Transcultural psychiatry

A theoretical approach and practical solutions

Frank Kortmann

Introduction

Mental health services are confronted with an increasing

number of immigrants and refugees from non-Western

cultures. This phenomenon requires interculturalisation of

the services to suit clients from different cultures.

Interculturalisation means adaptation of the services in

different levels: the interface between patient and

healthcare worker, the treatment context of the mental

health care facilities and the relation between the mental

health care system and the society (de Jong & van Ommeren,

2005). In this article we focus on interculturalisation at

the level of the interface between healthcare workers and

immigrant patients, even though we realize that the

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classical determinants for mental health and illness, like

socio-demographic characteristics and coping and social

support mechanisms, play a more important role in the

problems of migrants than cultural differences between help

seekers and providers (Kamperman, 2005).

Healthcare workers are supposed to treat non-Western

patients in a culturally competent way. But what does that

mean exactly? Robust research on this topic does not exist.

According to Kleinman (2005), we are limited to recommend

sensible and sensitive strategies that have resulted from

good practices and are inscribed in the Cultural

Formulation (American Psychiatric Association, 1994). Even

an elaborated theory for transcultural psychiatry is

largely missing. Therefore mental health workers approach

these patients often in a ‘method’ of trial and error. The

results are quite poor. Non-Western patients quit treatment

against advice far more often than native Western patients

for a variety of reasons (Arnow, Blasey, Manber,

Cobstantine, Markowitz, Klein, Thase, Kocsis & Rush, 2007;

Chiesa, Drahorad & Longo, 2000; Pina, Silverman, Weems,

Kurtines & Goldman, 2003; Self, Oates, Pinnock-Hammilton &

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Leach, 2005). That brings us to the question to what extent

non-Western patients can benefit from psychiatry. In

general, the more biological oriented psychiatrists have a

tendency to take this question not so heavy because they

think that psychiatry in general is universally applicable

for it is introduced successfully in many non-western

countries. Anthropological oriented ones are more sceptical

and have a more relativistic view on this speciality because

of the large number of non-compliant immigrants. The two

groups, however, don't oppose each other diametrically

(Hinton & Kleinman, 1992; Katz & Marcella, 1988; Kleinman,

& Cohen, 1997; Littlewood, 1990; Sartorius & Kaelber 1993).

Therefore, most probably the answer to the question lies

somewhere in between. But where exactly? What adjustments

are needed to serve patients from non-Western cultures

effectively in psychiatric practice? And how should these

adjustments be made? This paper presents a theoretical

frame of reference that may help professionals in psychiatric

practice to formulate an answer to these questions. The

frame is based upon (1) a breakdown of the concept of culture

in two meanings, (2) an elaboration of the universality-

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relativity dichotomy, and (3) a breakdown of the work of a

doctor or health worker into three components.

Culture in two meanings

Dealing with cultural differences is a main challenge in

transcultural psychiatry. There are numerous definitions of

culture; the Anglo-American literature count already more than

160 (Trujillo, 2005). Two are put forward here: a static and a

dynamic definition (Lionells, 1993).

Culture in a static meaning refers to the fixed patterns of

behaviour, acquired and transmitted by symbols, constituting

the distinct achievements of human groups, including their

embodiments in artefacts (Kroeber, 1952). It refers to the

concept of culture that was characteristic for groups of people

and was commonly used by anthropologists until the sixties of

the last century. Culture in this sense reveals itself through

books, movies, visits to other cultures, tv, internet, an so

on. It has its value in transcultural psychiatry. Knowledge of

some one’s culture facilitates the acquaintance with that

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particular person. The drawback of a static approach of

peoples’ culture is stereotyping them, as if everybody in a

specific group is culturally identical. The static approach

easily ignores the always existing cultural differences between

individuals. For example, if one sticks automatically to this

idea that Africans care less for being on time than Europeans,

one easily may overlook the possibility that being late of a

particular African may be caused by a reason that is beyond the

capacity of that person, for example involved in a car

accident. Culture, in a dynamic meaning, may keep us from this

kind of short-sighted prjudices. It refers to the semiotic

system that people use to interpret their inner and outer world

and to respond on it accordingly (Geertz, 1973). One has to

learn the specific meaning of some ones behaviour to understand

him fully. Tennekes (1990) describes dynamic culture as the

whole of meanings that provides men an orientation on their own

life, gives insight in issues that count, and indicates which

norms and values are to be taken into account. Culture, in the

dynamic sense, is a personal construct that is composed of a

variety of norms, values, meanings and opinions of different

groups to which an individual belongs to. A person is male or

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female, young or old, high or low educated, liberal or

socialistic, religious or not etcetera. He has characteristics

of the ‘culture’ of all these groups. His culture evolves

continuously in interaction with his environment. Therefore:

‘Every man is like other men, is like some other men, and is

like no other man’ (Kluckhohn e.a., 1953). So culture is not a

thing. Rather, culture is more adequately and usefully

conceived as a process in and between people (Kleinman, 2005).

