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CULTURAL PSYCHIATRY INTERNATIONAL

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CULTURE AND URBAN


MENTAL HEALTH
Giovanni Caracci, MD, and Juan Enrique Mezzich, MD, PhD

Approximately half of the world population currently lives in cities. From


a historical viewpoint the magnitude of urban growth worldwide is unprece-
dented and such a remarkable increment is destined to continue. It is projected
that by the year 2025 the size of urban population will The fastest
growth is occurring in developing countries, especially in Africa and Asia and
it involves poor populations. An estimated 30% to 60% of the world urban
population lives in slums, in degraded and squalid condition often lacking basic
services. Today’s cities are studies in contrast; on the one hand they are centers
of commerce, financing, cultural activities, opportunity, and access to a wide
range of services, recreation, and employment opportunities, on the other hand
they are reservoirs of inequality, injustice, crime, violence, poverty, and social
disintegration. As agents of change cities have always been evolving entities.
Over the past two decades however the pace of changing has accelerated because
of increased speed and decreased cost of communication and transportation. For
the same reasons, compared with the growth of cities during the first phases of
industrialization, cities are growing increasingly diverse in their population. As
a consequence of these major demographic shifts cultural factors have taken
center stage in our understanding of culturally mediated aspects of urban mental
health and a culturally attuned delivery of mental health in urban areas. This
article intends to highlight the main themes of a vast body of literature on
the subject. The complex interplay of sociologic, economic, environmental, and
political aspects in the life of a city makes grasping its cultural dynamics and
their impact on mental health a daunting task. For that reason we have chosen
to focus on select themes that illustrate the compelling relationship between
cultural aspects and mental health within the urban context.

From the Section on Urban Mental Health, World Psychiatric Association (GC, JEM); the
Division of Psychiatric Epidemiology and International Center for Mental Health
OEM), Department of Psychiatry (GC, JEM), Mount Sinai School of Medicine, New
York University, New York, New York

~~

THE PSYCHIATRIC CLINICS OF NORTH AMERICA

VOLUME 24 * NLTMBER 3 * SEPTEMBER 2001 581


582 CARACCI & MEZZICH

CULTURAL PAlTERNS IN TODAY'S CITIES

The cultural values expressed by city dwellers are a reflection of a variety


of variables that form patterns of cultural trends for each city. Examples of such
variables include the speed and organization of migratory waves, the climate of
acceptance or rejection of diversity within each city, the integration of the
cultural values within the prevalent culture of the city, and the socioeconomic
and environmental condition within which such cultural patterns manifest them-
selves. The process of urban renewal itself is shaped by these patterns, which
are by nature very uneven and often unfair from a social justice standpoint, as
in the case of minorities in central cities neighborhoods.

Cultural Diversity in Today's Cities

Increased opportunities for geographic and social mobility have created the
premises for an unprecedented multiethnic influx to cities. As an example, in
the quintessential metropolis, New York, almost 10% of the population is com-
prised of first generation immigrants, 50% of whom are from countries other
that the Americas." Some areas of the borough of Queens are regarded as the
most ethnically diverse in the world, with its 250,000 inhabitants speaking 80
different mother tongues and coming from 123 different countries.37This coun-
try's total ethnic composition is also rapidly changing as it is projected that by
the year 2050 one out of four inhabitants will be of Hispanic descent. On the
one hand this wealth of mostly motivated migration in many cities is changing
the practice of psychiatry as the complexities of cultural aspects of psychopathol-
ogy and mental health are woven with the layers of adaptation to migration
and city living, creating the scenario for a challenging learning process for
mental health professionals, patients and the entire mental health system. On
the other hand negative implications of this much varied migration include
among others compounding complexities of diagnostic problems, provision of
care that needs to surmount often unsurmountable problems, temporary stress-
related psychopathology health care professionals may be unfamiliar with, and
reluctance to use facilities, with significant delays in assessment and treatment
of both acute and chronic conditions. Therefore, juxtaposed in most urban
realities are the many advantages of multiculturalism including increased toler-
ance, improved quality of life, social stimulation, and health promotion, and
contrasting yet overlapping negative aspects such as heightened social tensions,
cultural conflicts, intra- and interethnic strives.

