Introduction: Culture and Psychiatry

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Back to table of contents Previous article Next article INFLUENTIAL PUBLICATIONFull AccessIntroduction: Culture and PsychiatryWen-Shing Tseng, M.D., and Jon Streltzer, M.D.Wen-Shing TsengSearch for more papers by this author, M.D., and Jon StreltzerSearch for more papers by this author, M.D.Published Online:1 Jan 2006https://doi.org/10.1176/foc.4.1.81AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Culture and its influence on medical practiceWhat is culture?The word culture refers to the unique behavior patterns and lifestyle shared by a group of people that distinguish it from other groups. A culture is characterized by a set of views, beliefs, values, and attitudes. Culture is manifested in the core of behavior and the various ways in which life is regulated, such as rituals, customs, etiquette, taboos, and laws. It is reflected in such things as common sayings, legends, drama, art, philosophical thought, and religions. Culture shapes people’s behavior, but at the same time it is molded by the ideas and behavior of the members of the culture. Thus, culture and people influence each other reciprocally and interactionally. Culture is generally recognized in social or institutional patterns, and it affects specific behaviors and reactions of the individual. The individual may be aware of these influences or the influences may be operating at a subconscious level (Tseng 2001, p. 26).Culture and medical practiceIn the medical setting, three types of culture are present: the culture of the patient, the culture of the physician, and the medical culture in which the clinical work is practiced. An appropriate understanding of these three cultural dimensions is essential to the comprehension and performance of culturally competent clinical work.The culture of the patientIn addition to individual factors—such as level of education, medical knowledge, and personal life experiences—culture will contribute to the patient’s understanding of illness, perception and presentation of symptoms and problems, and reaction and adjustment to illness. The patient’s expectations of the physician, motivation for treatment, and compliance with treatment recommendations are also influenced by culture.The culture of the physicianSuperimposed on individual style, personal belief, and professional knowledge, the culture of the physician will shape the pattern of interaction and communication with the patient. For example, a physician might have cultural biases and expectations about the behavior and needs of a patient of a particular gender, sexual orientation, race, or ethnicity; about a specific disease (such as acquired immune deficiency syndrome [AIDS] or alcohol abuse); or about a certain procedure (such as abortion). The culture of the physician explicitly or implicitly affects his or her attitude toward the patient, understanding of the patient’s problems, and approach to caring for the patient.The medical cultureMedical culture includes traditions, regulations, customs, and attitudes that have developed within the medical service setting beyond medical knowledge and theory. The practice of general psychiatry is strongly embedded in the medical culture that has developed within the medical system. Most physicians and medical staff members have become accustomed to living within this invisible cultural system and may be unaware of its influence on their practice. It often takes outsiders to recognize the existence of medical cultures, which may differ among specialties (such as surgery and psychiatry) but share common issues.Examining medicine practiced in America, anthropologist H. F. Stein (1993) pointed out that for the American doctor, being in control is very important. The physician’s dominant values are individualism (the doctor’s ability to do the work himself), mastery over nature (capability to cure the disease), and future orientation (being focused on the patient’s eventual cure). Actively intervening, aggressively treating, controlling, and fixing the patient are acceptable attitudes for the clinician; these attitudes strongly reflect American value systems, which might not necessarily be shared in other cultures.Whether the physician and nurse work together as egalitarian team members or in a distinct hierarchical order depends on the medical culture, which in turn reflects the culture of the society. How nurses and other medical staff members regard physicians varies in different cultural settings. For instance, in Japan, reflecting Japanese attitudes toward authority and male figures, male physicians are highly respected by medical staff and patients. Female nurses are accustomed to bowing to physicians and following orders obediently. In contrast, in America, the status of nurses is relatively high, and they often take charge in ward situations.In medical practice it is believed that there should be a “diagnosis” for each patient. Without a diagnostic label on a patient’s chart, the practice of medicine is not considered complete, and there can be no treatment. In addition, patients feel uncomfortable if they are not given a diagnosis and no medication is prescribed.In psychiatry there are certain rules that patients and their families are asked to follow. Psychotherapy patients are supposed to visit their psychiatrists weekly, typically for 1 hour each session. This is based on the convenience of the therapist in an era of technical development and reflects the spirit of industrialized societies. In many parts of the world the concept of visiting a clinic for a scheduled appointment does not apply, reflecting the realities of societies where there are no private cars or public telephones. Patients drop in whenever it is convenient for them and when they feel like it. It is only when they practice in such settings that psychiatrists realize there is no point in trying to force their established medical