Conclusion: The Limits of Culture

Conclusion: The Limits of Culture

The cultural formulation and the basic strategies of cultural com-petence represent useful initial approaches to exploring clinically relevant dimensions of patients’ cultural backgrounds. However, to apply these tools successfully, the clinician must avoid some biases implicit in psychiatric assessment and in the concept of culture itself.

Psychiatric diagnosis tends to be individual-centered, locating problems inside the individual, in their psychology, or neurophysiology. Cultural psychiatry, in agreement with family theory and therapy, recognizes that many problems are systemic and reside in interpersonal interactions or social contexts.

In the cultural formulation, culture tends to appear as something distinctive of patients who come from ethnocultural minorities, migrants, or indigenous peoples. The clinician too has a culture that is distinctive from the patients’ point of view. Indeed, culture also constitutes the larger social matrix in which the clinical encounter is embedded. The cultural critique of psy-chiatric theory and practice are important correctives to this view of culture as something only possessed by the “other”.

Talk of culture tends to reify and essentialize it as a fixed set of traits or characteristics shared by all members of a group. However, there is enormous diversity and individual variation within any cultural group, and many divergent perspectives. The integrated whole of culture then appears to be a fiction or idealization. Contemporary anthropologists have argued for en-tirely dispensing with the notion of culture or else viewing it as an abstraction for a shifting set of perspectives, discourses and resources used by individuals and groups to construct and po-sition socially viable selves. This perspective recognizes that cultures are flexible frameworks that provide both opportunities and constraints but do not wholly determine the trajectories of individual lives.

With these caveats in mind, the clinician can apply the cultural formulation by approaching each case as unique, with a focus on the social and cultural context of the behavior and experience of the identified patient and his or her family. Cultural competence involves using one’s knowledge of culture, language and etiquette as modes of inquiry rather than as a priori answers to the dilemmas of a specific case. With the help of cultural experts, the clinician can appreciate the range of variation in a cultural group and its significance for individuals and the com-munity. In this way, it is possible to recognize when culture is a camouflage for problems at other levels and when it is constitutive of problems itself. In assessment the aim is to formulate cultural dynamics as part of a comprehensive process model of pathology. This can then be used to design interventions to address the most flexible or accessible level of the individual, family, or social sys-tem. Whenever possible, clinical interventions should mobilize and work with the family and ethnocultural community, who will have their own strategies and resources for problem solving and coping with adversity.

Cultural competence is based on respect for and interest in difference. It requires that clinicians become familiar with and comfortable talking about cultural differences rather than attempting to “treat everyone the same” in a misguided sense of “colorblindness” or “neutrality”; lack of recognition of important differences results in ethnocentrism, seeing the world strictly from one’s own cultural point of view. Instead, the clinician must learn to de-center, to encounter the other on a more equal footing that allows some questioning of cultural assumptions relevant to psychiatric practice.

Mainstream care cannot respond adequately to the needs of a diverse population unless it gives explicit attention to cultural issues. The ethnocultural diversity of mental health professionals represents an invaluable resource. Training programs must rec-ognize this and make it safe for clinicians to explore their own ethnocultural background and assumptions as a path to more sen-sitive and responsive work with others.