Migrations/Acculturation/CulturalAdaptation

Migratory waves to the cities have become the norm during the last century
as opportunities of industrialization first and globalization after became an
irresistible siren for rural populations. In the past, however, migration to urban
areas was often intranational, the most recent migration has acquired a trans-
national connotation, facilitated by the blurring of national boundaries and the
advances in communication and transportation. Although rural migration is not
an uncommon phenomenon, most immigrants, especially the ones who cross
national borders move towards cities, in search for job opportunities. The study
of migration, both internal and external, can be viewed as a study of adaptation
to city life, a kind of urban acculturation with all its mental health correlates. It
CULTURE AND URBAN MENTAL HEALTH 583

should be noted that the term acculturation can fuse adaptation to a new,
challenging urban environment, on the one hand, and adaptation to a new or
alternative system of symbols, meanings, and traditions, on the other.
The process of adaptation and acculturation in immigrants has been de-
scribed as an experience with a range of patterns and outcomes that vary from
immigrant to immigrant. For example Khoa and Van DeusenZ9in addressing
acculturation across communities marked by differences in traditions and cus-
toms describe three patterns of acculturation, a rejecting pattern, with the refusal
to adapt to the new culture, most commonly seen in the elderly, the assimilative
pattern, expressed by the embracing of the new culture and its values, most
often noted in the very young, and the bicultural pattern, often exhibited by
young adults, an integration of selectively chosen values of both cultures. In the
first two patterns immigrants can incur the risk of a variety of stressful situations
and circumstances that may foster anxiety, identity confusion, marginalization
and isolation. Biculturality on the other hand has been seen as the best possible
compromise in a context of acculturation across two contrasting communities,
leading to a more adaptive Indeed preliminary findings on quality of
life in immigrants who happen to reside in urban communities have confirmed a
higher quality of life in patients who manage to acquire dual cultural identity
or at least integrate them. A stressful adjustment to the complex mix of tradi-
tions, customs, systems of beliefs and meanings, and opportunity structures that
are found in a city of a host society depend on personal variables such as coping
skills, age and social support, and on the nature of acculturation based on the
presence of discrimination and prejudice in the host city.6 Ironically, in certain
cities, Western and non-Western, biculturality is overtly discouraged and even
viewed as maladaptive or threatening to political stability. Values attached to
the acculturation process itself including its outcomes need to be taken into
consideration in the appraisal of adjustment patterns including cultural identifi-
cation of migrants and immigrants who encounter alternative traditions, values,
and religion in a host society.
A large contingent of people migrating to cities are refugees from their
countries. There are over 18 million international refugees and 24 millions
internal refugees (within the borders of their own countries) worldwide. This
represents a massive movement of relocating individuals, which can overwhelm
cities easily and even destabilize countries. A cogent example of how the men-
tally ill and the healthy are affected severely by huge waves of internal displace-
ment is offered by Bogota, Columbia’s capital, recently brought on the verge of
collapse by hundreds of thousands of Colombians fleeing terrorism.12Refugees
have often been exposed to a wide range of traumatic experiences that may
considerably alter their ability to adapt to the urban realities of the new culture.
As a consequence, a large number of refugees suffer from post-traumatic stress
disorder and other mental disorders. In the United States numerous studies on
the mental health of refugees comes from Minneapolis in Minnesota where
South East Asians refugees are comprehensively and prospectively assessed by
Westermeyer and co11eagues.46 In one of these studies, over the course of 10
years, refugees’ symptoms of depression, low self esteem, phobia, and somatiza-
tion improved, but other symptoms such as paranoia and anxiety
indicating long-term effects that may interfere with their process of accultura-
tion.
Moreover, cultural dimensions of post-traumatic stress disorder are likely
to affect the process of acculturation and adaptation to urban life. Green19 has
indicated some generic dimensions of trauma: (1) threat to life and limb; (2)
severe physical harm or injury; (3) receipt of intentional harm or injury; (4)
584 CARACCI & MEZZICH

