Ethnic Families and Mental Health

Mental health and well-being has become an increasingly important social concern today, and the manner in which families perceive and respond to mentally ill family members is often directly linked to symptom management and treatment outcomes. There has been a limited amount of research focusing on non-Caucasian families’ mental health concerns, yet some emerging evidence suggests that ethnicity may play a role in a variety of ways. The purpose of this article will be to apply the ABC-X Model of Family Stress to organize the research on ethnic families and mental health issues. In particular, occurrence of the stressor of mental illness among ethnic families, family resources that may be most relevant to ethnic families, and research highlighting the unique ways in which ethnic families may perceive mental health and illness conditions will be discussed. In addition, future research directions to better understand the interaction between ethnic families and mental health, as well as programmatic and policy initiatives that can address potential family, community, and large-scale social obstacles in seeking treatment will be presented.

The historical and stigmatizing view of mental illness as a mysterious and rare condition has evolved and, presently, is now accurately seen as a more common occurrence. Much of our society has become more knowledgeable about identifying symptoms and more willing to seek help from mental health professionals; we are gradually becoming more sensitive to the fact that mental health and mental illness can be everyday family issues. At the same time, however, the way in which individual families experience and cope with mentally unhealthy members can vary greatly based on family demographic variables. That is, ethnicity can have a significant impact on how families perceive and treat mental illnesses, and there is a need to increase our limited understanding of mental health/illness issues among ethnic and immigrant families (Takeuchi, Alegria, Jackson, & Williams, 2007). Some work has been done to identify links between research variables among ethnic samples in the United States (Mossakowski, 2007;Perez, Fortuna, & Alegria, 2008;, yet plausible explanations for existing findings and/or theoretical models have yet to be presented. The purpose of this article will be to discuss research findings using the ABC-X Model of Family Stress to highlight unique stressors, resources, and perceptions that should be considered when studying how ethnic families understand and seek treatment for mental health issues. Future areas of research, and ideas for programmatic and policy initiatives will also be presented.

The ABC-X Model of Family Stress and Ethnic Families
Family stress research has a history dating back nearly a century (Hill, 1949), and current family scholars continue to refine the family stress model (Boss, 2002) and expand the application of the theoretical perspective to a variety of family transitions and circumstances (Price, Price, & McKenry, 2010). The theory proposes that A (the provoking or stressor event of sufficient magnitude to result in chance in a family)-interacting with B (the family's resources or strengths)-interacting with C (the definition or meaning attached to the event by the family)-produces X (stress or crisis). (Price, Price, & McKenry, 2010, p. 6) The stressor can be classified using multiple dimensions (e.g., chronic or acute, normative or nonnormative), may be considered a positive or negative event, and will change some form of the family system. Many different family experiences have been discussed within the context of the ABC-X Model, such as divorce (Fine, Ganong, & Demo, 2010), financial hardship (Bartholomae & Fox, 2010), death (Murray, Toth, Larsen, & Moulton, 2010), and family violence (Gelles, 2010).
In their chapter on mental illness and family stress, Schock-Giordano and Gavazzi (2010) noted that "society is also becoming more sensitive to the fact that mental health and mental illness are family issues as well as individual concerns" and that "understanding the impact of daily stressors and the ways in which individuals and family members cope with stress are topics that must be integrated into any discussion of mental illness" (p. 163). Therefore, they apply the family stress theory and the ABC-X Model to review the most recent research on the epidemiology and etiology of mental illness, as well as the assessment of family resources and community-based resources. However, these authors note that there is far less information regarding ethnic individuals and their families, and that research is needed to identify reasons for lower mental illness rates among non-Caucasians in the United States and what role certain protective factors such as ethnic identity, religiosity, lifestyle choices and cultural values might have in contributing to mental health. (Schock-Giordano & Gavazzi, 2010, p. 169) How can the ABC-X Model of Family Stress (Boss, 2002) be used to frame the discussion of ethnic families' experiences of mental illness? By applying this useful theoretical model, "A" refers to the stressor event, which would be the family member's mental illness. Thus, it will be relevant to discuss the number of ethnic families in the United States who are affected by mental illness, as well as research related to the causes of mental illness that might be unique to many non-Caucasian families. The "B" factor represents available resources that can exist within the individual, within the family system, and within the community. Hence, it will be valuable to identify family strengths that are characteristic of ethnic families that can aid in the treatment of mental illnesses. Also, community resources that exist for families coping with mental illness, such as treatment programs, community-based organizations, web-based support systems, and social policy efforts must be evaluated in consideration of particular barriers that might exist for ethnic families. The "C" element in the family stress theory model refers to the family's perceptions of mental illness, recognizing that the family members' views of mental illness translate into behaviors and attitudes that have a direct impact on the wellbeing of mentally ill family members. For instance, the stigma that is attached to mental illness can be strongly influenced by cultural and family belief systems, and these views affect the manner in which family members show support to the mentally ill family member and display flexibility in seeking nonfamilial treatment for the mental illness.

