© Hoyle Leigh & Jon Streltzer 2015
Hoyle Leigh and Jon Streltzer (eds.)Handbook of Consultation-Liaison Psychiatry10.1007/978-3-319-11005-9_1111. Cultural Aspects of Consultation-Liaison Psychiatry
(1)
Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, 1356 Lusitana St., 4th Floor, Honolulu, HI 96813, USA
(2)
University of Hawaii, Honolulu, US
Deceased
11.3.4 Use of Interpreters
11.4.3 Family Involvement
11.5 Medical Culture
11.5.1 Vignette
11.6 Culture and Pain
Culture influences thoughts, emotions, and behaviors in individuals, groups, and communities, and thus it can have a significant impact on illness behavior and the practice of health care. Culture can influence disease through a variety of mediating factors such as diet, smoking, use of alcohol and other drugs, activity levels, and compliance with medical management. Increasingly culturally competent medical practice is the goal for psychiatrists consulting to patients of diverse ethnic or cultural backgrounds (Bigby 2003; Tseng and Streltzer 2008), The consultation-liaison psychiatrist should not only be aware of cultural aspects of the assessment of the patient but also of the consultation process itself. This chapter elaborates broadly on cultural aspects of consultation-liaison service, including: the process of referral; the nature of the clinical problems; the interview; and clinical management and liaison work.
11.1 Obtaining a Psychiatric Consultation: The Influence of Culture
Associated with the increase of medical knowledge in contemporary society, patients and families have become more familiar and comfortable with the work of psychiatry. However, perceptions by people of different cultural backgrounds vary about psychiatrists and their patients. In some cultures, the terms like “brain doctor” or “psychological doctor” are used to avoid negative connotations of “psychiatrist.” This reflects culturally stimulated stigma.
11.1.1 The physician’s Referral for “Psychiatric Consultation”
Before performing the consultation, it is desirable to know from the referring physician why psychiatric consultation is sought, how the referral has been explained to the patient, and how the patient reacted to the idea of psychiatric consultation.
For patients or families who have misconceptions about psychiatry, and equate psychiatric problems with psychosis or insanity, the primary physician’s explanation about the need for psychiatric consultation is critical. If not done carefully, the patient might react negatively, interpreting that the physician was dismissing him or her as a “crazy” person, and then failing to cooperate with the consulting psychiatrist.
11.1.2 The consultant’s Introduction to the Patient and Family
Ordinarily, the consultant will introduce himself or herself as a consulting psychiatrist, or simply a psychiatrist, or doctor, depending on the situation. The interaction and relationship that is going to develop with the patient is more important than the particular form of introduction. A relaxed, confident manner is far more likely to initiate a therapeutic alliance than a timid, apologetic tone, in which the patient may feel that he or she is being asked to put the consultant at ease.
11.2 Culture Influences the Exploration of Clinical Problems
Factors that shape the process of exploration of clinical problems include such things as the personality of the clinician, professional orientation and experiences, and the medical culture within which the service is provided. In addition, the cultural backgrounds of the patient and the physician are going to interact during the process of the clinical exploration and assessment.
11.2.1 The Dynamic Nature of the Patient’s Presentation of Complaints
The presentation of complaints by the patient and the assessment of problems by the doctor occur as a process that is subject to various factors (Tseng 2001, pp. 446–449). On the patient’s side, it starts with the experience of problems or distress, which is subject to the patient’s personality, personal background, and environmental context. The nature of the stress encountered is subject to the patient’s perception of the stress and coping style. Finally, the presentation of the problems by the patient to others depends on additional factors including the patient’s conception and understanding of the problems, motivation and expectations, and the patient’s orientation about the care system and the physician, psychiatrist or other medical staff. The patient’s presentation will then influence how the clinician interacts with the patient while making an assessment.
As for the clinician’s side, the process of assessment and diagnosis will be influenced by the clinician’s sensitivity, perception of a morbid condition, familiarity with the problems, and professional definition of pathology. Furthermore, the clinician is subject to the influence of professional training, choice of theoretical background, classification system utilized, and the medical culture within which he or she practices, in addition to clinician’s personality and personal experience. In another words, clinical assessment is a dynamic process subject to impact of various factors, including social and cultural factors of both the patient and the clinician.
11.2.2 Understanding the Potential Gap Between “Disease” and “Illness”
The consultation-liaison psychiatrist needs to understand the potential conceptual gap between “illness” and “disease,” a distinction related to professional and popular ideas of sickness (Eisenberg 1977).
