Ethical choices arise when ethical questions, complications, or dilemmas emerge. [1] Ethical decision-making is an approach that bases its foundation on ethical codes with a mutual understanding of right and wrong. According to their judgment of right and wrong vs. good and evil, people face certain barriers to mental health care that vary not only between individuals but between cultures as well. As our world advances through the 21st century, communication with many parts of the world within a fraction of a minute allows for limitless exposure to the enormous diversity of human beliefs and practices.[2] This practice through communication allowed many societies to exhibit cultural pluralism as cultural norms from all across the world have translated over to various domains of human society, including healthcare. However, despite the presence of cultural pluralism, universal ethical principles are more widely accepted and practiced with limited tolerance for culturally relevant ethical practices.[2]

To put the universality of ethical principles into perspective, let’s take a look at the following four principles on ethical decision making from the Canadian Code of Ethics:[1]

Principle 1: Respect for the Dignity of Persons and Peoples with an emphasis on non-discrimination, moral rights, and justice. [1]
Principle 2: Responsible Caring involves efficiency, greater benefit than harm, and mutual respect.[1]
Principle 3: Integrity in Relationships valuing sincerity and straightforwardness. [1]
Principle 4: Responsibility to Society where priority is put on benefiting society in a manner that does not breach any of the above principles.[1]

The principles represent a broad and universally applicable code of ethics. Unfortunately, these ethical principles can become subjective to the individual practicing them due to the broadness and influence by mass cultural practices. Within the context of the western healthcare system, the practice of ethical principles is often the center of discussion; however, ethical practice within mental health care has sparked limited discussion, especially surrounding people of color (POC). This is because the ethical codes and collective styles of meaning-making are mostly shaped by western theorists and clinicians with little to no consideration to culturally relevant practices amongst their minority population. As a result, the mono-cultural ethical lenses resulted in ineffective mental health support available for POC.[1][6] In this article, we will discuss the various ethical challenges POC seeking mental health support face in the western healthcare system and how we can challenge the existing practices to be more culturally conscious.

Culture, norms and ethical dilemmas surrounding mental health

Culture denotes a group’s common set of beliefs, norms, and values.[3] It can significantly impact one’s experiences in healthcare settings because it comprises what each person brings to it. [3] One way cultures can impact mental illness is through how patients explain their symptoms to the health care professional. How people communicate their symptoms can be linked to culture-bound syndromes, which are groups of symptoms that are more common in certain communities. Culture can even impact whether people seek help at all, the types of help they seek, their coping mechanisms and support systems, and how much stigma they attribute to mental illness. [3] When appropriate treatment is not established, severe consequences such as extreme suffering, disability, and worse, suicide can be observed amongst the help-seeking population. [3] Culture’s influence also translates over to how people cope with daily problems. For example, Asian American communities tend to prefer avoidance and discreteness, rather than brooding on or openly expressing personal problems. [3] A higher importance is placed on suppression and dealing with it as best as they can. On the other hand, African American communities tend to take a more active stance in facing problems. Spirituality also appears to help them cope with hardship and mental illness symptoms. [3]

It is also important to consider the role of genetics and environment on mental health. The frequency of Schizophrenia is similar across the world with high heritability, i.e., genetic role in the variation of disease in a population. [3] However, exposure to poverty, violence, and factors connected to race or ethnicity, country of origin, and/or socioeconomic status can increase the probability of contact with the stressors associated with depression.[3] Therefore, environment plays a significant role in the cause of mental health conditions, such as depression and post-traumatic stress disorder (PTSD). For example, extremely high levels of PTSD were discovered in Asian Americans and Hispanic Americans who had experienced high levels of trauma prior to immigration.