A: Mental Illnesses in Ethnic Families
The "A" element in the ABC-X Model represents the stressor. According to the ABC-X Model, and borrowing from family systems theory (Smith, Hamon, Ingoldsby, & Miller, 2009;White & Klein, 2002), mental illness will not only affect an individual, but it will also have an impact on his or her family members. What do we know about the overall occurrence of mental illness in this country? Current patterns of mental illness in the U.S. population can be estimated by using available information about the incidence and prevalence of various disorders. Several large-scale studies have been conducted in the United States to provide estimations of the most current mental illness rates, such as the National Institute of Mental Health's Epidemiological Catchment Area Study (Regier, Burke, & Burke, 1990) and the National Comorbidity Survey Replication (NCS-R; Kessler et al., 1994). Using the 2004 census data, it is estimated that nearly 56 million people in the United States will experience a diagnosable mental disorder in a given year (National Institute of Mental Health, 2008).
However, there have only been a few recent large-scale studies that have focused on collecting ethnic data; hence, the limited information that is available concerning mental illness rates among various ethnic groups in the United States is based on very few national epidemiological studies. For instance, the NCS-R collected data from Latinos and African Americans, but the sample was limited to Englishspeaking Latinos and did not disaggregate data among Latinos based on important factors such as immigration status or country of origin . The National Latino and Asian American Study (NLAAS) gathered data from a sample of 2,554 Latinos and 2,095 Asian Americans related to prevalence of mental illness disorders and mental health treatment/service usage in the United States. The sample was stratified into ethnic subgroup categories (e.g., Puerto Rican, Cuban, Mexican, Other Latinos, Chinese, Vietnamese, Filipino, and Other Asians) to allow for withinethnic-group comparisons (Center for Multicultural Mental Health Research, 2008). Data from these recent studies suggest that many mental disorder rates are lower for most ethnic groups compared with Caucasians Breslau et al., 2006;Kessler et al., 2005). Specifically, Latinos and African Americans had lower rates of internalizing disorders (e.g., anxiety disorder, depression, social phobia) and some externalizing disorders (e.g., oppositionaldefiant disorder, impulse control disorders) than did Caucasians (Breslau et al., 2006).
Data on mental illness rates for Asian Americans, however, appear to be inconsistent and complex, and depend on factors such as gender, nativity, generation status, and English-language proficiency . Furthermore, among Latinos, mental illness rates have been found to be lower for non-U.S. born Latinos versus those born in the United States (Grant et al., 2004;. These findings suggest that, in some way, immigrants' assimilation into American culture may have a deleterious effect on mental health, although exactly how so remains unclear. In addition, when within group comparisons among Latinos were investigated, differences emerged based on country of origin, such that Mexicans were at higher risk for anxiety and depressive disorder compared with Cubans, Puerto Ricans, and other Latinos . Thus, it will be imperative to consider important ethnic group variables, such as generation status and birth country, when conducting studies of immigrants who have and have not been born and raised in the United States. In addition, although these current rates present a positive outlook for many ethnic families, it still will be valuable to further understand potential causes of mental illness that may be uniquely related to ethnicity, such as economic hardship, assimilation challenges, and social injustices (Grant et al., 2004;.