Culture in both meanings are useful and valuable in the first

phase of the medical encounter. For example, a Dutch

psychiatrist meets an old Moroccan immigrant and his wife for

the first time. He knows from books that Moroccan men approach

their wives quite paternalistically. Besides he has seen this

quite often in other Moroccan patients of the same generation.

He, however, does not know to what extent this man has adopted

Western norms and values, after living for 30 years in a

Western country. Therefore the psychiatrist has to refine his

static knowledge about Moroccan men in general and has to

replace it for a more dynamic if he wants to acquaint him self

with this couple.

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The universality – relativity dichotomy

The coexistence of the biological and the anthropological

orientation on psychiatry indicates that this speciality

has universalistic and relativistic aspects. Theoretically

we can distinguish four varieties in the domain of

universality and relativity (Procee, 1991), as illustrated

in the following diagram.

Universality Relativity

absolute

universality

communicative

universality

communicative

relativity

absolute

relativity

The first concept in this subdivision is absolute universality.

This stance is based upon the platonic idea of the existence of

a stable system of absolute goodness and beauty. Human beings

are not able to fathom those ideas fully. This ideal system is

sacrosanct. Every normal human being should understand and

respect this, regardless his or her cultural background. People

who think in a different way are abnormal, stupid or bad,

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according to a supporter of absolute universalism. Examples are

statements without any debate, based upon the Bible or the

Koran. Therefore absolute universality has a fundamental

character. That is no true for the next one in the subdivision,

communicative universality. Its claim is less pretentious.

Assuming it is true that goodness and beauty are universal

phenomena, an individual never can claim his or her own

thoughts about goodness and beauty to be universal, because

everybody has acknowledged limitations in thinking. Universal

goodness and beauty may reveal themselves only in a dialogue

between human beings that ought to fulfil three criteria. The

dialogue is (1) based upon the honesty and veracity of the

participants, (2) conducted without reciprocal coercion, and

(3) aimed towards consensus (Habermas, 1971). The Declaration

of Universal Human Rights is often mentioned as an example of

it. It has revealed its universality in a consensus meeting of

all members of the United Nations (UN). Therefore, a

communicative universalistic statement is based on consensus in

a group of people. For the members of the UN there is no better

way to define universal human rights than has been set down in

the Declaration. The ICD or DSM can be seen also as product of

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communicative universalistic dialogues. They are established in

consensus meetings of leading professionals in psychiatry.

Within the domain of relativity there are also two varieties.

The first one is communicative relativity. Goodness and beauty

are considered as relative phenomena, because everybody has his

own norms and values to assess what is good or beautiful. This

does not mean that the gap between different opinions of two

people about what is good or beautiful is always unbridgeable.

In a dialogue people can reach a compromise in their opinion

which is acceptable to both. For example parents usually

resolve a disagreement about the upbringing of a child in such

a way. By giving and taking they mostly find a practical

solution that is acceptable for both, even though none of them

is one hundred percent satisfied with it. So a communicative

relativistic approach of problems gives way to compromises. That

is not true in the last concept in the row, absolute

relativity. Goodness and beauty are also considered as relative

phenomena. But the opinions about what is good or beautiful

differ fundamentally in people because everybody has his own

norms and values for it that never fully coincide with those of

others. Therefore it does not befit to judge on the opinions of

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others. If one does so, one wrongly puts one’s own norms and

values upon the other. Absolute relativity is relativity

without debate. It excludes any rapprochement of stands. It is

therefore fundamental, like absolute universality. Absolute

relativistic approaches may show up in discussions on strongly

controversial issues, like circumcision of women. Then there is

no room for a compromise.

