How is cultural psychiatry defined? What is its history in the United States and how will it continue to influence mental health care in the future? What do mental health care professionals need to know to provide culturally sensitive care?
Historically, cultural psychiatry did not get off to a particularly good start in the United States. Take the case of drapetomania (Szasz, 1971). In times of slavery, this medical diagnosis could be applied to slaves who tried to run away. Such slaves were thought to be "mad" or "crazy" for trying to escape. The medical therapy recommended was whipping, and the "cure" was submission to the slave owner. Although drapetomania has not been in any of our recent diagnostic manuals, the need remains to consider the influence of culture on psychiatry.
Definition of Cultural Psychiatry
In considering terminology of this topic, cultural psychiatry is the term that has the broadest references. Cross-cultural is often used, but only refers to interactions where the culture of the patient is markedly different from that of the clinician, as in drapetomania. Psychologically speaking, major perceived cultural differences between people can cause initial uncertainty, misunderstanding and fear. Culture is relevant, however, even in matches of very similar cultures, as in situations where there is a good therapeutic fit or where the clinician overidentifies with the patient and makes unwarranted cultural assumptions (Moffic et al., 1988).
The term transcultural usually implies interactions across cultures. Culture itself has problems in definition. Does it apply to the fine arts or, more generally, to the identification of groups of people by their collective historical values and behaviors (Moffic, 1983)? From a different perspective, cultural psychiatry can be defined by what it is not. It is not a psychiatric subspecialty, a psychiatry of ethnic minorities, a psychiatry of exotic lands, an antibiological psychiatry or a ploy of political correctness (Alarcon, 1998).
In this broad sense then, all clinicians and patients have a cultural identification or, in many cases, multiple cultural identifications. One's culture can refer to ethnicity, religion, sex, gender, sexual preference, age, socioeconomic status, language, geography, occupation and certain disabilities. Representative examples of each of these categories are those who identify with, respectively, Native Americans, Jewish-Americans, women, transsexuals, homosexuals, teen-agers, VIPs, Spanish-speaking people, Southerners, firefighters and the deaf. It can also be fluid and experiential, changing over time. Old simplistic labels may at times no longer fit, such as a child with an ethnic heritage of Nigerian, Irish, African-American, Russian, Jewish and Polish being simply called "black."
Importance of Cultural Psychiatry
Given that cultural psychiatry involves values, it should not be surprising that it influences psychiatric services (Kleinman, 1977). Even the field of psychiatry in the United States can be said to have a culture all its own, emphasizing the treatment of individuals--akin to the value of individuality in the United States. It also cannot help but be influenced by the health care systems that exist in the United States. The United States is the only developed country without universal health care coverage. Insurance often does not cover mental health care as well as it provides for general health care. No other country currently has such a well-developed and extensive managed care system that is designed to control costs and review utilization. This fits our capitalistic economy.
How culture interacts with this unique and fragmented system of psychiatric care is complex. It can influence the development and recognition of mental disorders, access to care, appropriate diagnosis, and the provision of treatment (U.S. Department of Health and Human Services, 1999). Even research findings can be influenced, depending in part on what patient culture(s) are included and identified in the research (Rogler, 1999).
History of Cultural Psychiatry
Reviewing the history of how culture has interacted with psychiatric services can help illustrate its effects. After drapetomania and slavery, and after psychiatry became a recognized specialty, there was a gradual improvement in addressing cultural factors in clinical services. Usually these changes shadowed cultural events and changes in the larger society (Moffic and Kinzie, 1996). The same cultural groups that have been often discriminated against in general society have been plagued by disparities in availability and access to appropriate mental health care (Lehmann, 2003).
Although oversimplifying to some degree, the first phase of cultural psychiatry in the United States can be traced to the period after World War I and through World War II. In this phase, some attention was paid to the mental problems of those who clearly seemed culturally "different," in an ethnic or religious sense, from the usual "Caucasian American." This viewpoint--a remnant of drapetomania--could encompass so-called Negroes, but also newer immigrants like Italians, Greeks and Jews. It was thought that "war neurosis" occurred more in such groups. Italianitis referred to Italians who seemed to have a tendency to develop symptoms of secondary gain after World War I stress, feeling that this wealthy country should provide for them (Benton, 1921). Of course there was little scientific evidence to support this claim. Some attention was also paid to cultural differences in inpatient treatment, such as higher hospitalization rates for Negroes and lower rates for Asian-Americans. A beginning realization that difficulties occurred in providing cross-cultural psychotherapy also emerged.
