We psychiatrists should take a biopsychosocial approach to assessing our patients. However, we are enamored with biology and individual psychodynamics. Thus, we often overlook the influence of culture, or the lack thereof, on human behavior.
The assertion of Dr. Douglas K. Novins that using foundational cultural beliefs and practices strengthens interventions with people of color is particularly powerful. Furthermore, Dr. Novins’s findings inform us about the importance of culture in the protective factors and risky behaviors of our patients.
Dr. Carl C. Bell
Culture Protects
While doing HIV prevention work in Durban, South Africa, I found it striking that 40% of the black African Zulu people were HIV positive, 6% of the white South Africans were HIV positive, but only 1% of the East Indian South Africans were HIV positive.
As it turns out, the East Indian South African culture (with its intact religious rituals, proscribed clothing customs, age-old mating practices, and so on) protected them. Meanwhile, the black African Zulu culture and its protective cultural influence had been stripped from them, making them vulnerable to activities such as risky sexual behavior, substance abuse, and violence.
In addition, it appears that the white South African culture is eroding, which is resulting in higher levels of HIV-positive individuals.
Culture Destroys
The latest Youth Risk Behavior Surveillance data offer a glimpse into just how paradoxical our world has become. The investigators looked at six categories of health-risk behaviors among young people and young adults.
Among their findings: The prevalence of having carried a weapon in general was higher among white males (27.2%) than among their black counterparts (21%). The prevalence of having carried a weapon onto school property was higher among white males (7.8%) than black males (6.7%). The prevalence of having ever used cocaine was higher among white males (7.6%) than black males (4.2%). Yet, people of color make up a higher proportion of children and young adults who are incarcerated. In fact, in 2010, the imprisonment rate for black non-Hispanic males (3,074/100,000 U.S. black male residents) was almost seven times higher than it was for white non-Hispanic males (459/100,000), according to the U.S. Bureau of Justice Statistics.
Some of these disparities can be deconstructed by looking at housing patterns. Structurally, we understand that most mid- and large-size cities have more absolute numbers of low-income whites than low-income blacks. But few low-income white neighborhoods exist because low-income whites have scattered-site housing, while low-income blacks are concentrated in inner cities. Police have a more difficult time finding and incarcerating illegal drug users when they live in scattered-site housing. Therefore, blacks who use illegal drugs are incarcerated more often than whites who use illegal drugs.
We also must acknowledge that some of these disparities are tied to the human construct of race. Buy-in to this construct explains why law enforcement officers traditionally "hunted" runaway slaves and returned them to their owners. It potentially explains the motivations of former Chicago police officer Jon Burge, who was convicted 2 years ago of lying about the torture of innocent black men in order to get confessions over many decades. Finally, this reality explains the thinking behind this saying in Chicago’s black community: "The police hunt black males!"
International psychiatrist Suman Fernando makes the point in his book "Mental Health, Race and Culture: Third Edition" (New York: Palgrave Macmillan, 2010) that much of Western culture is inherently racist. Derald Wing Sue, Ph.D., the preeminent multicultural scholar, reminds us of "ethnocentric monoculturalism," the notion that the only culture in the Western world that has any value is Western culture, and all other cultural values and practices are "primitive." Dr. Sue points out that ethnocentric monoculturalism and whiteness define a reality that puts those who are white European American males at an advantage (American Psychologist 2004;59:761-9).
In Canada, these destructive, entrenched views led to the removal of children from First Nations communities. This cultural dislocation, in turn, led to the loss of cultural protective factors, which ultimately contributed to the engagement in risky behaviors tied to suicide, intragroup homicide, and substance abuse. As I’ve discussed previously, many of the disruptive behaviors that result in incarceration can be traced back to alcohol consumption (Preventing fetal alcohol syndrome, April 12, 2012). It is well known that this syndrome is a leading cause of speech and language disorders, attention-deficit/hyperactivity disorder, and other developmental/cognitive disorders. These are often responsible for affect dysregulation, which leads to disruptive behaviors – which, in turn, can lead to incarceration.
It is heartening to see research like that produced by Dr. Novins and his colleagues. Their work reaffirms that culture protects. It also is a reminder that psychiatrists need to understand the sociological forces that exacerbate the emotional pain suffered by our patients – particularly those who are marginalized. We must redouble our efforts to incorporate respectful cultural components into our interventions. Doing so will produce better outcomes.