Culture Cannot Be Divorced From Psychiatric Care

When an African-American truck driver said that he frequently saw the devil sitting beside him warning that his life was about to take a turn for the worse, the attending psychiatrist was about to diagnose the patient as suffering from a delusional disorder. Fortunately, the East Indian psychiatry resident, who knew little about African-American folklore, decided to ask the man about his religious beliefs. He found that the patient’s story was an accepted way of speaking in many Southern communities in the United States and that it should not be taken literally but interpreted in its cultural context.

Gary E. Myers, Ph.D., M.Div., an assistant professor of medical humanities and psychiatry at Southern Illinois University School of Medicine in Springfield, relates this story to show how a little cultural sensitivity can go a long way when psychiatrists are treating patients from cultures other than their own.

“This example of a resident’s sensitivity being heightened and the willingness to ask additional questions regarding the cultural context of the patient’s story resulted in the best interpretation of the patient’s symptoms,” he said at the XIIth World Congress of Psychiatry in Yokohama, Japan, in August.

Myers emphasized that globalization places new demands on psychotherapists to practice culturally competent psychotherapy. His interest in breaching psychotherapeutic cultural barriers came about in a roundabout way. His interest had originally been in the interface between psychology and religion, and his Ph.D. is in theology and personality studies.

“I was employed by the United Methodist Church to evaluate the spiritual and emotional well-being of missionaries and their families when they returned from their assignments abroad. Through this work I was pressed not only to consider the religious beliefs of patients, but also their cultural experiences. This exposure to cross-cultural therapy developed into my academic focus on taking religion and culture into account when doing psychotherapy,” he said. He is an ordained United Methodist minister but has never been a missionary.

During his teaching career Myers has won two Templeton Awards, the first to develop curricula in religion, spirituality, and culture for psychiatry residents, and the second to teach the same subjects to family medicine residents. In his current group of 22 psychiatry residents, five are American. Most of the others are from Pakistan, India, and the Philippines.

“So I’ve been teaching this type of multicultural psychiatric education to a multicultural group of residents since I arrived here in the heart of Illinois—among the cornfields and all,” he laughed.

From his travels and supervisory and teaching experiences with international psychiatry residents, he has amassed a large vocabulary of culturally relevant metaphors that are important to establishing connections between patients’ cultures and their psychotherapy. He said that one of the biggest errors Westerners make is looking at all behavior through only their eyes.

“If a person in Southeast Asia or Malaysia began running around screaming and throwing things after a stressful event, then settled down and acted almost psychotic, a visiting Western psychiatrist who took a snapshot of that behavior isolated from its cultural context would insist that the patient be medicated. But DSM-IV identifies that culture-bound syndrome as ‘running amok.’ And if the psychiatrist were from that culture, he or she would know that this is how the patient’s people deal with trauma, and the community is prepared to deal with such behavior,” he said.

In an interview, Myers touched on some guidelines on practicing culturally competent psychotherapy. “Assuming that the language barrier is not insurmountable between the patient and psychiatrist, and if as the psychiatrist you know nothing about the culture of the patient, it would be best to do a quick overview to get a general idea so you are not coming in cold. At the same time, you can’t overgeneralize. You have to wait and see who the patient is. Even to be culturally informed doesn’t mean you know the patient and his or her culture completely.”

He cautioned not to be overly apologetic because in most traditional and non-Western cultures, patients want their healer/therapist to be authoritative, and they become uncomfortable if you present yourself too much as an equal, which implies “not knowing your stuff.”

Patients need to be approached in an affirmative way, he advised. “Admit that your knowledge of their culture is limited and indicate that you are interested in their cultural perspective as it relates to their treatment and would welcome their input,” he said. That helps to enlist the patient as a consultant.

“Ideally, you want patients to become a contributor to your learning about their culture, which helps them to build trust in you and to educate you a bit.”

He said it is a common mistake to be too quick to impose a diagnosis on behavior and attitude before you interpret this through the operative cultural context. And he warned against interpreting and pathologizing behavior that is not understood or uncritically interpreting behavior according to one’s cultural standards.

“A helpful guide to the major culture-bound syndromes is in one of the appendices of DSM-IV. That will give you a step forward in recognizing cultural differences, but it lacks nuance and needs supplementation by further study,” he said.

For those with no prior experience of treating people from cultures different from their own, it is helpful to divide cultures into the broad categories of collectivist, primarily being traditionally Eastern, and individualist, or Western, Northwest European, and Australian.

To people from a collectivist culture, the important value is connection to the group, which tends to define them by seniority and status in the group, while in individualist cultures, the distinguishing values focus on self, self-expression, self-realization, and being related but staying apart from the group, said Myers. As one Japanese expressed it, “Everyone in the West is an individual ego and uses the pronoun ‘I’ a lot, while we tend to prefer consensus and belonging.” A common Japanese saying expresses this aptly: “The nail that stands up gets hammered down.”

“Say you have a Japanese client who is depressed over a conflict with the family because he is completing a graduate degree aimed toward developing his career in a distinctive way that suits him, while his family really expects him to take a major role in the family business. It would be simplistic to tell your client that he should individuate and learn to separate from his family and do his own thing; that he should feel secure in what he is doing and his folks will get over it; and that he will establish the relationship on new grounds.

“That transition is possible with American families even if they are overinvolved with one another. But that’s simply not the case in Japan. Your client’s culture is a fundamental part of his identity. As the oldest son in his family, he has a deep obligation to this group. So you have to negotiate between cultures instead of imposing an entirely different system on him.”

How an Eastern patient’s problem is handled must take into account the degree to which he has been Westernized. Just because someone is Japanese or Chinese does not mean he or she is invested in those specific cultural views and values, Myers pointed out. Some young Japanese men have spiked blond hair and prefer rap music and Dr. Dre to Sumo wrestling and martial arts.

“So you have to make that determination, too, when fine-tuning your approach to cultural psychotherapy,” he said. ▪