Research roundup: Cultural and societal considerations when treating women of color

Until recently, most mental health research was conducted primarily with White participants. Now, research is becoming more inclusive, helping to pinpoint how people of different racial and ethnic backgrounds experience or manifest symptoms of mental illness.

One important finding is that while racial and ethnic-minority groups are just as likely as White Americans to experience mental health issues—or in some cases, more likely—members of such groups are often less likely to seek mental health resources or to have access to such services. For instance, Black individuals are around 10% more likely to experience severe psychological distress than non-Hispanic White individuals but are less likely to seek help (Brody et al., 2018).

Meanwhile, more than one-third of Latinas in the United States have experienced symptoms of depression (Bromberger, Harlow, Avis, Kravitz & Cordal, 2004), and young Asian American women have reported some of the highest suicidal ideation rates across all racial and ethnic groups of their age (Kim, Park, Storr, Tran & Juon, 2015; National Center for Health Statistics, 2012).

Below are several new studies on the mental health and treatment challenges faced by women who identify with specific racial and ethnic-minority groups. Throughout these summaries, we use the racial/ethnic terms used by the authors of the studies.

Overall, the studies offer further insight into the ways that internalization of stereotypes or cultural expectations can negatively affect women of color. The findings also underscore the need for psychologists to be informed, creative, and adaptive to effectively meet their patients’ needs, such as by fostering the development of a supportive social network, tailoring outreach efforts to a patient’s needs and cultural expectations, incorporating a social or environmental framework into treatment, and otherwise meeting the unique needs of women of color.

Abrams, J.A., Hill, A. & Maxwell, M. (2019). Underneath the mask of the strong black woman schema: Disentangling influences of strength and self-silencing on depressive symptoms among U.S. black women. Sex Roles, 80, 517–526. https://doi.org/10.1007/s11199-018-0956-y

In this study, Abrams and Maxwell offer a quantitative look at how aspects of the Strong Black Woman (SBW) Schema relate to depressive symptoms in Black women. The SBW Schema is defined as a combination of beliefs formed in response to the oppression that Black women have historically faced. It includes expectations of “incessant resilience, independence, and strength,” and has been linked to negative mental health and treatment-seeking behaviors in Black women.

In this study, researchers recruited 250 women, ages 18 to 82, from universities and local community centers. Almost 80% of participants endorsed the SBW Schema. Participants completed a questionnaire on their health and experiences as Black women. Specifically, researchers sought to understand the participants’ identification with three aspects of the SBW schema: perceived obligation to present strength (a need to constantly present a strong and unwavering image), self-silencing (neglecting to express emotions or needs to maintain relationships or prevent conflict), and externalized self-judgment (judging oneself according to societal expectations).

The researchers found that, consistent with previous findings, individual aspects of the SBW Schema significantly predicted depressive symptomology. However, further analyses found that self-silencing significantly mediated the relationship between the obligation to show strength and the development of such symptoms. This finding, the researchers say, indicates that the more Black women feel pressured to be strong, the more likely they are to silence themselves and, as a result, the more prone they are to developing depressive symptoms.

The same held true for the mediating role of externalized self-perception—the pressure to display strength shows itself in depressive symptoms through externalized self-perceptions. These results highlight how signs of depression may manifest in Black women in nuanced ways.

The authors suggest that taking time to deconstruct and process these behaviors—particularly self-silencing and externalized self-judgment—can help Black women achieve greater success in treatment.

Dillon, F.R., Ertl, M.M., Verile, M., Siraj, N., Babino, R., & De La Rosa, M. (2019). A social ecological study of psychological distress among recently immigrated, Latina young adults. Journal of Latinx Psychology, 7(1), 39–58. http://dx.doi.org/10.1037/lat0000106

This study examined the impact internalizing certain belief systems has on young Latina women’s mental health. The researchers sought to identify predictors of psychological distress in recently immigrated Latina women, and considered cultural, individual, and interpersonal factors. They surveyed 530 Latina women ages 18 to 23 who had immigrated to the United States within the previous 36 months.

Researchers measured psychological distress using the Spanish version of the Brief Symptom Inventory, which asks about symptoms experienced in the past week on a five-point Likert-style scale. Researchers also measured potential predictors focusing on acculturation, acculturative stress, and endorsement of marianismo—a traditional view of Latina gender roles.

Sample items included “I feel at home in the United States” (acculturation) and “Members of my family cannot communicate in public places” (acculturative stress). Marianismo—a more complicated social construct—was measured using five subscales corresponding to its core beliefs:

• Family pillar: The degree to which Latinas must be the main source of strength in their households
• Virtuous and chaste: The idea that Latinas must be morally and sexually “pure”
• Subordinate to others: The belief that Latinas should obey the traditional male/female hierarchy
• Self-silencing: The idea that Latinas should avoid conflict by not sharing their thoughts or emotions
• Spiritual pillar: The idea that Latinas must be the spiritual leaders of their households

The researchers also assessed sociodemographic variables and attachment to one’s social network. Attachment was measured by assessing how physically separated each participant was from their loved ones and by using the Inventory of Parent and Peer Attachment.

