Why Culturally Sensitive Care for Indigenous Populations with Schizophrenia Matters

In 2019, researchers summed up the need for cultural competence in mental health care, reminding mental health professionals of the importance of knowing how Indigenous populations may define, perceive, and respond to mental health conditions based on their own perceptions and conceptual terms.

Several things complicate how mental illness is generally perceived, defined, and treated, including:

• colonization
• Indigenous worldviews
• institutional racism
• political marginalization

Three aspects impact schizophrenia in particular for Indigenous populations.

Diagnosis and healthcare approach

The authors of the 2019 research review note that the diagnostic criteria and approaches based on Western classification systems often distort the social and cultural realities of non-Western populations.

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), to be diagnosed with schizophrenia, you must present with at least two of the following symptoms:

• delusions
• hallucinations
• disorganized speech
• catatonic behavior
• negative symptoms, such as flat affect, avolition, and alogia

These symptoms must occur most of the time in a 1-month period and often affect overall functioning in relationships and work.

When diagnosing schizophrenia, psychiatrists typically use the DSM-5 criteria along with other evaluative tools such as self-report forms and clinical assessments:

• BPRS (Brief Psychiatric Rating Scale)
• The Positive and Negative Symptom Scale (PANSS)
• Communication Disturbances Index

Since psychiatrists closely observe thought form, speech, language, and behaviors to form a clinical picture of someone being evaluated for a mental health condition, it’s important to consider how culture undoubtedly impacts the many ways Indigenous people communicate.

Language

Though clinicians should ideally take a multitude of aspects into consideration when diagnosing a person — such as their behavior and signs of cognitive decline — a schizophrenia diagnosis often largely hinges on language.

Psychiatrists evaluate many aspects of speech, including:

• phonetics
• morphology
• syntax
• semantics
• pragmatics
• schizophasia (unintelligible utterances)
• language output
• language comprehension
• vague or missing information
• confused reference
• derailment and tangentiality

Speaking in one’s second language could easily be the root of a confused reference or misaligned syntax.

Research in 2017 on bilingualism and psychosis found that people diagnosed with schizophrenia often show verbal deficits when speaking in their second language that do not appear or are less prominent in their native language.

The authors of the 2019 review noted that researchers and professionals assessing speech and language disturbances associated with schizophrenia must observe and interpret these characteristics, taking a person’s multiple worldviews into account.

Spirituality

While spiritual beliefs should not be taken as the basis for evaluating delusions, and clinicians should observe whether beliefs are part of a person’s culture, Indigenous people often have reservations and may feel a lack of understanding from healthcare professionals.

Research in 2018 reported that some Indigenous people were apprehensive about sharing their spiritual beliefs in healthcare settings out of fear of being judged or pathologized.

Through interviews with Māori people, the researchers discovered the spiritual, cultural, and societal explanations for what’s labeled as psychosis or schizophrenia by Western psychiatry.

Among other explanations, Māori people represented in the study explained symptoms through a variety of lenses, including:

• possessing a spiritual gift passed through generations
• a spirit disconnected from the body
• trauma as a doorway to negative experiences of spirituality
• sickness attributed to drug use

Many factors — from racism to colonization — contribute to the state of mental health for Indigenous populations.

A 23-yearlong study published in 2019 on the adult Indigenous population of Cape York and Torres Strait in Australia found a higher rate of psychotic disorders and a higher mortality risk overall. Researchers suggest this reality is linked to environment and neurodevelopment.

Understanding what’s behind the higher rates of psychotic disorders requires a historical lens and willingness to examine social timelines.

When alcohol was introduced for consumption and sales in now ex-DOGIT (Deed of Grant in Trust) communities, the men in the aforementioned study were estimated to be between 0 and 9 years old.

Indigenous men between the ages of 30 to 39 presented the highest prevalence of psychosis — a primary symptom of schizophrenia — presumably to be from the experience of heavy drinking and violence within their communities and households during childhood.

On Twitter, Dr. Tracy Westerman of Indigenous Psych Services wrote in 2020: “Aboriginal people having the highest rates of child suicide in the world; highest rates of incarceration; child removal; [and] there is virtually no indigenous curriculum embedded within psychology degrees across [Australia].”

Westerman’s comments speak to a larger need for culturally sensitive mental health care for Indigenous populations, from how mental health workers are educated to how Indigenous people are treated in healthcare settings.

Here are a few ideas for caring for the mental health of Indigenous populations:

• embrace the work of native healers
• consider the biopsychosocial model
• expand diagnostic criteria to account for differences in how populations speak, act, think, and believe

While it’s not always possible to draw parallels between Indigenous populations across the globe, studies and experiences from different parts of the world indicate that Western diagnostic criteria and approaches to mental illnesses like schizophrenia don’t necessarily take other cultural backgrounds into consideration.

The screenings, treatments, and representations of schizophrenia among Indigenous populations requires many innovations, including:

• cultural sensitivity
• increased governmental trust
• more comprehensive and accessible healthcare
• acknowledgement for and healing of longstanding trauma
• attention to existing research and opportunity for new research

For more information on seeking mental health support as a member of an Indigenous population, consider visiting:

• National Alliance of Mental Illness
• Indian Health Service
• Psych Central’s resource guide for People of Color and Indigenous people