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Chapter: Essentials of Psychiatry: The Cultural Context of Clinical Assessment

Ethnocultural Identity

The first dimension of the cultural formulation involves ethnocultural identity.

Ethnocultural Identity


The first dimension of the cultural formulation involves ethnoc-ultural identity. This includes the individual’s ethnic or cultural reference groups and the position of these groups vis-à-vis the larger society. Certain groups have a specific ethnocultural iden-tity ascribed to them by others; this may have an impact on indi-viduals’ everyday experience and narratives of identity whether or not they are explicitly aware of it.


In a world of mass migration and intermingling of peoples over generations, identity is very often hybrid, multiple and fluid (Bibeau, 1997). For immigrant and ethnic minorities it is impor-tant to understand the degree of involvement with both the culture of origin and the host culture. Ethnic identity may be situational and shift with social context. The ethnocultural and religious groups with which the patient most identifies may depend on who asks the question and in what context. For example, whether someone self-identifies as Canadian, West Indian or Trinidadian may depend on the perceived identity of the interviewer and the setting where the interview takes place.


Language is central to identity for many people and has a profound effect on clinical encounters. Individuals who speak multiple languages, learned at different stages in their life, may have different memories, affect and interpersonal sche-mas associated with the use of each language. Languages may be associated with developmentally important relationships and tied to specific areas of conflict or mastery. Personal and political allegiances within the family and community may be expressed through choice of language.


Language is the medium through which experience is ar-ticulated; hence, the assessment of higher cognitive functions, complex emotions and experiential symptoms of pathology all depend on the clinician’s access to the patient’s language. Pa-tients who are hobbled in a second language may be misjudged as less intelligent or competent than they are in fact; wishing to avoid such bias, clinicians may be overly generous in their as-sessment and miss significant problems or pathology.


Even where patients have a moderate level of facility in the clinician’s preferred language, they may not express them-selves fully in a second language so that important details are not conveyed. The use of a second language not only affects doctor– patient communication, it also influences individuals’ ability to reflect about themselves. When patients are forced to formulate their problems in a language in which they are not proficient, they may be less creative and effective as problem solvers. When patients are able to use their own best language, their accounts of experience become much richer, more complex and nuanced; their thinking is subtler; they can express a wider range of affect and engage in playful therapeutic exchanges.


Multilingual people sometimes report that they feel and think differently when using a second language. In part, this is due to the cognitive effort of having to find words in a language in which one is not totally fluent. Since each language favors cer-tain modes of expression and ways of thinking, bilingual speak-ers may report that they feel like a different person in their other language. It follows that aspects of the history and experience of a patient can be less accessible in a clinical evaluation if patients are not able to express themselves in the appropriate language. Of course, use of a second language may also afford the patient some distance from intense emotions and painful memories, and so assist in coping and affect regulation. Careful attention to spon-taneous or strategic shifts in use of language in a multilingual assessment can provide the clinician with important information about areas of conflict and strengths. Often this requires the use of a trained interpreter.


Religion is another key marker of identity. For many indi-viduals and communities, it may structure the moral world more strongly than ethnic or national identity. The term “spirituality” has gained currency to acknowledge the fact that many individu-als maintain deeply held personal beliefs about God, the meaning of life and what happens after death, without being formally af-filiated with one religion or another. Religious affiliation is also a frequent source of discrimination.


Despite the ubiquity of religious and spiritual experience, it is frequently neglected during routine psychiatric evaluation. A thorough cultural formulation requires consideration of the patient’s religion and spirituality. Areas to cover include reli-gious identity, the role of religion in the family of origin, cur-rent religious practices (attendance at services, public and private rituals), motivation for religious behavior (i.e., religious orienta-tion), and specific beliefs of individuals and of their family and community.

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