (Yinger, 1995) and in hiring practices (Kirschenman & Neckerman, 1991). Racism and discrimination also have been documented in the administration of medical care. They are manifest, for example, in fewer diagnostic and treatment procedures for African Americans versus whites (Giles et al., 1995; Shiefer et al., 2000). More generally, racism and discrimination take forms from demeaning daily insults to more severe events, such as hate crimes and other violence (Krieger et al., 1999). Racism and discrimination can be perpetrated by institutions or individuals, acting intentionally or unintentionally.

Public attitudes underlying discriminatory practices have been studied in several national surveys conducted over many decades. One of the most respected and nationally representative surveys is the General Social Survey, which in 1990 found that a significant percent-age of whites held disparaging stereotypes of African Americans, Hispanics, and Asians. The most extreme findings were that 40 to 56 percent of whites endorsed the view that African Americans and Hispanics “prefer to live off welfare” and “are prone to violence” (Davis & Smith, 1990).

Minority groups commonly report experiences with racism and discrimination, and they consider these experiences to be stressful (Clark et al., 1999). In a national probability sample of minority groups and whites, African Americans and Hispanic Americans reported experiencing higher overall levels of global stress than did whites (Williams, 2000). The differences were greatest for two specific types: financial stress and stress from racial bias. Asian Americans also reported higher overall levels of stress and higher levels of stress from racial bias, but sampling methods did not permit statistical comparisons with other groups. American Indians and Alaska Natives were not studied (Williams, 2000).

Recent studies link the experience of racism to poorer mental and physical health. For example, racial inequalities may be the primary cause of differences in reported quality of life between African Americans and whites (Hughes & Thomas, 1998). Experiences of racism have been linked with hypertension among African Americans (Krieger & Sidney, 1996; Krieger et al., 1999). A study of African Americans found perceived⁶ discrimination to be associated with psychological distress, lower well-being, self-reported ill health, and number of days confined to bed (Williams et al., 1997; Ren et al., 1999).

A recent, nationally representative telephone survey looked more closely at two overall types of racism, their prevalence, and how they may differentially affect mental health (Kessler et al., 1999). One type of racism was termed “major discrimination” in reference to dramatic events like being “hassled by police” or “fired from a job.” This form of discrimination was reported with a lifetime prevalence of 50 percent of African Americans, in contrast to 31 percent of whites. Major discrimination was associated with psychological distress and major depression in both groups. The other form of discrimination, termed “day-to-day perceived discrimination,” was reported to be experienced “often” by almost 25 percent of African Americans and only 3 percent of whites. This form of discrimination was related to the development of distress and diagnoses of generalized anxiety and depression in African Americans and whites. The magnitude of the association between these two forms of discrimination and poorer mental health was similar to other commonly studied stressful life events, such as death of a loved one, divorce, or job loss.

While this line of research is largely focused on African Americans, there are a few studies of racism’s impact on other racial and ethnic minorities. Perceived discrimination was linked to symptoms of depression in a large sample of 5,000 children of Asian, Latin American, and Caribbean immigrants (Rumbaut, 1994). Two recent studies found that perceived discrimination was highly related to depressive symptoms among adults of Mexican origin (Finch et al., 2000) and among Asians (Noh et al., 1999).

In summary, the findings indicate that racism and discrimination are clearly stressful events (see also Clark et al., 1999). Racism and discrimination adversely affect health and mental health, and they place minorities at risk for mental disorders such as depression and anxiety. Whether racism and discrimination can by themselves cause these disorders is less clear, yet deserves research attention.

These and related findings have prompted researchers to ask how racism may jeopardize the mental health of minorities. Three general ways are proposed:

(1) Racial stereotypes and negative images can be internalized, denigrating individuals’ self-worth and adversely affecting their social and psycho-logical functioning;

(2) Racism and discrimination by societal institutions have resulted in minorities’ lower socioeconomic status and poorer living conditions in which poverty, crime, and violence are persistent stressors that can affect mental health (see next section); and

(3) Racism and discrimination are stressful events that can directly lead to psychological distress and physiological changes affecting mental health (Williams & Williams-Morris, 2000).

Poverty, Marginal Neighborhoods, and Community Violence

Poverty disproportionately affects racial and ethnic minorities. The overall rate of poverty in the United States, 12 percent in 1999, masks great variation. While 8 percent of whites are poor, rates are much higher among racial and ethnic minorities: 11 percent of Asian Americans and Pacific Islanders, 23 percent of Hispanic Americans, 24 percent of African Americans, and 26 percent of American Indians and Alaska Natives (U. S. Census Bureau, 1999). Measured another way, the per capita income for racial and ethnic minority groups is much lower than that for whites (Table 2-2).

Table 2-2 gives Per Capita Income averages by ethnicity in 1999.

