Introduction: The Cultural Matrix of Psychiatry

Introduction: The Cultural Matrix of Psychiatry

Although it has long been recognized that the mode of expressing psychological distress and behavioral disturbances varies with cul-tural beliefs and practices, a growing body of evidence shows that the effects of culture are more far-reaching. Research has clearly demonstrated that the causes, course and outcome of major psychi-atric disorders are influenced by cultural factors (Kleinman, 1988; Kirmayer, 2001; Leff, 2001; Lopez and Guarnaccia, 2000). Wide variations in the prevalence of many psychiatric disorders across geographic regions and ethnocultural groups have been documented with current standardized epidemiological survey methods (Canino et al., 1997; Kirmayer and Groleau, 2001). In addition, social and cultural factors are major determinants of the use of health care services and alternative sources of help (Rogler and Cortes, 1993).

For all of these reasons, careful assessment of the cultural context of psychiatric problems must form a central part of any clin-ical evaluation (GAP, 2002). Beyond this, culturally based attitudes and assumptions govern the perspectives that both patient and cli-nician bring to the clinical encounter. Lack of awareness of impor-tant differences can undermine the development of a therapeutic alliance and the negotiation and delivery of effective treatment.

The changing demography of North America and around the world has made the recognition and response to cultural diversity in-creasingly important in psychiatric practice (GAP, 2002). The over-arching ideology took for granted that newcomers would gradually become just like all others through a process of cultural assimilation (Portes and Rumbaut, 1996; Susser and Patterson, 2001). However, sociological research has shown a high degree of retention of ethnic culture with the persistence of religious practices, family life-cycle rituals and ethnic enclaves in many cities. Added to this is the rec-ognition of the importance of maintaining and renewing ethnoc-ultural identity to combat the legacy of racial discrimination. This has led to rethinking the notion of assimilation to take into account other modes of acculturation including the development of multi-ple cultural identities. More recent waves of global migration from south to north and east to west have brought together new mixes of peoples with greater differences in their cultural assumptions, with corresponding challenges for intercultural clinical work.

These changes, along with larger forces of globalization, have encouraged a fresh look at culture in every area of psychiatry. In clinical practice, “cultural competence” has become the rubric under which to advance a broad range of skills and perspectives pertinent to working with a culturally diverse clinical population (GAP, 2002). In the sections that follow, we will summarize some of the concepts and approaches that can inform culturally competent clinical practice.