Culture as Wind: Adapting Recovery and Shared Decision-Making Across Cultures

CLINICAL REFLECTIONS

Recovery-oriented practice and shared decision-making (SDM) are now mainstream expectations in mental health services. Yet clinicians know the paradox: you can use the same tools with the same intent, and still have the conversation go nowhere. One underdiscussed reason is that culture shapes what support, autonomy, expertise, and collaboration look like in real encounters.

Recovery colleges (RCs) offer one window into how recovery-oriented mechanisms travel across contexts, and the same tensions show up in routine psychiatric encounters. In a large international survey of RCs across 28 countries, most sites showed moderate-to-high fidelity to the original model, but some components (notably coproduction and tailoring to the student) varied by region, with lower scores reported in Asia compared with England.¹

This does not mean these components are unimportant; it signals that how they are enacted may need cultural translation. Parallel work across the 28 countries examining associations between RC fidelity components and country-level cultural characteristics suggests that many components were associated with certain cultural characteristics (eg, higher country-level indulgence was associated with higher scores on some fidelity components).^2,3

SDM has accumulated a growing evidence base in recent years.⁴ A Cochrane review update of SDM interventions for individuals with mental health conditions found that SDM can increase service users’ involvement and does not necessarily lengthen consultations.⁵

A useful heuristic is “culture as wind.” Culture is not a fixed label on a person; it is the shifting set of norms and expectations that can push an intervention off course. A good clinician does not fight the wind, they trim the sail: keeping the same destination (recovery, dignity, participation) while adjusting how they get there.⁶

A Composite Vignette: When SDM Feels Like Abandonment

“Ms A” is a 29-year-old graduate student who recently moved for work. She presents with depressive symptoms and panic attacks. In her first appointment, she is quiet, answers politely, and repeatedly asks, “What do you think is best?” Her partner attends and looks to the psychiatrist for clear recommendations. The psychiatrist, committed to SDM, says: “There are a few options: medication, therapy, or both. It is your decision. What would you like to do?” Ms A freezes, looks down, and says, “I don’t know.” The psychiatrist repeats, “It is really up to you.” Ms A nods, agrees to “think about it,” and does not attend the next visit.

What happened? The psychiatrist offered autonomy, but Ms A experienced it as a withdrawal of expertise and care. In some contexts, being asked to choose without scaffolding increases uncertainty, shame (“I should know”), or the sense that the clinician is avoiding responsibility. Family involvement can amplify this: a partner may interpret the clinician’s neutrality as lack of competence, while the patient may feel caught between “choosing correctly” and “not disappointing” others.⁷

A culturally safer SDM approach in the follow-up visit looks different. The psychiatrist asks permission to be more directive (“Would it help if I make a recommendation?”), offers a recommendation with options (“Based on what you have told me, I suggest starting therapy and considering a low-dose SSRI. We can also discuss nonmedication options”), then invites Ms A’s values and concerns (“What worries you most about medication?”). The partner is explicitly included as support, not as proxy decision-maker (“How can you support Ms A with whichever plan she chooses?”). Autonomy is preserved, but the burden is reduced.⁸

The Wind-Check: 5 Quick Questions Before You “Adapt”

Before changing any SDM tool or recovery-focused approach, do a 60-second “wind-check.” The goal is to prevent 2 common clinical errors: (1) labelling a patient as “nonadherent” when the intervention does not fit their context, and (2) stereotyping by assuming culture explains everything.

1. Who is the decision-maker in practice (individual, family, team, community)?
2. What does “good care” look like here (directive expertise, collaborative exploration, or a mix)?
3. What is the main risk right now: loss of agency, loss of safety, or loss of relationship?
4. What support is needed to participate (language, literacy, time, peer coaching, advocacy)?
5. What signals respect and hope in this context (words, roles, rituals, pacing)?

Applying Wind-Checks to Recovery-Oriented Practice

Recovery-oriented practice aims to strengthen connectedness, hope, identity, meaning, and empowerment,⁹ but these mechanisms are expressed differently across services and cultures.^10,11 One widely used educational model, RCs, draws on adult learning, strengths-based practice, and coproduction with people with lived experience. However, a cocreated scoping review suggests that while evaluations are increasing, meaningful cocreation in evaluation and governance can be variable or unclear.¹²

My cross-cultural work in RCs focuses on language and implementation patterns. For example, RCs are advertised differently across England, Japan, and the Netherlands. Our corpus-based discourse analyses found that while the promotional texts of RCs in all countries emphasized lived experience, the texts in England highlighted self-management and skill acquisition, whereas those in Japan highlighted learning together and lifelong learning, and those in the Netherlands described recovery in the context of daily life.^13,14 The same approach is presented very differently across cultures. Similar mismatches can occur in everyday psychiatric practice when concepts like choice, autonomy, and empowerment are interpreted through different cultural expectations (Table).

Clinical Pearls: Make Adaptation Measurable

If you adapt SDM or recovery-focused elements, decide what success looks like in observable terms. For example:

• After the visit, the patient can explain the plan in their own words (teach-back).
• The clinician offers a recommendation only after asking permission.
• A brief values question is asked in every SDM conversation (“What matters most to you right now?”).^10,11
• Each care-planning discussion ends with a written ‘who decides what’ summary (including safety boundaries).
• Patient-facing written materials (letters, leaflets, plan summaries) are checked for unintended meanings and stigma.

From Evidence to Action: What Cross-Cultural Studies Add

Cross-cultural datasets can help clinicians and service leaders avoid two extremes: assuming that one model fits all, or assuming that culture makes evidence irrelevant. The emerging pattern across RCs and SDM work is that there are shared principles (respect, learning, partnership) but variable pathways to express them. A global Delphi study is now underway to identify which RC components are cross-culturally applicable, and which require adaptation, providing a structured consensus route from field experience to practical guidance.¹⁵

Meanwhile, cross-European survey work suggests that clinicians’ SDM preferences, including assumptions about autonomy, directiveness, and how explicitly to recommend, vary across countries.¹⁶ A wind-check helps clinicians recognize and adjust for this variation without losing ethical grounding.

Conclusion: Keep the Destination, Trim the Sail

Recovery and SDM are not “Western exports” so much as ethical commitments that must be delivered in locally meaningful ways. The culture-as-wind metaphor offers a pragmatic stance: do not over-explain behavior with culture but do not ignore cultural headwinds either. Use a quick wind-check, protect core mechanisms, and adapt delivery, so patients experience SDM as support (not abandonment) and recovery as possibility (not pressure).

Dr Kotera is an associate professor at the University of Nottingham, a collaborative researcher at the University of Osaka, and an honorary professor at Azerbaijan University.

References

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16. Kotera Y, Newby C, Kuzman MR, et al. Cultural impacts on shared decision-making: a cross-European study of psychiatrist preferences in 38 countries. Eur Psychiatry. 2025;68(1):e108.