Ethnocultural variations in mental illness discourse: Some implications for building therapeutic alliances

Objective: In the delivery of mental health services over the past decade, the field has attempted to shift from paternalism to client-centered care, in which treatment and recovery are based on client-practitioner collaboration. Such a shift requires that providers elicit and work with clients' discursive accounts of their illness experiences and understand these accounts in the context of clients' ethnocultural backgrounds. The purpose of this ethnography was to elucidate ethnocultural aspects of illness accounts and interactions with the mental health system. Methods: Over 18 months, 25 ethnically diverse, unemployed, inner-city residents with severe and long-term mental disorders participated in an ethnographic ( participant observation) study of illness accounts and their relationship to sociocultural background. Field ethnographers shared in activities with participants at many of their regular haunts, engaging in observation, conversation, and informal interviewing in many real-world contexts and settings. Results: The study revealed significant differences between the ways that European Americans, African Americans, and Puerto Rican Americans discursively constructed their illness experiences and their interactions with the mental health system. The clients' narratives of their illness experiences provided valuable information, which clinicians could use to open up topics for discussion, insert themselves into an engaging relationship with clients, and link clinical advice or guidance with the clients' own conceptions of how mental illness fits into their larger lived world. Conclusions: To develop a working therapeutic partnership with clients, mental health service providers must become aware through context-sensitive, context-informed dialog of the differences in how individual clients "en-story," communicate, and experience their illnesses.