If we apply these new concepts in our search for an answer on

the core question in this paper, what adjustments are needed

in psychiatric practice to serve non-Western patients

effectively, it follows that this question cannot be

answered from an absolute universal and absolute relativist

stand because of its fundamental character. The two

communicative approaches remain open. That means that a

psychiatrist and a non-Western patient have to reach either

consensus or a compromise, if issues are at stake in the

consultation room which are related to a cultural gap between

the two, as shown in the following diagram.

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absolute

universality

communicative

universality

communicative

relativity

absolute

relativity

no debate consensus compromise no debate

A breakdown of the work of a doctor

Which approach, communicative universalism or communicative

relativism, is most appropriate in psychiatric practice? The

answer depends on the type of activity of the psychiatrist. The

German psychiatrist and philosopher Von Gebsattel (1954)

distinguishes three stages in a medical encounter, each with

its specific type of doctor-patient relationship (Welie, 1994).

These stages are not essentially chronological ones that

succeed one another in time, but contribute reciprocally to the

final outcome of the medical intervention.

The first one is the elementary-sympathetic stage. In this stage the

doctor aims to establish a genuine, beneficent and confidential

relationship with the patient. Von Gebsattel emphasizes that

the original relationship between doctor and patient cannot be

just a scientific one. The very idea to develop a biomedical

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science for the treatment of ill people presupposes the need to

do so, felt by doctors and scientists. What happens in medical

practice? Some one is suffering and attributes his suffering to

an illness. He looks for help by someone he trusts, in this

case a doctor. The doctor is touched by the suffering of the

patient, feels empathy for him and is motivated to help him

(Levinas, 1969). The benevolent interaction between a help-

seeker and a help-provider in the elementary-sympathetic stage

is fundamental for the medical encounter, but not specific

typical for it. Some ones’ cry for help is audible for every

fellow human being. The helping relationship in the elementary-

sympathetic stage has first of all a cultural-anthropological

and ethical origin, more than a medical. This fundament of the

medical profession is sometimes overlooked in contemporary

bioethics. Modern Western ethicists may give priority to the

patients’ right to self determination, that might be

detrimental to the benevolent aspects of the contribution of

the doctor to the needs of a patient. The elementary-

sympathetic stage is essential in the work of a physician; it

precedes evidence based treatment along the lines of protocols

and guidelines.

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In the second stage, the diagnostic-therapeutic stage, the specific

medical interaction between doctor and patient takes place. This

interaction is characterized by inequality. The doctor has the

knowledge of applying biomedical and psychosocial science,

which the patient has not. And on the other hand, the patient

is diseased and suffers, and not the physician. In this stage

the doctor changes his attitude towards the patient to some

extend, from an empathic one into a more distant objectifying

one. He tries to come to a medical diagnosis that enables him

to learn more about the causes of the pain and the suffering of

the patient and about the possibilities for effective help.

Such a technical medical approach implies some alienation of

the doctor from the patient as a subject who is in need for

help, and a change into more objectifying approach.

The diagnostic-therapeutic stage is, however, not the final

one; it must be succeeded by the third one, the personal stage. Now

the doctor restores the empathic rapport with the patient, that

was established in the first stage, and that was broken to some

extent in the second stage, by translating his professional

knowledge about the disease of the patient, as set down in

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protocols and guidelines, into a tailor made treatment

approach. This means that the approach should be adjusted to

the ideas and expectations of the patient, as much as possible.

This translation in the third stage is necessary to strengthen

the patients’ compliance to treatment.

The three stages in the medical encounter are dialectical. The

thesis of the elementary-sympathy and the antithesis of the

scientific diagnostic alienation must be encompassed by a

synthesis in the personal stage, which contains elements of both

previous stages. In the personal stage scientific medicine

becomes an art by the ability of the clinician to judge what is

unique about the individual and appropriate in his culture and

to weave these insights in the generalist categories of

biomedical science and techniques.

In the third stage the clinician has to balance a scientific

medical approach and a personal, cultural appropriate one. That

brings us back to the core question of this paper, how

universalistic should a psychiatrist be in the provision of

cure and care to non-Western patients and how relativistic

could he be. How much should he link up with the

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requirements of scientific psychiatry and how relativistic

is he allowed to be to comply to the culturally based ideas

and demands of a non-Western patient? In the next paragraphs

a theoretical frame of reference is presented to answer on

these questions, specified for difficulties due to cultural

differences between patient and professional in each of the

three stages in the medical encounter.

