The new president of the Norwegian Psychiatric Association has personal long-term experience as a doctor in quite different cultures than his origins in the sturdy Norwegian inland, both Finnmark in the far North and Namibia in Southern Africa. Here are his reflexions.
The interest of culture should be on the forefront of every psychiatrist. The definition of culture is broad and Fredrik Barth formulated culture as the ballast of ideas and norms that a person carries with him/her based on what the person has learned and experienced that is his/her knowledge, conventions, opinions, attitudes and values. According to Segall, culture consists of learned opinions and common information that is transmitted, often somewhat changed, from one generation to the next through interaction.
So why should we care about culture in our everyday work? The simple answer is that all persons that we get in professional contact have a cultural background that should interest us to provide good care. Several studies show that we tend to give the best treatment to persons that have the same background us ourselves concerning educational level, way of living and worldview. The further away from ourselves the person is from our own background the more challenging we find it giving good treatment although we seldom recognize this blind spot.
Differences in culture do not need to be someone from a different country or with another language and ethnic background. People with less education, different dialects and from other parts of our own country might pose a huge cultural barrier to adequate treatment. The problem with cultural ignorance and bias is that we don’t acknowledge our own prejudices. The best way to connect to other cultures is therefore to admit and accept our bias towards cultures and to be more curious about the cultural background of any person we meet in therapy.
So, is there specific knowledge we could learn to better connect with other cultures? Studies showing differences between the west and the rest do not lead us any further as this is often black box epidemiology where we put people with many different cultures into same group without the possibility to find useful differences. Just as a beginning, we should evaluate if the person in front of us is from an individualist versus collectivistic culture. This will have an important influence on the way we involve the family and wider society.
What else should we aim to be interested in from a cultural perspective? Family roles and organization of the family, who is head of household and which gender roles are expected in the relevant culture. Further, we should explore dominant language and the cultural communication patterns, heritage, spirituality and rituals connected to childbearing and death. Taboos and specific high-risk behaviors are also important together with perceived discrimination and stigmatization.
The Cultural Formulation Interview (CFI) is a very powerful tool to assess all kind of cultural dimensions of all patients. CFI has 16 questions and was first published as part of DSM 5 and fits very well in as a first assessment of any patient. Otherwise, we should assess possible language barriers, stigma connected to seeking psychiatric help, emotional restraint, avoidance of shame and social harmony adjustment. To provide for anonymity is especially important for people from other cultures and the use of translator might be a problem where there are few people speaking the specific language.
To ease the use of mental health facilities we should try to collaborate with ethnic organizations and establish psychoeducation groups. We should look at the staff composition in our clinics and if possible hire qualified staff with a diversity of ethnical background, as seeing staff of the same ethnic background may dramatically increase patient access and initiation into treatment. In addition, if the treatment provider is not of the same ethnic background, it is best that he or she take on an inquisitive role and not make any ethnocentric assumptions based on his own cultural heritage as mention above. The goal of the clinician should be to uncover sociocultural issues that will affect acceptance, retention, and ultimately, treatment outcome.
One way to better understand how it is to be a part of the minority population is to travel or work in parts of the world with another culture than your own. From my own experience, I have tried to live and work in different cultures both within Norway and other countries. After graduation, I worked for three years in a fishing village as far up north in Norway as it possible to get. To learn about the historical hardships of getting food and to survive in an artic climate was an experience that was important in the contact with the patients.
For five years now, I have been working as a psychiatrist in Karasjok, which is the hearth land of the indigenous Sami population in Norway. Again, it is important to know the culture with the strong tradition of reindeer herding, but also their roots as a strongly discriminated population where the majority population almost eradicated their languages. The Sámi Klinihkka in Karasjok is now offering both somatic, addiction and mental health services to not only the Norwegian, but also the Finnish and Swedish Sami population.
The patient you meet may have a different culture than yourself despite the fact that you have grown up in the same place and belong to the same ethnic or cultural group. Becoming culturally conscious is a process that starts by reflecting on one's own values and how these are socially constructed. □