Help-Seeking Determinants and Ideological Barriers

The Sociocultural Context

Culture is a social context in which people share social norms, beliefs, values, language and institutions (Guerra & Jagers, 1998). It provides a cognitive map of unwritten rules for living (Leininger & McFarland, 2002) and a framework for interpreting and giving meaning to personal experiences (Lindisfarne, 1998). Thus, the culture of a people is a model for human behaviour as people generally act in ways that correspond to cultural influences and expectations. Culturally constructed beliefs function as a prism in perceiving mental health issues and shaping pathways for helpseeking (Leong & Lau, 2001; Tabora & Flaskerud, 1997). People can feel ‘trapped’ within the values of tradition which affects perceptions of mental health issues and may inhibit willingness to engage with services (Gilbert, Gilbert, & Sanghera, 2004; Sen, 2001).

Arab women, for instance, can feel obliged to operate within a set of norms of family and community honour that can override personal concerns (Kassam, 1997). Living in a society that is both collectivist and paternalistic, these women see no acknowledged legitimisation for deviating from the traditional path. In these cultures, women can perceive themselves as ‘carriers’ of family honour, requiring them to modulate their actions so as not to dishonour or bring shame upon the family. Exploring psychological distress and self-harm, Chew-Graham and colleagues (2002) found that Tzzat’ (a set of norms of family and community honour in Asia) could be used to reinforce a woman's subordinate role in family life and to coerce women into remaining silent about their problems.

Asian students were found to be far more focused on external shame (what others think) and reflected shame (shame they can bring to others, e.g. family), than non-Asian students. Yet they do not suffer any less from internal shame (Gilbert et al., 2007). Studies of Asian and African immigrants in Western cultures also show that the more closely people adhered to their ethnic, cultural values, the less likely they were to seek professional psychological help for mental health concerns (Essandoh, 1995; Hamid, Simmonds, & Bowles, 2009).

As Cauce and colleagues (2002) noted, when salient and valued social norms are incongruent with formal service use, individuals will inevitably be influenced not to seek help. For instance, sociocultural norms such as a high regard for saving face characteristic of the Igbo culture of southeastern Nigeria may deviate from the basic principles of formal treatment such as disclosure and may inevitably translate into underutilisation of professional mental health services. This is reflected in 74.9% of the respondents in the case study of south-eastern Nigeria (Ikwuka, 2016) indicating that, before discussing the mental health problem of someone close to them, they must be sure they are talking to someone they can trust with a secret. Similarly, 61.3% of the respondents believed that problems such as mental illness are better handled privately because of the shame they could bring. Mental illness is a taboo in this culture, and discussions about it are treated with utmost confidentiality beyond the formality of data protection. The mental health crisis of a family member is among the things that are discussed in hushed tones, and it could be very unnerving to be openly identified with a psychiatrist or psychiatric hospitalisation.

Drummond and colleagues (2011) discovered that shame was a significant factor dissuading West African refugee women in Australia from seeking help for mental illness. A further cultural twist to the finding was that the more educated among the women felt more shame being associated with mental illness than the less educated. This surprised the Australian researchers presumably because they had supposed that education would have a moderating effect on the sense of shame. But this is not the case in a cultural setting where social conformity is achieved through the use of ‘shaming’ (including public booing) as a sanction against culturally unacceptable behaviour (Nzewi, 1989). Thus, in their socialisation, shame is associated with deviance such that ‘higher status’ and more educated individuals would be much more wary of a situation that would bring them shame. Until psychiatric illness is normalised in such regions, to be culturally appropriate, services must proceed with the utmost confidentiality.

Moreover, the dichotomy between the unitary African and dualistic Western conceptions of reality could be reflected in the people’s helpseeking behaviour. As Lambo (1978) observed, the African world-view does not discriminate between the living and non-living, conscious and unconscious, natural and supernatural. These pairs which are conceived of as opposites in the West are realised as unities in Africa. For instance, there is a deep sense of reverence for ancestors, who are believed to intervene actively in the affairs of the living. Such a vision of reality, whereby the seen and the unseen dynamically interrelate, contrasts with the dualism of the West, such that an experience like hearing of voices, which could easily be pathologised as a hallucination in the latter,

Help-Seeking Determinants and Ideological Barriers 67 could, for instance, be welcomed in the former as communication with ancestors - a spiritual gift (Furnham & Igboaka, 2007; Nwoko, 2009). A similar experience is reported of indigenes in the Pacific island of Bali who believe that to become a traditional healer, one has to experience an episode quite similar to psychosis which, when resolved without active treatment, is confirmation that an individual has been selected super-naturally to be a healer and hence endowed with special ability and powers (Stephen & Suryani, 2000). Against such backgrounds, Dinos and colleagues (2017) contend that for experiences to be labelled as psychotic, they need to be unexplainable from a cultural perspective or from what would be considered acceptable in a local context and by the peer group of the patient.

The unitary vision of reality is also consistent with the relatively greater somatisation of distress reported in sub-Saharan Africa whereby psychological problems present in physical symptoms, a tendency associated with seeking treatment for mental health problems in the general medical rather than the psychiatric sector (Alegria et al., 1991; Corrigan, Druss & Perlick, 2014). Ranguram and Weiss (2004) considered that generally, physical illnesses tend to be associated with lesser stigma than mental illnesses, and this may contribute to a high presentation of somatic complaints in patients with underlying mental illnesses in areas where there is low mental health literacy. Here, doctors are consulted mostly for physical symptoms, hence the undiagnosed persistence of psychological distress.

Russell and colleagues (2008) found that a greater number of immigrant students presenting with more severe mental health symptoms felt the need to seek help from medical health professionals rather than counselling services. Compared with American students, who tend to experience stress as anxiety and/or depression (Aubrey, 1991), foreign students struggle with the discrimination between emotional distress and somatic illnesses and may attribute their problems to organic processes (Flaskerud, 1986; Russell, Thomson, & Rosenthal, 2008). This could lead to a delay in psychiatric help-seeking.

Somatisation may also be indicative of a lack of emotional competence (the ability to identify, understand, describe and manage emotions in an effective manner) which has equally been linked with poor help-seeking behaviour (Ciarrochi & Deane 2001). Nwokocha (2010) observed that language plays an important role in how a person communicates mental health concerns and that a person’s inability to express their symptoms, or a practitioner’s inability to understand symptom conceptualisation can influence and even change the attitude of the mental health provider. On the other hand, it was also observed that some clinicians from Western cultures fail to recognise or appreciate the seriousness of somatised symptoms expressed in some of the immigrant cultures and, as a result, not all the symptoms are being addressed (Nwokocha, 2005).

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