Culture is a network of knowledge, meanings, ideas and social rules shared by a group, often referred to as an ethnic group, who may also share geographical origins, religion and language. Culture will affect how illness is understood, the presentation of symptoms, and expectations regarding treatment and treatment choice⁴. The culture of the clinician will often differ to some extent from that of the patient⁵. The clinical setting in which treatment occurs has its own culture, which in turn influences the clinical relationship. Cultural competence means having an awareness of all three dimensions – that is, the culture of the older person, the culture of the clinician and the cultural setting – even when these are not obvious⁴. A culturally competent clinician can recognize the diversity of viewpoints, is willing to seek background cultural information from other members of the ethnic group or experts, and is flexible in approaching the doctor–patient relationship⁴. It should be appreciated that, in today’s multicultural world, many people move between or within different cultures, and so it is important to avoid making assumptions about a patient’s background which can lead to ethnic stereotyping⁶. Awareness of one’s own culture and of potentially strong feelings about another’s culture is important. Respectful enquiry and a desire to learn about other lifestyles is the only way to engage with a patient’s lived experience of ethnicity and its role in determining what is important for them. One consequence of cultural differences is that occasionally a patient may interpret a well-intentioned enquiry as intrusive or stigmatizing⁶. The Explanatory Models Approach is a method of understanding symptoms without making cultural assumptions⁶. The following questions form the basis of a discussion which explores the patient’s experience and perception of illness:

What do you call this problem?

What do you believe is the cause of this problem?

What course do you expect it to take? How serious is it?

What do you think this problem does inside your body?

How does it affect your body and your mind?

What do you fear most about this condition?

What do you fear most about the treatment?

The patient should be asked early on about his or her background and, for migrants, his or her place of origin, experience of migration and existence in the new setting. The clinician will sometimes need to work hard to develop rapport and trust. Within reasonable professional boundaries, the clinician should be willing to respond to any questions about him or herself. For example, with older Jamaican migrants, making ‘a connection’ with the doctor has been found to facilitate the assessment and acceptance of care⁷. The power imbalance in the patient–doctor relationship may evoke feelings of mistrust, particularly when the patient has been subject to discrimination. The clinician should be willing to discuss issues such as racism and social needs. It is helpful to show sensitivity, but not to neglect important areas on ‘cultural’ grounds (e.g. alcohol consumption in the case of Muslims). Ideas that appear persecutory must be explored and may reflect an appropriate response to injustice. History-taking should include use of traditional medicines and complementary treatments. Enquiries about spirituality may reveal deeply held views which are important for the patient to follow as part of recovery. Attitudes to death, widowhood and care homes may vary considerably. Consultation may be needed with a wide circle of people from the relevant culture.

Assessment will naturally include family and carers’ roles and needs. The levels of caregiver stress, burden and depression vary across cultures. The use of prayer, faith or religion may be used as a coping mechanism. There may be a difference between generations in adapting to a new culture, for example because of fewer opportunities for older people to learn a new language or make social contacts at work. This may exaggerate differences between generations. Many groups, including refugees, may not have family support in their adopted country.

Requiring patients to speak in a non-native language can distort the clinical picture. Language barriers can be reduced by employing an ethnically close bilingual worker. Alternatively, you can use a competent interpreting and advocacy service, preferably with individuals with experience in the mental health field. Some local services and national bodies, such as the Royal College of Psychiatrists in the UK, keep lists of psychiatrists who can speak different languages.