expectations and culture on these patients.Elements of clinical cultural competenceTo be clinically competent, every clinician needs to be culturally competent. Clinicians typically work in multiethnic, multicultural societies, providing care for patients of diverse backgrounds. The presence of diverse populations in a society creates the need for training in cultural psychiatry. Even when the cultural background of the patient is not significantly different from that of the clinician, it is inevitable that some differences will exist. Therefore, virtually all clinical practice can be considered to be transcultural (Comas-Díaz 1988).Clinical cultural competence requires the attainment of several qualities (Foulks 1980; Lu et al. 1995; Moffic et al. 1988; Tseng and Streltzer 2001; Westermeyer 1989; Yutrzenka 1995). They include cultural sensitivity; cultural knowledge; cultural empathy; flexible, culturally relevant doctor-patient relations and interaction; and cultural guidance (the ability to use these qualities therapeutically) (Tseng 2001, 2003). These elements are elaborated in the following sections of this chapter.Cultural sensitivityCultural sensitivity refers to a recognition of the diversity of viewpoints, attitudes, and lifestyles among human beings. It includes the recognition that groups of people may tend to experience different types of stress in living and to utilize relatively distinctive coping patterns. Beyond being aware of these factors, the clinician needs to appreciate them without bias, prejudice, or stereotyping. Such appreciation requires a willingness to explore these areas and to learn from patients and their families about their beliefs, attitudes, value systems, and ways of dealing with problems. It is not only sensitive perception but also a desire to learn about others’ lifestyles, rather than being trapped in one’s own subjective perception and interpretation of their behavior.Cultural knowledgeIn developing sensitivity it is helpful to have a certain base of cultural knowledge about humankind as a whole with which to put the particular patient and family into perspective. This is not to say that the clinician needs an anthropologist’s knowledge of the subtleties and varieties of extant cultural systems. However, it is desirable to have some basic anthropological knowledge about how human beings vary in their habits, customs, beliefs, value systems, and especially illness behavior. This basic knowledge should be extended with regard to the cultural systems of patients, so that culturally relevant assessment and care can be delivered. Reading books and other literature is one way to obtain such cultural information. Consulting with medical anthropologists on general issues or with experts on a particular cultural system is another approach. When such material or consultation is not readily available, the patient and the family, or friends of the same ethnic-cultural background, may be used as resources. Of course, careful judgment is needed to determine the accuracy and relevance of the information obtained.Cultural empathyAn intellectual understanding about a patient’s culture is often not sufficient for effective treatment. There is another quality needed: the ability to feel and understand, on an emotional level, the patient’s own cultural perspective. The ability to participate in the emotional experience of the patient, known as cultural empathy (Pinderhughes 1984), is important to the quality of therapy.Culturally relevant relations and interactionsThe interaction between the therapist and the patient involves the cultural background of both the patient and the therapist and the setting in which the therapy takes place. These influence not only the nature of the relationship between the therapist and the patient—in terms of role, status, and level of intimacy—but also issues of interaction, including communication, understanding, and giving and receiving between the therapist and patient. In particular, it is always necessary to consider the proper relation between an authoritative and a subservient figure and persons of different genders, and whether the setting is a professional or a social occasion or an accidental encounter. Such cultural knowledge will enhance clinical judgment, leading to a proper therapist-patient relationship that is culturally relevant and therapeutic.The ability to detect, comprehend, and manage ethnic- or race-related transference and counter-transference is also needed in dealing with patients of distinctly different ethnic or racial backgrounds. This is particularly true when problematic relationships have existed between the ethnic or racial groups of which the patient and therapist are members. For instance, the patient may be a member of a minority or majority group and the therapist the opposite. There may be a history of discrimination and an imbalance of power between these two groups. This interacts with the unequal roles of doctor and patient. The willingness of the therapist to give careful consideration to these issues, in order to properly manage and make appropriate adjustments to therapy, is important for cultural competence.Cultural guidanceSpecific treatment models for particular ethnic groups are unlikely to be useful in clinical practice. There are so many kinds of problems within any given ethnic group that different therapeutic approaches must be applied accordingly. However, a certain general approach might be better suited to a specific ethnic group because of varying ways to relate to a doctor, cope with mental problems, and understand the role of psychiatric services.To formulate the most effective intervention for patients in dealing with their problems, the clinician should assess the extent to which and the ways in which the patient’s problems are related to cultural factors. Sometimes, direct advice should be given to challenge or adjust culturally determined norms, values, and goals so that the