Results indicated that lower levels of attachment to one’s social network, higher levels of acculturation and acculturative stress, and undocumented status were associated with greater psychological distress. However, the effects of marianismo proved to be more complicated. Women who endorsed the spiritual pillar and virtuous and chaste beliefs reported lower levels of distress, while women who endorsed the family pillar, subordinate to others, and self-silencing beliefs reported higher levels of distress.

Finally, attachment to social network moderated many of these correlations: Higher levels of attachment served as a protective factor in most scenarios. For instance, the women who endorsed the subordinate to others and self-silencing beliefs but reported higher levels of attachment to their social network reported less psychological distress than those who endorsed the beliefs and reported lower levels of attachment.

These findings support some previous conclusions regarding Latina mental health, while challenging others. The study confirmed that factors such as undocumented status and lower levels of social attachment can have a negative impact on Latina mental health. However, it also challenged the idea that marianismo is always similarly detrimental. Instead the findings suggest that Latinas who remain aligned with Latinx culture through such traditional beliefs may sometimes help prevent psychological distress.

Augsberger, A., Rivera, A.M., Hahm, C.T., Lee, Y.A., Choi, Y., & Hahm, H.C. (2018). Culturally related risk factors of suicidal ideation, intent, and behavior among Asian American women. Asian American Journal of Psychology, 9(4), 252–261. http://dx.doi.org/10.1037/aap0000146

This study focused on Asian American women—a group often thought to be exempt from racial or cultural struggle due to the pervasive “model minority” myth that portrays Asian Americans as unphased by racism and able to achieve high levels of success (Sue & Morishima, 1982). Researchers specifically examined risk factors of suicidal ideation and intent among young Chinese, Korean, and Vietnamese American women.

Researchers recruited a sample of these women to take part in a culturally informed psychotherapy group called “Asian Women’s Action for Resilience and Empowerment.” Participants were ages 18 to 35, either born outside the United States but raised in the country, or born in the United States to immigrant parents and living in the Greater Boston area. Because the study explored intimate partner violence, being sexually active was also an inclusion criterion.

Out of the 435 women initially screened, 173 met the criteria and responded to the follow-up questions for this study. Participants were screened for any degree of psychological distress, experiences of interpersonal violence in relationships, or other trauma, and were asked about their experiences with suicidal ideation and intent using the Columbia Suicide Severity Rating Scale.

The researchers recorded occurrences of suicidal ideation and of specific plans, along with the methods participants planned to use, measured on a scale ranging from “mild lethality” to “extremely high lethality.” The results were analyzed to identify recurring themes.

Of the 173 participants, 110 (64%) reported at least one instance of suicidal ideation in their lifetimes. 101 (58%) reported passive ideation, while 32 (19%) reported experience with suicidal intent. 64 individuals (37%) described a plan for suicide. Of those 64 participants, 36 (56%) described plans of mild lethality, 16 (25%) of moderate lethality, 10 (16%) of high lethality, and two (3%) of extremely high lethality. No significant distinction was found between the different ethnic groups for the severity of ideation or intent.

Researchers identified six precipitants to the women’s suicidal ideation or intent based on the women’s narrative descriptions of their suicidal experiences:

• health concerns
• social isolation
• inability to cope
• pressure to achieve
• controlling parenting
• loss of power in intimate relationships

By analyzing the responses against existing literature, and by consulting Hyeouk Chris Hahm—an expert in Asian American women’s mental health—pressure to achieve, controlling parenting, and loss of power in intimate relationships were each determined to be connected to Asian culture.

Pressure to achieve is often characterized by unrealistic familial or societal expectations and internalization of familial disapproval. Researchers also suggested that it may be linked to an internalization of the model minority myth, though this was not measured.

Controlling parenting often includes parents intensely monitoring the participants’ grades or limiting career options.

Finally, the loss of power in intimate relationships often refers to either parental control over dating or to experiences with abusive or failed relationships in young adulthood. Intimate partner violence was reported among 65% of the women who experienced suicidal ideation or intent.

The researchers concluded that Asian American women exhibiting any of these factors may be at particular risk of suicidal ideation or intent. Given that 64% of participants reported some experience with ideation and 12% reported specific plans or intent (compared with 13.7% and 4.3% of other treatment-seeking Americans, respectively), psychologists may want to carefully assess for these factors when treating Asian American women.

Despite the study’s narrow sample, the researchers recommend active screening for suicidal ideation in young Asian American women and treatment that addresses familial and interpersonal conflict and identity development.

Psychologists working with these populations are encouraged to learn more about the social and cultural pressures that may be connected to a patients’ psychological distress. APA’s professional practice guidelines can help psychologists working with specific populations or in particular areas, including multicultural practice.