The role of culture in psychiatric care.

Ms. A was a 55-year-old Hispanic American woman of Cuban extraction who was referred to me by a local Catholic priest for psychiatric assessment and possible treatment. Ms. A’s symptoms consisted of early morning awakening, crying spells, loss of appetite, weight loss of approximately 20 pounds in 3 months, headaches, pain in the back of her neck, and suicidal ideations. The symptoms had appeared approximately 4 months earlier and had become progressively worse. Two months before the appearance of Ms. A’s symptoms, her mother in Cuba had suddenly died from a stroke at the age of 78 years. Shortly after her mother died, Ms. A began to blame herself for departing from Cuba at the age of 25 years and leaving behind her mother and father. In addition, Ms. A thought that she was not a good daughter and that her obligation was to stay in Cuba and take care of her parents during their older years. She also felt extremely guilty because she was not able to visit her mother after leaving Cuba or to be present during her mother’s funeral. Furthermore, Ms. A felt that her symptoms and feelings were the result of God’s punishment for the abandonment of her mother in Cuba. Shortly after the appearance of Ms. A’s symptoms, her daughter, a 31-yearold high school teacher, fully bilingual and bicultural, took her to see a psychiatrist after they had consulted their family doctor about Ms. A’s symptoms. The psychiatrist to whom Ms. A was referred was an American, highly respected in the community and trained in Canada. He did not speak Spanish, so he consulted with her in English. Ms. A, however, was able to speak and comprehend English fairly well. Moreover, she was accompanied to the consultation by her daughter, a secondgeneration Hispanic American who had no problem whatsoever in communicating with the psychiatrist and, when necessary, assisting her mother during the psychiatric evaluation. Permitting the daughter to be present in the interview had advantages and disadvantages. In a way, the participation of Ms. A’s daughter provided an opportunity for support and assistance based on the extended family network system, which is very predominant in Hispanic communities. Her daughter’s presence, however, also generated tensions for Ms. A because she was exposing her vulnerabilities in front of her daughter. Such advantages and disadvantages, related to clinical and cultural issues, need to be assessed in each occasion. At the end of the visit, the psychiatrist told Ms. A and her daughter that the patient suffered from depression, that she needed to take antidepressants, and that he thought she would recover fairly well from her illness. He also prescribed fluoxetine hydrochloride, 20 mg p.o., in the morning with breakfast and gave Ms. A an appointment to come to see him again in 1 week. Upon leaving the psychiatrist’s office, Ms. A told her daughter that the psychiatrist was wrong, that she was not depressed, that her suffering was a punishment from God, and that she would neither take the medication prescribed nor return to see the psychiatrist. Two months passed, and her symptoms became progressively worse. In addition, Ms. A began to experience suicidal ideations and told her daughter about them. The patient’s daughter, who was becoming very worried about her mother’s illness, decided to seek help through her local Catholic church; she consulted a local priest known to the family. The priest, after being apprised of the situation, called for a family meeting and counseled the whole family about the situation that they faced. Attending this meeting were Ms. A, Ms. A’s husband, her daughter and son-in-law, as well as their two children, aged 4 and 6 years. During the meeting, the priest acknowledged Ms. A’s guilty feelings and her thoughts that her illness was due to God’s punishment for having abandoned her mother in Cuba. He prescribed a penance, which consisted of praying a rosary once a week for 8 weeks, and advised her to see me for a second opinion. I had been well acquainted with the priest for some time. Since Ms. A had been instructed by the priest to see me for a second opinion, she acquiesced to the request and asked her daughter to make an appointment with me.