Racial and Ethnic Cultural Factors in the Process of Acceptance of Mental Illness

Abstract

Acceptance of mental illness is essential to promoting recovery and is uniquely impacted by issues of culture, race, and ethnicity. Qualitative case narrative methodology was used to identify themes related to the cultural facilitators and barriers in the acceptance process. Five participant narratives are presented to assist practitioners in applying these findings to rehabilitation counseling. Selected case narratives represent participants from diverse racial and ethnic backgrounds to illustrate cultural facilitators and barriers in the acceptance process. Implications are suggested for culturally responsive counseling and research pertaining to the process of acceptance of mental illness.

Keywords

mental illness acceptance culture race ethnicity

Rehabilitation Counseling Bulletin has called attention to the need for qualitative research on recovery from serious mental illness (Hanley-Maxwell, Al Hano, & Skivington, 2007). The recovery movement in mental illness treatment defines recovery as a process of living a satisfying life of well-being and autonomy, as opposed to symptom elimination alone (Davidson, Drake, Schmutte, Dinzeo, & Andres-Hyman, 2009). A number of leaders of the recovery movement have identified acceptance of mental illness as a crucial stage in the recovery process, and one of the most challenging (Deegan, 1996; Ridgway, 2001; Spaniol & Gagne, 1997). Acceptance of mental illness has been reasoned to be critical to medical and mental health management of the illness as well as overall quality of life (Kravetz, Faust, & David, 2000). In this article, we define acceptance as a multidimensional process of understanding and recognizing one’s mental illness, and actively engaging in the management of related symptoms and experiences. An important factor is the role of one’s racial and ethnic cultural background in impacting the process of acceptance of mental illness (Carpenter-Song et al., 2010; Chen & Mak, 2008; Kirmayer & Bhugra, 2009).

To examine racial/ethnic (i.e., racioethnic) cultural factors in the acceptance process for people with serious mental illness, we conducted the present study of qualitative interviews with 30 participants with serious mental illness. The cultural backgrounds of these individuals varied with regard to race, ethnicity, gender, age, immigration experiences, and acculturation levels. To contextualize this research, we will begin with an overview of the literature on the acceptance process and cultural issues in the experience of serious mental illness. Next, we will provide five case narratives of participants to illustrate these racioethnic factors in the acceptance process. These narratives are presented to assist rehabilitation practitioners in considering racioethnic factors in the acceptance process. Finally, we will highlight implications for culturally relevant rehabilitation counseling and research pertaining to the process of acceptance of mental illness.

Acceptance of Mental Illness

Acceptance is a crucial stage in the recovery from serious mental illness, and one of the most challenging (Deegan, 1996). A serious mental illness (or mental illness) is a mental disorder that interferes with at least two areas of functioning—social functioning, vocational functioning, and self-care (National Institute of Mental Health, 2008). Acceptance is an emotional, cognitive, and behavioral process that can foster empowerment and hope (Spaniol & Gagne, 1997). Acceptance can involve self-education, overcoming negative self-judgment, developing a positive identity, working past denial, and achieving understanding of one’s mental illness (Ridgway, 2001). However, acceptance may mean something different to each person with mental illness, ranging from insight to adapting to changes in functioning (Kravetz et al., 2000). Acceptance does not require accepting an illness model or a traditional diagnostic label to facilitate recovery (Ridgway, 2001). In contrast, acceptance may mean developing an explanatory model of the illness that feels adaptive and meaningful to people within their cultural context (Kleinman, 1988; Ridgway, 2001).

A lack of acceptance of mental illness (i.e., denial) may be a normal reaction to feeling overwhelmed by the illness and associated stigma (Ridgway, 2001). Stigma refers to negative attitudes, prejudice, and discrimination toward individuals with mental illness and other marginalized backgrounds (Link & Phelan, 2001). Given the stigma of mental illness, acknowledgment of one’s mental illness may initially reduce one’s self-esteem, social status, and social network (Kravetz et al., 2000; Perlick et al., 2011).

Other research suggests that acceptance of mental illness may enhance self-efficacy and improved functioning (Warner, Taylor, Powers, & Hayman, 1989). When individuals are able to engage in this process of acceptance, a number of positive outcomes can result. These outcomes include the recognition of strengths, the deepening of relationships, compassion for others, and active engagement in life (Spaniol & Gagne, 1997).

