The importance of cultural sensitivity and intercultural competence in psychiatry and psychotherapy
Culture and cultural identity
The term “culture” is used in many different contexts and disciplines (e.g. ethnology, anthropology, sociology, historiography, etc.) with a wide variety of meanings.
In the context of the topic of this article, I would like to use the following definition for “culture”:
The learned, commonly shared and transmitted values, beliefs, norms and ways of life of a particular group or community that influence and guide thinking, decisions and actions according to recognisable patterns (Leininger, 1991).
The term “culture” is distinguished from the term “ethnicity”. People of a certain ethnicity share a common ancestry and history, but not necessarily a common cultural heritage. One should therefore distinguish between ethnic identity and cultural identity (cf. Ton & Lim, 2006, pp.7-8).
Cultural identity is defined among people by different things, such as ethnicity, age, occupation, religion, socio-economic status, education, gender, sexual orientation, etc. So defined in this way, there are many different cultural groups or communities.
At the micro level, individuals usually belong to several cultural groups and combine their various characteristics in their identity. Therefore, we could speak of “micro-identities”.
Also important in the context of cultural identity is the significance of the subjective and objective dimension (cf. Ton & Lim, 2006, pp. 10-11). How does the person see him/herself and to which cultural group does he/she feels belonging to? How is the person perceived by others and to which grouping is he or she attributed?
Influences of culture in clinical practice
How diseases and disorders are seen and experienced is always influenced by culture. For the interpretation of suffering and symptoms as well as the way they are expressed and communicated, we also draw – mostly unconsciously – on our cultural background.
In clinical practice we are dealing with three, possibly different cultures: The culture of the patient, the culture of the doctor or therapist, and the medical culture within which the doctor or therapist is practicing (Tseng & Streltzer, 2004, pp. 1-3).
It is important for the doctor or therapist to always be aware of the influence of culture in relation to signs and symptoms (cf. Ton & Lim, 2006, p. 14; Weiss & Somma, 2007) but also in relation to treatment and therapy approaches (cf. Smith, 2006, pp. 207-235).
With regard to mental health, mental disorders and illnesses, culture can have an influence as follows:
- Causing disorders and diseases(pathogenic effects). Example: culturally conditioned beliefs that lead to anxiety disorders.
- Behavioural patterns and reactions of affected people to suffering or stress(patho-selective effects).
- Shaping of symptoms(patho-plastic effects). Example: Content of delusions that are culturally different in those affected.
- The reinforcement of symptoms or behaviours(patho-elaborating effects). Example: Symptoms and behaviours related to one’s own body that are reinforced by a culturally-typical body ideal that is constantly promoted in the media.
- The promotion, maintenance or increase in frequency of symptoms or behaviours(patho-facilitative effects). Example: Culturally determined alcohol or drug abuse, e.g. as an important part of socializing within certain cultures.
- The way society reacts to symptoms, disorders and diseases, which also affects their course (patho-reactive effects). This factor can also be of relevance where or from whom affected people seek help and healing.
The often significant influence of culture on symptoms and behaviour with regard to mental health can also be seen in so-called “culture-bound syndromes”. These are symptoms, disorders or illnesses that are normally restricted in their appearance to certain societies or cultures and for which biochemical causes can be excluded. Examples are the Dhat syndrome (fear of losing semen and the resulting loss of “life energy”), which is well known in India, or bulimia or anorexia nervosa (both psychological eating disorders), which are mainly found in Europe and North America.
Cultural sensitivity and intercultural competence in clinical and therapeutic practice
The cultural differences among people as well as the diverse influence of different cultures on mental health, disorders and diseases make cultural sensitivity and intercultural competence of doctors and therapists indispensable for adequate health care.
Intercultural competence has been defined, among other things, as “the ability of individuals to see beyond the boundaries of their own cultural interpretations; to be able to maintain objectivity when faced with individuals from cultures different from their own; and to be able to interpret and understand the behaviours and intentions of people from other cultures non-judgmentally and without bias” (Walker, 1991, p. 6).
The cultural competence that is necessary in psychiatry and psychotherapy includes:
- The knowledge and understanding of the concept of “culture” and its influence on people.
- The openness and willingness to learn about other cultures and acquire knowledge about them.
- The willingness to recognise cultural differences.
- The understanding of how culture influences disorders and diseases, the experience of them and the communication of suffering and symptoms.
- The ability to develop and implement culturally appropriate and adequate treatment and therapy strategies.
Cultural sensitivity and intercultural competence should not only be reflected in the doctor’s or therapist’s interaction with the client, in their diagnosis, formulation and treatment, but also in the organisation and setting of the facility, institution or practice.
Specialised intercultural training for doctors, psychiatrists and therapists is fortunately already standard in many educational institutions around the world. Research and studies on this topic are numerous in our modern world and corresponding education and training programmes are constantly being developed (cf. Dogra & Karim, 2010).
For Germany, I would wish that the importance of cultural sensitivity and intercultural competence would become even more apparent to doctors and therapists and be appreciated and taken into account even more in teaching and training.
Through my work with religious (especially Muslim) and ethnic minorities in Germany, it is still evident at the moment that there unfortunately still seems to be a great lack of cultural sensitivity and intercultural competence among doctors and therapists in Germany.
However, I have hope that there will soon be adequate mental health care for all people living in German society as citizens without them having to give up their cultural identity and without having to assimilate.
We are all human beings. One of the things we all have in common is that we are all different.
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Sources:
Bhattacharya, Rahul, & Cross, Sean, & Bhugra, Dinesh (Eds.). (2010). Clinical Topics in Cultural Psychiatry. London: RCPsych Publications
Bhugra, Dinesh, & Bhui, Kamaldeep (Eds.). (2007). Textbook of Cultural Psychiatry. Cambridge University Press
Dogra, Nisha, & Karim, Khalid (2010). Diversity Training for Psychiatrists. In Bhattacharya, Rahul, & Cross, Sean, & Bhugra, Dinesh (Eds.). Clinical Topics in Cultural Psychiatry (pp. 348-365). London: RCPsych Publications
Leininger, M. (1991). Culture Care Universality and Diversity: A theory of nursing. New York: National League for Nursing Press.
Lim, Russel F. (Ed.). (2006). Clinical Manual of Cultural Psychiatry (pp. 3-31). American Psychiatric Publishing, Inc.
Smith, Michael W. (2006). Ethnopsychofarmacology. In Lim, Russel F. (Ed.). Clinical manual of cultural psychiatry (pp. 3-31). American Psychiatric Publishing, Inc.
Ton, Hendry, & Lim, Russel F. (2006). The Assessment of Culturally Diverse Individuals. In Lim, Russel F. (Ed.). Clinical manual of cultural psychiatry (pp. 3-31). American Psychiatric Publishing, Inc.
Tseng, Wen-Shing, & Streltzer, Jon (Eds.). (2004). Cultural Competence in Clinical Psychiatry. American Psychiatric Publishing, Inc.
Walker, Martha L. (1991). Rehabilitation service delivery to individuals with disabilities: a question of cultural competence. OSERS News in Print (pp. 6-11)
Weiss, Mitchell G., & Somma, Daryl (2007). Explanatory Models in Psychiatry. In Bhugra, Dinesh, & Bhui, Kamaldeep (Eds.). Textbook of cultural psychiatry (pp. 127-140). Cambridge University Press