Cultures have different views of understanding psychological disorders a

Available online at www.sciencedirect.com

Clinical Psychology Review 28 (2008) 211–227

A conceptual paradigm for understanding culture's impact on mental health: The cultural influences on mental health (CIMH) model

Wei-Chin Hwang a,⁎, Hector F. Myers b, Jennifer Abe-Kim c, Julia Y. Ting d

a Department of Psychology, Claremont McKenna College, 850 Columbia Avenue, Claremont, CA, 91711 United States b University of California, Los Angeles, United States

c Loyola Marymount University, United States d University of Utah, United States

Received 14 February 2007; accepted 3 May 2007

Abstract

Understanding culture's impact on mental health and its treatment is extremely important, especially in light of recent reports highlighting the realities of health disparities and unequal treatment. This article provides a conceptual paradigm for under- standing how culture influences six mental health domains, including (a) the prevalence of mental illness, (b) etiology of disease, (c) phenomenology of distress, (d) diagnostic and assessment issues, (e) coping styles and help-seeking pathways, and (f) treatment and intervention issues. Systematic interrelationships between each of these domains are highlighted and relevant literature is reviewed. Although no one model can adequately capture the complex facets of culture's influence on mental health, the Cultural Influences on Mental Health (CIMH) model serves as an important framework for understanding the complexities of these interrelationships. Implications for clinical research and practice are discussed. © 2007 Elsevier Ltd. All rights reserved.

Contents

1. The CIMH model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 1.1. Cultural issues in the development of illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 1.2. Culture and the expression of distress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 1.3. Expression of distress, diagnostic accuracy, and the prevalence of illness . . . . . . . . . . . . . . . . . . . 217 1.4. Culture, expression of distress, and help-seeking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218 1.5. Help-seeking, diagnoses, and their relation to treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220 1.6. Meeting the needs of ethnic minority and immigrant communities: policy implications . . . . . . . . . . . . 222

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223

Recently in the United States, the Surgeon General and the Institute of Medicine reported that racial and ethnic health disparities exist, and that in general, ethnic minorities continue to be missing from the research from which evidence-based treatments (EBTs) are drawn (Smedley, Smith, & Nelson, 2003; USDHHS, 2001). In addition, there is

⁎ Corresponding author. E-mail address: [email protected] (W.-C. Hwang).

0272-7358/$ – see front matter © 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.cpr.2007.05.001

212 W.-C. Hwang et al. / Clinical Psychology Review 28 (2008) 211–227

a growing body of European and other international literature supporting these findings and suggesting that immigrants and ethnic minorities evidence a disproportionate burden of illness and unequal access to health care services (Department of Health, 2003; Fernando, 2005). This accumulating body of evidence underscores the idea that extant health care systems may not be adequately prepared to meet the needs of minority and immigrant populations. The importance of incorporating issues of culture, race, and ethnicity into research, teaching, and clinical practice are sorely needed. This task has proven to be quite complicated given the limited resources that have been invested towards improving our understanding of cultural influences on mental health. Without guiding frameworks from which to work from, the larger audience of mental health professionals will continue to acknowledge that culture is important, but struggle in articulating how culture makes a difference and be unprepared in addressing growing world-wide health disparities.

The goal of this article is to provide a conceptual framework, the Cultural Influences on Mental Health (CIMH) model, to help bridge this gap and increase cultural understanding and awareness (see Fig. 1). In this article, we define culture broadly as not only including the set of attitudes, values, beliefs, and behaviors shared by a group of people (Barnouw, 1985), but also as inclusive of culture-related experiences such as those related to acculturation and being an ethnic minority. The CIMH model argues that culture permeates and affects several core domains of the illness process. Culture contributes to differences in (a) the prevalence of mental illness, (b) etiology and course of disease, (c) phenomenology or expression of distress, (d) diagnostic and assessment issues, (e) coping styles and help-seeking pathways, and (f) treatment and intervention issues. Because of the multitude of ways that culture can influence mental health issues, these domains are not meant to be all-inclusive, but rather provide a starting point for understanding the more visible ways that culture influences the development and treatment of psychopathology.

