Cultural identity refers to the complex, contextually dependent manner in which individuals live and understand themselves and is manifested in their behaviors, practices, beliefs, and values. Although related to ethnicity—that is, a person’s ancestry and heritage—it is more fluid, in that an individual may acquire new aspects to his or her cultural identity as his or her situation evolves. For example, an Indian immigrating to Chicago from Mumbai, India, may experience his caste as less relevant and his status as a minority as more significant in his new home. Different psychosocial stressors may accompany such a shift.

Patients of differing cultural backgrounds may be subject to widely different norms. Whereas pregnancy may for an unwed young woman from one background represent a rite of passage, it may be a source of humiliation and shame for a member of another group. Individuals vary in the degree of intensity and fastidiousness to which they adhere to traditional cultural norms. Conflict between expectations based on traditional norms and mainstream values is a common source of stress for immigrants and their children.

Various factors interact to form individuals’ cultural identity, including their membership in groups, the role in those groups, and their place in their social context. Clinicians in psychiatric emergency settings are often quite skilled at taking in and integrating information efficiently and rapidly. Much can be gleaned in the initial moments of interaction with a patient: The patient’s physical appearance, name, marital status, clothing, and spoken language may yield significant information about group membership, degree of acculturation, and status within a group. Indicia such as these may differentiate a recent immigrant from a second-generation member of the same ethnic group and help the clinician anticipate possible stressors, operative beliefs, available supports, and barriers to treatment.

Although some aspects of a patient’s cultural identity may be inferred from these obvious affiliations, the depth, subtlety, and at times accuracy of these initial inferences are limited. Some areas relevant to cultural identity, such as the patient’s social supports, with whom he or she lives, and source of income, may be gleaned in the course of obtaining a general social history. Other areas, such as primary language or immigration history, may need to be accessed more deliberately. When exploring cultural identity further, the clinician must be able to quickly establish a rapport that allows further inquiry into the patient’s cultural identity. Conveying a sense of respect and an interest in understanding in order to offer help is critical, or questions in this area may leave a patient feeling judged or the object of curiosity. When clinically feasible, it is best to allow patients freedom to describe themselves (3). Cultural identity derives from aspects of a person that are often quite personal; clinicians and
patients may find themselves uncomfortable discussing these topics, much as they might find discussing sexual history.

Information obtained from the patient about his or her cultural identity can be supplemented by secondary sources of information. Family may be able to offer insight into important aspects of the patient’s background. The staff often mirrors the diversity of the population it serves, and informal consultation often comes from colleagues who are members of the same group. However, people of the same background vary widely in their degree of identification with that background, membership in other groups (e.g., the cultural identity of an Iraqi Kurd is different from an Iraqi Sunni), and the degree to which they value and adhere to cultural norms.

In emergency settings, patients may offer explanations for their symptoms at odds with the clinician’s understanding of their condition. They may refuse recommended treatment or may not see themselves as in need of treatment at all. Although at times this situation arises from poor insight related to the underlying illness, it can also stem from the patient having a different, culturally derived explanation for his experience. From a patient’s explanatory model of his illness comes his understanding of the etiology and nature of his problem, its likely course, and whether and how he believes it should be treated (5). Indeed, the biologic explanatory model of chronic psychotic illness favored in mainstream psychiatry is not universal even within “mainstream” culture. For example, McCabe and Priebe (6) found that among 29 white patients with schizophrenia in the United Kingdom, only 10 cited a biologic explanation for their illness. Also, patients may entertain aspects of multiple explanatory models for their illness either sequentially or concurrently (7).

Western clinicians may find that patients from non-Western cultural backgrounds understand their conditions in ways that are unfamiliar. Supernatural powers, moral failings, or an imbalance in forces may be put forward as causes, and patients or their families may have tried or advocate for interventions with which the psychiatrist is not familiar or does not support. In emergency settings, this sort of discordance can be difficult to resolve quickly, especially when prompt treatment is required to maintain safety. Replacing a patient’s explanatory model with the clinician’s goal is generally neither a respectful nor realistic objective. A more effective approach is to aim for integration of the clinician’s understanding of the illness with the framework the patient brings to the encounter.

Exploration of how the patient views her problem and what is to be done about it is critical to determining a course of treatment that the patient can accept and therefore cooperate with. By inviting the patient’s understanding of her experience into the discussion, the clinician also conveys respect for the patient’s culture and perspective. This beneficial effect of making an inquiry sets the stage for appropriately aimed education about the patient’s condition, prognosis, and recommended treatments. It is also important to assess what the patient is already doing about the problem. One study found that over 30% of Americans used nonallopathic treatments (8). These treatments inform the clinician about the patient’s understanding of his or her problem and must be considered when planning treatment.

Clinicians dealing with psychiatric emergencies often are charged with reaching a diagnosis, and patients of different backgrounds can differ in the way in which they manifest psychiatric illness.
Patients use idioms of distress according to their understanding of their experience and observed patterns of behavior, and to communicate with caregivers and elicit the desired response (9). In schizophrenia, although the nature of symptoms is consistent, the content may be widely different depending on the patient’s background. For example, a western European patient may attribute delusions of being controlled to a computer chip being implanted in his head and demand surgery to excise it.