Cultural sensitivity is not only about those patients who come from a different country to that of the practitioner, but also includes those with other differences such as family background, education, religion, belief system or socio-political outlook. Essentially, culture is about the individual ‘self’ (you) and how you are influenced by your surroundings. Culture provides us with a framework within which we can relate to one another and co-exist. It is a means for the transmission over time of ideas, values and customs; and more generally, ways of living.

When thinking about how to be more culturally sensitive in consultations, doctors need to take into account three additional variables: ethnocentrism, health literacy and transcultural perceptions of illness.

1. Ethnocentrism of the practitioner

Ethnocentrism is the normal tendency of each person to see the world from the viewpoint of their own ‘tribe’, the subculture that is the most dominant in their life. 

Practitioners have their own socialised and cultural view of what constitutes ‘normal’, and it is from this position that they assess patients. Professor Issy Pilowsky, who was Professor of Psychiatry in Adelaide, Australia, from 1971-97, taught that doctors assess a person’s mood within half a second of their meeting. Such an opinion will often be culturally based, and so it is important to consciously challenge this automatic initial assessment. It is imperative for doctors to suspend their own belief system and to find out what is truly happening in the patient’s life from their different cultural viewpoint. The doctor needs to have a conscious awareness that the patient’s culturally based experience and characteristics of distress, diagnoses, expectations and outcomes will probably be different. 

Even the conservative DSM-IV (the fourth edition of the American Psychiatric Association Diagnostic Statistics Manual, which is a tool used to identify and diagnose mental illness) says “diagnostic assessment can be especially challenging when a clinician (from one ethnic or cultural group) uses the DSM-IV Classification to evaluate an individual from a different ethnic or cultural group … a clinician who is unfamiliar with the nuances of an individual’s cultural frame of reference may incorrectly judge as psychopathology those normal variations in behaviour, belief, or experience that are particular to the individual’s culture”.

For as long as psychiatry has existed, it has sometimes been inappropriately used as a socio-political tool to ‘explain’ behaviours that are disapproved of by the dominant culture. As practitioners using a Western model, it is important not to unconsciously fall into the trap of doing the same, when psychiatric diagnoses such as abnormal grief reactions and factitious disorder are discussed.

2. The health literacy of the patient

Improving the patient’s health literacy will decrease their fear of illness, investigation and treatment and give them more control over their own health and lives. The Ottawa Charter for Health Promotion (1986) states: “Health promotion supports personal and social development through providing information, education for health and enhancing life skills. By so doing, it increases the options available to people to exercise more control over their own health and over their environments, and to make choices conducive to health.”

A common complaint about doctors is that they speak their own jargon that is unintelligible to patients. Both parties need to be ‘speaking the same language’ about the condition that is being discussed, even if they are not speaking the same cultural language.

Apart from language, there is another essential element needed to communicate successfully in a bilingual, inter-cultural situation. This is an awareness of world-view. Concepts doctors take for granted such as the use of percentages, asking questions, evidence-based uncertainties, bacterial and viral causes for illness, and so on, are often unfamiliar to other cultures. When treating and communicating with patients from some cultures, it is important to acknowledge that a hierarchy based on gender, age, religion and relationships can influence whether or not the patient will accept advice or information.

On occasions, patients may present with an illness, which can’t be defined from a biological viewpoint or where there is an established cultural treatment that is not based on evidence. 

Many patients will not have a level of health literacy that gives them an ability to sort through symptoms, signs, consequences of illness, sideeffects and so on, such that these issues can be appropriately prioritised. This means that patients will sometimes present with a complex and seemingly random array of problems. Many of these may seem trivial to doctors but carry a greater weight in a different culture. For instance, different cultures will see the ‘life-force’ as residing either in the heart, the liver, or the kidneys. A symptom in that organ will be more important and will need to be taken more seriously. 

For a diagnosis of mental illness in particular, the distress and disability must be a response that is considered ‘abnormal’ within the person’s own culture and be able to be viewed as a dysfunction in the individual. However, there seems to be a generality about mental illness and its treatment that needs to be communicated to patients in words and concepts consistent with the patients’ own understanding and expressions of that illness.

3. The patient's culturally mediated perception of illness

In Australia, Aboriginal people don’t see health as a separate issue from all the other things that are happening in their lives. There are different issues for Aboriginal people than what non-Aboriginal people think. Certainly the presentation and treatment of mental illness such as depression in this community is very different from the Caucasian English-speaking community.

Culture and language give humans the basis with which to grapple with deeper concepts and choices, the foundation of which begins in childhood. From birth to adolescence, the brain is learning about its environment. At adolescence, the brain goes through a ‘use-it-or-lose-it’pruning process whereby billions of brain cells are shed, and only those that are deemed ‘useful’ by experience are kept. The more cells are exposed to a particular stimulus, the more they will be strengthened, and if not, they will degenerate. In this way, the brain develops according to the demands of a specific environment. Therefore the social and cultural become the biological.