Cultural influences each of the above domains, which are also clearly and logically related. For example, cultural differences in the expression of distress (e.g., emotional distress or physical symptoms) could influence diagnostic accuracy in the assessment of depression, which in turn, impacts our ability to reliably estimate the prevalence of depression. What one believes to be the causes of one's problems (e.g., bodily problems causing depression or depression causing physical health problems) also plays a role in where one seeks help (e.g., primary care or mental health facility), and one's confidence in the treatment provided (e.g., belief that talk therapy is effective versus feeling like talking about problems makes one feel worse). Research conducted to examine how culture impacts each of these domains as well as how they are systematically interrelated continues to be limited. Understanding these inter- relationships is integral to understanding how culture influences the development, progression, and treatment of mental illness.

The CIMH was initially developed to provide students and professionals with a broad and more sophisticated understanding of culture's dynamic influence on mental health. Specifically, in our teaching of culture and mental health issues, professionals and students often developed a simplistic understanding that culture matters, but often had difficulty understanding the dynamic and interactive nature of culture on interrelated mental health domains. The

Fig. 1. The Cultural Influences on Mental Health (CIMH) Model.

213W.-C. Hwang et al. / Clinical Psychology Review 28 (2008) 211–227

CIMHmodel serves as an illustrative roadmap to help students and professionals visualize the complexities involved in understanding culture's influence on mental health. We acknowledge that no single conceptual model can adequately capture the complexities involved in understanding cultural influences on mental health, but hope that the CIMHmodel will provide a solid foundation for those wanting and needing to improve their cultural awareness.

1. The CIMH model

1.1. Cultural issues in the development of illness

At a basic level, we understand that the cultural background and characteristics of the individual plays an important role in the etiology of disease and the resulting psychological distress and mental illness as illustrated by Pathways A and B in Fig. 1. For instance, we know that the day to day experiences of people from different backgrounds may be very different. We also know that ethnic minorities are likely to be exposed to a disproportionate burden of unique stressful experiences. A basic example would be that of the refugee experience. Many refugees immigrate to countries around the world having experienced a variety of traumatic experiences, including war, genocide, violence, famine, and political persecution (Gong-Guy, Cravens, & Patterson, 1991; Williams & Berry, 1991). Whether one escapes to another country or not, those exposed to violent experience evidence increased risk for depression and post traumatic stress disorder, as has been found among Southeast Asian, African, Bosnian, and Kurdistanian refugees (Chung & Kagawa-Singer, 1993; Hirschowitz & Orkin, 1997; Kinzie et al., 1990; Kroll et al., 1989; Sundquist, Johansson, DeMarinis, Johansson, and Sundquist, 2005; Wahlsten, Ahmad, Von Knorring, 2001). Traumatic experiences are culture-universal in that anyone exposed to such stressors would likely be negatively affected. However, refugees are much more likely than the general population to experience traumas (Gong-guy et al., 1991; Williams & Berry, 1991), and as a result, their vulnerability to developing psychological problems increase with accumulated stress burden. Refugee experiences can be very different from that of other ethnic minorities. For example, Native Americans who have suffered from the cumulative impact of colonization and generations of oppression also suffer from higher rates of lifetime trauma and violent victimization than other groups living in the U.S. (National Center for Injury Prevention and Control, 2002; Walters & Simoni, 1999).

Regardless of refugee status, many immigrants also experience acculturative stresses while trying to adapt to a new cultural environment that those in the majority population are unlikely to face (Hovey, 2000; Williams & Berry, 1991). Acculturative stress, defined as the stress related to transitioning and adapting to a new environment (e.g., linguistic difficulties, pressures to assimilate, separation from family, experiences with discrimination, and acculturation-related intergenerational family conflicts) refers to adaptational stressors that can increase risk for mental health problems (Berry, 1998; Berry & Sam, 1997). These stressors have been found to have a detrimental effect on immigrant health and mental health, especially among recent immigrants (Berry, 1998; Goater et al., 1999; Hovey, 2000; Jarvis, 1998; King et al., 2005; Myers, & Rodriguez, 2003; Oh, Koeske, & Sales, 2002; Organista, Organista, & Kurasaki, 2003; Schrier,Van de Wtering, Mulder, and Selten, 2001; Vega & Rumbaut, 1991; Veling et al., 2006). The degree to which acculturative stresses are likely to have a negative impact partially depends on a number of pre-post migration factors, such as educational status, linguistic ability, refugee status, access to thriving ethnic neighborhoods in the host country, and support networks available (Williams & Berry, 1991).