exposure to the grotesque; (5) violent or sudden loss of a loved one; (6) wit-
nessing or learning of violence to a 'loved one; (7) learning of exposure to a
noxious agent; and (8) causing death or severe harm to another. It can be argued
however that even though dimensions such as one to three may be regarded as
universal, for other dimensions there can be found exceptions that are based on
cultural beliefs. The cultural relativity of these dimensions is exemplified by the
acceptability of the dimension 8 in certain cities in war-torn countries, where
killing for a cause may actually be considered heroic, especially if the perpetrator
is a child.I3The wide variety of meaning different cultures assign to manifesta-
tion of distress after a traumatic experience is outlined by Kirmayer, who
emphasizes the inadequacy of our classification system to categorize what in
some contexts are culturally accepted dissociation and the somatization.**In
some cultures dissociative phenomena are considered normal response to certain
stress and even a necessary step towards re-establishing a personal sense of
balance. Similarly somatization in relation to a traumatic event is the norm
among many Asian and Mediterranean cultures. A good understanding of
culturally determined reactions to stress in refugees moving to urban areas is
fast becoming required knowledge for mental health professionals.

SOME MAJOR URBAN PROBLEMS

Violence in Urban Areas

The Scope of the Problem


Violence is an endemic reality for most cities in developed and developing
countries. It is estimated that violence claims at least 3.5 million lives a year.5o
In high and low income countries interpersonal violence ranks third among the
leading causes of death in people aged 14 to 44, and fifth in high income
countries in the 5 to 14 years of age group. The cost of violence is calculated to
be $500 thousand million a year in medical care and loss of productivity as,
interpersonal violence is third in the list of the main injury related cause of
Disability Adjusted Life Years, after road-traffic injuries and falls. The burden of
injuries related to violence is therefore a significant public health issue.32The
Latin American and Caribbean Regions have the highest rates of homicide and
criminal victimization in the world. Social tensions brewing in a climate of social
polarization are often fertile ground for urban expressions of aggression. In a
World Bank study, M0se13~demonstrated that increasing inequalities in urban
areas in four Latin American Countries (Ecuador, Jamaica, Mexico, and Vene-
zuela) were associated with an increase of youth, gang, and community violence.
Interpersonal violence in urban areas affects especially vulnerable popula-
tions such as children and women. The young populate urban areas especially
in developing countries. By the year 2025, 6 out of 10 children will live in cities.
Because of constant rural-urban migration and high fertility rates, it is calculated
that about 50% of the urban population in developing countries is below 25 and
that in Latin America 35% of the population is below 14. There are approxi-
mately 30 million street children worldwide, the majority in urban areas and
involved in illegal activities.
Violence against and among children is a widespread urban phenomenon.
The form it takes and the extent of its acceptance are culturally sanctioned. For
example, parental attitudes towards corporal punishment vary a great deal
among cultures as in some, it is seen as a necessary part of the education
CULTURE AND URBAN MENTAL HEALTH 585

process. One can see the importance of recognizing what according to western
thinking would be considered child abuse in a patient who considers being
beaten by his or her parents and a normal part of his or her upbringing. In a
study providing a link between cultural norms and extreme forms of violence
Baron and Strauss5 found a correlation between homicide and an instrument
they had developed (index of legitimate violence, according to various cultural
norms in different American States). Domestic violence is highly prevalent in
urban areas. Men are the perpetrators of virtually all the domestic violence,
although in developed countries the rate of child and spousal abuse by women
is increasing sharply. Substance abuse and poverty are mentioned repeatedly as
risk factors. Nevertheless a crucial role is played by attitudes about when
violence is justified and what role the abuser has in the family. For example, the
Pan-American Health organization has highlighted how in certain inner cities
resorting to violence to settle disputes is culturally supported and accepted
within the community.
Mass media also play a role. Huesmann and GuerraZ3inquired about norma-
tive beliefs in young urban kids with question such as when it is allright to do
certain things such as yelling or kicking. This research shows that children learn
the scripts of aggression from the media. In this area the work on social learning
by Bandura4shows that the most aggressive children have three main character-
istics. First, they give moral justifications for what they do. Second they use
projection, blaming others for their behavior. Third, they tend to dehumanize
victims. These three elements have been known to be used by media in their
depiction of violence. The characters are often described as living in cities that
offer a much more familiar background to violent scenes.
A typical urban phenomenon is gang violence, which accounts for 20% of
homicides due to gang warfare where the fight is over drugs in the United
States. In Nicaragua, half of the crimes are committed by youth gangs.4O Gangs
have rules and modus operandi that vary considerably from culture to culture
and even within the same cultures. They are usually involved in illegal, criminal,
and violent activities, considered by society to be the norm in these groups. And
they are found in inner cities, where the social environment of degradation,
poverty, unemployment, and drug use contributes to an explosive blend favoring
violent solutions. Latin American gangs have been studied extensively. Examples
of Latin American gangs include the Brazilian quadrillias, mostly drug-trafficking
males between 13 and 25. Fights among gangs for territory and supremacy tend
to be murderous. Argentinean barras de la esquina are by and large nonviolent
except for clashes with police. They meet at night to talk, play soccer, drink, and
smoke marijuana. Relationship with community is very poor and they appear
to be very isolated. Columbia sicarios join for money and prestige. They are
hired to kill people (politician, cops, and dueling gangs) and they are involved
in other illicit activities. These gangs are related to drug cartels and may act as
vigilantes or turn on the community. Finally, Nicaraguan pandillas roam the
streets of the barrios and are involved in petit delinquency. Violence erupt with
police and other gangs but they usually do not harm the Familiar-
ity with how gangs operate what their code of ethics and normative rule are
and their relationship with the community are likely to enhance the mental
health care delivery in inner cities, and are necessary to address the contextual
issues concerning assessment and treatment plans.
In cities in developed and developing countries women are at greater
risk than men of being assaulted by intimates.= Violence against women is a
multidimensional phenomenon that reflects the multitude of roles women play
in society, including gender, sexual, reproductive, marital, and family roles, each
586 CARACCI & MEZZICH