patient can cope with problems and resolve conflicts. Culturally sanctioned coping mechanisms may need to be reinforced or, if they are ineffective, to be confronted. Alternatives to culturally defined solutions may need to be proposed. To find relevant and optimal solutions, not only clinical judgment but also cultural insight and wisdom are sometimes required (Tseng and Streltzer 2001).When the patient and therapist have different cultural backgrounds, therapy involves the interaction of two value systems. Thus, therapeutic interaction provides opportunities for exposure, exchange, and the incorporation of differing cultural elements between therapist and patient (Tseng and Hsu 1979). Cultural insight into the therapist’s own beliefs and value system allows regulation of this core interaction and the overall therapeutic process in a competent manner.Society, culture, and psychiatric care: a general viewThe practice of psychiatry occurs within a general context that includes the society, the cultures within it, and the medical system itself. Recognizing the social and cultural perspectives in which psychiatric service is delivered will present the clinician with more flexible therapeutic options.Impact of culture on psychiatric practiceFolk concepts and stigma of mental disordersEven though modern psychiatry has made significant progress in its scientific understanding of the nature of psychiatric disorders, many people still believe various folk concepts about mental illness. Loss of soul, intrusion of illness objects, the wrongdoing of ancestors, deficiency of vitality, and an imbalance of yin and yang are some examples of folk interpretations of mental illness (Tseng 2001). An individual holding these beliefs might resist taking psychotropic medications. Such a patient may want to perform religious rituals to regain his or her “lost soul” or may want to eat certain foods to correct “an imbalance of yin and yang.” Talking therapy is not considered to be effective for removing “an intruding ill spirit” or for correcting “deficient vitality.” Although increased knowledge and improvements in clinical care are changing peoples’ attitudes toward mental disorders, there are still broad cultural differences in these attitudes. For instance, in Arab societies and in India, the mentally ill are respected and tolerated because of the historical notion that divine messages are sent through them. In contrast, in many societies, there is a general fear of and a strong stigma attached to “insane” people. These negative views of mental disorders obstruct the practice of psychiatric care.Ethnicity, minority, and racismMembers of minority groups are often subjected to less favorable medical care, and psychiatric care and treatment are less likely to be available to them (Well et al. 1987). In general, this is the result of misperceptions and prejudice on the part of psychiatrists and, among patients, misconceptions and lack of knowledge about mental disorders and their treatments.Concern about the effects of racism on psychiatric practice has been expressed since the 1970s in North America (Sabshin et al. 1970; Siegel 1974) and later in Western Europe (Burke 1984; Littlewood 1992). Minory patients tend to be given more severe clinical diagnoses. Misperceptions and miscommunication between doctor and patient occur because of patients’ unfamiliarity with clinical settings and psychiatrists’ unfamiliarity with symptom manifestation patterns and biased attitudes toward patients of certain ethnic or racial backgrounds. Mistrust on both sides interferes with the therapeutic relationship (Neki et al. 1985).Patients who are members of minority groups tend to have fewer sessions and to drop out of treatment more frequently. They are more likely to receive biological or somatic treatments rather than psychotherapy. There is a risk that clinical care will be colored by subtle unfairness if not explicit discrimination (Kaplan and Busner 1992). Therefore, sensitive attention to race and minority status is critical to a therapeutic relationship (Collins et al. 1992; Griffith 1977).Impact of the social-medical systemNumber and geographical distribution of psychiatristsIn different societies around the world, the number of psychiatrists available in a community varies tremendously, directly influencing the quality of psychiatric care (Tseng et al. 2001). In many developed societies there is a heavy concentration of psychiatrists in urban settings and a severe shortage in rural areas, even though the total number of psychiatrists in the society is relatively high. In many developing societies psychiatrists are very few in number and they focus mainly on those with severe mental illness.Medical insurance and paymentAnother factor that influences the mode of clinical practice is the extent to which psychiatric treatment is covered by medical insurance and whether the payment system is public or private. The payment system reflects the value placed by the society on the types of treatments available. For instance, in societies where talking therapy is not highly valued, it is difficult to charge patients very much for the service. This discourages psychiatrists from learning and performing this time-consuming therapy. In contrast, traditional medical habits and concepts deem it reasonable to charge for prescribing medications. Indirectly, this encourages drug-oriented treatment. Laboratory examinations using sophisticated scientific instruments usually qualify for high fees. This naturally leads to the performance of many unnecessary laboratory examinations such as brain scans or electroencephalograms for patients with psychological problems, who may not need these expensive examinations. Thus, payment systems, more than medical need, could shape the pattern of service delivery.Legal and ethical aspectsHuman rights and psychiatric treatmentCertain issues of practice—such as involuntary hospitalization, the use of physical