Improving Care Through Cultural Awareness


All clinicians know that culture influences virtually every aspect of a person's life. Sometimes the influence of culture is obvious; other times it is subtle. In either case, culture as a clinical variable is often overlooked. Being cognizant of the influence of culture is especially important for clinicians who manage psychiatric emergencies, because failing to do so can lead to misdiagnosis and delays in treatment.

In this issue, Drs Alarcón and Hart provide a clear and comprehensive overview of cultural psychiatry in the emergency setting. The idea that culture has a broad influence in medicine in general and psychiatry in particular is not new. However, a number of events--diversification of our armed forces, immigration and migration leading to a multiethnic society, and globalization--have increased the importance of a cultural approach to psychiatric evaluation.1

Cultural competency is increasingly being recognized as an important skill for all physicians.2,3 Yet it is generally accepted that physicians in the United States have much to learn about the practice of culturally competent medicine. This topic is highlighted in a popular book that tells of how cultural differences between a sick child's parents who are Hmong refugees from Laos and physicians in California lead to tragedy.4

Despite the acknowledgment that cultural competency is important, I know of nothing written about the influences of culture on and the cultural approach to emergency psychiatry. Therefore, this issue of Psychiatric Issues in Emergency Care Settings is especially informative.

Drs Alarcón and Hart define culture as a set of beliefs, traditions, customs, and habits that are part of every person's identity and personality. They frame their discussion by explaining that cultural psychiatry is a concept that recognizes the importance of culture in the pathogenesis, clinical presentation, course, diagnosis, treatment, and outcome in all mental illness.

The authors point out that culture plays a role in all encounters between patients, their families, and health care providers. For clinicians, one point of significance is that culture is a two-way street. Although the culture of the patient is important, the culture of the provider must be taken into account to fully use a cultural approach to any patient encounter.

In the overview article, Drs Alarcón and Hart summarize the clinical dimensions of cultural psychiatry for use in the emergency setting. The interpretive/explanatory role of culture can be used to help recognize when seemingly pathologic behaviors have a strong cultural basis. The pathogenic impact of culture can be seen in how a given clinical condition presents. It may be easy to forget that culture itself can be a diagnostic tool. Understanding culture can help clinicians work more effectively with a patient's strengths and support systems. In addition, cultural awareness can help us make the emergency department (ED) environment more accessible to and supportive of all patients.

On a cognitive level, health care providers who work in the ED are aware of the importance of understanding "where the patient is coming from" and the pros and cons of using interpreters. However, taking the time to think about issues, such as calling in an interpreter, beyond Diagnostic and Statistical Manual of Mental Disorders diagnoses and appropriate, rapid disposition is often difficult.

In their review article, Drs Alarcón and Hart advise emergency clinicians to take a few extra minutes to evaluate patients' social situations more closely. Insight into a patient's psychiatric emergency may be gathered from answers to questions about a patient's cultural identity; his or her ethnic, religious, or other cultural reference group affiliation; the importance of his culture of origin; whether there are cultural explanations for his symptoms; and how the patient's culture influences his interpretation of social stressors, functioning, and disability (see Table 1, page 14).

Despite our training and skill as clinicians, we carry our own cultural beliefs and mistaken understanding of others. We, as clinicians, must take our personal views into account when considering the differences in culture and social status between our patients and ourselves. Culture will inevitably influence our ability to make a correct diagnosis and appropriately treat patients. As the authors point out, exploring and understanding these issues in ourselves can make us more effective clinicians.

Cultural factors related to the patient, the provider, and the encounter should always be considered. Because ED clinicians are accustomed to the pace of ED care and the mechanics of a team approach to care, it is easy to forget that this environment and care model can be overwhelming for patients who have had little or no exposure to the emergency setting. Other influences at work in the ED are the patient's family and the use of medications and interpreters. The authors note the importance of considering the use of interpreters even if patients' language skills are adequate. Sometimes, a "cultural interpreter" can be very helpful in assuaging patients' fears.

The overview information the authors provided about how culture may influence disorders such as psychosis, depression, anxiety, violence, and personality disorders is especially useful. One study found that non-Western immigrant groups were overrepresented in psychiatric emergency care and compulsory admissions, perhaps because of how culture can skew clinical presentation.5 Immigrant groups may also be less likely to know how to access psychiatric services to avoid a visit to the ED.