of them heavily influenced by culturally held belief systems. The subordinate


role women have in many cultures often colors the violent encounter with
coercion, humiliation, and deprivation.” This complex array of variables in-
volved in interpersonal violence against women defines the physical, sexual,
and psychologic nature of violence occurring in the family, in the community,
and coercive practices concerning reproduction. Prevalence studies of physical
and sexual violence show a wide variation among different cultures with a high
percentage in countries such as Australia and a low percentage in other countries
such as Canada. The estimated prevalence is that from one fifth to one third of
all women will be physically assaulted by a partner during their lifetime.3 In a
large size study in the United States, Koss30 found that 24% of the women
interviewed had been victims of forced oral, anal, or vaginal intercourse and
21% had experienced a completed forcible rape. Examples of Nonwestern sites
include a Papua New Guinea Study (over half of the women were beaten by
their partners), Sri Lanka (51% of a sample of 200 reported being attacked with
a weapon, Japan (in a sample of 796 women surveyed nationally, 59% of battered
women were also raped by their partners. Pregnancy seems to be a risk factor
for violence as a large number of women (depending upon the culture) are
traumatized during this period of their lives.31Unplanned pregnancies also are
considered a risk factor for violence.I8Substance abuse is implicated in a large
number of domestic violence situati0ns.2~Major risk factors are poverty, unem-
ployment, and homelessness.
Depression and anxiety, post-traumatic stress disorder, and suicidality have
been studied in victimized women. There are few studies, however, that look at
what constitutes positive health and mental health outcomes in the treatment or
prevention of interpersonal violence in women. Andrews and Brown2 in their
longitudinal study found the improved self-esteem was associated with im-
provement in work status and positive changes in the quality of close relation-
ships. Social support and the presence of confidants or close relationships appear
to be significantly protective against violence.I6Conversely, negative social rela-
tions are associated with poor health 0utcomes.4~ Building the woman’s esteem,
autonomy, dignity, ability to work, and social networking seems to be crucial in
the reduction of violence and of its psychologic consequences.Certainly all these
protective factors may be difficult to find out in dilapidated urban areas, espe-
cially in cultures where women’s independence and assertiveness is discouraged.

Hornelessness

One of the most severe and humiliating stressors of today’s urban reality is
homelessness. In developed and developing countries the homeless population
is growing at a fast pace. Ironically even in cities that experience a recent
economic boom (or perhaps because of the unavailability of affordable housing
for many) such as New York, the number oh homeless people is rapidly increas-
ing. In studies done among the homeless, a large percentage (up to one third)
have been found to be affected by severe mental illness? As cities swell exponen-
tially in conditions of socioeconomic deprivation, the composition of the home-
less population also changes, with many of them being children and women.
Moreover, whereas in the past in developed countries the homeless was mostly
mentally ill or substance abuses, a large number of homeless is neither. Home-
lessness is often the consequence of violence, poverty, and inability to afford a
house. Among homeless women there is a high rate of battery, rape, mental
distress,15 and depression. Substance abuse suicide attempts and physical ill
CULTURE AND URBAN MENTAL HEALTH 587