Cultural assimilation, or the process of gradually taking on the characteristics of a new environment, can also increase risk for health problems as immigrants acculturate, possibly due to a regression to the normative prevalence rates of illness in the general population (Berry, 1998). For example, there is a growing body of research indicating that U.S. born Latinos evidence higher rates of a variety of mental and physical health problems than foreign-born Latinos (Escobar, Nervi, and Gara, 2000; Ortega, Rosenheck, Alegria, and Desai, 2000). Chinese Americans also evidence this cultural assimilation effect in relation to major depression (Hwang, Chun, Takeuchi, Myers, & Siddarth, 2005). A similar problem is also developing in European countries. For example, several studies have found that the rate of schizophrenia was approximately 2–3 times higher for African immigrants, Afro-Caribbeans, Asian, Surinam, Netherland Antilles, Moroccan, and other immigrants than Whites in Great Britain and the Netherlands (Goater et al., 1999; Jarvis, 1998; King et al., 2005; Schrier et al., 2001; Veling et al., 2006). There is little empirical evidence that explains why this is happening, however, some believe that it may be due to a combination of accumulated stress burden, increased exposure to culturally unfamiliar environmental and psychosocial experiences, racism and dis- crimination, and the loss and attenuation of culturally protective factors.

214 W.-C. Hwang et al. / Clinical Psychology Review 28 (2008) 211–227

Immigrant issues aside, ethnic minorities are likely to be exposed to a number of other stressors that are unique to their minority status. For example, many minorities report negative experiences with racism and discrimination (Clark, Anderson, Clark, & Williams, 1999; Kessler, Mickelson, & Williams, 1999; Williams, 1996). Racial discrimination (whether overt, covert, or perceived) is likely to have a negative impact on health and mental health, and often leaves people with feelings of anger, disempowerment, fear, loss of control, and helplessness (Clark et al., 1999; Krieger, Sidney, & Coakley, 1999). Persistent ethnic and racial discrimination continues to be highly prevalent around the world with many citizens holding disparaging and negative stereotypes of ethnic minorities being dangerous, lazy, less intelligent, and so forth (Davis & Smith, 1990). Recent reports also indicate that ethnic and racial discrimination not only results in economic disadvantages for many ethnic minorities, but also persist in health care systems and exacerbate health disparities (Smedley et al., 2003).

In addition to being the target of racism, ethnic minorities are less likely to benefit from a number of privileges available to Whites (McIntosh, 1989; Rothenberg, 2005). In discussing White privilege, McIntosh (1989) notes, “I was taught to see racism only in individual acts of meanness, not in invisible systems conferring dominance in my group” (pp. 31). White privilege acts to confer a number of advantages to White people that ethnic minorities do not have. In the U.S., for example, Chin, Cho, Kang, and Wu (1999) note that:

For many people of color, racism has decreased the amount and value of economic, social, and cultural capital inherited from our ancestors. Not only did we receive less material wealth, we also received less “insider knowledge” and fewer social contacts so instrumental to one's educational and professional advancement. The fact that runners today might compete on more equal “footing” does nothing to change this fact…even if you are individually innocent of any racial discrimination, do you still enjoy its illicit fruits? After all, discrimination (by others) has shrunk your pool of competitors for admissions, public contracting, and jobs. (pp. 3, 5)

Because of this, White privilege not only reduces the amount of stressful experiences that White Americans face, but also serves as a protective factor and increases their resources for anticipating and coping with adversity relative to persons of color.

Some ethnic minorities are exposed to a different set of stressful experiences that White Americans are less likely to face. In addition, these experiences may affect different groups differently, and as a result, bias research findings. For example, African Americans, Latino Americans, Native Americans, and some Asian American groups evidence a higher burden of poverty in the U.S. (Proctor & Dalaker, 2003). Given the high rates of poverty and the cumulative and current exposure to racism and discrimination experienced by many of these groups, it is surprising that ethnic minorities do not evidence even higher disproportionate rates of mental dysfunction than White Americans (Chernoff, 2002). Chernoff (2002) noted that while positive coping resources (e.g., kinship, spirituality, ethnic pride, collective unity) may help to preserve the mental health of minority communities, the disproportionate risk burden they carry still takes its toll as evidenced by the disproportionate burden of medical morbidity in many of these groups.