Spaniol and Gagne (1997) mention several of the following barriers and facilitators to the acceptance process for people with serious mental illness. These authors indicate that shame and stigma may pose barriers to acceptance of psychiatric disability until one has the resources to deal with the reality of a psychiatric disability. Acceptance is facilitated by the presence of various resources that are needed to deal with associated losses, including the sense of loss over who the person could have been. Acceptance may be facilitated by the support and acceptance of others, which can promote self-acceptance. Effective coping with stigma is another facilitator in the acceptance process that can help to deal with other problems associated with mental illness, including mistreatment from providers, side effects of medication, and vocational barriers. Spaniol and Gagne have highlighted a few of these facilitators and barriers to acceptance in their theoretical article. However, additional study is needed to further identify cultural facilitators and challenges in the acceptance process in particular.

Culture and Mental Illness

Culture is a critical factor in the acceptance process for people with mental illness. Sam and Morreira (2012) proposed that “there cannot be mental illness without culture” (p. 2). Culture impacts the development, onset, expression, course, outcome, understanding, and treatment of mental illness (Alverson et al., 2007; Carpenter-Song et al., 2010; Kleinman, 1988; Sam & Morreira, 2012). Understanding the recovery process requires consideration of culturally relevant stressors, such as racism, homophobia, sexism, and colonization, in the lives of people with mental illness (Ida, 2007). Culture can refer to race, ethnicity, gender, region, nationality, socioeconomic status, religion, sexual orientation, age, disability status, and many other identity factors. The present article focuses on racial and ethnic cultural factors given the specific impact of racial and ethnic background on understanding, treatment, and attitudes toward mental illness as well as related disparities in mental health care (Alverson et al., 2007; Carpenter-Song et al., 2010).

The New Freedom Commission on Mental Health (2003) recognized the importance of studying cultural issues in serious mental illness and mandated research in this area given disparities in care across cultural groups. As a result, the literature on cultural issues in mental illness has addressed some of the culturally relevant problems and resources for recovery from serious mental illness in general. For example, research has indicated that nondominant racial and ethnic groups in U.S. society may experience concrete barriers to mental illness treatment in the Western mental health system, such as lack of translators, high cost, and lack of insurance (Primm et al., 2010; Singh & Hiatt, 2006). Several cultural facilitators to recovery from serious mental illness have also been mentioned, such as cultural values in family support and spiritual activity (Primm et al., 2010). However, this research has lacked a focus on racioethnic factors in the acceptance process for people with serious mental illness, a process vital to living with and managing mental illness. The present study was conducted to fill this research gap.

Prevalence of Mental Illness Across Racial/Ethnic Groups

A difference in prevalence rates of mental illness across racial and ethnic groups attest to the impact of racioethnic factors on mental illness (Primm et al., 2010). According to several studies, American Indians have the highest reported rates of mental illness (50%–54% men, 40%–46% women), followed by non-Hispanic European Americans (21%), Latino Americans (16%), African Americans (15%), and last, Asian Americans (9%) (Beals et al., 2005; Primm et al., 2010). Although African Americans and Latino Americans have lower prevalence rates of mental illness, they experience a longer course and more disability associated with the illness, and are both overrepresented in homeless or incarcerated populations, which are often excluded in data-gathering surveys (Breslau et al., 2006; Kessler et al., 2005; Primm et al., 2010). In addition, differences in perceptions and understandings about mental illness across racial and ethnic groups may impact reports of the Western notion of a mental illness in data gathering (Primm et al., 2010).

Stigma, Culture, and Mental Illness

A central cultural barrier to the general recovery process is stigma. Stigma of mental illness is one of few stigmas found universally across cultural groups (Carpenter-Song et al., 2010; Ida, 2007). However, stigma may vary in meaning and presentation across cultures (Carpenter-Song et al., 2010; Kleinman, 1988). The stigma of mental illness is also culturally defined and socially constructed (Sam & Morreira, 2012). Mental illness stigma reflects the values within one’s culture and constitutes a complex sociocultural process stemming from competition for resources (Campbell & Deacon, 2006). The explanatory model a culture has for mental illness can both enhance and reduce stigma faced by people with serious mental illness (Carpenter-Song et al., 2010). The present study is needed to further identify the impact of cultural stigma on the acceptance process.

