For our purposes, we define culture as the amalgam of languages, social customs , traditions, beliefs, and values shared by a group of people linked by family, race, ethnicity, region, or culture of origin. The USA is home to many different cultures, races, and ethnicities, and this diversity has enriched the nation in a number of areas: science, literature, the arts, politics, sports, and religion. Not a static concept, culture can change over time as people acclimate to a new environment and later begin to influence it. For example, when immigrants arrive in the USA, they may initially hold on to their country’s cultural traditions , though over time many incorporate the traditions of their adopted country. Examples of this are seen with immigrants from Ireland or Mexico, who gradually adapted to the social norms of the USA without letting go of rituals like the annual celebration of Saint Patrick’s Day or Cinco de Mayo, which are widely recognized as symbols of how Irish and Hispanics have contributed to US culture. Acclimation can also apply to “small world” situations, such as when a family moves from one state or region (e.g., the South) or neighborhood (e.g., the West Side) to another that has a different set of beliefs and values. In Fig. 7.1 we see what is referred to as the culture iceberg, a visual representation of both surface and deep cultural factors. Frequently, individuals base their impressions of a given culture on surface factors (e.g., color of skin, the accent from native language , or social etiquette). This is stereotyping, which, needless to say, involves lack of appreciation of deep cultural aspects that are more representative of true beliefs and values. An example of mutual stereotyping is as follows: A psychiatry resident in psychotherapy supervision is disappointed upon meeting her supervisor, Dr. Cortez, as she had hoped he would be Hispanic and could help her with two Mexican patients she has started seeing. When she states, “It’s ok if you are not Hispanic. Many people with Hispanic names are white, have been raised in the US, and aren’t true Hispanics,” the supervisor is surprised, as he assumes that his name is enough to indicate his Hispanic descent. When he asks what has led the resident to think that he is not “a true Hispanic,” she replies, “You don’t look Hispanic, and you don’t have an accent.” Though the faculty physician is initially shocked, he uses this interaction as a teachable moment and helps the resident openly discuss cultural issues and how they might affect her psychotherapeutic work with Hispanic patients. This example captures how easily stereotyping can occur. The faculty physician has expectations that the resident will somehow know his name represents his cultural heritage and stereotypes her as not being culturally sensitive. The resident stereotypes the faculty physician, who does not look or speak “like a Hispanic.” This interaction shows how biases involving surface cultural factors can result in misleading, even hurtful, assumptions.

Cross (1988) has advanced the widely accepted definition of cultural competence as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals, and enable that system, agency, or those professionals to work effectively in cross-cultural situations.”

When a person moves from a stable culture to one that is unfamiliar to them, they may experience what is colloquially termed culture shock . Ticho (1971) described culture shock as a result of a sudden change from an “average expectable environment to a strange and unpredictable one.” The complex process that follows such a disruption undoubtedly will have psychological repercussions. The intensity, form, and content of the psychological changes are unique to each person, based on the cognitive and affective flexibility, temperament, and attachment style that was present before moving to a new cultural environment. Culture shock is masterfully described in Garza-Guerrero ’s (1974) classic psychoanalytic paper, in which he defines the phenomenon as “a reactive process stemming from the impact of a new culture upon those who attempt to merge with it as a newcomer.” Garza-Guerrero adds that culture shock profoundly tests the adequacy of an individual’s personality functioning, as there will be an initial phase of mourning the abandoned culture that severely threatens identity . Further stating that “three definable elements invariably constitute common denominators of this phenomenon,” Garza-Guerrero discusses the psychological challenges a person goes through when changing cultural environments (Table 7.1). He proposes that a mourning process is a prerequisite to working through the healthy inhibitory forces seen in adhering to customs and traditions of the past culture and in the resistance to those of the new one. When the mourning process occurs, it allows for the assimilation of the new culture’s values and beliefs in a mature manner, providing a healthy resolution of the culture shock, which is viewed by Ticho, as a self-limiting crisis (1971).

It is hardly a surprise that culture shock is a stressful, anxiety -provoking situation, a violent encounter that puts the newcomer’s coping mechanisms to the test, challenging the stability of his or her psychic organization. When this crisis is resolved, emotional growth may emerge; if it is not resolved successfully, diverse degrees of stagnation and even pathological regression may occur—brought on by the profound loss of a variety of love and transitional objects in the abandoned culture. Among others, these losses are family, friends, language , music, food, and culturally determined values, customs, and attitudes.

Most academic hospitals have specialty programs that attract patients from across the country and, at times, the globe. In many of these cases, if not all, the patient and family leave their original culture under duress after the diagnosis of a difficult-to-treat illness, and if the move happens abruptly due to medical necessity (treatment of burns, bone marrow transplants, atypical gastrointestinal surgeries, etc.), the intensity of the situation may contribute to an acute stress reaction, not to be confused with severe psychopathology.

When the psychiatric consultation requested by the treatment team includes an element relating to cultural issues, it is necessary for the consultant to be culturally sensitive. Table 7.1 can help identify the phase in which the patient and family find themselves, and in using this chart, the consultant can tailor the interventions needed to improve the treatment outcomes. It will be quite different for a family if a member becomes ill during the identity crisis phase, which may result in the patient displaying social inhibition with the treatment team. On the other hand, if the family member becomes ill during reshaping-of-self-and-others phase, the psychiatric consultant may not be needed, as the family system will have gone through the mourning necessary to allow for a mature and healthy way of addressing adversity and will have a social support group in their current environment.

As described in Chaps. 2 and 3, when an individual has a difficult temperament, limited cognitive functioning , and an insecure attachment style, they will have more pronounced problems in changing environments and can regress in a pathological manner to the point of requiring urgent psychiatric care. In such situations, the psychiatric consultant can facilitate interventions by the treatment team , suggesting concrete actions that may help patients feel less alone in a different cultural environment. The team should be encouraged to request help from a culturally sensitive social work staff and to provide patients with the time and means for communication (by phone or electronic media) with family or friends, both near and in other countries. By learning about the treatments commonly provided for a patient’s condition in their original culture, the treatment team can carefully compare them with the current recommendations, and discussing with the patient and family what led to the differences in medical approaches. Furthermore, acknowledging the difficulties with the transition they have experienced can significantly reduce the impact of the culture shock.