Difficulties in the elementary-sympathetic stage in

transcultural psychiatry and solutions

A cultural gap between patient and doctor may hamper the

impending relationship in the elementary-sympathetic stage of

the medical encounter. Due to ethnocentricity, both parties

tend to judge the norms, values and customs of the other party

from their own normative frame of reference. They categorize

deviations from their own norms as less correct, old fashioned

or condemnatory and therefore they may approach the other

accordingly (Bernstein, 2001). This may cause tension and

conflicts between both parties. Mutual negative prejudices

weaken the patients’ trust in the doctor and the doctor’s

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empathy for the patient (Comas-Diaz, 1988; Comas-Diaz &

Jacobsen, 1987). For example, an immigrant from a minority

culture who has been discriminated against by people from the

majority group almost all his life, feels reserved and

suspicious towards a doctor of the majority group, while

entering the consultation room, and is not very communicative.

The doctor in his turn may have also strong negative prejudices

against the new patient, as if all patients from minority-

groups often exaggerate because they don’t like to work. It may

disturb their communication. Another example of

miscommunication. A non-Western patient keeps his head

downwards all the time during the first encounter with the

doctor. He does not look at the doctor at all, expresses

himself hardly spontaneously and gives only short answers on

open questions of the doctor. The latter does not like this

kind of ‘withdrawn’ behaviour. He may interpret it as if the

patient is uninterested and not motivated for treatment and may

react accordingly.

How could a doctor or other health worker approach such

problems in the helping relationship?

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The first step is establishing a good climate for a safe

conversation between doctor and patient about their differences

in norm and values. Therefore the doctor has to be aware of his

own cultural identity and whether it seems at all relevant

(Kleinman, 2005). The initiative for this conversation has to

be taken by the doctor. He should mention to the patient that

he notices a difference between the actual behaviour of the

patient and the behaviour he expects. He has to do this without

giving a value judgement or, even worse, condemning the patient

for his ‘abnormal’ behaviour. He may try to relieve the patient

from the feeling not to be good by explaining that people from

different cultures often behave in a different way in a

doctors’ office. He should convince the patient that the one

type of behaviour is not by definition better or worse than the

other. Every bird sings his own song.

Next both parties should exchange their ideas about the issue

at stake. The doctor may explain why he prefers to see the

mimicry of the patient, because it helps him to make a reliable

diagnosis. The patient may tell the doctor that he feels

embarrassed and shy if he is forced to look in the face of

someone who has a higher position. He may be convinced that

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this behaviour is not polite. The doctor should realize that in

sociolinguistic terms power inequity may influence

conversational cooperation of the patient directly, and

consequently disrupt information transfer (Marshall, 1988).

Therefore he has to encourage the patient explicitly to give

his opinion. If such a dialogue is successful and the

doctor is able to put the differences in behavioural norms

between the two parties into a relativistic perspective

the patient may feel respected and accepted. Such a

conversation might be a unique experience for the patient

in a world full of discrimination.

The final step in the solution of these kind of relational

problems is that the doctor and the patient should try to

find a way of interacting that is acceptable for both. The

patient may change his ‘withdrawn’ behaviour to a certain

extent, according to the whish of the doctor. The doctor

appreciates this. His empathy for the patient may grow. But it

is also possible that the patient is not able to comply to the

wish of the doctor. If so the doctor is more capable to accept

the ‘withdrawn’ behaviour of the patient because he now knows

the reasons behind. The danger that the doctor misinterprets

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the ‘abnormal’ behaviour of the patient and feels irritable is

lessened. The patient feels more at ease in the office and

better understood by the doctor, which might help him to open

up more easily in the next two stages of the medical encounter.

The barriers in the establishment of a good doctor-patient

relationship in elementary-sympathetic stage may vary in

seriousness (Struijs & Brinkman, 1996; Struijs, 1997). Minor

differences in norms and values may create mild tension. This

can be reduced quite easily by some giving and taking of both

parties. An example. For a Western health worker it is normal

to shake hands with his new patients. He knows that female

Muslim patients might not appreciate this custom. He, however,

does not know the preference of a particular female Muslim

patient who enters his office for the first time. In a short

dialogue he can learn from her what she likes. Next both

parties quite easily can reach a compromise in their way of

mutual greeting. For the doctor the issue whether or not to

shake hands is apparently less important than for the Muslim

patient. Therefore the patient gets what she wants, a little

nod or a hand. In any case she feels respected.