Narrative Research, Culture, and Mental Illness

Qualitative case narrative research has been identified as particularly useful in analyzing the complexity of cultural experiences (Trahar, 2009) and the recovery process of people with mental illness (Ridgway, 2001). Moreover, there has been a call in the evidence-based practice literature for the use of participant case narratives to heighten the counseling relevance of empirical research (Edwards, Dattilio, & Bromley, 2004). Qualitative case narrative research methodology entails attending to and constructing participant narratives based on the research interview, as well as identifying key themes from the interview data (Adler, Kissel, & McAdams, 2006; Mishler, 1991). Narrative research is a social constructivist approach that emphasizes meaning and content in the narrative accounts told by participants to researchers, and can highlight cultural issues in participants’ lives that are particularly valuable for informing counseling (Patsiopoulos & Buchanan, 2011).

Study Rationale

This literature suggests a gap in research on racioethnic factors in the acceptance process for individuals with mental illness. In addition, the literature describes the value of case narrative methodology for researching this phenomenon about which little is known and to facilitate experiences with culture and mental illness within the narratives of people with serious mental illness. Much of the literature on the acceptance of mental illness is more than 10 years old and would benefit from an update. The present study was conducted to examine cultural factors in the acceptance process in the narratives of participants with serious mental illness with a focus on race and ethnicity. Participants with a variety of racial and ethnic backgrounds participated in qualitative interviews to examine cultural facilitators and barriers to the acceptance process of mental illness. Qualitative case narrative methodology was utilized to analyze the interviews and present case narratives that assist practitioners in understanding the rehabilitation counseling relevance of the present data for participants with mental illness from various racioethnic cultural backgrounds.

Method

Participants

Participants consisted of 30 individuals (15 women, 15 men) with a serious mental illness. These individuals were recruited from a psychosocial rehabilitation and education center in the Northeast for people with serious mental illnesses. Selection criteria necessitated that participants were 18 years of age or older, had received mental health services for at least 5 years, and had a primary diagnosis of bipolar disorder (n = 9), major depression (n = 9), or a schizophrenia spectrum disorder (i.e., schizophrenia or schizoaffective disorder; n = 12). The sample included 20 European American participants, 5 African American participants, 3 Asian participants, 1 Latino participant, and 1 Native American participant. With regard to immigration, 10% identified as an immigrant to the United States, 10% as first generation, with 80% second generation or more. In the present study, a subsample of 5 participants was selected to examine racioethnic cultural factors among participants representing a range of racial/ethnic identities.

Procedure

Nonrandom sampling was used where participants were selected for the study based on the aforementioned selection criteria. Participants were recruited on an ongoing basis to fill approximately equal groups stratified by gender and diagnosis. Semistructured qualitative interviews were conducted by the primary investigator (first author). In addition, a research team took part in data coding, analysis, and interpretation. The research team included three researchers who varied demographically by ethnicity, nationality, immigration experiences, and age. Researchers included doctoral-level investigators trained and experienced in qualitative data analysis and coding.

Institutional review board approval was received prior to conducting the study. Participants were then recruited from the targeted psychosocial rehabilitation center during a phone screening process that ensured participants met selection criteria. Participants were informed of the study’s focus on their experiences associated with mental illness and sense of self. The interviews ranged from 40 to 60 min in length and took place in a private research space within the psychosocial rehabilitation and education center from which participants were recruited. Each participant signed a consent form to participate and completed a brief demographics questionnaire. Participants were paid US$25 for participation in the study. Audio recordings of the interviews were transcribed verbatim.

Semistructured research interview

The research team developed a semistructured interview guide to focus on several topics related to acceptance process associated with serious mental illness, including experiences with diagnoses, symptoms, mistreatment, identity, losses, coping, and resilience. Drafts of the semistructured interview protocol questions were reviewed, revised, and modified by the team to enhance the ability of the interview to gather narrative data related to the topics at hand. The interview questions were written to be accessible and easy to understand by participants. If participants needed clarification of terms or concepts (e.g., acceptance, mental illness, mistreatment) during the interview, the researcher provided explanation and confirmed participants’ understanding.

The use of a single research interview was selected as appropriate methodology for several reasons. The single qualitative interview is the most prevalent approach used in qualitative methodology (DiCicco-Bloom & Crabtree, 2006). In addition, narrative research typically utilizes a single interview in its methodology to develop a case narrative (Lieblich, Tuval-Mashiach, & Zilber, 1998; Riessman, 1987). Per the iterative process of a qualitative research, questions may be added to the interview guide over the course of an interview to allow for further exploration (DiCicco-Bloom & Crabtree, 2006). The research team conducted ongoing review of interview transcripts over the course of the study to confirm that the single interview approach and length of the interviews were sufficient for investigating the research topics at hand.