restraints, and involuntary administration of medications—are dealt with differently in various societies, and these differences may reflect basic attitudes and concepts about human rights. Thus cultural factors shape the way treatment is provided to patients with mental disorders.Ethical concernsIt is assumed that ethics apply absolutely and universally in medical practice. All physicians must keep the patients’ best interests in mind in the course of care and, as much as possible, do them no harm. However, in cross-cultural applications this assumption may be arguable. Variations in ethics are observed from a cultural point of view and from international perspectives (Okasha et al. 2000). For instance, is it ethical for a physician to suggest sterilization for psychotic or mentally retarded patients? Is it ethical to treat homosexual persons as patients with a disorder?In apartheidera South Africa, when there was widespread political conflict between races, Steere and Dowdall (1990) pointed out that a set of ethical guidelines was likely to be plagued by recurrent dilemmas. A comparison of psychological ethics codes of 24 countries was made by Leach and Harbin (1997). They reported that Canada’s code of ethics was the most similar to that of the American Psychological Association in the United States and that China’s was the most dissimilar, demonstrating a relationship between professional ethical codes and cultural values.Cultural considerations in clinical practiceCultural differences in therapist-patient relationshipsInterpersonal relations are closely defined and regulated by social etiquette and cultural norms. This is particularly true for attitudes toward authority, which encompass the physician-patient relationship. In the United States, the predominant form of physician-patient relationship is egalitarian, based on a contractual agreement between the two and heavily influenced by an ideological emphasis on individualism, autonomy, and consumerism. In contrast, in many Asian cultures, the relationship is modeled after the ideal hierarchical relationship. The physician is seen as an authority figure who is clearly endowed with knowledge and experience. The ideal doctor should have great virtue and should be concerned, caring, and conscientiously responsible for the patient’s welfare. In return, the patient must show respect and deference to the physician’s authority and suggestions (Nilchaikovit et al. 1993).Ethnic/racial transference and countertransferenceEthnic or racial transference is a situation in which a patient develops a certain relationship, feeling, or attitude toward the therapist because of the therapist’s ethnic or racial background. Ethnic or racial countertransference is the reverse phenomenon, in which a therapist’s feelings and interventions are influenced by the patient’s ethnic or racial background. Similar to personal transference or countertransference, ethnic or racial transference or countertransference can be positive or negative and can severely influence the process of therapy. It is therefore critical to recognize when treating the patient.Ethnocultural transference may be manifested as denial of ethnicity and culture; mistrust, suspicion, and hostility; ambivalence toward the therapist; or overcompliance and friendliness (Comas-Díaz and Jacobsen 1991). Likewise, countertransference may be manifested as denial of ethnocultural differences; excessive curiosity about the patient’s ethnocultural background; and excessive feelings of guilt, anger, or ambivalence toward the patient.The possible negative impact of racism on psychiatric practice has attracted a great deal of attention (Carter 1995). In extreme circumstances psychotherapy can be quite difficult (Bizi-Nathaniel et al. 1991; Lambley and Cooper 1975), particularly when negative or even hostile relations preexist between the two racial groups concerned.Being open with patients at an early stage of therapy about the possible effects of race and ethnic differences on therapy is encouraged as a way to minimize the ill effects associated with negative interracial relations (Brantley 1983).Therapist-patient matchingAlthough the matching of therapist and patient by ethnicity, race, or cultural background sounds reasonable and desirable, it is not a simple matter. Such matching may not only be impractical, but clinically it does not necessarily guarantee success. Successful therapy relies on professional competence reflected in knowledge and experience. It also depends on the therapist’s personal ability to establish a positive relationship with and show empathy toward the patient. In other words, although the matching of ethnic or cultural background might be beneficial, clinical competence could be more effective in bringing about desirable therapeutic outcomes. In addition, therapists with the same ethnic or racial backgrounds as their patients may sometimes be at a disadvantage. This can occur, for example, if the patient does not want to reveal his or her personal background to a therapist with the same background for fear of being judged harshly, or if the therapist does not offer a proper figure for ethnic identification.LanguageLanguages vary greatly in their grammatical and communication patterns. For instance, differences in gender among subjects are noted in some languages (such as English, Russian, French, and Spanish) but not in others (such as Japanese and Chinese). This is related to the basic structure of the language, but it could also reflect the perceptions and conceptions of the people who use it. For instance, the vocabulary and grammar of the Japanese, with their hierarchical orientation, changes depending on the person to whom they are speaking.The richness of variations and differentiations of certain words often indicates the level of concern for the subject in the culture. For instance, Westerners use different words to describe various kinds of wine or liquor, whereas the Chinese have