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More substantial differences in norms and values may lead to

conflicts. For example, a Turkish female patient is referred

to a psychiatrist because of a depressed mood. According to the

referring family doctor the depression is probably due to

marital problems, domestic violence and abuse. The husband of

the patient accompanies her inside the office. The psychiatrist

prefers to see the referred patient first alone, because he

thinks that she should get an opportunity to express herself

freely without her husband who might be a cause of her illness.

He, however, knows that Turkish men may not like their wives

speaking with a stranger in their absence, because such

encounters may elicit rumours and gossip in their

neighbourhood. This difference in norms may create a conflict

between the psychiatrist and the couple. To reduce the chance

of it the psychiatrist brings the issue into discussion to find

a solution that is acceptable for both parties. He expresses

his preference in general terms, but assures the couple that he

does not condemn them in case they have a deviate stand. Also

the couple is invited to give their opinion. The exchange of

ideas may yield to different solutions. The couple may accept

the procedure that is preferred by the psychiatrist. Or a

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referral to a female psychiatrist might be a solution that is

acceptable for them. Or the psychiatrist may decide to comply

to the whish of the couple and sees them first together because

after the discussion he realizes that such a compromise is much

better than an angry couple that leaves the office and refuses

any further medical assistance, because they were not given any

other choice than following the doctors’ orders. Another

example. A patient from Ghana is referred to a psychiatrist

because of headache. In the past he has been investigated by

several neurologists and other somatic specialists, without any

positive finding. The patient enters the office and states

right away that he does not like to speak with a psychiatrist;

he only wants an X-ray of his head. The psychiatrist knows that

African patients may attribute magical power to X-rays. But in

this case he cannot be as ‘generous’ as in the previous

examples of shaking hands or seeing a couple together. He is

supposed to give help to the patient, and not doing harm to

him. Harm could be the result of just complying to the demand

of the patient. To find as yet a solution that is acceptable

for both, a more thorough dialogue between the two is needed.

Extensive explanation and information from the side of the

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psychiatrist is now very important. In this case example the

patient has to ‘give’ more than he may take, because

psychiatrists will not just comply to the demand of this

patient. The patient may accept an alternative approach. Or he

may be so disappointed that he refuses any further contact. Not

all cultural gaps are bridgeable.

What happens in theoretical terms in the elementary-sympathetic

stage, inferred from the previous cases? A doctor or other

health worker meets a new patient from another culture. At best

he can start the encounter with some static knowledge of the

culture of the patient. To avoid stereotyping, he has to refine

his static prejudice about the patient and has to replace it by

a more dynamic image of his idiosyncratic norms and values. The

first section of the Cultural Formulation, ‘cultural identity

of the individual’ (APA, 1994) might be helpful in this

refining process.

Next, the doctor notices differences in norms and values

between him and patient in the acquaintance. This can

create tension or conflicts between the two parties and

may hamper the establishment of a trusting relationship.

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He looks for a way to bridge their cultural gap along the

lines of communicative relativity. That means that they should

try to suppress their ethnocentric tendency and should listen

to each other with an open mind. By giving and taking they

should try to achieve a compromise in a code of conduct. A

basic attitude of mutual respect is a prerequisite for it. The

psychiatrist should keep the dialogue with the patient open as

long as possible. He should comply as much as possible to the

wishes of the patient, but not exceed his own (professional)

limits. Such a communicative relativistic approach may increase

the cooperation of the patient in the next two stages of the

medical encounter. Cultural barriers in the elementary-

sympathetic stage cannot be eliminated along the line of

communicative universality. It is unreal to expect that

the two parties will reach consensus on a code of conduct

that fits both one hundred percent. A compromise is almost

always the most optimal result.

In summary, in the elementary-sympathetic stage of a

transcultural medical encounter the doctor or health worker

has to take the following steps.

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1.He has to refine his static knowledge of the patients’

culture, if present, for a more dynamic one, to avoid

stereotyping the patient.

2. In case of tension or conflicts due to differences in

the norms and values between both parties the

psychiatrist should:

a. make the differences explicit in a safe

conversation,

b.give his opinion about the issue, and ask the

patients to do so as well, and

c. invite the patient to look together with him for

a compromise that is acceptable for both.