Data analysis

Thematic analysis (Aronson, 1994) was used by the research team to analyze the 30 interviews. The research team read the interview transcripts and identified themes in the interviews by coding the transcripts in a line-by-line coding process. The research team convened intermittently throughout reading of the 30 transcripts to compile a codebook of themes and representative quotes from transcripts related to these themes. Themes were extracted based on comparison of the coded transcripts of the research team members, followed by discussion to determine the codes applied to the transcripts. When investigators arrived at the same coding for themes individually, this enhanced confidence and confirmed accuracy of the resultant themes. In the case of inconsistency of coding, consensus was utilized to arrive at a final code. The present theme selected from this codebook included data relating to racioethnic factors in the acceptance process of mental illness.

The interviews were further analyzed by the research team using a multiple case narrative approach (Shekedi, 2005). This approach allowed for a cross-comparison of multiple narratives of participant experiences with the acceptance process surrounding mental illness, gathered from the research interviews. Per the multiple case narrative approach, case narratives were selected by the research team to highlight the themes of cultural facilitators and barriers to the acceptance process of mental illness. The case narratives were selected based on consensus of the research team with regard to several criteria: (a) the case would lend to rich analysis and understanding of the impact of the participant’s racial and ethnic culture on experiences of acceptance surrounding mental illness and (b) the case would allow for the representation of a cross-section of participant narratives from different racial and ethnic identities. The primary investigator (first author) wrote case narrative accounts based on the interviews, including content related to the identified focus of this research theme of racioethnic factors in the acceptance process. All members of the research team reviewed the interview transcripts to ensure consistency between the case narratives and the interview data. The narratives were organized as follows: (a) presentation of the participant’s cultural background and mental illness narrative, (b) the participant’s definition of the acceptance process, and (c) the participant’s description of culturally relevant barriers and facilitators to the acceptance process. Key quotes within participant interviews were embedded into these case narratives, also based on consensus by the research team. Case narratives were developed from participant interviews to highlight racioethnic factors in the acceptance process across a diverse range of racial and ethnic backgrounds. In addition, case narratives were constructed to contextualize the racioethnic factors within the recovery stories of participants to help practitioners relate these findings to rehabilitation counseling. In some cases, minor information was altered about the participants to further mask identity.

Validity

Validity in the present study was established through a number of strategies as described by Barbour (2001) in a validity checklist for qualitative research:

Purposive sampling was utilized to assemble five case narratives to represent participants from a range of racioethnic cultural backgrounds.

Multiple coding of interview themes by the three researchers enabled the comparison and revision of themes to enhance validity of themes and the resulting case narratives.

Cross-checking of the written case narratives and the interview transcripts was conducted by the research team to ensure consistency—a standard procedure in narrative methodology (Patsiopoulos & Buchanan, 2011; Polkinghorne, 2007).

Investigator triangulation was utilized through the use of three research team members to provide complementary perspectives on development of the research case narratives (Guion, Diehl, & McDonald, 2011).

Memos of research team meetings were kept and redistributed to the research team over the course of the 4 months of data analysis to keep record of themes, key quotes from the interviews, and interpretation of case narratives. Memo-keeping is a validity measure used to enhance reflexivity in qualitative data analysis (Corbin & Strauss, 2008).

Consensus among research team members was used in the selection of case narratives and when disagreement arose with regard to coding themes. Consensus is a research strategy often used to reduce bias and enhance validity of case-based research (Edwards et al., 2004).

Results

Cultural barriers and facilitators associated with mental illness are reflected in the following representative case narratives selected by the research team. These case narratives include a presentation of the illness narrative, individual definitions of the acceptance process, and cultural facilitators and barriers to this process. Last, each case narrative is contextualized in the research on mental illness within the participant’s cultural group.

Case Narrative 1

“Pearl” is a woman in her mid-50s who belongs to a Native American tribe in the Northwest. She was diagnosed with schizoaffective disorder, bipolar type in her 20s. She began to develop psychiatric symptoms while attending a prestigious college on the East Coast, hoping to return to her tribe to help her community as a physician. She stated, “My whole goal in my life was to come out here, get educated like a White person, go back and fight after I got my education, see? . . . And then I turn around and become mentally ill.” Pearl left school and returned to the reservation where she faced mental illness stigma from her community and family. Her relatives attributed her mental illness to psychiatric medication, encouraging her to “get off the drugs” and at times throwing away her prescriptions. She indicated that in some American Indian tribes, individuals with mental illness were given shamanistic roles in society. However, her tribe emphasized the warrior role, which was less inclusive of the abilities of many people with mental illness. She returned to the Northeast, where she found a less stigmatizing mental health community; however, she continued to encounter mistreatment in the mental health system for her Indian heritage, stating “Some people think you’re inferior anyway because you’re Indian.”

