The cultural expectations of gender roles, groups of people or communities with significant historical trauma, oppression, and hardship may also have distinct expectations and patterns in dealing with depression and anxiety. Examples of such groups would include refugees, immigrants, targets of ethnic cleansing, Japanese-Americans interned during World War II and their descendants, individuals from the Great Depression era, Holocaust survivors and their descendants, ex-cult members or individuals raised in highly rigid circumstances including religious groups, active duty military veterans, law enforcement personnel, trauma survivors, sexual abuse victims of clergy, trauma responders, adult children of alcoholics (ACAs), and many other groups. Within certain populations "minority stress" may be a relevant but nuanced consideration. For example, Lewis et al (2009, page 987) found that "All components of sexual minority stress were not similarly related to sexual orientation conflict and dysphoria. Concerns about discrimination at work, 'being out,' and violence/harassment were related to increased conflict and dysphoria. Concern about discrimination in general was related to increased depressive symptoms but not sexual orientation conflict. Stress about one's family was related to more sexual orientation conflict but not to dysphoria. Our work offers evidence that exposure to stigmatizing environments in which one experiences stressful events related to sexual orientation is associated with poorer well-being for bisexuals."
Individuals for other identifiable minority groups may have similar nuanced experiences of emotional issues and functional discrimination that affect individuals and their relationships that the therapist should examine. The therapist needs to be aware of not only personal histories, but also of social, economic, and historical circumstances that may have influenced the attitudes, values, beliefs, motivations, and behaviors of clients not only with regard to depression and anxiety but also to all areas of functioning. In addition, the therapist should consider if developmental eras might be relevant to identifying issues for individuals or a couple. For example, "Existing research has also highlighted that the interaction between marital dynamics and depression may not be the same for older men as for older women (Sandberg & Harper, 2000a, 2000b). Specifically, Tower and Kasl (1996a, 1996b) noted that emotional distance in older marriages was particularly problematic, in terms of depression, for women (Harper and Sandberg, 2009, page 547). Of potential relevance may be the potential long duration, development, and history of depression in addition to exploring circumstances, effects, consequences, and prior problem solving attempts. The couple's and family-of-origin expectations and response to depression and anxiety may give guidance to the therapy. While such influences are considerable in of themselves, the therapist should remember that they also occur within various cultural contexts. The relevance of cultural models or perspectives of depression, anxiety, or other emotional/psychological stress or distress bears examination. Yet, the therapist also needs to be aware that mutual reciprocal effects of discord and emotional distress occur as a human condition across cultures, rather than being culturally bound.
"The findings of this study provide evidence that the Marital Discord Model of Depression (Beach et al., 1990) is applicable to Latina populations, which suggests that marital discord both causes and maintains depressive symptomatology… Although Beach's model describes marital discord as an important antecedent of depression, it should be noted that there is evidence that depressive symptoms can also be a predictor of marital satisfaction. With the heterogeneity of depression etiology, it is not surprising that there is empirical evidence that supports both scenarios (Beach & O'Leary, 1993; Prince & Jacobson, 1995). In situations in which depression predates marriage, it is logical that depression leads to subsequent marital distress. Other times, marital distress is a clear precursor to subsequent depressive symptoms. After reviewing the research literature, Prince and Jacobson concluded that marital distress can be ''an antecedent, concomitant, and consequence of depression'' (p. 407). Even Beach recognized the reciprocal nature of the etiology of marital distress and depression (Beach et al., 2003). Nevertheless, there is substantial evidence that marital distress leads to subsequent depression, and the treatment of marital distress alleviates depressive symptomatology (Beach, 2001; Dessaulles, Johnson, & Denton, 2003; Prince & Jacobson), which makes the validation of Beach's model across different cultures important" (Hollist et al., 2007, page 494). When addressing depression and anxiety in a couple, the therapist should look beyond family-of-origin or cultural expectations to consider the interplay caused by potentially relevant cultural patterns about dealing with depression or anxiety. An individual may have expectations from both his/her family-of-origin and his/her culture to deny depression or anxiety. Or, it may be acceptable to self-medicate depression or anxiety with alcohol, other substances, gambling, affairs, and so forth. Identifying the family or community model of dealing with depression or anxiety also leads to the individual and couple considering whether or not the model is effective in the current relationship. If it is not, then a change in the model or process may be considered a cross-cultural intervention. Hollist et al. (2007, page 486-87), for example discuss cultural issues in Latino or Brazilian families.