Difficulties in the diagnostic-therapeutic stage in

transcultural psychiatry and solutions

In the diagnostic-therapeutic stage the doctor changes his

attitude somewhat from a empathic one into a more objectifying

professional one, to come to a diagnosis and a corresponding

treatment plan. In general, a diagnosis is based on the

patients’ complaints and his behaviour, supplemented with the

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result of somatic investigations. Five diagnostic categories

can be distinguished in medicine (Lamberts e.a., 1999).

The first category includes the so called pathological diagnoses.

These are the most solid ones, because they are based on

characteristic objective aberrations in the body morphology,

like a bone fracture, a genetic abnormality specific for

Huntington’s disease or senile plaques in case of Alzheimer’s

disease. These morphological findings confirm the diagnosis

unquestionable, independent from the idiom of distress of the

patient.

The second category includes the patho-physiological diagnoses. These

are also based on physical phenomena, but they are not

pathognomonic for a specific disease, for example hypertension,

anaemia or intoxication.

The third category comprises the symptom diagnoses. They are

directly named after the complaints of the patient and/or his

behaviour, like low back pain, psychotic or delirious.

The fourth category are the syndrome diagnoses. They include

specific clusters of complaints and behaviour, for example

schizophrenia or bipolar disorder.

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The fifth category is a rest group of problem behaviour. This

category contains painful or disabling human conditions on the

border between abnormal and normal, like adjustment disorders.

The contribution of physical findings to the establishment of a

diagnosis diminishes, going down from category one to category

five, whereas the importance of the narrative and behaviour of

the patients increases, going up accordingly.

Disorders of the first two categories are conceived as quite

universal phenomena, because human beings from all over the

world have many somatic characteristics in common. Therefore

their phenomenological variability is mild in different

cultures, also in psychiatry. For example, delirious patients

due to encephalitis or metabolic disturbances because of a

severe liver disease look quite similar everywhere. Differences

in expression of these kind of illnesses in different cultures

are regarded as epi-phenomena, as a varnish that covers the

hard core of this kind of disorders.

The great majority of psychiatric diagnoses is classed under

the fourth and fifth category. They are based on the narrative

of the patient and his behaviour only. Some psychiatric

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syndromes are accompanied by physical abnormalities, for

example aberrations in the levels of dopamine in the brain in

schizophrenia, but these findings are not significant for a

specific syndrome diagnosis. That means that there is hardly

any ‘golden standard’ to confirm most of the psychiatric

diagnoses. In essence, they are an interpretation of the doctor

of an interpretation of the distress or disability that the

patients and/or his family encounter.

The verbal and non-verbal building blocks for most diagnoses

are moulded by the patients’ culture. If a doctor is not

familiar with that particular culture, he may misinterpret the

patients’ information. An example. Irish and Italian patients

use different idioms of distress, being ill. Irish patients

usually control themselves as much as possible while presenting

their complaints, whereas Italians are more exuberant in their

presentation. Therefore Italian doctors are inclined to

diagnose more depressive states, if they examine Irish

patients, while conversely Irish doctors may assume more

hypomanic states, seeing Italian patients (Zola, 1966).

Up until the sixties of the last century there was quite some

variability in diagnostic customs in different countries. For

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example, American psychiatrists used the diagnosis of

schizophrenia more widely than their British colleges (Cooper,

e.a., 1969). To limit the variability in diagnostic customs in

the psychiatric world the American Psychiatric Association

developed the Diagnostic and Statistical Manual of Mental

Disorders (DSM) and the World Health Organisation the

International Classification of Diseases (ICD). These

diagnostic systems are considered to be universally applicable,

even though their descriptions and diagnostic criteria are

almost totally based on Western research and Western idioms of

distress. That means that a psychiatrist has to find out

whether the narrative and behaviour of a patient from a non-

Western culture fit into his (western) diagnostic system, if

such a patient looks for psychiatric help. The theoretical

approach to find an answer to this question differs

fundamentally from the way problems in the elementary-

sympathetic stage are solved. For the latter problems a

compromise in the domain of communicative relativism appeared

to be sufficient, as we saw. A communicative relativistic

approach in making a psychiatric diagnosis is, however, not

appropriate because it would mean that the knowledge and skills

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of the psychiatrist in diagnostic work are regarded as

equivalent to those of the patient. This presupposition

undermines professionalism in psychiatry which is not

beneficial for the patient, because the latter came to the

psychiatrist precisely for his professional expertise. After

all, the psychiatrist is the expert in professional psychiatry.