When asked about the meaning of acceptance of mental illness, Pearl indicated, “It means that somebody can understand that you may be different in a way, but it doesn’t really make you inferior . . . out here mental illness is more accepted.” Cultural facilitators to the acceptance process for Pearl included gaining distance from stigma in culture of origin and living in more accepting communities. Cultural barriers for the acceptance process included a sense of cultural inferiority as an American Indian, double stigma of her Native American and mental illness identities, internalized stigma and feelings of disgust toward herself, and racism and mistreatment in the mental health system.

Pearl’s case narrative highlights unique factors in the acceptance process surrounding mental illness for many people of American Indian backgrounds. Native American communities face elevated rates of substance abuse problems due to coping with the effects of genocide and poverty (Ida, 2007). As a result, some Native American groups may have negative attitudes toward psychiatric medications that can help people to deal with and manage symptoms of mental illness. Many Native Americans may face the double stigma of racism and mental illness, interfering with acceptance of mental illness. Pearl’s narrative highlights within-group differences in cultural attitudes toward mental illness among the vastly diverse Native American tribes. Moreover, the acculturative effects of dominant Western stigma toward mental illness may increase stigma within tribes that have been historically accepting of mental illness.

Case Narrative 2

“Glenda” is a woman of African American heritage in her 50s with a strong connection to her Baptist religion. She was diagnosed with bipolar disorder, followed later by a diagnosis of schizophrenia in her 20s. She experienced debilitating bouts of psychiatric symptoms that often left her feeling “at war” with her mind. Glenda’s explanatory model for her illness included a chemical imbalance as well as the trauma of a violent relationship and the death of her infant. She described a key incident of being mistreated during a hospitalization by male staff who were sexually coercive toward her and other women of color on her unit. She stated,

They used to be mean to us in hospitals. They thought you were crazy; they could push you around and do anything to you mentally or physically. . . . I tried to bring everybody together and say, “Let’s take hands and pray, and we’re going to show them that God has the power.”

When asked about the meaning of acceptance of mental illness, she indicated, “It means that I can see better now . . . nothing can’t come past me that I can’t deal with.” She reported cultural barriers to the acceptance process to include experiences of racism, sexism, and stigma toward mental illness. She described cultural facilitators to the acceptance process to include a belief in justice, social action, as well as spiritual and religious practices and beliefs. She also described the value of role models with mental illness who share her identity as a person of color:

When you meet people that are doing good in your cultural identity, it makes you want to good, too. It makes you want to say, “Well, they can do it, I can do it.” It gives you a broader outlook than the stereotypes that people have about people.

She also described a sense of cultural pride and positive identity as important facilitators to her acceptance process.

Glenda’s case narrative illustrates some racioethnic factors in the acceptance process surrounding mental illness for many people of African American descent. Once in the mental health system, many individuals of African American heritage often face mistreatment, misdiagnosis, and inappropriate treatment such as increased rates of hospitalization for mental health problems with lower rates of outpatient care (Ida, 2007; Mizock & Harkins, 2011; Primm et al., 2010). As a result of mistreatment, many African Americans may be less likely to use mental health care (Primm et al., 2010) or experience treatment that is often incongruent with their religious and cultural values (Alverson et al., 2007).

Case Narrative 3

“Margaret” is a Jewish, European American woman in her early 60s with severe depression. She was diagnosed with dyslexia and depression following her difficulties with completing graduate school. Margaret experienced problems at work and school as a devastating blow to her sense of self, given that scholarship and traditional work success was heavily emphasized in her Jewish community and family. She encountered daily verbal abuse from her mother, further contributing to her depression. In addition, Margaret noted her struggle to feel good about herself given challenges with the American cultural value of “pulling yourself up by your bootstraps.” The mental illness stigma she faced was compounded by multiple incidents of anti-Semitism in her youth. Her home was painted with swastikas, her lawn set on fire, and her house flooded in a number of hate crimes. She described the experience as feeling, “like the ten plagues. . . . I was waiting for the locusts to come.” Despite these struggles with depression and stigma, she found a way to “live with it better, or roll with the punches better.”

