31st October 2023

Ethnic Minorities, Acculturation, and Mental health

Culture is defined as ‘people’s way of life, including their attitudes, values, beliefs, arts, sciences, modes of perception, and habits of thought and activity’. Culture is acquired through the process of enculturation, which involves the learning of cultural rules, values and beliefs.

Transcultural psychiatry explores the ways in which cultural factors impact human behaviour and mental health presentations and outcomes. As part of this, transcultural psychiatry looks at the psychological impact of moving from the cultural background that one has been raised within and adapting to living within a new cultural context – for example, through immigration. This process of adaptation is referred to as acculturation.

Acculturation involves ‘a process of cultural and psychological change resulting from contact between cultural groups and their individual members’. Acculturation can occur via four different processes:

• Assimilation – In which people lose their background culture altogether, instead adopting the culture of their new environment entirely. When many individuals from different cultures choose to assimilate into a new culture, this can result in a melting pot – whereby each group loses their background culture and assimilates, eventually all melting together into the dominant culture. However, when individuals are forced to assimilate and abandon their background culture in this way, this results in a pressure cooker society.
• Integration – Where people manage to adopt some of the culture of their new society whilst also maintaining some of the integrity of their background culture. Successful integration is only possible where the dominant cultural group is inclusive and open to the notion of diversity. Thus, a mutual accommodation is required, with all groups showing respect and acceptance towards each other.
• Separation – Whereby people retain their background culture but resist interaction with the new culture and fail to participate in the new society. Note that when this separation from the dominant culture is not an individual choice but is forced upon individuals by the dominant society, this is referred to as segregation.
• Marginalisation – When people fail to adapt to the new culture and participate in society whilst also losing their background culture. Marginalisation can result from failed attempts at forced assimilation (pressure cooker) in combination with forced exclusion (segregation).

National policies can be designed in ways that encourage certain methods of acculturation. For example, some expect all immigrants to assimilate completely into the dominant culture, whilst others encourage integration with some retention of background cultures. Other policies may enforce the segregation of groups or encourage the marginalisation of groups considered unwanted.

The social and psychological implications of the acculturation process are variable. Some individuals adapt psychologically to acculturation simply through learning a new set of appropriate behaviours for the new cultural context whilst simultaneously unlearning some aspects of their background culture that are no longer appropriate in context. Culture conflict is experienced whereby there is a clash between different cultural values and beliefs, which can create discomfort. Culture shock occurs when there is significant conflict, resulting in psychological stress. Extreme difficulties in the acculturation process can result in psychopathology, for example, clinical depression.

Psychological adaptation is influenced by numerous factors. The characteristics of both the society of origin and the society of settlement are important. The discrepancy between the two is important in order to make an estimation of cultural distance (the degree to which the two cultures differ). The conditions experienced by individuals in the society of origin are also important if we aim to understand the motivation behind immigration, i.e. push and pull factors. In the society of settlement, the general attitude of the society towards immigration is an important factor in determining the success of psychological adaptation. Some societies support multiculturalism, whereas others view this in a negative light and aim to eradicate diversity through forced assimilation through segregation or marginalisation.

Plural societies are found where a variety of people from different cultural backgrounds all live together within a diverse society with a shared political structure. The presence of individuals from different cultures within the society is influenced by three factors:

• Voluntariness – For example, immigrants who have voluntarily moved into a new cultural context, compared to refugees, for example, who have to undergo acculturation by necessity.
• Mobility – Typically, groups who have moved to a new location (immigrants, refugees).
• Permanence – Whether the individual will remain on a permanent basis (e.g. immigrants) or temporarily (e.g. international students, temporary workers).

Mental healthcare and ethnic minorities

According to 2021 UK Census data, around 18% of the UK population are from Black and minority ethnic backgrounds. Ethnic minority groups face a distinct set of challenges and barriers to accessing healthcare, and as such, it may be necessary for accommodations and adjustments to be made to the healthcare model (which is typically designed with the dominant cultural group in mind) in order to improve access to and the delivery of healthcare for these groups. It is important for mental healthcare professionals to have an understanding of the challenges faced by ethnic minority groups and to be sensitive and adaptive in their clinical interactions with these groups.

The specific rates of illness and challenges faced by ethnic minority groups vary in relation to each other and in relation to the dominant population. Ethnic minority groups generally fall into a lower socioeconomic status level, and they may experience a degree of social isolation. The psychological toll of migration and the acculturation process can also impact on mental health. Refugees and asylum seekers are a particularly vulnerable group who face significant barriers to accessing healthcare and who have been shown to experience higher rates of mental illness compared to the general population.