He is fully responsible for the outcome of the diagnostic-

therapeutic stage.

Diagnostic problems in transcultural psychiatry have to be

approached from the stand of communicative universalism. That

means that the psychiatrist has to engage himself in a real or

an imaginary dialogue with his college-professionals, to find

out whether or not they can reach consensus that the narrative

and behaviour of the patient fit sufficient in one of diagnoses

of their (western) diagnostic system.

The level of difficulties in the second stage of the medical

encounter depends on the diagnostic category at stake.

Consensus in the assessment of psychiatric diagnoses in

category 1 and 2 is usually quite easily obtain because these

diagnoses are based on the irrefutable results of physical

examinations. Consensus in category 3-5 diagnoses is more

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difficult to reach, because different psychiatrists may

attribute different meanings to verbal expressions of a

patient. For example, a Western examiner may interpret an

affirmative answer of an Ethiopian patient to the question of

the Self Reporting Questionnaire (SRQ) whether the patient has

cried more than usual in the last weeks, as an indication for a

depressed mood. An Ethiopian psychiatrist who know the

patients’ culture better, may know that such it may also

indicate that the patient has attended a large number of

funerals recently where crying is a common ritual phenomenon

(Kortmann e.a., 1988).

In the second stage of the medical encounter the psychiatrist

must communicate intensively with the patient and exchange

ideas with the latter if he is not familiar with his culture.

He has to scrutinize the meaning of the verbal and non-verbal

expressions of the patient. He may have some static knowledge

of the patients culture in advance. He should refine this

knowledge in a dialogue with the patient and people from the

patients’ neighbourhood, to obtain a more dynamic cultural

image of the patient. That means that he cannot do his

diagnostic work without the patient, especially not if the

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patient from an non-Western culture. He needs the input of

patient and his environment, as a cultural reference point. In

a transcultural diagnostic interview the psychiatrist has to

invite the patient to elaborate extensively on his complaints.

He should asks the patient and others who know the patient well

to give concrete examples of the complaints of the patient, to

reveal their meaning. This approach may help him to assess

whether the presented history and behaviour show sufficient

overlap with the criteria of a disorder in his Western

diagnostic system. Some examples.

African patients may complain of long lasting crawling,

gnawing, burning and itching sensations in the head (Ayorinde,

1977; Ebigbo, 1982). They can describe and localize these nasty

sensations very precisely. They are convinced that there is

something in their heads which is not normal, despite no

abnormalities are found in physical examination. Do those

complains refer to a psychotic state? Yes, according to the

ICD, because the patient presents a way of thinking that is not

in tune with reality. But that is not the case, according to

people who are familiar with the culture of these patients.

Crawling sensations in the head are quite common in Africa. The

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presenters of this kind of complaints have not lost contact

with their reality. It is important to realize that for the

determination of a delusion in a patient it is not important

that the patient lost contact with the reality of the

psychiatrist, but that the people around the patient cannot

follow the patient anymore. Therefore, diagnostic validity is

based on a type of ethnographic understanding of the meaning of

a complaint and of abnormal behaviour in a local cultural field

(Kleinman, 1988). The answer on where exactly shyness turns

into social phobia, worrying about health into hypochondria and

the need for guidance into a dependent personality disorder is

strongly related to culture of the patient. A paranoid attitude

might be quite normal in the culture of an Ethiopian patient,

whereas the same attitude in a Western person might be a

symptom of a paranoid state. The same counts for ideas of

grandiosity. Such phenomena are not pathological in it self, but

refer to an illness if they create distress or disability for

the person concerned within his own culture. In some

collectivistic cultures dependent behaviour might be considered as

normal and independent behavior as pathological. In such cultures,

independent personality disorder might be a more appropriate

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diagnostic label than a dependent personality disorder, as described

in DSM-IV.

Following this approach, Kleinman (1982) concluded that the

meaning of complaints of neurasthenia in Taiwan overlap

conceptually for 87% with the diagnostic criteria of the DSM

for a mood disorder. According to him, it was therefore

justifiable to put the psychiatric diagnosis of depression upon

Taiwanese people with this kind of neurasthenic complaints. If,

on the contrary, the complaints of a patient show conceptually

insufficient correspondence with the Western diagnostic

criteria, we deal with a culture bound syndrome. An example is

Koro, a syndrome seen in males in South East Asia that consists

of extreme fear that the penis is shrinking excessively with

dangerous consequences, such as death (Gwee, 1968).