The next phase began in the 1960s, with the development of government-sponsored community mental health care centers. One of the goals of these centers was to provide better access to care for minorities and the poor. However, many studies indicated that, in fact, minority and refugee patients were accepted into treatment less frequently, had a higher dropout rate and, as a continuation of an earlier trend, received less psychotherapy (Moffic and Kinzie, 1996). When treatment facilities hired more minority staff members, this difference diminished somewhat.
The years following the civil rights and ethnic pride movements of the 1960s saw more use of community education, more bilingual staff, and more collaboration with folk healers and religious leaders--all of which proved helpful in addressing the continuing deficits in the care of patients from poor and minority cultural backgrounds. Special clinics and inpatient units devoted to specific cultural groups have yielded some success and continue to be studied (Mathews et al., 2002).
By the end of the 20th century, cultural psychiatry became broader and more complex. The possibility that drug response could be affected by ethnic or racial biological differences was substantiated by research (Lin et al., 1993). While specific guidelines have been slow to evolve, clinicians were advised to proceed with some caution in cross-cultural prescribing. Beyond ethnic or minority status, culture also came to encompass such factors as religion, age, disability, celebrity, gender, sexual preference and occupation. For example, after the Sept. 11, 2001, bombing, it was striking that New York City firefighters often had a "tough-it-out" ethos that tended to deny symptoms and avoid treatment (Moffic, 2003).
Cultural influences made their way into the DSM-IV. Each diagnostic category has a section titled "Specific Culture, Age, and Gender Features." An appendix has an "Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes." Training programs developed model educational guidelines to teach this new information (LoboPrabhu et al., 2000; Moffic et al., 1988). Culture even found its way into managed care. Although most companies are still owned by white males, cultural competence has made its way into the process of accrediting managed behavioral health care organizations.
The term and goal of cultural competence can be said to characterize the state of cultural psychiatry at the beginning of the 21st century (Lu, 1996). This competence is important at both the system and clinical levels. Various states have even begun to incorporate cultural competence into contracts, such as the New York State Cultural and Linguistic Competence Standard Evaluation.
Although some African-Americans still mistrust white clinicians (possibly a lingering remnant of drapetomania) (Whaley, 2001), gains in cultural competence have been documented. For example, in contrast to prior studies, a recent study at a community mental health care center in New Haven, Conn., did not find any racial or ethnic disparities in the prescription of atypical antipsychotics (Woods et al., 2003). A five-stage model for family intervention for Asian-Americans with schizophrenia was developed and includes preparation, engagement, psychoeducation, therapy and termination (Bae and Kung, 2000). A third example is a new six-step formula to separate out cultural factors in the diagnosis of attention-deficit/hyperactivity disorder, especially in African-American children (Pitts and Wallace, 2003).
Gender issues are also coming to the forefront. Women are now known to have a prevalence of major depressive disorder twice that of men, likely due to both neurobiological and psychosocial factors (Kornstein et al., 2002). So-called atypical vegetative symptoms of the depression are seen more often in women. There are suggestions that estrogen may play a role in the pathophysiology of depression and even possibly the response to serotonergic antidepressants.
Future of Cultural Psychiatry
Given the increasing cultural diversity of the U.S. population, it seems likely that cultural influences will take on even greater importance. The increasing attention to and expectation of cultural competence should help improve psychiatric care to all.
Put simply, the writer George Bernard Shaw provided the core guideline to cultural competence when he said: "Do not do unto others as you would that they should do unto you. Their tastes may not be the same." In a more complex sense, clinicians can become more culturally competent by following the Ten Commandments for Cultural Competence (Table).
These commandments should improve the psychiatric care of all patients. As a field, cultural psychiatry needs to incorporate the cultural variable into our remaining cultural blind spots. These include incorporating cultural values into informed consent (Roberts, 2002), improving substance abuse treatment for ethnic minorities (Wells et al., 2001) and including the cultural variable in pharmacogenomic studies (Licinio, 2000). All treatment guidelines and disease management protocols should explicitly reflect and include the cultural variable.
Like many other things, globalization will likely have an important effect on the future of cultural psychiatry (Kirmayer and Minas, 2000). The global economy, Internet communication and mass population migration can increase cultural sensitivity and knowledge. Clinicians and systems of care in different countries may more readily be able to influence and teach each other. While modern psychopharmacology can be applied in developing countries, more traditional countries can teach us about the therapeutic use of trance and benefits of indigenous plants. Perhaps cultural psychiatry will someday no longer be a separate variable, but routinely incorporated into mainstream society.
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