B: Resources
According to the Model of Family Stress, resources can exist at the individual, family, and community levels (McCubbin & Patterson, 1985). Resources will contribute to the "X" or outcome in the ABC-X Model, such that the existence and utilization of resources at multiple levels will always relate to how families experience a stressor. Thus, to further examine the possible reasons for lower mental illness rates among non-Caucasians in the United States, future research should consider the way in which these variables, such as factors related to immigration, act as resources or protective factors that might contribute to the mental health of ethnic families. For instance, some findings have shown that ethnic identity (e.g., sense of ethnic pride, cultural commitment to an ethnic group, involvement in ethnic practices) has been related to fewer depressed symptoms (Mossakowski, 2003). Similarly, several studies involving foreign-born and U.S.-born Latinos (Grant et al., 2004;Vega et al., 1998) and Filipinos (Mossakowski, 2007) have found that foreign-born ethnic members have a lower risk of mental illness than U.S.-born ethnicities. Based on these findings, it appears that adhering to one's traditional family culture and having a strong sense of personal ethnic identity serve as protective factors against mental illness.
Protective factors can also be available through many types of formal and informal social networks. In fact, in a sample of Mexican migrant farmers, high levels of reported instrumental support (e.g., financial and transportation assistance) and emotional social support (providing comfort when needed) were related to lower rates of depressive symptoms (Alderete, Vega, Kolody, & Aguilar-Gaxiola, 1999). Research has also shown that residing in an ethnically alike community can also serve as a protective factor, in that living in a neighborhood that is populated with those who share one's cultural background may translate into a greater number of local social networks (Eschbach, Ostir, Patel, Markides, & Goodwin, 2004;Perez et al., 2008).
Clearly, there is a need to specifically investigate the way in which some protective factors, which are common among many ethnic families, are related to rates of mental illness. For instance, how influential is the strong emotional, psychological, and financial support from immediate and extended family members that is characteristic of many ethnic and immigrant families' cultural value systems in maintaining mental health? What role do factors such as socioeconomic status, location of residence, age at immigration, and community support play in mediating the relationship between ethnicity and mental health?

C: Family Perceptions
In the ABC-X Model of Family Stress, perceptions are critical in determining the eventual impact of the stressor on the family because they are important in understanding how a family assesses the magnitude of a stressor, and also how the family assesses the availability and utility of internal and external resources. When focusing on non-White families in the United States, there may be some particular types of perceptions that are more common among ethnic families and that are also related to how the family copes with stressor events, such as perceived discrimination and the stigma associated with mental illness.
It has been estimated that prevalence rates of discrimination experiences among Latinos and African Americans are at 38% and 53%, respectively (Stuber, Galea, Ahern, Blaney, & Fuller, 2003), and findings have shown that perceived discrimination (e.g., self-reported experiences of everyday unfair treatment) has been linked to the mental health of ethnic families living in the United States. Specifically, discriminatory practices, in the form of job inequalities, inadequate mental health, and lack of community supports have been related to elevated depression rates in a sample of Mexicanorigin adults (Finch, Hummer, Kol, & Vega, 2009), and an increase in perceived discrimination over time was related to higher rates of depressive symptoms and poorer general health among African American females compared with Caucasian women (Schulz et al., 2000). Research also shows that ethnic identification is related to less perceived discrimination, suggesting that "people with high levels of ethnic identity may be more likely to associate with people of their own ethnicity and therefore be less exposed to discrimination" (Perez et al., 2008, p. 430). Disentangling the association between perceptions of self, perceptions of stressors (e.g., discrimination), and mental health will be a valuable direction for further research.
The perceived stigma of mental illness that families experience can have negative psychological consequences for the mentally unhealthy individual, such as lower selfesteem levels, reduced social contacts, job loss, and family relationship difficulties (Mittleman, 1985;Wahl & Harman, 1989). Research shows that ethnic families may be more concerned about stigma related to mental illness than Whites (Cooper-Patrick et al., 1997). For instance, in a qualitative study in which participants responded to vignettes about mentally ill (i.e., schizophrenia) persons, non-Caucasians were more likely to report less pity for the individual's health condition and also perceive the condition of mental illness to be more dangerous than did Caucasians (Corrigan & Watson, 2007). Also, a sample of depressed African Americans and Latinos were significantly more likely to site social barriers (e.g., embarrassment of disclosing the mental health problem and worry that one's employer would find out) as reasons to not seek treatment when compared with Caucasians (Ojeda & McGuire, 2006). Other similar findings have shown that in a sample of Asian American college students, the less acculturated students were more likely to exhibit more stigmatized attitudes toward seeking professional psychological assistance (Atkinson & Gim, 1989); again, it will be important to examine the relative impact that level of acculturation has on ethnic families and their mental health.