In summary, the diagnostic assessment in transcultural

psychiatry is carried out in four steps.

1. The psychiatrist observes the behaviour of the patient and

registers the complaints in the idioms of distress of the

patient, as much as possible.

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2. If indicated, he examines the patient physically and

carries out additional tests

3. In a thorough conversation with the patient and his

relatives, the psychiatrist tries to find out what

meanings the patient attributes to his narrative and

behaviour, especially if category 3-5 diagnosis are

considered.

4. Finally, he assesses whether the meaning of the presented

information correspond sufficiently with the diagnostic

criteria of the DSM or ICD. If so, he can conclude to a

psychiatric diagnosis. If not, he deals with a culture

bound syndrome.

Difficulties in the personal stage and their solution

In the personal stage, the psychiatrist tries to restore the

empathic rapport with the patient, that was established in the

first stage and was broken to some extent in the second stage,

by translating his professional knowledge about the disease and

the possibilities for treatment into a tailor made treatment

approach, adjusted to the ideas and expectations of the

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patient, as much as possible. After all, a psychiatric

treatment not only needs to be professional, but should also be

acceptable and meaningful for the patient and carried out by a

doctor whose role behaviour is in line with the patients

expectations to enhances the patients’ compliance to treatment.

Professional treatment should be brought in line with the

patients ideas about 'good' treatment, as much as possible.

Therefore the psychiatrist has to know the explanatory model of

his patient regarding his illness. With this anthropological

knowledge in mind, he should inform the patient about his

illness and the proposed treatment extensively, preferable in

the patients’ idioms of distress. He should wrap up his

professional treatment proposal in cultural 'packing material'

that induces trust in the patient that he is well understood

and that he is receiving a treatment, concordant with his own

opinion. An example. In some African cultures epilepsy is

supposed to be caused by evil spirits. The professional

treatment approach of epilepsy consists of anti-epileptic

medication. But African epileptic patients with evil spirit

ideas most probably will quit taking this medication quite

easily, if the doctor just prescribes the pills without any

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correspondence to the conceptual frame of reference of the

patient about this illness.

Consensus between doctor and patient about the cultural

appropriateness of the intended treatment is preferable. But

sometimes only a compromise is attainable. For example, some

patients have no trust in a doctor who does not prescribe any

medication. Or they want medication because they feel

embarrassed towards their family if they come home without a

prescription. If there is no need for any medication for such

a patient from a scientific point of view, the doctor is put

in a dilemma. Either being strict professional following the

protocol and not prescribing any drugs, but losing the

patient. Or prescribing some drugs, but not acting fully in

line with his professional standards. In such cases a

compromise is sometimes unavoidable; the doctor may prescribe

some vitamins.

Tailor made care also means that the treatment is provided by a

doctor whose role behaviour corresponds sufficiently with the

patients expectation of it. Appropriate role behaviour induces

trust into the patient. Generally speaking there are two

varieties in appropriate behaviour: egalitarian and

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paternalistic. In a egalitarian encounter, the doctor and the

patient interact on equal terms. The patient and the doctor

negotiate about the treatment and finally the patient decides

for himself. This kind of relationship is becoming more and

more popular among highly educated Western patients. Many

patients from non-Western cultures, but also patients from the

West - especially the older and/or the less educated ones -

prefer however a more paternalistic doctor. That means that a

doctor has to acts for them as an authority because who he has

knowledge and skills in medical affairs. Or, in theoretical

terms, along the line of communicative relativity a

psychiatrist should try to behave in a way that is acceptable

for himself and for the patient.

In summary, in the personal stage of the medical encounter

a transcultural psychiatrist should be:

1.professional, in providing treatment that complies to

the state of the art,

2. creative, in making his professional treatment

acceptable and meaningful for the patient, and

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3. flexible, in adapting role behaviour that induces

trust in the patient.

Conclusion

One concluding remark. This article does not deal with a

special form of psychiatry, named transcultural psychiatry. It

addresses just ordinary psychiatry because there is always a

cultural gap between the psychiatrist and the patient that has

to be bridged. Therefore all psychiatry is transcultural

psychiatry.

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