health are commonly found. If one extends the notion of homelessness to people
who live in precarious housing with lack of security of tenure and personal
safety, it is easy to apply these severe stressors to people living in slums,
informal housing, or squatter building in inner cities? Blue et a1 demonstrated
that for women living in urban areas in India, Chile, and Brazil, having a low
income, living in slums, and being uneducated were associated with high risks
for mental disorders because of severe stres~ors.~ International agencies such as
the United Nations Department of Economic and Social Affairs (DESA) and
United Nations Center for Human Settlement (HABITAT) working securing
housing and tenure in cities worldwide often have to overcome cultural barriers
that consider homelessness and insecure tenure part of the normal landscape of
city living. As a consequence it is usually easier for these agencies to work on
the city infrastructures than on its cultural values. This is the reason why recent
efforts have focused on rebuilding communities rather than only structures.

Work and Mental Health

The drive to create new jobs fueled by new economic realities has not been
matched by a successful effort to help the workforce acquire new vocational
skills. If this phenomenon is true in the well-adjusted urban population, it is
particularly significant for its consequences on the marginally functioning and
emotionally vulnerable citizen. In a recent report on mental health and work by
World Health Organization and the International Labor Organization the authors
clearly indicated progress in reintegrating mentally ill patients, in rural areas in
various countries by using family and community support. The report states,
”In the large fast-moving areas, with crowded living space and no alternative
accommodation available, the situation is often quite difficult.”zoaBut even this
finding presents cultural exceptions.20The influence of cultural factors especially
linked to prejudice and stigma on the functioning of patients with mental illness
in urban areas remains a central obstacle to the reintegration of psychiatric
patients. The same report by the International Labor Organization found that
there is a growing awareness that disability is not so much an impairment of
the individual as a product of the environment in which he or she lives.
Research findings on potential predictors of successful patients’ participation in
employment programs show that, among the most relevant variables, are work
expectations (those to be expected to be working within a year were 4.5 times
as likely to be enrolled in the program) and attitudes about work as source of
pride and accomplishment.1°It is easy to see the potential impact of cultural
values on these variables. This is an issue where cultural and economic realities
meet at a cross road, especially in developing countries where the limited
availability of jobs in today’s economic reality may further exacerbate hostile
and discriminatory practices against the mentally ill, who are relegated further
in the lowest priority group for access to gainful employment.

CULTURAL CONSIDERATIONS ON PSYCHOPATHOLOGY IN


URBANAREAS

Although one can’t generalize about some recent findings related to urban
living, the effect of cultural variables accounts for much of the variance of
findings in different parts of the world. For example urban areas are known to
have high levels of tobacco consumption, traffic accidents, fatalities, and obe-
588 CARACCI & MEZZICH