The term “disease” refers to the pathological or malfunctioning condition that is diagnosed by a clinician. It is the physician’s conceptualization of the patient’s problem, which derives from the paradigm of disease in which the physician (including psychiatrists) was trained. For example, a biomedically oriented psychiatrist is trained to diagnose “mental disease,” a pathological condition that can be grasped and comprehended from a medical point of view, providing an objective and professional perspective on how the sickness may occur, how it is manifested, how it progresses, and how it ends.
In contrast, the term “illness” refers to the sickness that is experienced and perceived by the patient and his/her family. It is patient’s subjective perception, experience, and interpretation of his/her suffering. Although the terms “disease” and “illness” are linguistically almost synonymous, they are purposely used differently to refer to two separate conditions. It is intended to illustrate that “disease” as perceived by the physicians healer may or may not be similar to “illness” as perceived and experienced by the person in suffering. This artificial distinction is useful from a cultural perspective, because it illustrates a potential gap between the healer (physician) and the help-seeker (patient) in viewing the problems. Although the biomedically oriented physician tends to assume that “disease” is a universal and medical entity, from a medical anthropological point of view, all clinicians’ diagnoses, as well as patients’ illness experiences, are cognitive constructions based on cultural schema.
The potential gap between disease and illness is an area that deserves the clinician’s attention in order to make the clinical assessment meaningful and useful, particularly in a cross-cultural situation.
11.2.2.1 The Cross-Cultural Consultation
11.2.2.1.1 Vignette
A Caucasian-American psychiatric consultant was called to consult on a 58 year-old, second generation, Japanese-American man, suffering from terminal stomach cancer. The consultant introduced himself, but before he could explain why he was consulting, the patient spontaneously reported that he had gone to Japan and received vials of a special injectable medicine to treat his cancer. He wondered if the consultant knew of this treatment and could help him take the formula correctly. The consultant expressed interest, but responded that he had no knowledge of such treatment. The patient was enthusiastic about this medicine and seemed to be in denial of his terminal illness (indeed, he died 3 weeks later). His wife was present during the session. At the end, she asked to talk to the psychiatric consultant separately out of the room. She complained that her husband was driving her crazy and was also not relating on any meaningful level with their only child, a 19-year-old daughter, who felt quite alienated from him. The consultant assured her that he would be back to talk to her husband further. The next day the consultant met with the patient alone. The consultant focused the conversation on the family, and the patient stopped talking about his miracle cure. The patient acknowledged that his first priority was the well-being of his wife and daughter. It was for this reason that he was obsessed with a cure. He needed to regain his health, so he could continue to be the provider for his family. He was not good at expressing himself in words, and did not know how to relate to his family, other than by being a good provider. He was unable to communicate with his daughter, and it bothered him a lot.
The consultant helped him articulate his love for his wife and daughter, and then arranged a meeting so that he might have the opportunity to say what had always been unsaid, and to leave them with positive memories of him. The consultant agreed to be at the meeting to facilitate the discussion, which alleviated somewhat the patient’s anxiety about such a conversation. The meeting began with tension, but soon the family members cried and hugged each other, and they talked at length. The positive feelings and open communication continued the next few days until the patient became too ill to talk. The family grieved without ambivalence when he died.
Denial is often useful in medical illness, and in terminal disease. It is compatible with some cultures including Japanese, and tends to be fostered by the family and the doctors. In this case, however, there was much unfinished business within the family. For the dying process to be successful, the patient needed to feel that he was leaving the family with good memories of him, a positive legacy. The family needed to resolve their anger and disappointment with the patient.
This case has been described in great detail as an example of a psychotherapeutic intervention by a consultation-liaison psychiatrist (Streltzer 2001). Cultural issues were involved at several levels. The alternative treatment of the Japanese cure turned out to be a superficial issue covering more meaningful concerns. The patient was the provider but not the manager of the family, a traditional role for a second-generation Japanese man. The wife had acculturated more to the host culture, and was more “liberated” in philosophy, but not to the point that she could directly confront her husband. The “cultural gap” between the patient and the consulting psychiatrist allowed the psychiatrist to serve in effect as a “cultural broker” to resolve the conflict.
11.2.2.2 Culture-Related Mind–Body Issues
A cultural perspective is particularly helpful in understanding the clinical ramifications of beliefs about the mind–body relationship. Often unaware of the philosophical implications, Western physicians commonly view the issue in dualistic terms, body and mind conceptualized as separate, dichotomized things. Closely associated with this epistemological view is the notion that it is more mature or superior to express psychological problems through psychological complaints rather than somatic complaints. Eastern medical philosophies do not necessarily hold the same view. By viewing body and mind as integrated parts of a whole being, they do not distinguish distinctly between them, and do not try to view psychological or somatic manifestations in a hierarchical way. For many cultures, people learn how to express their emotions through language pertaining to the body.