Research has identified inequalities in psychiatric healthcare outcomes for ethnic minority groups in the UK. Compared with the experience of White British people, ethnic minority groups have been found to experience reduced access to mental healthcare services, with poorer engagement, higher rates of conflict with staff, and variations in the use of drug treatments.

Rates of compulsory admission to psychiatric inpatient wards are higher amongst individuals of Afro-Caribbean ethnicity, as are rates of admission for schizophrenia and affective psychoses. Rates of readmission are also higher amongst Afro-Caribbean patients, and Afro-Caribbean men are over-represented in forensic units and in prison populations.

Immigration and schizophrenia

Research has shown that migrant and ethnic minority groups in the UK have higher rates of schizophrenia and psychosis compared to the general population. This disparity is most noticeable in Afro-Caribbean groups, with studies showing increased rates in this group ranging from 2-18 times that of the general population. The AESOP study aimed to explore the high rates of psychosis in Afro-Caribbean populations in the UK, with results showing that the incidence of schizophrenia is 9 times higher in the Afro-Caribbean population compared to the white British population.

There is no single clear explanation for the higher rates of schizophrenia in Afro-Caribbean populations. However, an environmental explanation, rather than a genetic one, is thought to be more likely.

Rates of schizophrenia are similar in Caribbean countries compared to the indigenous UK population, whilst rates are considerably higher amongst second generation Afro-Caribbean immigrants to the UK compared to first generation immigrants. This suggests that environmental factors are likely to be responsible for the disparity rather than genetic factors. The excess risk is not exclusively found in Afro-Caribbean immigrants but has also been noted to some degree in other immigrant populations, indicating that risk is not specific to any one race, and therefore, a genetic explanation is less likely. Furthermore, Afro-Caribbean patients who develop schizophrenia are more likely to be at a social disadvantage compared to their white counterparts. Immigrants have been found to experience long delays in seeking mental health support, they are less likely to be referred, and they have higher rates of police or emergency services involvement as well as compulsory admissions.

Culture-bound syndromes

Culture-bound syndromes describe sets of behavioural, cognitive, and affective presentations that are specifically seen within defined cultures. These syndromes are regarded as deviations from normal behaviour for individuals in that particular culture, and they can cause distress in the way that other psychiatric illnesses do. Given that culture-bound syndromes, by definition, affect members of a particular cultural group, these syndromes are typically limited to specific geographical regions. Several of these syndromes are acknowledged in the ICD-10 classification; see the table below.

References

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• Berry, J. W. [1997]. Immigration, Acculturation, and Adaptation. Applied Psychology: An International Review. 46 (1). 5-68
• Cooper, B. (2005). Immigration and schizophrenia: The social causation hypothesis revisited. The British Journal of Psychiatry, 186(5), 361-363.
• ‘Criminology’. Oxford Reference. Accessed May 2023. [Website: https://www.oxfordreference.com/display/10.1093/oi/authority.20110901080526139]
• Bhui, K., Aslam, R., Palinski, A., McCabe, R., Johnson, M., Weich, S., Singh, S., Knapp, M., Ardino, V., Szczepura, A. [2015]. Interventions to improve therapeutic communications between Black and minority ethnic patients and professionals in psychiatric services: Systematic review. The British Journal of Psychiatry, 207(2), 95-103.
• Bhui, K., & Bhugra, D. [2002]. Mental illness in Black and Asian ethnic minorities: Pathways to care and outcomes. Advances in Psychiatric Treatment, 8(1), 26-33.
• McKenzie, K. (2008). Improving mental healthcare for ethnic minorities. Advances in Psychiatric Treatment, 14(4), 285-291.
• Morgan C, Dazzan P, Morgan K, Jones P, Harrison G, Leff J, Murray R, Fearon P. [2006]. AESOP study group. First episode psychosis and ethnicity: initial findings from the AESOP study. World Psychiatry. 2006 Feb;5(1):40-6
• Office for National Statistics (ONS). [29 November 2022]. ONS website, statistical bulletin, Ethnic group, England and Wales: Census 2021. [Website: https://www.ons.gov.uk/peoplepopulationandcommunity/culturalidentity/ethnicity/bulletins/ethnicgroupenglandandwales/census2021]
• World Health Organization. [1993]. Culture-specific disorders. International statistical classification of diseases and related health problems. 176-187.