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Providing Culturally Competent Care: Understanding the Context of Psychosis

Providing Culturally Competent Care: Understanding the Context of Psychosis

Culture—the way people make meaning and live their lives in particular social worlds—matters in psychosis. Culture affects the risk that someone will fall ill with psychosis. It influences its course and outcome, as well as who has access to care and to what kind of care. Culture affects not only the way others interpret unusual sensory experiences associated with the illness, but also the way those who have them experience them.

These observations resonate with the most important recent turn in the clinical care of persons with psychosis: that the way people interpret their voices may alter what their voices say. Some people, to some extent, can learn to experience their voices differently. This should influence the way clinicians think about treatment and care. We begin with 3 findings about the way culture affects psychosis.

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Culture affects the risk of developing psychosis

Over the past few decades, epidemiologists have documented multiple cultural and socio-environmental risk factors for psychosis, including migration; urban living; childhood physical, sexual, and emotional abuse and adversity; ethnic density; and neighborhood social capital. Significantly heightened risk of psychosis within particular ethnic minority groups—including black minority and South Asian–origin ethnic groups in the UK and Northern Europe, and African Americans in the US—has been documented. Both first- and second-generation immigrants are at heightened risk for psychosis.1 In general, scholars attribute the increased risk to social adversity or social defeat—the experience of being “one down” in social relationships—rather than to genetics.2

Culture shapes the course and outcome of psychosis

The striking finding that schizophrenia has a more benign course and outcome outside of the developing world has been supported by further research.3 Recently, a cross-cultural comparison of outcomes for first-episode patients treated in Montreal, Canada, and Chennai, India, found significantly improved functional outcomes and negative symptoms for the Chennai patients in spite of no differences in positive symptom severity.4 To be clear, some so-called treatments in the developing world are barbaric (for example, people abandoned at temples or prayer camps, harshly exorcised, or chained to trees). Nevertheless, a series of systematic studies has found that 2 years after an initial diagnosis, patients in the developing world have significantly larger periods of unimpaired functioning, and complete clinical remission is far more common.5 The best data come from India, and while explanations of these findings vary, greater social inclusion and access to social institutions such as marriage are likely important.

Culture also shapes course and outcome in more subtle ways. In white communities, those from non-white minority groups may be more reluctant to seek psychiatric care. When they enter care, they may experience it as more aversive. One study found that black British men were 4 times as likely as white British men to enter initial treatment involuntarily. Another study found that black British women had 7 to 8 times greater odds of being detained and hospitalized before outpatient treatment compared with white British women.6,7 Significantly heightened rates of criminal justice system interactions and/or police referrals for ethnic minority patients before initial care were also observed.

Culture shapes the phenomenology of voice-hearing and other symptoms

Even in clear-cut cases of psychosis, culture shapes the subjective phenomenology of psychotic symptoms. Luhrmann and colleagues,8 for example, found that compared with US subjects, patients in India and Ghana experienced their voices as less distressing, with less violent content, and as more relational. Within non-immigrant, racially homogeneous samples, culture and religious/spiritual beliefs still shape both the content and structural characteristics of psychotic symptoms.9 Barrett10 found that in a setting in which people did not regard the mind as a container, people did not understand the concept of thought-insertion. Meanwhile, socially different family expectations alter the response to psychotic experience in patterned ways. For example, traditional families in India and Mexico exhibit less “expressed emotion” than those in the UK and US.11,12


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