Some acknowledged differences arise in symptom presentation across cultures. Asian patients, for instance, are more likely to report bodily symptoms but not their emotional symptoms. However, when probed further, they do admit to having emotional symptoms. [3] Patients from different cultures are inclined to express symptoms in culturally-suitable ways selectively. Therefore, healthcare professionals that provide mental health services must remain culturally sensitive. This can be done by taking the initiative to support a patient by determining whether their beliefs clash with the patient’s beliefs. Being more informed about different cultures, customs, and traditions, can allow healthcare professionals to form trusting relationships with their patients. [3]

Critical Race Theory

When discussing mental health support for POC, critical race theory (CRT) is an important academic framework to consider. CRT was first popularized by Kimberle Crenshaw and Derrick Bell and it focuses on the idea that racism is systemic and not just a display of prejudices from select individuals.[4] It argues that racial inequality is incorporated into legal systems and as a result, POCs are negatively affected in public institutions such as schools, the criminal justice system, doctors’ offices, and other parts of life. [4][5] Although the theory is applied more frequently within social sciences, the concept can be applicable across all aspects of human society. CRT’s central message argues that racism is a deeply embedded feature of social structure, constructing racial groups into a social hierarchy and ultimately distributing societal resources unequally within this hierarchy. [4] Therefore, CRT is an important theory to be discussed in the context of ethical mental healthcare support for POC as mental health support and ethics are often created by western white theorists and clinicians for mainly western white populations.[3][6]

When making ethical healthcare principles, it should be noted that human societies are composed of many customs and traditions, and it is not uncommon to see intersections between cultural and religious customs and traditions. Certain beliefs, whether rightfully or wrongfully practiced, can be understood as unethical by the dominant culture; however, only to the extent that the cultural expression is not affected. Such consideration is especially important to keep in mind for POC who may have lived experiences surrounded by a culture that differs from the dominant culture. [2]

Roberts (2021) explored the concept of embodied ethical decision-making and the impact of openness to understanding and providing culturally sensitive mental health support can be effective when supporting POC.[6] Ethical dilemmas are a common issue that many healthcare professionals face when supporting clients with differing beliefs on mental health support as ethical decision-making is often disembodied and justified based on the universal ethical codes as well as the dominant societies’ understanding of right vs. wrong.[6] As a result of this mono-cultural perspective on ethical codes plus potential personal biases of healthcare professionals, mental health support becomes narrow for POC. Hence, Roberts (2021) explored the practice of embodied ethical decision-making (EEDM) to encourage therapists to focus on body language to understand patient needs. The application of EEDM is helpful when navigating ethical dilemmas, especially revolving around race, ethnic, or spiritual association during mental health treatment, particularly in hospital settings.[6] Roberts (2021) also proposed that the three M’s, mutuality, mutual empathy, and mutual empowerment can greatly benefit progression towards bringing greater multicultural diversity in mental healthcare settings.[6]

How Discrimination Impacts Treatment Seeking for POC

Ethnic minorities are less likely than Caucasians to pursue mental health treatment, which mainly accounts for their under-representation in mental health services. [3] Treatment seeking is defined as the ways taken to reach treatment and the types of treatments pursued. The pathways are the succession of networks and their duration once someone (or their family) characterizes their anguish as a health problem.[3] It is crucial to discuss this aspect because ethnic minorities face disparities in gaining access to mental healthcare due to discriminatory behaviour of the providers. Patients are treated differently by the providers such as showing less eagerness because of their racial profile, even though they may be well-grounded. [7] This is in direct contrast with the first principle of the Canadian Code of Ethics and manifests how clinicians can unintentionally violate ethics.

Mistrust has been noted to be a chief barrier to receiving mental health treatment, usually as a result of historical oppression and/or existing struggles with racism and discrimination. [3] It also results from recent and past known maltreatments from clinicians. For example, in a survey it was found that some African American and Latino communities felt skeptical of their health care provider because they were disrespected and treated wrongly as a result of their race or ethnic background. [3]

While many mental health specialists try to deliver treatment that is sensitive to the culture of the consumer, complications can happen. Verbal communication can easily be misunderstood among clinicians and patients even if they speak the same language but come from distinctive cultural backgrounds. [3] Further complications can arise leading to misdiagnosis, disagreements, overtreatment, and poor adherence to a treatment plan. [3] Although, when the patient and clinician do not speak the same language, these difficulties intensify.