Why Does the Stigma of Mental Illness Seem to Have a Greater Impact on Ethnic Families?
Reflecting on their findings involving Asian American college students, Atkinson and Gim (1989) proposed, It may be that some of the values common across these ethnicities (e.g., fear of bringing shame to the family, submergence of individuality, somatization of symptoms, self control to resolve problems, restraint of strong feelings, and respect for authority) account for the similar pattern across ethnicities of attitudes toward professional psychological help. (p. 211) In other words, a high value for self-reliance, a trait that is characteristic of many ethnic families, actually contributes to a negative view of mental illness by implying a weakness; thus, individuals in the family do not want to admit to having mental health problems, and the family does not allow for nonfamilial persons to become aware of or help with any mental illnesses that may exist within the family system (Ortega & Alegria, 2002). In addition, a negative perception could exist because ethnic families, especially new immigrants who may have difficulty with English-language proficiency, do not understand or feel comfortable accessing services in the U.S. mental health system. These possible considerations can be especially helpful in proposing future community and policy initiatives.

Religion
Affiliation with a particular religion is a common characteristic of many ethnicities in the United States: "Religious involvement is a vital factor in some ethnic minority groups that enables people to retain cultural roots in a dominant society that holds different values" (King, Weich, Nazroo, & Blizard, 2006, p. 161). When studying the way in which religion can aid ethnic families in coping with stress, such as a mental illness, some researchers have posited that a multidimensional conceptualization of religion must be used because religion can be helpful in a variety of ways. Specifically, religion can manifest as (a) religious/spiritual beliefs and faith in a higher power, (b) religious affiliation and membership in religious communities, and (c) increased social relationships and interactions through church attendance (van Olphen et al., 2003). Interestingly, then, in the context of the ABC-X Model, religion can be viewed as both a resource (social supports, personal relationships) and a perception (faith, a sense of belonging to a group and/or purpose).
Religious beliefs and experiencing faith in a higher power through prayer can serve as a barrier to mental illness among ethnic families. For example, findings have shown that Mexican families are more likely to use religion, faith, and reframing as a coping mechanism compared with Caucasians (Farley, Galves, Dickinson, & Perez, 2005), and frequency of prayer has been linked to fewer self-reported depressive symptoms in a sample of African American women (van Olphen et al., 2003). Furthermore, in the same study of African American women, frequency of church attendance and reported feelings of social support from within the church were also related to fewer self-reported depressive symptoms. Ellison, Boardman, Williams, and Jackson (2001) found mixed support for several theoretical models that were tested in their study that linked ethnicity, religion, stress, and mental health; hence, the authors conclude that future studies should identify which types of religious involvement are related to particular mental health outcomes. Further research must provide a more clear understanding of the mechanisms by which ethnicity, religion, and mental health are related.