For centuries, it has been known that people living in poverty, whatever their race or ethnicity, have the poorest overall health (see reviews by Krieger, 1993; Adler et al., 1994; Yen & Syme, 1999). It comes as no surprise then that poverty is also linked to poorer mental health (Adler et al., 1994). Studies have consistently shown that people in the lowest strata of income, education, and occupation (known as socioeconomic status, or SES) are about two to three times more likely than those in the highest strata to have a mental disorder (Holzer et al., 1986; Regier et al., 1993; Muntaner et al., 1998). They also are more likely to have higher levels of psychological distress (Eaton & Muntaner, 1999).

Poverty in the United States has become concentrated in urban areas (Herbers, 1986). Poor neighborhoods have few resources and suffer from considerable distress and disadvantage in terms of high unemployment rates, homelessness, sub-stance abuse, and crime. A disadvantaged community marked by economic and social flux, high turnover of residents, and low levels of supervision of teenagers and young adults creates an environment conducive to violence. Young racial and ethnic minority men from such environments are often perceived as being especially prone to violent behavior, and indeed they are disproportionately arrested for violent crimes. However, the recent Surgeon General’s Report on Youth Violence cites self-reports of youth from both majority and minority populations that indicate that differences in violent acts committed may not be as large as arrest records suggest. The Report on Youth Violence concludes that race and ethnicity, considered in isolation from other life circumstances, shed little light on a given child’s or adolescent’s propensity for engaging in violence (DHHS, 2001).

Regardless of who is perpetrating violence, it disproportionately affects the lives of racial and ethnic minorities. The rate of victimization for crimes of violence is higher for African Americans than for any other ethnic or racial group (Maguire & Pastore, 1999). More than 40 percent of inner city young people have seen someone shot or stabbed (Schwab-Stone et al., 1995). Exposure to community violence, as victim or witness, leaves immediate and sometimes long-term effects on mental health, especially for youth (Bell & Jenkins, 1993; Gorman-Smith & Tolan, 1998; Miller et al., 1999).

How is poverty so clearly related to poorer mental health? This question can be answered in two ways. People who are poor are more likely to be exposed to stressful social environments (e.g., violence and unemployment) and to be cushioned less by social or material resources (Dohrenwend, 1973; McLeod & Kessler, 1990). In this way, poverty among whites and nonwhites is a risk factor for poor mental health. Also, having a mental disorder, such as schizophrenia, takes such a toll on individual functioning and productivity that it can lead to poverty. In this way, poverty is a consequence of mental illness (Dohrenwend et al., 1992). Both are plausible explanations for the robust relationship between poverty and mental illness (DHHS, 1999).

Scholars have debated whether low SES alone can explain cultural differences in health or health care utilization (e.g. Lillie-Blanton et al., 1996; Williams, 1996; Stolley, 1999, 2000; LaVeist, 2000; Krieger, 2000). Most scholars agree that poverty and socioeconomic status do play a strong role, but the question is whether they play an exclusive role. The answer to this question is “no.” Evidence contained within this Supplement is clearly contrary to the simple assertion that lower SES by itself explains ethnic and racial disparities. An excellent example is presented in Chapter 6. Mexican American immigrants to the United States, although quite impoverished, enjoy excellent mental health (Vega et al., 1998). In this study, immigrants’ culture was interpreted as protecting them against the impact of poverty. In other studies of African Americans and Hispanics (cited in Chapters 3 and 6), more generous mental health coverage for minorities did not eliminate disparities in their utilization of mental health services. Minorities of the same SES as whites still used fewer mental health services, despite good access.

The debate separates poverty from other factors that might influence the outcome — such as experiences with racism, help-seeking behavior, or attitudes — as if they were isolated or independent from one another. In fact, poverty is caused in part by a historical legacy of racism and discrimination against minorities. And minority groups have developed coping skills to help them endure generations of poverty. In other words, poverty and other factors are overlapping and interdependent for different ethnic groups and different individuals. As but one example, the experience of poverty for immigrants who previously had been wealthy in their homeland cannot be equated with the experience of poverty for immigrants coming from economically disadvantaged backgrounds.

An important caveat in reviewing this evidence is that while most researchers measure and control for SES they do not carefully define and measure aspects of culture. Many studies report the ethnic or racial back-grounds of study participants as a shorthand for their culture, without systematically examining more specific information about their living circumstances, social class, attitudes, beliefs, and behavior. In the future, defining and measuring different aspects of culture will strengthen our understanding ethnic differences that occur, beyond those explained by poverty and socioeconomic status.

⁶ Perceived discrimination” is the term used by researchers in reference to the self-reports of individuals about being the target of discrimination or racism. The term is not meant to imply that racism did not take place.