A Complex Quilt: Clinical Concerns in Cross-Cultural Psychiatry

Waguih William IsHak, MD

Medical Director, Outpatient Services, Director, Psychiatry Residency Training Program, Cedars-Sinai Medical Center, Assistant Clinical Professor of Psychiatry, UCLA

This interview was conducted by Peter Cook on July 13, 2006.

Introduction

Over the last two decades, awareness of the impact of cultural and/or ethnic background on the presentation of psychiatric symptoms has grown substantially. Indeed, the DSM-IV, published in 1994, was the first edition to include diagnoses of “culture-bound” syndromes, most of which had previously been ignored or lumped in with psychotic disorders. As Medical Director of outpatient services and Director of the psychiatry residency training program at Cedars-Sinai Medical Center in Los Angeles, Dr. Waguih William IsHak deals daily with a very diverse set of patients and residents, and, having received his medical training at Cairo University School of Medicine in Egypt, Dr. IsHak is particularly familiar with the complexities of cross-cultural psychiatry. He points out that there are more than 200 definitions of “culture.” One of the most recent, from UNESCO, states that: “culture should be regarded as the set of distinctive spiritual, material, intellectual and emotional features of society or a social group, and encompasses, in addition to art and literature, lifestyles, ways of living together, value systems, traditions, and beliefs.”

Attitudes Toward Illness and Treatment

In psychiatric treatment, there are two main issues in treating patients from diverse cultures: their attitudes toward illness and their attitudes toward treatment.

“People with different cultural backgrounds have different labels for their mental and emotional experiences,” Dr. IsHak says. “In modern Western cultures, there is a general cultural agreement on the meaning and use of the feeling labeled as ‘depression.’ Many other cultures don’t even have a word synonymous to ‘depressed’ in their daily language. ‘Feeling broken hearted;’ chest, extremity, or back pains; or just feeling ill in general, equate to what we call depression.”

The prevalence of most psychiatric disorders is actually quite stable across cultures; the difference is in how the disorders are expressed. This is further complicated by the fact that some cultures have certain beliefs where, mental illness is a punishment from a god or negative karma. These patients will often go to a priest or a healer before seeing a doctor.

“Many times they will go to a psychiatrist or a mental health professional when the traditional cultural intervention doesn’t work, and more often they come on the express advice of the cultural healer they originally went to with their problem.”

Even when an agreement has been reached about the nature of the psychological condition, certain cultures still have quite different views regarding treatment, both psychotherapeutic and pharmacological. While speaking about culture always carries the risk of generalization, their is myriad evidence that cultural background can affect psychiatric presentation and treatment compliance.

African American patients tend to mistrust traditional psychiatric institutions, leading to reluctance in proceeding with indicated treatments, or being overly reticent regarding their issues when dealing with mental health professionals.

“It becomes even more complicated,” Dr. IsHak says, “when research findings indicate that disparity does exist in the health systems, and that minorities tend to get less than adequate care.”

Patients with British origins tend to trust psychiatric institutions in general, but have no faith in long, drawn out psychotherapy. Patients of traditional Chinese ancestry don’t necessarily believe in talk therapy, as they usually feel that talking about past troubles gets in the way of fixing present problems. Native Americans sometimes feel intense embarrassment about psychological difficulties, and are averse to discussing them with anybody, psychiatrist or otherwise.

Treatment issues get even more intricate when patients have little or no education.

“For example,” Dr. IsHak says, “some patients insist on getting their medicines by injection only, their underlying belief being that oral medications do not work because the body excretes them.”

Balancing Treatment

Patients with culture-bound syndromes often choose to pursue culturally specific, non-medical treatments. In Egypt, North, and East Africa, for example, a particular type of psychiatric perturbation is thought to be the result of possession by spirits. The traditional solution is to attend a ceremony called a Zar, in which ritualistic motions and loud percussion music are used to relieve the patient from the spirits.

“A patient might still pursue this culturally specific mode of treatment, either in conjunction with or in lieu of Western treatment. Their clinician will have to make a decision to accept or oppose those cultural treatments,” he says. “Regardless of the clinician’s position on the issue, one should gain a full understanding of alternative therapies his or her patient is using. Some Zar ceremonies involve the use of psychoactive drugs, and it’s the clinician’s duty to both warn his or her patient of the possible negative effects of those substances, and, of course, to make them aware of possible drug interactions.”

Cultural factors also come into play in regard to chronic or serious mental illness such as schizophrenia. In the US and Europe, many patients with schizophrenia conduct isolated lives (on their own, or in group homes) or struggle with homelessness, incarceration, and unemployment. Most people with schizophrenia in other parts of the world live with their families or institutionalized in long-term facilities. They might be offered low-stress jobs or financial assistance by their social support system.

It is important to note that not all culturally specific treatments are harmful. In rural communities in the Middle East, patients with erectile difficulties due to psychological factors have resorted to traditional healers for centuries. These healers’ exceptional success record is attributed, for the most part, to powerful reassurance and managing the patient’s performance anxiety utilizing prayers and religious beliefs.

Conclusion

Dr. IsHak points out that, while it’s easy to make broad generalizations across culture, and certain patterns of behavior are more widely spread than others, clinicians must educate themselves about the issues attendant to their patients’ specific cultures. It is important to examine the context of the cultural background.

“Recent immigrants often have different issues than first or second generation immigrants; a recent immigrant from Japan would likely follow most Japanese cultural beliefs as opposed to a Japanese-American who shares an entire culture with both America and Japan.” Dr. IsHak admits that keeping track of all the different cultural factors at play can seem daunting, but there are a number of excellent resources. Monica McGoldrich’s Ethnicity and Family Therapy, now in its 3rd edition, as well as the Clinical Manual of Cultural Psychiatry Edited by Russell F. Lim, MD, are particularly useful, compiling information on a multitude of different ethnicities.

“Most importantly,” Dr. IsHak says, “clinicians need to form strong therapeutic bonds with their patients. When a patient fully trusts you, he or she is more likely to openly discuss his or her concerns with you.”

Disclosure: Dr. IsHak reports no affiliation with or financial interest in any organization that may pose a conflict of interest.