Her acceptance process around her experiences of mental illness was facilitated by traditional therapy as well. For her, acceptance means, “I can move on, and I can work on it.” Self-education about her diagnosis was an important part of the acceptance process for her, and was congruent with her family and Jewish cultural values of engaging in scholarship to promote a positive sense of self. Her acceptance process was further facilitated by therapy, a rehabilitation education center, self-education, and awareness of stigma in her broader culture and in family. Barriers to her acceptance process included double stigma of mental illness and anti-Semitism, lack of acceptance from others, academic pressures, and the U.S. individualist pressures to be self-sufficient.

Margaret’s case narrative highlights racioethnic cultural factors for European Americans with Jewish identities in the acceptance process surrounding mental illness experiences. Research has found that European American perceptions of mental illness may be more likely to utilize traditional mental health treatment and view mental illness as permanent and debilitating, having an internal locus, and biomedical in origin (Alverson et al., 2007; Carpenter-Song et al., 2010; Primm et al., 2010). As a result of these cultural values, many European Americans with mental illness often experience elevated levels of self-stigma and social isolation (Alverson et al., 2007). Also illustrated in Margaret’s case are ways in which higher levels of family stigma may be represented in some Jewish families where mental illness is interpreted as a threat to a cultural emphasis on family functioning (Pirutinsky, Rosen, Safran, & Rosmarin, 2010).

Case Narrative 4

“Marco” is a Latino immigrant from Central America with a history of severe depression. He immigrated with his wife and two children 30 years ago during a civil war in his country. He worked several jobs to support his family. After a number of years and problems with depression, his wife sought a divorce, and he became estranged from his children. He spoke of how these devastating losses magnified his depression:

When you have a culture then you have a close family, right? And you think your wife and your children are forever in your life. And then . . . suddenly, they’re gone . . . and is a stressful thing.

Marco’s explanatory model for mental illness was stress, family problems, as well as witnessing economic strife and war atrocities in his country of origin. He spoke about the difficulty of feeling understood about his experience of ataque de nervios, a culture-bound syndrome found in many Latino cultures. He stated, “Sometimes I get mad, so that means, ataque de nervios, . . . I know that maybe the other people don’t know what I mean.” He also understood his mental illness as being brought on by acculturative stress of immigration, including social isolation, language challenges, and adapting to new places and people.

For Marco, acceptance meant, “that I couldn’t be seen [as different] from the . . . other citizens, like the other people, like the normal people.” Facilitators to the acceptance process included working on problems, self-education, and setting additional goals to counterbalance the losses associated with mental illness. Barriers to the acceptance process included the fear of losing friendship and family ties, and his belief that he was unable to remarry due to mental illness.

Marco’s case narrative demonstrates cultural factors for many Latino Americans with mental illness in the acceptance process. Losses of work and family were especially devastating for Marco. This is reflected in research on Latin American cultural values in familismo—a family orientation and value (Añez et al., 2005), as well as values in hard work as a means of survival, social mobility, and purpose of immigration (Flores et al., 2011). He also understood his mental health problems as the previously mentioned ataque de nervios, a syndrome experienced in some Latino communities that is believed to be an expression of anger and grief resulting from problems in the family and immigration stress (Alverson et al., 2007; Guarnaccia, DeLaCancela, & Carrillo, 1989). Barriers to the acceptance process included political factors in his country of origin, similar to many immigrants seeking refuge from national conflict (Sam & Morreira, 2012) who face acculturative stress, which may interfere with acceptance.

Case Narrative 5

“Dennis” is a Japanese American, separated, graduate student whose parents emigrated from Japan prior to his birth. Over the course of numerous mental health treatments since his teens and suicide attempts, he received multiple diagnoses before settling on major depressive disorder with psychotic features and posttraumatic stress disorder. He reported severe physical abuse during his childhood, auditory and visual hallucinations, as well as paranoid ideation that the government was trying to steal his identity. He also had physical symptoms with no medical explanation, including physical convulsions and severe fatigue. He described stigma as one of the biggest problems he faced: “Society tends to be very stigma-oriented, where you’re like damaged goods if you’re trying to apply for a job.” He often felt like “an outcast, a failure in the family” and was told by his mother he was “damaged goods.” Dennis described the impact of stigma on his life:

When people hear about the label they don’t want to be around me. It’s like the plague. My wife didn’t want to—she didn’t want to acknowledge I had any of this. She didn’t want to be around me. And that sticks in my head.