11.2.2.3 The patient’s History of Self-Management: Utilization of Indigenous and/or Traditional Remedies
The consultation-liaison psychiatrist may want to explore the patient’s and family’s folk concept of sickness and history of possible utilization of indigenous and/or traditional remedies. Patients from both Eastern and Western cultures, developed modern societies and undeveloped traditional societies, use traditional remedies to try to heal their medical condition. They often do not inform their physician about their use of traditional remedies, because they may believe that it is a separate matter. It may not be so separate, however, as in the case of drug interactions between modern and traditional medicine, for example. They may hesitate to reveal that they are using indigenous healing methods, concerned that the modern physician will look down upon their behavior. The consultation-liaison psychiatrist needs to gently ask if traditional and modern treatments are being utilized simultaneously by the patient.
11.3 The Interview Process
In order to carry out culture-relevant and competent clinical assessment, there are several issues that deserve attention. It starts with how to maintaining culture-appropriate physician–patient relationship.
11.3.1 Culturally Appropriate Physician–Patient Relationship
Most consultations are not initiated by the patient, and, therefore, rapidly building rapport is a special skill extremely desirable for the consultation-liaison psychiatrist. The relationship is itself a therapeutic tool and the outcome of the consultation may vary significantly depending on the quality of this relationship. This is particularly true with patients of different cultural backgrounds from the consultation-liaison psychiatrist.
An important perspective can be seen by examining contemporary American culture. In the medical setting, the predominant form of physician–patient relationship is egalitarian, based on an implied contractual agreement between the two that is influenced heavily by an ideological emphasis on individualism, autonomy, and consumerism. In contrast, in many traditional Asian cultures, there is more emphasis on an ideal form of hierarchical relationship. The physician is seen as an authority figure who is endowed with knowledge and experience. An ideal doctor should have great virtue and be concerned, caring, and conscientiously responsible for the patient’s welfare. In return, the patient must show respect and deference for the physician’s authority and suggestions. This respect and deference may inhibit the patient from asking questions and discussing choices and alternatives.
The psychiatric consultant has the task of rapidly developing a working alliance with a patient who usually did not request the doctor’s services (see Chapter on Interviewing). This task is all the more difficult if a cultural gap exists between them. Bridging this gap may become critical to gaining rapport, making a correct assessment, and engaging in therapeutic interventions. One should not assume that having an ethnic or cultural mismatch with the patient is a disadvantage. A patient may feel less likely to lose face to an outsider, who may be perceived as less judgmental and more accepting. The doctor may also plead ignorance of the patient’s background, expressing an interest in learning about it. This may promote a connection with the patient (Tseng and Streltzer 2001).
When cultural issues are suspected at all, the patient should be encouraged to explain his or her culture, in essence becoming the cultural guide to help the doctor put the issue into proper cultural perspective. The objective is to demonstrate to the patient that one’s concerns are synchronous with the patient’s interests. This increases the chances of developing a working relationship quickly.
Such communication works best when there is a shared language. If there is not, interpreters are often required, and cultural differences are more difficult to overcome.
11.3.2 Culturally Appropriate History-Taking
The interview is the major aspect of psychiatrist-patient interaction. How the patient presents complaints and informs the consultation-liaison psychiatrist of his or her problems and how the psychiatrist, reciprocally, listens, asks questions, and provides relevant explanations to the patient are key areas of communication that closely relate to the achievement of meaningful and effective clinical service.
From a cultural point of view, the clinician should judge to what extent the patient is familiar with the psychiatric interview, and provide explanations if necessary for those who feel unfamiliar with this type of communication. Whenever appropriate, the interviewer should ask the patient whether he/she identifies with his/her ethnic or parental culture. If the patient does, it would be a good idea to tell the patient to let the interviewer know if some of the questions or discussions touch on culturally sensitive areas. The interviewer should then use an active style to obtain basic information needed for assessment of “disease,” but make sure that the patient is given the opportunity to communicate concerns and problems from the perspective of “illness.” The ability to skillfully intertwine these two interview styles is an indication of competence from a clinical as well as a cultural perspective.
Although it is desirable for a patient to communicate freely about his or her personal background, illness history, and other related information to the consultation-liaison psychiatrist, this does not always happen in clinical situations. The patient’s ability to describe things and willingness to communicate are often influenced by clinical condition, motivation, and understanding of the purpose of doing so. In addition, there is a cultural impact on the process of problem communication.
Related posts:
The Why and How of Psychiatric Consultation
Interviewing in Consultation-Liaison Psychiatry
Anxiety and Anxiety Disorders
Dissociative Disorders
The Renal Dialysis and Kidney Transplant Patient
Obstetrics and Gynecology Patients: Menstrual Cycle, Pregnancy, and Postpartum-Related Psychiatric Disorders
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