~ $ 7 . ~Yet
~ in the Western world, because of sociocultural pressures concerning
certain habits such as smoking and overeating, these two problems are much
less prevalent than in less developed countries. Perhaps the main study featuring
cross-national comparisons of the prevalence and correlates of mental disorder
is the World Health Organization (WHO) from the consortium on psychiatric
epidemiology. Using a WHO version of the Composite Diagnostic Interview
(CIDI) this study described the findings in seven countries in North America,
Latin America, and Europe. In the five countries where urban versus rural
comparisons were available there was a consistent pattern of mental disorders
being more prevalent in urban areas.5l
The discussion of diagnostic entities and urban life usually intersects with
one on socioeconomic status, which is an important variable in inner cities. In
addition to having higher rate of mortality and morbidity in his study Heltzer
found a 6-month prevalence of any DSM-I11 disorder to be 2.86 times higher in
the lowest socioeconomic status group than in the highest.22A review of various
studies by Doherenwend showed a strong evidence that schizophrenia, major
depression, antisocial personality disorders, and substance abuse were more
common in the low socioeconomic status (SES) group.I4Finally, a lifetime preva-
lence study by Kessler showed the lowest income group to be more likely to
have affective disorders, anxiety disorders, substance abuse disorders, and anti-
social personality disorderZ6Theories on the reason for these findings range
from a natural selection of predisposed individuals by the lower socioeconomic
strata to a more contextually oriented view of adverse environmental and stress-
ful factors accounting for high levels of mental imbalance. Both of these theories,
however, have their cultural correlates. In the former, cultural determinants such
as attitudes towards the mentally ill might have a great influence of the drifting
of untreated individuals towards the lower layers of society, and in the latter
culturally sanctioned attitudes about the disabled or impaired may hamper
chances of reintegration. The relationship between social ranking and psycopa-
thology is also relevant to the study of urban expressions of psychopathology.
For example, Gilbert and Allan have recently developed scales to research the
role of entrapment and defeat within the framework of the social rank theory.17
Ample evidence already exists that feelings of inferiority, low self-esteem, shame,
and being of low rank are commonly found among depressed people.’ This is a
promising area of research for urban mental health as entrapment, loss, defeat,
humiliation, and a sense of being in danger are common theme in urban areas.
Regarding schizophrenia the influence of cultural factors has been studied
especially in relation to its outcome. The International Pilot Study of Schizophre-
nia (IPPS) was designed to transculturally compare over 1200 patients in nine
countries, using rigorous and culturally adapted methodology. The main finding
of the study was that schizophrenics in developing countries tend to have less
severe course and outcome than the ones in developed countries. The authors
also concluded that the outcome may be more favorable in rural settings.&The
cultural relevance of this finding for urban mental health may lie in the report’s
finding that in addition to rural settings, favorable outcome seemed to be
associated with little vertical mobility, extended families, psychiatric services
that include the active participation of the family and the absence of specific
community stereotypes of the mentally i11.4s*49 This clearly brings to the fore the
discussion of the issues of cultural expectations, support systems, especially
family, and of stigma and how severe mental illness is viewed by urban dwellers
in various cultures. Specifically it appears that culturally determined high toler-
ance for mental illness appears to have a significantly positive impact in devel-
oping countries. In an effort to understand the reason for such findings, the
CULTURE AND URBAN MENTAL HEALTH 589

Determinants of Outcome of Severe Mental Disorder (DOSMeD) study was


~ndertaken.2~ On all the indices of outcome measured patients with a diagnosis
of schizophrenia living in developing countries had better outcomes than in the
developed ones. Among the most intriguing findings was that the index of
outcome-based on impaired and unimpaired social functioning throughout the
follow up was 41.6% in the developed countries cohort as opposed to 15.7%in
developing countries. How much of this huge difference can be accounted for by
the local cultural expectations for functioning remains an unanswered question
awaiting further inquiry. Another effect of culture on outcome of schizophrenia
in urban area comes from the copious literature on Expressed Emotions (EE).
Leff et aF3 compared a sample of schizophrenics in an urban area in India with
a cohort in London and found that lower proportion of expressed emotion in
the Cachanga, India sample may account for better outcome in schizophrenic
patients. The pathoplastic effects of culture on schizophrenic symptomatology
have been demonstrated in studies comparing symptoms of schizophrenic pa-
tients in Indian cities and cities in the developed world. For example in his
sample Varma" found the onset to be more frequently acute more often catatonic
than the paranoid and disintegrative type and other symptoms such as loss of
interest in sex, and loss of sleep and appetite. Confirming the complexity of the
impact of culture on the manifestation of the illness even within the same
culture, the authors found that, compared with the rural cohort of Chandigarth,
the urban sample had more frequent hallucinatory and persecutory experiences,
claiming impossible things, and fear of being harmed or bewitched than in the
rural sample. This study's interesting methodology offering different levels of
comparisons, within its culture and across different cultures, could find wider
applications in larger samples.

CULTURAL CONSIDERATION IN THE DELIVERY OF URBAN


MENTAL HEALTHCARE

Over the past few years, interest in providing culturally competent mental
health services in cities has increased considerably. Driven among other consid-
erations by a need to optimize care by decreasing costs and properly allocating
resources, a few agencies such as the Substance Abuse and Mental Health
Services Administration have pioneered programs complete with performance
indicators that cut across all levels of delivery of mental health. Cultural compe-
tence is viewed as a must because of the imperative on delivering better care
and because many ethnic groups are highly mistrustful of the entire structure of
the system. Thus, increasing competence also means attracting patients to a
welcoming, sensitive, and respectful environment that values diversity and
tailors the patients' needs to the system. Some ground braking programs with
Asian and Latino focus have proven highly effective. Nonetheless, despite of all
the talk about culturally competent services, much remains to be accomplished
in the field. In the United States, one of the clearest examples of words not
matched by facts is the virtual absence of requirements by accreditation agencies
in the educational and administrative arena and of criteria for cultural compe-
tence to be met by institution and staff for proper certification. Unless cultural
competence becomes an institutionalized program requirement permeating ev-
ery level of the organizational structure including regulatory agencies, it is
destined to remain unlikely to get translated into real change for minorities and
ethnic groups in our cities.
Within the day to day activities of an institution, attempts have been made
590 CARACCI & MEZZICH

