Communication with patients from other cultures: the place of explanatory models

We discuss the complicated nature of communication between people from different cultural groups, perhaps using a second language. We focus on the fact that mental health practitioners and service users often have in common neither their cultural backgrounds nor their explanatory models of illness. Communication even in a shared language can be less than optimal as words carry multiple meanings. Consequently, consultations that involve culturally grounded explanatory models of illness challenge the professional. We give examples showing that reconciling different explanatory models during the consultation is a core task for psychiatrists and mental health practitioners working in multicultural settings. Kamaldeep Bhui is Professor of Cultural Psychiatry and Epidemiology at St Bartholomew’s and The Royal London School of Medicine and Dentistry (Queen Mary and Westfied College, Mile End Road, London E1 4NS, UK. E-mail: [email protected]). He is interested in cross-cultural and epidemiological psychiatry, service development and explanatory models of illness. Dinesh Bhugra is Professor of Mental Health and Cultural Diversity and heads the Section of Cultural Psychiatry at the Institute of Psychiatry, London. His research interests include cultural factors in the aetiology and diagnosis of mental illness. Communication with patients from other cultures 475 Advances in Psychiatric Treatment (2004), vol. 10. http://apt.rcpsych.org/ The process of exploring explanatory models The concept of explanatory models as it was originally formulated appears to have had little impact on psychiatric practice in general, even though there is now a greater emphasis on user views and satisfaction (Bhui & Bhugra, 2002b). Patients’ explanatory models are not fixed and are influenced by the circumstances of their symptoms, but they can influence a physician’s assessments (Bhui et al, 2002; Bhui & Bhugra, 2002a). It is the process of exploring with the patient his or her identity and explanatory model that ensures improved understanding and informs the successful negotiation of different world views. This exploration does not require psychiatrists to enter into another culture as a participant observer, a prerequisite for any form of authentic ethnography. Nor does it require them to undergo in-depth psychoanalysis of their own world view. However, they do have to transfer models of mind and functioning from these disciplines into the therapeutic clinical setting. Personal psychotherapy is core to the training of psychiatrists and this may be an appropriate opportunity to begin explorations of cultural differences. It should be remembered, though, that psychotherapeutic theories and practice have their own cultural biases, which are often made manifest in a mismatch at a theoretical, technical or philosophical level (Bhugra & Bhui, 1998, 2002). Cultural formulations Cultural formulations were introduced into DSM– IV in an attempt to make diagnostic practice more culturally appropriate, relevant and representative. This marked a beginning of the exploration of values in diagnostic criteria, but cannot replace a thorough exploration of the values of patient and professional during the clinical process. The American Psychiatric Association (2002) recommends five elements in the cultural formulation (Box 1). The second of these relates to the patient’s explanatory model of the illness, and explores cultural factors beyond race and ethnicity. However, in isolation from the other elements, awareness of explanatory models is unlikely to influence the quality of the consultation, the assessment or the management of the patient’s distress. Readers might like to explore what further information a cultural formulation might have yielded to influence the management of the young man in the following case history. (For conciseness, the full cultural formulation of Mr B’s beliefs is not reproduced here.) Case history 1 Mr B was an 18-year-old Bangladeshi man under investigation for unexplained physical symptoms by gastroenterological, orthopaedic and general medical services in a teaching hospital. His general practitioner knew that the young man was very distressed and was avoiding school, but could not reassure him. The specialists could find no organic illness. Mr B was seen by two senior psychiatrists (one English and one Indian: no Bangladeshi psychiatrist was then available), and their overall view was that his symptoms were psychosomatic but that his unwillingness to attend psychiatric appointments and failure to communicate with them made it unlikely that he would come to understand why he would not benefit from further physical investigations. Mr B was eventually seen by another Indian psychiatrist, who found that Mr B spoke English well. Unlike the two previous psychiatrists, the third psychiatrist was able to explore Mr B’s problems from the young man’s own perspective. During the course of the assessment sessions Mr B revealed that he had first noticed ‘stomach noises’ in the mosque and had immediately attributed them to an abnormal mass in his stomach – stomach cancer or something equally ‘bad’. He became unable to visit the mosque, which distressed both him and his father. Both were concerned that he could not remain active in worship within the local Muslim community, as this would have violated their religious practices. He also admitted that he had palpitations and sweats and became frightened when his stomach made the noises. The psychiatrist and Mr B acknowledged the latter ’s belief in this growth in his stomach as both important and disabling, causing much concern to his family. However, the psychiatrist pointed out that there was no evidence of any physical abnormality and recommended an antidepressant, explaining that this fitted into his schema of what was causing Mr B’s problems. It was thus explicitly acknowledged that Mr B might have been unfamiliar with this remedy. The young man’s belief that there was a mass in his stomach resonated with the phenomenon of Tharan, which the psychiatrist had previously encountered among patients of Indian origin. Tharan is described Box 1 The five elements of cultural formulation (American Psychiatric Association, 2002) 1 The cultural identity of the individual 2 Cultural explanations of the individual’s illness 3 The influence of the patient’s psychosocial environment and level of functioning within it 4 Cultural elements in the patient–professional relationship 5 The use of cultural assessment in deciding diagnosis and care