Shore JH, Savin D, Novins D, Manson SP. Cultural aspects of telepsychiatry. J Telemed Telecare. 2006;12:116-121.
This article is based on the experiences that the American Indian and Alaska Native Programs at the University of Colorado at Denver and Health Sciences Center and the Veterans Administration have had in providing 5 years of telepsychiatry in 9 telepsychiatry clinics serving 5 western states--Alaska, Colorado, Montana, South Dakota, and Wyoming.
Telepsychiatry often involves the working together of clinicians, patients, and organizations that are both geographically and culturally distinct. Thus, culturally appropriate care is an important component of telepsychiatry. The authors encourage clinicians who provide telepsychiatry to familiarize themselves with the Cultural Formulation from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The components most relevant in telepsychiatry are how the cultural background of patients influences their comfort with technology and the effect of cultural differences on the relationship between patient and provider.
For telepsychiatry to be successful, patients must be comfortable with videoconferencing. The authors suggest that clinicians assess and discuss a patient's comfort level with such technology. Of interest was that some veterans who reported having very limited exposure to technology were very comfortable with telepsychiatry, probably because of their experience with sophisticated communication systems during their military service.
Psychiatrists and other mental health clinicians who engage in telepsychiatry must understand the communication style, both verbal and nonverbal, of the patient population. The authors provide one example of how some Northern Plains American Indian elders believe that too much direct eye contact is discourteous and caution psychiatrists to not misinterpret this nonverbal communication as a clinical sign.
Establishing trust and rapport is also important, as is discussing patient concerns about confidentiality. Clinical facilitators--persons from the patient's community who lend credibility to the psychiatrist and perhaps the system of care--may be useful to help establish rapport between the psychiatrist and the patient but are not always needed to reach treatment objectives.
The authors recommend that providers ascertain a patient's feelings and attitude about and experience with the organization that will deliver telepsychiatry to avoid "system transference" (positive or negative feelings toward the system that may be transferred to the provider). Because telepsychiatry generally involves coordination between multiple systems of care, it is important that care is tailored to meet the needs of the patient population and not those of the individual systems.
Cultural differences between patient and provider are often highlighted in telepsychiatry by the patient and provider location (eg, rural vs urban differences). Providers of most telepsychiatry services are from urban areas. Providers who were raised, trained, reside, and practice in urban areas may have a limited understanding of rural environments and their influences on a person's communication styles and world views. Thus, familiarity with the rural community and regular contact with the communities served are important.
Shore and colleagues' focus on how culture intersects with telemedicine is a very important consideration. Clinicians treating patients remotely in the acute psychiatric setting face multiple culture-related challenges.
First, there will be rapidly changing cultural mismatches based on language and regional differences between patients and clinicians. The emergency clinician will need to change cultural sets quickly and, unlike in this article, there will not be the opportunity to have caseworkers trained to work with patients from one specific cultural group. A second culture-related challenge is that there will have to be rapid access to translators in multiple languages, including sign language. Necessity will dictate that these translators be integrated into the video conference to complete the assessment. Finally, a network of mental health professionals will have to be available on demand 24 hours a day, 7 days a week for consultation via telemedicine.
A frequent criticism of using telemedicine in the acute psychiatric setting is that decompensated, psychotic patients will apply their paranoid delusions to being "watched" on the television monitor and, therefore, refuse assessment. In practice, this rarely happens. In fact, in many acute psychiatric presentations, patients often feel freer to express themselves or reveal embarrassing information because there is physical distance between them and the clinician. For some patients, revealing this information becomes less difficult when the therapist is not in the room.
Because of the severely limited availability of mental health professionals in emergency settings, especially in rural locations, emergency telepsychiatry is a necessity that will inevitably become increasingly available.
Avrim Fishkind, MD
President, American Association for Emergency Psychiatry
Medical Director, Comprehensive Psychiatric Emergency Program
MHMRA of Harris County