His explanatory model was primarily neurologic, combined with a Buddhist notion of karma, which helped him to make meaning of his suffering as compensation for problems committed in a previous life.

For Dennis, acceptance of mental illness meant acknowledging that “living life is actually walking around a track together.” This meant finding adaptive ways to accept, tolerate, and recover from mental health problems instead of denying these experiences. Facilitators to his acceptance process included helping others, recognizing strengths and talents, and Buddhist beliefs and meditation. The barriers to acceptance included stigma in his family and marriage, as well as denial and repression in his family.

This case narrative highlights racioethnic factors in the acceptance process that may be faced by some Asian individuals with mental illness who experience somatic symptoms of mental illness as opposed to the cognitive and emotional symptoms typical in Western culture due to differences in beliefs about the mind–body relationship (Sam & Morreira, 2012). Some East Asian individuals may experience especially high rates of suicide as a result of stigma (Ida, 2007; Mori, Panova, & Keo, 2007; Saetermoe, Scattone, & Kim, 2007), as seen in Dennis’ history of multiple suicide attempts. In addition, Dennis was born and raised in the United States, which may have contributed to genetic and biomedical explanatory models of mental illness and treatment seeking (Fogel & Ford, 2005). Many East Asian cultures are often characterized by collectivist cultural values, which are more likely to attribute mental health problems to internal, personal causes that might bring shame on the family (Chen & Mak, 2008). His higher level of acculturation into Western culture may also reflect his use of traditional psychotherapy, seen in some Asian Americans’ access of services in the United States (Chen & Mak, 2008).

Discussion

As evidenced by comparison of these case narratives, culture has a significant impact on one’s definitions of acceptance of mental illness. The meaning of acceptance is informed by the personal and cultural framework within which individuals make meaning. In addition, a number of general cultural facilitators and barriers to the acceptance process occurred across these case narratives. These racioethnic factors took the form of facilitators or barriers to the acceptance process of mental illness. Cultural facilitators included low-stigma explanatory models, awareness of stigma, taking social action, as well as spiritual and community supports. Cultural barriers included high-stigma explanatory models, cultural stigma, internalized stigma, mistreatment, immigration stress, and isolation.

The level of stigma in an explanatory model (high vs. low) reported by participants refers to the degree to which the participant’s culture promotes negative attitudes, beliefs, and treatment toward individuals with mental illness. This level of stigma varied depending on the degree to which the participant’s culture tends to place internal blame on an individual for mental health problems (i.e., “laziness”) versus attribution to external causes (i.e., karma). Per these case narratives, participant cultures that had low-stigma explanatory models of mental illness reduced blame on the individual and increased the likelihood of acceptance of mental illness, making a low-stigma versus a high-stigma explanatory model a cultural factor in the acceptance of mental illness. Cultural stigma can be heightened or reduced by an explanatory model, further interfering with acceptance. In contrast, awareness and self-education about cultural stigma of mental illness was one facilitator to the acceptance process mentioned by participants. Moreover, if stigma became internalized and taken on by participants, this further interfered with acceptance. However, if participants were able to draw from and become aware of their personal and cultural strengths in dealing with mental illness, this facilitated the acceptance process.

Participants with multiple marginalized identities reported the oppression of multiple intersecting identities to further interfere with the acceptance process (i.e., racism, sexism, and mental illness stigma). Conversely, participants were able to draw from the added cultural resources offered by their multiple cultural identities to facilitate their acceptance process. Mistreatment in the mental health system associated with the double stigma of mental illness and status from a marginalized group interfered with acceptance of mental illness. Many participants took social action and supported peers with serious mental illness in overcoming mistreatment to facilitate acceptance of mental illness. Last, acculturative stress among immigrant participants added another layer to the racioethnic factors in the acceptance process, sometimes resulting in social isolation for people with mental illness and further interfering with acceptance. Through affirming religious, spiritual, or community supports, participants were able to overcome the isolative effects of stigma to further accept and deal with mental illness in their lives.