Betancourt and Lopez (1993) caution that understanding the relationship between race and socioeconomic status (SES) is a complex process and vulnerable to methodological and statistical bias. For example, they note that the prevalence of depressive symptoms was found to be higher among Latinos than White Americans in a study conducted by Frerichs, Aneshensel, and Clark (1981), which provided evidence of an ethnic difference. However, this effect may be overestimated because when SES is controlled, the ethnic effect disappeared and SES became the significant predictor of depression. Because SES and ethnicity can be highly overlapped in some minority groups, both variables need to be included in statistical analyses. However, this overlap also effectively limits our ability to disaggregate shared variability. In order to properly understand these relations, they caution that a sufficient representation of ethnic groups in multiple SES stratum is required (Betancourt & Lopez, 1993).

Social factors such as familial relationships serve as an important risk and protective factor for all people, but may also affect ethnic minorities differently. For example, research examining expressed emotions found that while family interactions involving criticism was more predictive of relapse for White Americans returning home after hos- pitalization for schizophrenia, emotional distance and lack of warmth played a stronger role than emotionally negative interactions in predicting relapse for Mexican American families (Lopez et al., 2004). Chao (1994) also challenged what were believed to be culture-universal relationships between parenting styles and child outcomes by noting that Chinese American parents tended to be more “authoritarian” but that Chinese American children still performed well in school. She introduced the notion of a Chinese parenting style called “Xiao xun” or “child training,” and believes that this culture-specific parenting style, based on Chinese notions of filial piety, may better explain child-parent relations

215W.-C. Hwang et al. / Clinical Psychology Review 28 (2008) 211–227

than predominant Western conceptualizations. More research needs to be done to examine operational differences in how family and social relations preserve or exacerbate mental health outcomes. In addition, more research needs to be conducted to examine how acculturation impacts family relations. Recently, Hwang (2006a) proposed a theory of Acculturative Family Distancing (AFD), noting how growing acculturative gaps place immigrant families at risk for developing AFD along two dimensions, a breakdown of communication and an increase of incongruent cultural values, both of which negatively impact family relations and increase risk for psychological distress and functional impairment.

1.2. Culture and the expression of distress

The cultural background of the individual not only influences the etiology and development of disease, but also plays a role in the definition and sociocultural meanings of illness. The sociocultural meanings in turn are shaped by cultural norms and beliefs, and ultimately serve as a filter to shape the manner in which distress is expressed as illustrated by Pathways C and D. People from all around the world experience mental illness, and for the most part, symptom profiles for the major disorders are similar (USDHHS, 2001). However, the manifestation of such difficulties (e.g., how they are communicated, experienced, whether they are expressed, and the social meanings of different symptom clusters) can vary by age, gender, and cultural background (Kleinman, 1978). For example, although there may be core symptoms of depression that are similar across cultures, there may also be differences in emphases placed on certain types of symptoms (e.g., differences in the loading of affective, cognitive, and somatic complaints) and/or symptoms associated with depression (e.g., headaches and stomachaches) that are not currently included in the U.S. Diagnostic Statistical Manual (DSM) or the International Classification of Disease (ICD) (APA,1994; WHO, 1992). The sociocultural environment may act as a contextual backdrop and influence cultural conceptions of illness (e.g., what an illness is), symptom recognition and tolerance, the manner in which it is expressed, social meanings associated with it, and the manner in which it is communicated (e.g., directly, indirectly, or not at all) (Marsella, 1980).

When considering cultural differences in the expression of distress, etic (culture-universal phenomena) and emic (culture-specific phenomena) distinctions are also important to make (Fischer, Jome, & Atkinson, 1998; Sue, 1983). Using depression as an illustrative example, the etic perspective assumes that all people express depression in similar ways and that our diagnostic criteria can be applied to people from all backgrounds without significant cultural bias. On the other hand, an emic perspective would argue that there are likely to be both universal forms of depressive symptoms (i.e. criterial symptoms), as well as cultural variability in symptom expression (Fischer et al., 1998; Sue, 1983).