All ED personnel should receive training in cultural awareness. As the authors suggested, the systematic use of Cultural Formulation can help clinicians improve their cultural competence.6 It may also be prudent to provide special guidance for international psychiatry residents who practice or train in the United States that helps them understand the nuances of American culture.7,8 Implementing a cultural/clinical approach to care is especially useful in the potentially volatile psychiatric emergency setting, where a misunderstanding can lead to increased tension and potential risks to both the patient and the ED staff.

In the 3 case presentations, the authors highlight some of the important points from their article. The first is a case of mistaken ethnicity, which nearly led to a misdiagnosis of psychosis. When thinking about cultural characteristics, ethnicity and race are often at the forefront. For some patients, however, other elements of culture, such as religion or cultural identity, may be more influential. The second case demonstrates a possible pitfall when using an interpreter. An interpreter who has strong beliefs might introduce his or her own bias to an already difficult clinical situation; in the case presented, such an occurrence delayed the diagnosis of drug misuse. The third case highlights a culture-bound psychiatric syndrome that easily might have been mismanaged if not recognized.

A better understanding of culture can help all mental health care providers adapt therapies so they are more compatible with a patient's culture.9 Although perhaps not relevant in everyday practice at an ED or psychiatric emergency service, this could be very beneficial for emergency disaster situations (terrorist attacks, natural disasters, war) that occur both inside and outside the United States.


As I read this article and the accompanying clinical case presentations, I found myself thinking about a discussion I had with a senior medical student several years ago. The student told me that she had decided to go into emergency medicine because she especially loved the interpersonal connection to each patient. She was most interested in "where the patient was coming from" and how she could best help. Because emergency medicine--with its rapid pace; emphasis on diagnosis, treatment, and disposition; and few opportunities for follow-up care--is not the first field I think of for students who want to connect with patients, I asked her to explain.

She said that she knew she was really good at developing rapport quickly and seeing things from patients' points of view. She discovered that it was easy for her to understand patients and families based on their backgrounds and cultures. She also said that she was good at gaining patients' trust. She wanted to work in an environment in which she could use these skills to help people who are really ill and frightened.

This student very wisely recognized the importance of understanding patients in the hectic, fast-paced, chaotic ED. She had the wisdom to realize the significance of the patient-physician relationship even in a single encounter. She also knew instinctively that to provide the best care, she had to understand people and culture, not just pathophysiology and treatment.

The article and case presentations by Drs Alarcón and Hart can help those of us who do not intuitively recognize this truth to rethink our approach and provide better care.



1. Ruiz P. Assessing, diagnosing and treating culturally diverse individuals: a Hispanic perspective.

Psychiatr Q.

2. Alarcón RD, Westermeyer J, Foulks EF, Ruiz P. Clinical relevance of contemporary cultural psychiatry.

J Nerv Ment Dis.

3. American Psychiatric Association. Position Statement on the Delineation of Transcultural Psychiatry as a Specialized Field of Study.

Am J Psychiatry.

1969; 126:201-203.
4. Fadiman A.

The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures.

New York: Farrar, Strauss and Giroux; 1997.
5. Mulder CL, Koopmans GT, Selten JP. Emergency psychiatry, compulsory admissions and clinical presentation among immigrants to the Netherlands.

Br J Psychiatry

. 2006;188:386-391.
6. American Psychiatric Association. Outline for Cultural Formulation.

Diagnostic and Statistical Manual of Mental Disorders.

4th ed (Text Revision). Washington, DC; American Psychiatric Association: 2001:897-898.
7. Kramer M. Educational challenges of international medical graduates in psychiatric residencies.

J Am Acad Psychoanal Dyn Psychiatry.

8. Lu FG, Primm A. Mental health disparities, diversity, and cultural competence in medical student education: how psychiatry can play a role.

Acad Psychiatry.

9. Verdeli H, Clougherty K, Bolton P, et al. Adapting group interpersonal psychotherapy for a developing country: experience in rural Uganda.

World Psychiatry.


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