to incorporate the inner cities multicultural diversity in a way conducive to


proper treatment. To address the mistrust that some cultures often have towards
traditional medicine it may be desirable to combine folk approach with psychiat-
ric ones. For example Ruiz and L a n g r ~ dworking
~~ with the community in
the Bronx, became involved with espirifisfas (traditional Hispanic healers) in a
systematic fashion. Their involvement included identification of medium, visits
to spiritual centers to observe how they operate, exchanging views with medi-
ums, reciprocal referrals, research for training non-Hispanic staff and plans for
sharing training workshops.
Folk and religious healing practices have great significance in urban mental
health as they are often the first line of treatment. Across cultures these practices
present common traits and differences. Although some main stream religious or
folk healing may have been made popular by various media, there exists other
more marginal belief systems and healing methodologies that are not well
known among clinicians and are based not so much on religious beliefs but on
superstitious ones. In a recent article on the topic, LeafleyM summarizes the
main characteristics of folk and religious healing also known as traditional
healing. The cause of the disturbance is usually considered to be supernatural
or divine, which provides individuals with balance and purpose. Failure to
follow the supernatural rules may lead to disruption of such balance, with
consequent physical or mental illness, disrupting in turn interpersonal contacts.
The only interventions that restore the balance are communicating with the
supernatural agents and by relying on ritualistic performances often involving
families designed to restore the equilibrium of biologic needs, spiritual harmony,
and individual and cultural attachment." Understanding these belief systems
and integrating these approaches into the modern mental health system may be
the only approach to delivering culturally sensitive and effective mental health
within inner cities.

SUMMARY

The previous panoramic view provides sufficient evidence that cultural


understanding of urban realities and expressions of their impact on mental
health are necessary for a successful approach to mental health in cities. The
issues go beyond understanding how urban realties and cultural issues differ in
New York from Jakarta; every city has a variety of unwritten cultural norms
that permeate every aspect of its mental health. Unless these norms are under-
stood within the dynamic structure of city living, any attempt to intervene on
mental health programs will be doomed to failure. Understanding the cultural
blueprint of a city, however, is only the first step, as we need to shed our cultural
assumptions while we consider contextual socioeconomic and political factors
for each city. Finally we need to adapt our western view of cultural values and
how citizens function or do not function within the urban environments. Because
each city in is its own culturally specific entity, the three steps outlined pre-
viously can help create an accurate portrait of what is needed to implement
culturally sensitive changes. A paradigm shift, laid on a bicurcated foundation,
on the one hand a locally attuned awareness of urban cultural dimensions and
on the other educational programs based on extensive knowledge of worldwide
problems such as stigma, gender-specific issues, disability, and the plight of
vulnerable populations can potentially have far reaching implications on mental
health policy changes addressing the cultural needs of cities.
Urban mental health is poised to be one of the central issues for the next
CULTURE AND URBAN MENTAL HEALTH 591

few decades, because of the size of the world urban population and because of
the protean nature of its problems. Cultural factors interplay with urban dynam-
ics in a unique, at times creative, other times destructive, fashion. Under condi-
tions of socioeconomic disadvantage vulnerable individuals who lack adaptive
mechanisms may become mentally ill or experience an exacerbation of their
mental illness. Understanding how cultural dynamics articulate with adaptation
to urban life may greatly enhance our ability to properly assess and treat mental
disorders in cities. In the assessment and treatment of patients living in urban
areas contextual cultural factors rather than being merely complementary as-
sume a preeminent if not crucial role.

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Address reprint requests to


Giovanni Caracci, MD
Department of Psychiatry
Mount Sinai School of Medicine
(Cabrini) Program
227 East 19th Street
New York, NY 10003