Somatization, or the degree to which people express their distress through physical symptoms can vary across cultural groups, affect different parts of the body, and carry different social meanings. For example, in Asian cultures, research suggests that somatic expression of distress is very common place; whereas, in Western cultures, there is a greater emphasis on talking about problems and expressing oneself verbally and emotionally (Chun, Enomoto, & Sue, 1996). When comparing Chinese and American psychiatric patients with depressive syndromes, Kleinman (1977) found that 88% of Chinese patients compared to 20% of U.S. patients did not present affective complaints and reported only somatic complaints. In Taiwan, nearly 70% of psychiatric outpatients presented with predominantly somatic complaints at their first visit (Tseng, 1975). Chun et al., (1996) note that somatization may be more prevalent among Asians because open displays of emotional distress is discouraged, possibly because of differences in value orientation and strong stigma associated with mental illness. Displays of psychological symptoms of depression may be perceived as characteristic of personal or emotional weakness. As a result, Asians may deny, suppress, or repress the experience and expression of emotions. This is not to say that Asians and Asian Americans do not experience psychologically related depressive emotions per se. Instead, there may be cultural differences in selective attention (e.g., amount of focus on the mind vs. body), ordering of such foci (e.g., focusing on somatic symptoms first because this is more culturally acceptable and less stigmatized than acknowledging cognitive and emotional symptoms), and/or willingness to express distress based on what's culturally appropriate or accepted (e.g., greater stigma associated with mental illness and/or differences in divulging problems to people outside of the family). In some Latino groups for example, somatic disturbances take the form of chest pains, heart palpitations, and gas (Escobar, Burnam, Karno, Forsythe, & Golding, 1987); whereas, in some African and South Asians groups it is sometimes expressed through burning of the hands and feet and the experience of worms in the head or the crawling of ants under the skin (APA, 1994; USDHHS, 2001).

There may even be linguistic differences in the language available to describe, interpret, and communicate one's problems. For example, in Native American culture, words for many Western conceptualizations of illness such as

216 W.-C. Hwang et al. / Clinical Psychology Review 28 (2008) 211–227

depression and anxiety do not exist (Manson, Shore, & Bloom, 1985). In examining ethnic differences in the clinical presentation of depression, Myers et al. (2002) found that even after controlling for SES and severity of distress, African American and Latina women who were depressed reported more somatic complaints than White American women. Greater somatic manifestations among many ethnic groups may be associated with philosophical or cultural underpinnings that emphasize an integrated or holistic mind-body-spirit experience (Hwang, Wood, Lin, Cheung, & Wood, 2006). This can be seen in Traditional Chinese Medicine (TCM) where the mind and body are treated as one, inseparable, and a balance of yin (negative) and yang (positive) energies.

How psychological or emotional distress is initially expressed can also be culturally incongruent and open the door for social or self-criticism (Chun et al., 1996). In some cultures, extreme emotional reactions may elicit negative social responses (e.g., other perceiving this person as crazy, weak, or lazy); whereas, somatic expression of distress may elicit empathy and help rally support from social networks (e.g., the belief that this person has a real medical problem and needs help). Illnesses are dynamic in that they represent complex social constructs that are influenced by social norms and complex social feedback interactions between the person and their social environment (Chun et al., 1996). In some cultures, attribution of interpersonal distress to physical causes may also initially protect patients from feeling negative emotions and worry, and reduce feelings of shame, weakness, and loss of control.

Although Chinese patients may initially report more somatic symptoms and suppress or ignore emotional symptoms, this does not mean that they do not experience emotional and cognitive symptoms (Cheung, 1982; Cheung & Lau, 1982). In fact, clinical experience tells us that after developing a good therapeutic relationship, Chinese patients begin to feel more comfortable expressing more cognitive and affective symptoms. In addition, studies have found that although some patients were more likely to focus on physical complaints when they initially came into treatment, they were fully aware of and capable of expressing feelings and talking about the social problems that had brought them into treatment after a strong patient-therapist relationship developed (Cheung, 1982; Cheung & Lau, 1982).