"Although the characteristics of depression are similar cross-culturally, characteristics of Latino marriages are different. Latino marriages are largely hierarchical (Korin, 1996), in which roles and responsibilities are clearly defined, with women traditionally responsible for family nurturance. Most Brazilian women continue to regard themselves as primarily responsible for caretaking in the family (Korin). These role differences may have an impact on the degree to which marital satisfaction is related to depression, especially for the Latina, who traditionally feel more responsible for the marital relationship than do the men. This perception of increased responsibility on the part of the women may contribute to an increase in the association for women and a decrease for men" The greater female sense of responsibility for caretaking in the family and for the marital relationship is similar to that of American women. However, a difference may be in the degree of responsibility. Brazilian women may have the same sense of responsibility but to a much greater degree with much greater negative consequences. Conversely, another group may have the same sense of responsibility but to a significantly less degree with lesser negative consequences. Anticipated and experienced consequences may differ significantly from group to group as well. In addition, traditional to modern or current allegiance to cultural expectations may also vary. Economic considerations impact emotions and the couple in American and Brazilian couples, but arguably to different degrees including when factoring in class differences in the respective societies. "For a majority of Brazil, socioeconomic level has a large impact on marriage. Because the cost of obtaining a marriage license is almost equivalent to the monthly minimum wage, many poor and middle-class individuals in Brazil do not get legally married. Many low-income individuals perform informal ceremonies to celebrate their union. With mean income and education levels lower in Brazil than the United States, many of the individuals who have been studied have marriages arranged by common law" (Hollist et al., 2007, page 486-87).
Due to cultural, economic, and other considerations, the therapist should be aware that "…marital satisfaction may have a stronger cross-sectional relationship with depression among Brazilian women than women in the United States (Hollist et al., page 494). While the therapist may not encounter a Brazilian couple in his/her practice, the principles underlying various relevant considerations may enlighten assessment of some other couple. The therapist may find economic issues similar to those experienced by Brazilian couples compelling for another couple. In a further example, Stimpson et al. (2005, page 390) noted gender differences in older Mexican-American spouses. "Our study also contributed by identifying gender differences in concordance of well-being among older Mexican American spouses. Women are more likely to be affected by their husband's well-being, and this effect is usually negative, while men seem less likely to be affected by their wife's well-being. This pattern is consistent with past research that found women are more likely to be influenced by family events and interactions (Conger et al., 1993; Wallhagen et al., 2004), and is particularly relevant among Mexican Americans which have a more traditional orientation toward marriage and family (Blee & Tickamyer, 1995). The evidence seems to suggest that women bear a bulk of the emotional and physical burden of the marital relationship (Moen, 2001). Overall, men either do not respond to the well-being of their wife or have a stronger effect on their wife." The American therapist, especially those in California, the southwest, and major cities is more likely to encounter older Mexican-American individuals or couples. However, the gender differences may be less enlightening for the therapist for its stereotype about older Mexican-Americans than for highlighting the socio-economic characteristics underlying it. The therapist may better serve a potential Mexican-American couple, but also any couple where there may be the relevant dynamics of socio-economic class vulnerability, aging, marginalization, recent or historical immigration or migration, traditional values, close family (especially, multi-generation and extended family) dynamics, bi-cultural experiences, and so forth. Either specific cultural knowledge or general awareness of relevant cultural concepts can aid in therapeutic interventions and strategies.
Grace, a Chinese-born woman came to therapy very unhappy with her marriage. She is an educated professional married to an American-born man. Grace continually asked the therapist if she could make this or that adjustment in her attitude or behavior so the marriage can work. Over a few sessions, it became clear that her husband had not, was not, and will probably not ever be capable of any real change. Despite this clarity, Grace continues to ask the therapist if she can stay in the marriage. Underlying her persistent return to the same question was a cultural tradition of Chinese women historically having little or no recourse in unhappy marriages. Acculturated to the traditional economic political, and physical vulnerability of Chinese women over thousands of years, Grace had difficulty considering that she had other viable options in the more democratic American society. Suffering through an unhappy marriage seemed to be her destiny- her doom… from her unchallenged cultural perspective. Choosing a very culturally provocative intervention, the therapist finally answered Grace's repeated question about whether she could stay in the marriage. The therapist said authoritatively, "Sure you can stay in the marriage. Chinese women are good at being depressed! Chinese women have thousands of years of experience and training to be depressed and staying in unhappy marriages!" Grace's mouth opened and her eyes widened in shock. The therapist continued, "And, you have a personal model from your mother of being depressed and staying in her marriage to your father." With the appropriate therapeutic dramatic pause, the therapist gently shifted tone to ask, "Are you one of those Chinese women? Are you still one of those Chinese women who could not make it on your own? Are you one of those Chinese women who have to accept a marriage and life of depression?"
Conceptually, this therapeutic intervention was based on Grace's own unidentified and unchallenged cultural determinism as a Chinese woman and a Chinese wife. By identifying the determinism (destiny or doom), there came the possibility of challenging it. Upon examining her cultural perspective, Grace could consider if it served her in her current circumstances. As she was able to reconcile her unhappiness and her current viability as an educated professional woman with social and economic independence, Grace was then able to consider a cross-cultural transition. She eventually decided to be a new kind of Chinese woman that now lived in America who could choose to seek happiness and fulfillment rather than stay depressed and stay married. Each person may have different models of handing depression or anxiety coming from his/her family-of-origin, a historical era, family immigration circumstances, ethnicity, nationality, and more. While the therapist may not have the cultural knowledge of all such models, he or she can discover his/her clients' models with appropriate therapeutic inquiry. Using culturally aware conceptual knowledge, the therapist can probe for the individual's, couple's, family-of-origin, and cultural responses to depression, anxiety, and other feelings.