When looking at the expression of depression as, for instance, somatisation in some cultures, it is not helpful to try to challenge the resistance to viewing the illness as a psychiatric rather than a physical condition.

There is a necessity to work out ways of assessing a patient’s mental health status that takes into account these different perceptions. When doing more work with one particular culture a doctor can obviously ask other workers, or they can read, or learn from experience how that culture expresses and relates to illness. Practitioners can improve rapport markedly by running the consultation using the words and concepts that the patient uses.

For example, some university students may tend to complain about anxiety, fatigue and difficulty with their studies. Their main concerns are usually relationship problems or the consequences of failing their exams. Many of them are very young and come to the doctor with minor illnesses that are often the result of anxiety and insecurity. Others may blame their studies for their problems and can become even more upset if depression is cited as the cause. For some this situational crisis can lead to ‘sub-cultural’ ways of dealing with the issues with drugs, alcohol or even suicidal ideation. Some doctors like to focus on such concepts as ‘reaching their coping limits’ as a means of approaching diagnosis and treatment of the problems.

In contrast, Australian Aboriginal people, like most other indigenous populations throughout the world, are often steeped in illness, grief and loss as their primary presentation of depression. Alcoholism, domestic violence, lack of self-care, withdrawal and unemployment, as consequences of depression, add to the overwhelming social problems faced by many of these people. Three of the biggest issues in Aboriginal communities are the high incidence of suicide in young men (up to 3 times higher than the rest of the population), the increased incidence of violence, especially against women (19 times greater than for non-Aboriginal women) and the rate of imprisonment (12 times higher both for men and women). The life expectancy for the Australian Aboriginal population is 20 years less than for the non-Aboriginal people. When treating illnesses such as diabetes, alcohol-related illness, injury, dental problems, etc., doctors need to be aware that depression, social issues and self-neglect may be complicating factors that need to be treated alongside the physical conditions.

Research into mental illness amongst refugees in the UK shows that it may not always be helpful to refugees to have their distress articulated through conventional Western definitions of psychological ill health. Refugees suffer language and communication difficulties and a lack of understanding of the culture, religious beliefs and attitudes of the host country, and resultant misunderstandings can lead to a misdiagnosis of mental illness. Central to establishing appropriate services is a willingness to integrate mental health and social care into a holistic approach. Refugees rarely view their problems as about mental health. When questioned most talk in terms of basic needs such as housing, employment, education and being able to re-establish links with family members.

However, it is important that practitioners who are interested in the cultural and religious aspects of their patients do not resort to national or racial stereotypes. Cultural sensitivity is also about being aware of the core personal differences such as family, politics, education, finances, religion, sexuality, ethics or local community, that are integral to everyone. Whenever a doctor and a patient are communicating, there will be cultural differences that are fundamental to both parties that will be mediating the interaction.

It is near impossible for doctors to undertake education for themselves on the ever-growing variety of cultural factors that can influence the interaction with patients. One useful way of communicating in a consultation is outlined in the ‘Cultural Awareness Tool’. This involves a change in the way of relating whereby the patient and family members take on the role of experts, while the practitioner breaks out of their ‘doctorly’ role for a moment to become a student intrigued by the culture presented to them.

This is in contrast to the blunt line of questioning sometimes used and emphasises a respect and curiosity for the patients’ different way of viewing their illness. The questions are not prescriptive but reflect the usual movement of a consultation through symptoms, past history, assessment of severity, safety issues, treatment, safety net and so on. With experience in different cultural settings, the style of questioning can be refined and rendered more specific for that culture.

The following is an adaptation of the questions from the Cultural Awareness Tool refined to suit the experience and practice of this writer:

1. What is the main problem you would like me to help you with today?

This initial question may or may not reveal the main problem that needs to be addressed, but will give an insight into what is going on in the patient’s life. If they come from a background where mental health problems are taboo or not part of the culture, they may discuss physical complaints such as backache, headache, diarrhoea or abdominal pain. Sometimes they will talk about social problems such as family difficulties, housing, employment, finances or grieving issues. However, often they will complain of more recognisable symptoms such as insomnia, fatigue, anxiety, depressed mood, inability to work, withdrawal, anger or irritability. Whatever the presenting symptoms, the rest of the questioning must primarily focus on that issue as an entrance into the patient’s inner world.

2. How is this problem affecting you?

This inquiry will usually provide a broader set of complaints, and if the patient is depressed may lead to the diagnosis. Some see their ‘worrying’ as perfectly normal and even respectful and will discuss physical symptoms and social factors as the cause of their psychological problems. The patient will see the initial problem as the cause of the symptoms, not something called depression, and this must be respected as the consultation continues.

