Introduction: Culture and Psychiatry

In 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.

Superimposed 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.

Medical 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.

Even 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.

Members 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).

In 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.

Another 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.

Certain 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.

It 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.

A person experiences pain when he is hit; feels anxious if he is worried about something; becomes paranoid if he suspects that he is being persecuted by others; or feels sad if he has lost something significant to him. All these reactions to distress—which may be manifested as symptoms or signs—are subjective, experiential phenomena. However, it is clear that the source of the distress can be influenced by sociocultural factors. For instance, stress can be produced by culturally demanded performance. Stress can be created by culturally maintained beliefs. Stress can be generated by cultural restrictions of behavior, culture-supported attitudes, or other culture-related factors (Tseng 2001, pp. 128–136).

After the experience of distress and the emergence of symptoms, the patient perceives and interprets the distressing experience. This psychological phenomenon is subject to the influence of cultural factors in addition to other variables, such as the patient’s personality, knowledge, and psychological needs. Depending on how the problem is understood and perceived by the patient, he will show a secondary process of various reactions to the distress. In other words, the patient’s perception of and reaction to the primary symptoms will add secondary symptoms that compound the clinical picture. The process of forming secondary symptoms is usually subject to cultural influences.

The next step is the presentation of the complaints or illness by the patient to others—the process and art of “complaining.” Analysis of this process has shown that the way the problem, symptom, or illness is presented or communicated to the clinician is based on the patient’s (or his or her family’s) orientation to illness, the meaning of the symptoms, motivation for help seeking, and culturally expected or sanctioned problem-presenting style. It is a combination of the results of these factors that affects the process of complaining. However, culture definitely plays a role in this complaining process.

For instance, patients of certain ethnic groups tend to make somatic complaints to their clinicians in their initial sessions at mental health clinics. This tendency requires careful understanding. There may be several alternative implications: a physical condition is the patient’s primary concern; somatic symptoms are being used as socially recognized signals of illness; the symptoms constitute a culturally sanctioned prelude to revealing psychological problems; or the symptoms are a reflection of hypochondriacal traits that are shared by the group (Tseng 1975). Therefore, the nature of the somatic complaint needs to be carefully evaluated and understood rather than simply dealt with or labeled as a somatoform disorder.

Conversely, as mentioned earlier, a patient from another ethnic background might present many psychological problems to the therapist in the initial session, complaining that as a small child she was abused by some adult, was never adequately loved by her parents, and is now confused about her own identity, unclear about the meaning of life, and so on. It is necessary for the clinician to determine how much of this psychologized complaint may merely reflect the patient’s learned behavior from public communication about patienthood and how much of it is really of primary concern. The performance of complaining or problem presentation is an art that does not directly reflect the distress or problem that the patient is experiencing. A dynamic interpretation and understanding are necessary.

A clinician, as a cultural person and a professional, has his or her own ways of perceiving and understanding the complaints that are presented by the patient. The clinician’s psychological sensitivity, cultural awareness, professional orientation, experience, and medical competence all act together to influence his or her assessment of the problems a patient has presented (Streltzer 1997). The cultural background of the clinician is a significant factor that deserves special attention, particularly when he or she is examining a patient with a different cultural background or one with which the clinician is unfamiliar. The clinician’s style of interviewing, perception of and sensitivity toward pathology, and familiarity with the disorder under examination all influence his or her interaction with the patient, which in turn influences the outcome of the clinician’s understanding of the disorder (Tseng et al. 1992).

The final step in the process of evaluation is making a clinical diagnosis. Determination of the appropriate clinical category for the diagnosis is influenced by the professional orientation of the clinician, the classification system used, and the purpose of making the diagnosis (Cooper et al. 1969; Jilek 1993; Tseng et al. 1992). In many societies, a clinician needs to take into consideration the social impact of diagnostic labeling on the patient and the family.

In sum, making a clinical assessment and diagnosis is a complex matter involving a dynamic process between the help seeker and the help provider. The assessment and diagnostic process is influenced in a variety of ways by the cultural background of the patient, as by that of the clinician. The clinician who is aware of how cultural factors affect each step in the process has a distinct advantage.

In addition to socioeconomic and medical factors per se (including knowledge and theory), the mode of psychiatric treatment is also directly or indirectly influenced by cultural factors. For instance, the decision to follow a more biologically or a more psychologically oriented treatment model is subject to the patient’s and the therapist’s views on the usefulness of these models, and these views are based on their cultural attitudes and beliefs. Decisions regarding whether the patient should be treated in a closed institution with custodial care or in an open system in the community are greatly influenced by the family’s and the community’s attitudes toward mental illness.

Psychotherapy is greatly influenced by cultural factors (Tseng and Streltzer 2001). This is true of both the technical aspects and the theoretical and philosophical considerations of psychotherapy (Tseng 1995). This influence is discussed in detail in Chapter 11 (Culture and Psychotherapy).

Genetic and other biological factors affect pharmacokinetic and pharmacodynamic processes. In addition, significant psychological factors—closely associated with social and cultural factors—influence the giving and receiving of medication. These issues are discussed in detail in Chapter 10 (Culture and Drug Therapy).