X: Outcome and Implications
According to the family stress model, when families are experiencing mental health problems, the result, which will be a function of the stressor, resources, and perceptions, can end in numerous positive and negative outcomes. For instance, negative outcomes that families may experience could include dealing with objective burdens (e.g., cost of providing medical care, housing, insurance) and subjective burdens (e.g., exhaustion, reduced social contacts, family stigma), whereas positive outcomes may involve enhanced family relationships, caregiver satisfaction, and advocacy efforts (Schock-Giordano & Gavazzi, 2010).
Additional positive outcomes that the mentally ill individual might experience, such as adaptive coping strategies and symptom management, certainly could be facilitated through service use and treatment adherence, yet research has shown that some ethnic groups report lower rates of utilization of mental health services than do Caucasians (Abe-Kim et al., 2007;Alegria et al., 2007;Hodgkin, Volpe-Vartanian, & Alegria, 2007;Wang et al., 2005). It has been estimated that "among Latinos with a diagnosable mental health disorder, fewer than one in eleven contact a health professional for treatment, compared with one of every three non-Hispanic whites" and "the percentage of African Americans receiving mental health services is only half that of whites" (Alegria, Pérez, & Williams, 2003, p. 53). This trend might be explained by inadequate family resources in the form of financial issues (e.g., cost of care, poor insurance coverage, loss of pay from work) and social issues (e.g., discomfort with English-language fluency) that serve as significant barriers to accessing mental health services for ethnic families (Ojeda & McGuire, 2006). Another practical obstacle to seeking services for ethnic families may be geographic accessibility. In fact, in their study of mental health outpatient recipients, Kouzumi, Rothbard, and Kuno (2009) found that Latino and African American clients were not as likely as Caucasians to travel a large distance for treatment, suggesting that geographic proximity to care will be an important issue to consider in ethnic communities. Furthermore, the authors note that "variation in provider quality by geographic location appears to be one of the mechanisms that may generate racial disparities in quality of care, given the previous finding that poorer quality programs were found in high minority, low income neighborhoods" (Kouzumi, Rothbard, & Kunop, 2009, p. 430).
To better understand the many different barriers that exist for ethnic families coping with mental illness, it also will be necessary to study the important links between ethnic families' perceptions of mental illness as a condition, such as whether the issue will resolve on its own and expectations about the effectiveness of treatment (Anglin, Alberti, Link, & Phelan, 2008), especially since many ethnic families may seek out and rely on nonprofessional help (e.g., extended family members, religious leaders) to ameliorate their mental health issues (Blank, Mahmood, Fox, & Guterbock, 2002). In addition, it will be helpful to further investigate the preferred method of treatment for various mental illnesses among ethnic families (Givens, Houston, Van Voorhees, Ford, & Cooper, 2007) and these families' satisfaction with received services.
When ethnic families do seek mental health care, how well do existing interventions translate among and resonate with families' various culturally specific values, needs, and perspectives? In their comprehensive review of existing mental health treatments, Miranda et al. (2005) examined the efficacy of evidence-based treatments when serving ethnic families to determine whether culturally enhanced treatments should be developed. Their review suggested that existing treatments are effective with ethnic individuals, yet the authors contend that "protocols or guidelines that consider culture and context with evidence-based care is likely to facilitate engagement in treatment and probably to enhance outcomes" (Miranda et al., 2005, p. 22). In addition, they propose two important areas for future research for clinicians and professionals working with culturally diverse populations; that is, researches need to (a) develop a method for ensuring that interventions include the unique concerns and needs of ethnic families and (b) develop strategies to encourage ethnicities to engage in available mental health care options.
Major mental health system and public policy efforts are needed to improve service delivery to ethnic families. For instance, initiatives could include a more comprehensive public awareness educational campaign that addresses symptoms, course, and treatment plans related to mental illnesses; greater variety in available services, including where and when appointments are offered and languages used by professionals; enhancing workplace tolerance for mental health leave; and improvements with insurance coverage and use (Ojeda & McGuire, 2006). Based on previously sited research, expanding mental health locations within the ethnic communities for easier accessibility and perhaps the use of religious places of worship as potential liaisons to link mental health services with ethnic families might be potential avenues to explore. Educating extended family members about mental illness etiology and treatment, especially those who might adhere to negative stigmas toward mental illness, will be an effective way to foster supportive family environments. Furthermore, larger scale social policy concerns that exist for many ethnic families, such as income, housing, and education inequalities, have an impact on mental health and should be addressed as well (Alegria et al., 2003). Future research and policy efforts that aim to better understand how ethnic families approach factors related to elements in the ABC-X Model will be valuable in identifying the most effective way to address their mental health issues and result in positive outcomes for families and individuals.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research and/or authorship of this article.