Rehabilitation Counseling Implications

The case narratives in the present study suggest a number of important practices for rehabilitation practitioners to work with individuals with mental illness in a culturally sensitive manner. Practitioners should learn about the impact of culture on the experiences of a client with mental illness. It is important to discuss the nature of stigma in the client’s culture of origin and any experiences of mistreatment that might interfere with acceptance. It is also important to investigate the individual’s definition of acceptance of mental illness and the culturally relevant barriers and facilitators to acceptance in his or her life. Practitioners can support the individual in accessing cultural resources that enhance acceptance. In addition, counselors can investigate other community resources that might further facilitate the acceptance process and evaluate the effectiveness of these resources with the individual, for example, mental health support groups that are specific to men or women, various immigrant groups, and racial/ethnic minorities.

The literature suggests additional strategies for promoting culturally responsive rehabilitation for individuals with mental illness. Culturally sensitive care may necessitate the integration of spirituality and traditional healers (Ida, 2007). The acceptance process for immigrants may involve increasing resources and language skills to enhance agency (Ida, 2007). As Spaniol and Gagne (1997) have indicated, acceptance of mental illness can be facilitated by access to the resources needed to adequately deal with the experiences of mental illness. Therefore, culturally congruent care can facilitate the acceptance process through “the acquisition of new skills, job training, language proficiency, or obtaining decent housing” (Ida, 2007, p. 51). In addition, there is a need to be aware of the different racioethnic factors in mental illness narratives and to recognize the complexity and individual differences within cultural groups to avoid stereotyping (Alverson et al., 2007). Although these participant narratives may reflect some common issues within different cultural groups, they are by no means meant to encompass the experiences of all members of that group. There may be variations to which each person identifies with their cultural group of origin, as well as other within-group differences.

Counselors, researchers, and peers can become involved in anti-stigma efforts given the universality of mental illness stigma across cultures (LeVine, 2012; Reddy, Spaulding, Jansen, Menditto, & Pickett, 2010), which may vary in degree and intensity depending on the cultural background and experiences of the individual. Anti-stigma efforts can support the acceptance process among people with mental illness to consider cultural differences in experiences with serious mental illness (Angermeyer, Buyantugs, Kenzine, & Matschinger, 2004). Additional interventions can be utilized to learn about stigma in one’s life and culture, challenge and reduce stigma, as well as facilitate the acceptance process surrounding mental illness. For example, the PhotoVoice intervention, which integrates photography, writing, and psychoeducation, has been used to reduce cultural stigma experienced by individuals with mental illness (Gagne, Bowers, & Russinova, 2010).

Limitations and Future Research

A number of limitations in the present research can be addressed in future research. The present article focuses on racial and ethnic aspects of cultural diversity, and future research may expand beyond this aspect of cultural identity. Cultural identity is broader than solely racial or ethnic background alone. There is a need for research that evaluates the effect of other cultural factors on mental illness and to use research findings to help develop culturally relevant interventions (Primm et al., 2010). These interventions can reduce stigma and facilitate the acceptance of mental illness among people with serious mental illness and within their cultural communities. Future research is needed to further delineate the barriers and facilitators to mental illness, and this research is underway (Mizock, Russinova, & Millner 2013a; Mizock, Russinova, & Millner 2013b).

A small sample size was utilized in the present article to allow for a cross-cultural exploration of the illness narratives of a wide range of racioethnic identities among people with serious mental illness. This small sample size and qualitative focus were selected to provide for more in-depth study. However, the sample size and qualitative methodology of the study pose limitations to generalizability. A larger, quantitative study examining more within-group differences across racioethnic groups would allow for further analysis beyond the primarily European American larger sample of the present study. Further qualitative study focused on each group would allow for additional exploration of within-group variations in a racioethnic culture as well. Although research team members conducted cross-checking to ensure consistency of the case narratives and interview data, member-checking by research participants could further enhance validity in future studies. Follow-up interviews with participants may also address limitations of the single semistructured interview used in the present methodology.

In conclusion, people with serious mental illness face a number of barriers and facilitators to the acceptance process that stem from different norms, values, beliefs, and practices within one’s culture of origin. However, people with serious mental illness from a variety of backgrounds can be supported in drawing from their culture to identify various resources and actions to affirm a positive sense of oneself in accepting and dealing with the experience of mental illness. Additional research and implementation of culturally responsive rehabilitation interventions can help individuals to overcome cultural stigma in the process of acceptance of mental illness.

Footnotes

Acknowledgements

The authors are grateful to Dr. Uma Chandrika Millner for her assistance with data coding, analysis, and interpretation.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the National Institute of Disability and Rehabilitation Research (NIDRR) Advanced Rehabilitation Research Training Program in Psychiatric Rehabilitation CFDA Number 84.133P.

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