Cultural worldviews influence what many counsellors and helpers understand to be normal and acceptable behaviour, including our beliefs about mental health. However, research on multicultural psychology suggests that mental illnesses like depression can manifest differently for people of colour. This can limit our understanding of depression because much of the research relies heavily on the conceptualization in the Diagnostic and Statistical Manual (DSM-5), which is based on a Westernized and Eurocentric understanding of mental illness.
Culturally competent mental health clinicians must be familiar with both the DSM-5’s understanding of depression and the variations in which depression may present for our patients.
The DSM-5 defines depression as the presence of at least one core symptom plus at least five or more somatic symptoms. The core symptoms of depression include a sad or depressed mood and/or a loss of interest or pleasure in previously enjoyed activities. The somatic symptoms of depression can include fatigue, concentration issues, appetite changes, loss of libido, and/or sleep disturbances. Other DSM-5 criteria also consider the degree to which these symptoms affect one’s social, vocational, employment, and/or academic functioning.
Because depression can manifest differently for people of colour, culturally competent mental health clinicians must be familiar with both the DSM-5’s understanding of depression and the variations in which depression may present for our patients.
Culture significantly influences how patients describe or present their symptoms to a clinician. Individuals from Eastern and Asian societies tend to focus on the somatic and cognitive manifestations of depression such as dizziness and headaches. Whereas individuals from Westernized cultures report more emotional symptoms such as sadness and worthlessness. This difference in clinical presentation may also affect help-seeking behaviours where individuals with more physical complaints are likely to first present to a medical professional, resulting in a possible misdiagnosis.
It appears that what we believe causes our depression is heavily influenced by our cultural worldviews. Cultures heavily rooted in religious beliefs often attribute depression to weak morals resulting in elevated levels of shame and guilt. Those from collectivist cultures are more likely to view depression as a problem with interpersonal distress or disconnection from others. And those from an individualistic or independent mindset may see their depression as being caused by a personal failing or poor self-image. Our explanation for why we feel depressed often dictates what treatments we believe will be helpful in alleviating our symptoms.
What we believe causes our depression is heavily influenced by our cultural worldviews.
The DSM-5 suggests that one’s symptoms of depression are only clinical once they interfere with an important area of functioning. However, people of colour who are multi-stressed and live at the intersection of several marginalized identities cannot afford for their depressive symptoms to interfere with their work responsibilities, ability to care for family, school performance, ability to fulfill personal obligations, etc. This is often referred to as a “smiling depression” and is more common among women of colour, immigrants, LGBTQ people, and individuals living at or below the poverty line. These people outwardly appear to be high-functioning and competent, all while minimizing or hiding their internal emotional experience of depression. For this reason, smiling depression is often overlooked and treatment is likely to be delayed, if offered at all.
Mental vs. Physical Distinction
The DSM-5 clearly makes a distinction between mental and physical functioning in mental health treatment. Individuals who believe in more spiritual or supernatural understandings of mental illness are often misdiagnosed or overpathologized. For example, a common belief about distress among Puerto Ricans is that depression is characterized by uncontrollable crying and visions, while Hmong people experience a phenomenon of “soul loss” as a symptom of depression. The DSM-5 would characterize these symptoms as possible signs of psychosis, which is likely to be treated with medication. Rather, these individuals may be most responsive to treatment that incorporates meditation, mind–body interventions, and/or Indigenous healing techniques.
Mental health treatment is still an evolving field and its acceptance as an effective form of healing varies significantly across cultures. For many, depression is considered a weakness and something that must be hidden away from others. As a result, many people of colour do not know who to talk to or where to get help. Perhaps this is due to a limited number of culturally competent clinicians, a lack of culturally informed treatment options, or inadequate social/familial support. Without adequate support, many people of colour are likely to go without proper intervention for long periods of time.
The ability to accurately diagnose a patient is the cornerstone of good clinical care. In the counselling field, we cannot begin to help improve the mental health for people of colour unless we educate ourselves on the variety of ways depression can manifest. The DSM-5 is a useful guide, but we must also think beyond the criteria and become skilled in identifying the many faces of depression. Only then can we provide competent care and select culturally appropriate treatment plans to facilitate lasting psychological change.
We cannot begin to help improve the mental health for people of colour unless we educate ourselves on the variety of ways depression can manifest.
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