Some Ways Practitioners Can Foster a Culturally Inclusive Environment for POC

Cultural humility involves pondering over the knowledge of what one knows and does not know about the values, experiences, meanings, and goals of the individual of a particular group regardless of their affiliation to that certain group/community. [8] In this way, practitioners can self-reflect on their lived experiences and cultural influences so they can be more aware of their blind spots as a result of their privilege in relation to the client. Humility serves as a way practitioners can adapt to their client’s needs with an open mind and healthy curiosity to avoid possibly inaccurate assumptions. [8]

Culturally responsive services have several advantages such as greater client engagement, healthier therapeutic relations, and enhanced treatment retention and aftermath for racial and ethnic minorities. This approach was found to produce the most positive outcomes for the practitioner, the client, and their shared therapeutic alliance. [8]

As mentioned earlier, ethnic minorities may be resistant to engaging in mental health treatment. To promote a more inclusive engagement, there are a few steps that clinicians can take. [8]

• Assert a cooperative environment. This can be established by being supportive and involving family members where needed. Key community members can be incorporated into the process to provide a better mental health network so that clients can feel more connected and be more willing to get better which links back to the second principle of the Canadian Code of Ethics.
• Evaluate barriers to treatment by being culturally sensitive. Practitioners must be conscious of their prospective for causing microaggression towards their client. They may be intentional or unintentional but can convey adverse, offensive, or negative racial insults. Consequently, clients may dwell upon this causing uncertainty, frustration and self-isolation ultimately affecting their engagement in therapy. This strongly supports the first principle of the Canadian Code of Ethics.
• Describe the process. It is imperative for practitioners to provide an explanation of what to expect out of the therapeutic process if the individual has never accessed mental health services before. It will serve to put the client at ease and help in building a stronger relationship between the client and practitioner. This aligns with all the principles of the Canadian Code of Ethics.

Conclusion

Ethical decision-making is significant in generating and sustaining trust, respect, responsibility, and fairness. These traits serve as a foundation for making better decisions by setting regulations for behaviour in a professional setting. Even though there are many ethical opinions people share, ethics may differ from individual to individual, which is largely molded by culture. Therefore, systematic ethical decision-making can reduce conflicts and protect the rights and integrity of people seeking mental health support while also fostering the rise of a righteous society.

References:

1. 1. Canadian Psychological Association. (2017). Ethical Decision Making. In Canadian Code of Ethics for Psychologists (4th ed, pp. 4–4) https://cpa.ca/docs/File/Ethics/CPA_Code_2017_4thEd.pdf
   2. Sheikh A. (2001). Dealing with ethics in a multicultural world: willingness to appreciate less familiar views and traditions is crucial. The Western journal of medicine, 174(2), 87–88. https://doi.org/10.1136/ewjm.174.2.87
   3. Satcher, D. (2001). Chapter 2 Culture Counts: The Influence of Culture and Society on Mental Health. Mental health: Culture, race, and ethnicity: A supplement to mental health: A report of the surgeon general. https://www.ncbi.nlm.nih.gov/books/NBK44249/
   4. Crenshaw, K. W. (2011) ‘Twenty Years of Critical Race Theory: Looking back to Move Forward’, Connecticut Law Review, 43(5), pp. 1253–1354. http://shain003.grads.digitalodu.com/blog/wp-content/uploads/2014/09/Twenty-Years-of-Critical-Race-Theory-Looking-Back-to-Move-Forward.pdf
   5. Iati, M. (2021, May 29). What is critical race theory, and why do Republicans want to ban it in schools? The Washington Post. https://www.washingtonpost.com/education/2021/05/29/critical-race-theory-bans-schools/
   6. Roberts, M. (2021). Embodied Ethical Decision-Making: A Clinical Case Study of Respect for Culturally Based Meaning Making in Mental Healthcare. American Journal of Dance Therapy 43, 36–63. https://doi.org/10.1007/s10465-020-09338-3
   7. McGuire, T. G., & Miranda, J. (2008). New evidence regarding racial and ethnic disparities in mental health: policy implications. Health affairs (Project Hope), 27(2), 393–403. https://doi.org/10.1377/hlthaff.27.2.393
   8. American Psychological Association, Working Group for Addressing Racial and Ethnic Disparities in Youth Mental Health. (2017). Addressing the mental health needs of racial and ethnic minority youth: A guide for practitioners. Retrieved from www.apa.org/pi/families/resources/mental-healthneeds.pdf