only one inclusive word, “wine.” In contrast, the Chinese use several different terms to address uncles or aunts, distinguishing paternal from maternal relatives and distinguishing hierarchically by age.Meanings in cultural contextIn psychiatric practice, it is important to grasp meanings expressed explicitly, tacitly, or in a symbolic way. Cultural idioms may invoke subtle or symbolic meanings of words. For instance, if someone says, “My house is far away,” it might mean that you are not welcome to visit it. If someone asks whether you have already eaten, it might not mean the person is concerned about your eating or interested in offering you a meal, it may simply be a social greeting, like asking “How are you?” Even when a patient reveals a wish to kill himself, it should not necessarily be taken literally but requires a clinical judgment about the patient, his psychopathology, and the possible motivation for such a revelation. In addition, a cultural judgment is needed: an understanding of the general custom among people in the patient’s culture of revealing a wish to end their lives, its common implication, and the possible message that the person wants to communicate. For example, if a Muslim person, whose faith forbids self-killing, expresses the wish that God would “take back” his life, the person may be indicating that he has suicidal thoughts, which must be taken seriously.Culture-shaped communication patternsBeyond the words and language used for communication, cultural factors influence how a person communicates with others, both verbally and nonverbally, which has an impact on the clinical setting. It is well known that the Japanese tend to respond by saying, “Hai! Hai!” when they are being spoken to. Although hai in Japanese literally means “yes,” it does not mean that the person is responding affirmatively to whatever is said. It simply indicates that he is listening to what is being said, even though he might disagree with it. In a similar way, a Filipino patient who keeps saying “Yes, doctor!” is not agreeing with the physician’s instructions but is simply indicating respect for an authoritative figure with whom it is not proper to disagree (see “Case 4: A Quiet Man With High Blood Pressure,” in Chapter 5, Culture and Consultation-Liaison Psychiatry).Styles of problem presentationA patient might make a somatic complaint not because she actually has a somatic problem but simply because it is a culture-patterned behavior to initially present somatic problems to a physician, or even to a psychiatrist. Sensitive probing, however, often reveals the more important emotional problems (Tseng 1975). In contrast, a patient might present a psychologized complaint—such as how much he hates his father or a trauma he encountered in his early childhood—at his first session with the therapist, as if he were very psychologically minded and aware of his psychological problems. However, as the therapy goes on, it might be shown that the patient learned to present such “psychoanalytical” material from the mass media or from his friends, whereas he actually knows nothing about his own psychological problems.Disclosure of personally sensitive information or taboo subjectsIn general, a therapist would like to have the patient disclose as much personal information as possible so that a proper, in-depth understanding of the patient can be achieved. There are many cultural variations, however, regarding how much internal information a person should reveal to an outsider and what issues are taboo. For example, in many cultures (including Asian cultures) it is taboo to discuss imminent death from a terminal disease. In such a circumstance, breaking the social taboo and helping the person face reality and prepare for the end of life has to be done delicately and subtly, rather than discussing the subject openly and liberally. Otherwise, the patient might conclude that the therapist wishes him to die soon.ConfidentialityClosely related to revealing private matters is how confidentiality is conceived and practiced in various cultural settings. If, in the patient’s social setting, the rights of the individual are more or less emphasized and personal boundaries are relatively well established, confidentiality is understood and expected in the clinical situation. However, in a society where the group (or family) is emphasized and individual autonomy has less value, the patient or the family might assume that the therapist will share information, an assumption that could greatly complicate treatment.Communication through an interpreterWhen the therapist and the patient do not share the same language they need to rely on interpreters for communication. Selecting a proper interpreter and utilizing the interpreter for the goal of communication is a clinical skill and art (Kinzie 1985; Marcos 1979; Paniagua 1998). In general, it is desirable to have an interpreter who has knowledge and experience in mental health work. The interpreter needs orientation, and perhaps training, for the work to be done.There may be problems in translating properly, relevantly, and meaningfully for clinical purposes. Deletion or omission of information, distortion of meaning, and exaggeration or addition of information are some of the problems that might be encountered with interpretation (Lee 1997). It has been reported that even when medically trained bilingual nurses were used as interpreters in medical settings, many serious miscommunication problems still occurred that affected either the physician’s understanding of the symptoms or the credibility of the patient’s concerns. Among the many factors that resulted in misunderstandings were the following: 1) physicians resisted reconceptualizing the problem when contradictory information was mentioned; 2) nurses (acting as interpreters) provided information congruent with clinical expectations but not congruent with the patient’s comments; 3) nurses slanted the interpretation, refl