A clinician scans the chart of the next patient. The name is unfamiliar, and the chart states that the patient only speaks Spanish. An interpreter waits outside with the client.
Are we comfortable seeing this patient? We should be and we shouldn’t be. We know that we are unfamiliar with this patient’s cultural background, and we have to have help communicating with them. That makes us nervous, taking us out of our comfort zone. That zone is a trap of diagnostic shortcuts that may or may not work with the current situation.
Cultural psychiatry is a way of looking at patients that assumes they are not going to fit into a box of DSM-5 symptoms, and our assumptions about how their life is being lived with a nuclear family, a spouse, and two and a half children. Patients come in all varieties — White, African American, Asian, Hispanic, gay, straight, atheist, Catholic, Jewish, Muslim — and a mix of all of the above.
A psychiatrist’s thinking about cultural considerations puts aside his or her assumptions, and tries to evaluate the person in front of them in their cultural context, not in ours. Even the most “mainstream” patient has subtleties that can be explored, as many cultural details are not as easily recognized, such as where a person grew up or now lives, or their economic background.
I like using the DSM-5 Outline for Cultural Formulation for teaching how to identify cultural considerations as a way of breaking down the bio-psycho-social formulation into: A) the cultural identity of the individual; B) cultural concepts of distress; C) stressors and supports; D) cultural aspects of the clinician-patient relationship; and E) the overall cultural formulation.
The Cultural Formulation Interview (CFI), included for the first time in DSM-5, is an important advancement to help clinicians formulate questions to gather the clinical data necessary for a culturally appropriate assessment. I would encourage readers interested in cultural psychiatry take a look at the CFI in the back of the DSM-5, and try to create their own questions similar to its’ 16 questions.
Some questions that can be asked of patients during the initial interview include, “What do you think is causing your problem?” Patients may demur to answer this question, bowing to the expertise of the clinician. But the patient may also hide beliefs that they feel the clinician will find strange or hard to understand, and avoid contradicting the clinician or being embarrassed by revealing nonmainstream beliefs. As culturally sensitive clinicians, we accept these beliefs with a nonjudgmental, “I understand that you have suffered, and many have suffered in the way you have.”
The appropriate follow-up question is then, “Have you seen any healers that help with those types of problems?” The clinician further validates the patient’s experience by asking about help-seeking pathways that have led the patient to today’s visit, but more importantly, creates rapport between the clinician and the patient by showing interest in the patient’s explanations and experiences.
The clinician also needs to pay attention to the dynamics present in the room, noting which similarities and differences may be affecting the relationship, and comment on them if appropriate.For example, “How can we help you?”
Finally, when making a treatment plan, the clinician needs to bridge the gap between the patient’s explanatory models and the clinician’s, using the patient’s words, and concepts if possible, to negotiate the treatment plan with the patient.
The clinician should also have some basic knowledge about the patient’s cultural group, understanding that not all members of that group will fit the profile of a “typical” member. If clinicians learn about what typically is common in a cultural group, then they may ask about how is it in their patient, and see how much they are like versus unlike a majority of members of their group.
There are many websites and books that can be consulted for many countries and ethnic groups, including EthnoMed.org, The Clinical Manual of Cultural Psychiatry (2nd edition) edited by the author, and Ethnicity and Family Therapy (3rd edition) by McGoldrick, Giordano, and Garcia-Prieto.
The cultural approach is vitally important for the assessment of all patients, as often their culture is not visible to the clinician’s eye during the assessment, and only discovered with careful questioning. Many psychiatrists will say that cultural issues only come up in patients that are non-English speaking, or in patients who are obviously “different.” That belief will undermine their efforts to get to know patients beyond a superficial assumption that they “know” the patient, because they are like the clinician, an American, or however they are perceived to be alike.
Performing a culturally appropriate assessment means that the clinician will not take shortcuts or assume that a patient will fit a cultural profile or stereotype. Only then can the clinician feel confident that he or she has avoided any conscious or unconscious bias during their evaluation.
Russell F. Lim, MD, is a professor in the Department of Psychiatry and Behavioral Sciences at the University of California, Davis School of Medicine. He is also the editor of the book, Clinical Manual of Cultural Psychiatry, from American Psychiatric Press.