Culture-bound syndromes, defined as culture-specific idioms of distress that form recognized symptom patterns and have distinct clinical characteristics, symptom constellations, and social meanings, have been documented in many cultures (APA, 1994; Levine & Gaw, 1995). Two of the most researched include ataque de nervios and neurasthenia. Ataque de nervios, often characterized as a form of panic attack among Latinos, is associated with feelings of being out of control due to stressful events relating to family difficulties (APA, 1994). Unlike traditional panic attack, it is not associated with the hallmark symptoms of acute fear or apprehension. Other symptoms include trembling, uncontrollable shouting or crying, somatic feelings of heat rising through the chest to the head, dissociative experiences, seizure-like fainting episodes, and aggressive behavior (APA, 1994). Recent evidence suggests that although a portion of those diagnosed with ataque de nervious also meet criteria for panic disorder, the majority of subjects with ataque de nervios do not, suggesting that ataque de nervios is a more inclusive construct (Lewis- Fernandez et al., 2002). Key features that distinguish ataque de nervious from panic include a more rapid onset of attack, being preceded by an upsetting event in one's life, and greater fears of losing control, going crazy, depersonalization, sweating, and dizziness (Lewis-Fernandez et al., 2002; Liebowitz et al., 1994).

Neurasthenia (NT) or shenjing shuairuo in Mandarin Chinese, commonly referred to as a Chinese form of depression, is characterized by two highly overlapping symptom domains including increased fatigue after mental effort (e.g., poor concentration, increased distractibility, inefficient thinking) or physical weakness or exhaustion that is accompanied by physical pains and inability to relax (e.g., headaches, dizziness, sleep difficulties, gastrointestinal problems, anhedonia, and bodily pain) (WHO, 1992). This diagnosis continues to be used in China and is included in the Chinese Classification of Mental Disorders, Second Edition (Neuropsychiatry Branch of the Chinese Medical Association, 1989). There continues to be controversy about whether neurasthenia is merely major depression with a cultural label or whether it is a distinct diagnostic entity. For example, Kleinman (1982) found that 87% of psychiatric patients diagnosed with NT in a Chinese clinic could be rediagnosed with major depression. In contrast, a recent epidemiological study of Chinese Americans in Los Angeles found that 78% of those diagnosed with neurasthenia did not meet criteria for major depression or an anxiety disorder, yielding a neurasthenia prevalence rate that was as high as that of major depression (Zheng et al., 1997).

Many other culture-bound syndromes have also been documented (Levine & Gaw, 1995). Unfortunately, there is less empirical research to help us understand these syndromes which affect people from all around the world. For example, many cultures believe in magical powers, spiritual possessions, and witchcraft or juju. In Northern Africa and parts of the Middle East, cases of “Zar” or a spiritual possession type culture-bound syndrome have been reported (Grisaru, Budowski, & Witztum, 1997). In Western Africa and different parts of Asia, similar but qualitatively distinct

217W.-C. Hwang et al. / Clinical Psychology Review 28 (2008) 211–227

small-scale epidemics of genital shrinking distress have also been reported (Dzokoto & Adams, 2005). There is clearly a link between culture and the development, expression, and definition of psychiatric disorders. Because of the link between Westernization and increasing rates of eating disorders across the world, some have also begun to question whether commonly accepted psychiatric disorders which were believed to be culture-universal, such as anorexia nervosa and bulimia, are actually western culture-bound syndromes (Banks, 1992; Keel & Klump, 2003).

1.3. Expression of distress, diagnostic accuracy, and the prevalence of illness

The ability to accurately identify and classify illness is an essential part of providing quality health care (Corey, Corey, & Callahan, 1993). Accurate diagnoses help practitioners properly identify the problem, prescribe an appropriate treatment, and understand the etiology, course, and prognosis of the illness. Moreover, the ability to accurately diagnose a problem helps us determine the prevalence of different illnesses and assess the public health needs of different populations. Diagnostic and assessment practices can be especially challenging because of cultural differences in the manifestation, presentation, and concealment of problems (Pathway I). As a result, current diagnostic systems, which are based on Western conceptualizations of mental illness, may be less accurate in diagnosing those from differen

Collepals.com Plagiarism Free Papers

Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.

Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS

Why Hire Collepals.com writers to do your paper?

Quality- We are experienced and have access to ample research materials.

We write plagiarism Free Content

Confidential- We never share or sell your personal information to third parties.

Support-Chat with us today! We are always waiting to answer all your questions.