3. Why do you think it started when it did?

Often a question such as this will help both the patient and the doctor to gain insight into what the precipitating factor is and hence make the diagnosis clearer. This may also bring to light religious beliefs associated with the illness. There is a wide range of beliefs about what causes mental illness. Some believe that it is because the person has done something wrong or bad, that it is caused by evil spirits or bad deeds in an ancestor, that it is a weakness, that it is contagious, that the medication makes it become entrenched and the patient can never get off it, or that it is the responsibility of the family to deal with it without medication.

4. What do you most fear about this problem?

As well as being an opening to allay the unrealistic fears that many people have about their illnesses, this may give the doctor an idea of what are the priorities in the person’s life, for example job, family commitments or dying at an early age.  If the patient comes from a culture with little knowledge of anatomy and physiology this might be an opportunity for education that will help them gain a deeper understanding of how psychological issues such as stress, anxiety, depression and grief can affect their physical health.

5. What solutions have you tried or have you thought of?

This can be a way of both assessing the severity of illnesses such as depression and suicide, but also see if there is a cultural treatment for the problem. Often people will discuss what their own culture would do in this situation and it is important to attend to this in order to gain more insight into these cultural beliefs. Respecting the patient’s own ability to deal with their problems, and listening to what happens on those occasions when they have found an answer, can also build up a different therapeutic relationship. The doctor can stand then, with the patient, the health worker, other health professionals or family, and look together at the problem. This approach where the problem is ‘externalised’ and the ‘community’ is involved in finding the solution is often much more familiar and acceptable to the patient than the usual Western approach to mental illness.

6. What were you hoping that I would do for you today?

This is an extremely important question that doctors don’t tend to ask of their own cultures. The expectations can range from a housing letter to a script for a medication to massage. If the patient’s expectations can be met, a trusting alliance has been formed that may then allow other suggestions for treatment to be made, either at this consultation, or in the future.

7. How can your family and community help you with your problem?

Central to establishing appropriate services is a willingness to integrate health and social care into a holistic approach that also involves the family and community. The resources of the community may be difficult to gather, but community health workers who have more knowledge about these things can often be accessed. The concept of going alone to the doctor is quite foreign to many cultures and so the whole consultation will often be done in the context of family. However it is very important to try at some stage to see the patient alone, as the family can be part of the problem, as well as part of the solution.

8. How will we know when you are well again?

In a transcultural setting it is important to hear whether or not the patient is really expecting a solution (eg: to their back pain). It may be that at some level they are aware that there is another problem underlying their presenting complaint, and that they are aiming to be feeling well enough to laugh with their grandchildren and have a good night’s sleep. The concept of lifelong medication for chronic diseases and that medication cannot ‘cure’ illness but only ‘treat’ it, is also something that can be very confusing. Many are concerned that the continued need for medication over a long period of time implies addiction and therefore some patients give themselves ‘breaks’ from their medication or try to decrease the dose.

9. When would you like to come back?

If a trusting relationship has been built, the solution has been acceptable and well communicated and the aims of treatment agreed upon, it may be left up to the doctor to suggest a realistic timeframe. However the patient’s insecurity about their illness may lead them to suggest an earlier time and if possible this should be accommodated. The issues dealt with in the initial consultation may give a deeper insight and confidence for both parties and further appointments will continue the assessment or treatment with a more collaborative association.

In asking questions in this way, it is likely the patient’s self-esteem will be enhanced and the alliance is strengthened when the patient recognises that you are genuinely interested in their country and culture of origin.

As the practitioner, it is important to try to change the approach with the patient, not necessarily the view of the illness. Keeping social, cultural and spiritual issues in the forefront of one’s view of diagnosis and treatment can be quite a juggling act, but can lead to a way of relating that is more acceptable for patients without sacrificing your own integrity. Respectful questioning and discovery of the core issues for each individual is the best approach when dealing with cultural differences rather than maintaining lists of cultural characteristics of different ethnic groups.

For many patients, the concept of both counselling and medication in the treatment of depression is completely foreign. Despite much education, follow-up and encouragement, the compliance rate with anti-depressants continues to be very low. Problems to compliance will include the stigma associated with mental illness. This is a cultural rather than a personal perspective and hence is almost impossible to challenge. Cognitive Behaviour Therapy, useful in many consultations with depressed patients, may not be useful in some cultures as ‘cognition’ is very much culturally mediated. It has been suggested that by stepping inside the private world to understand the feelings and personal meanings that a patient is experiencing may be too intrusive or offensive in some cultures.

In the current multicultural climate, the split between social, cultural, psychological and physical concepts of medicine is narrowing. Doctors need to have the knowledge and ability to use appropriate cultural as well as medical diagnostic skills to guide treatment, as mistakes can be made without taking the time to respond effectively to linguistic, cultural or psychosocial concerns. Reflective questioning, exploration of beliefs and fears, respect for differences in perception, clear explanations and pro-active follow-up are all part of being interested in the person as well as the illness.

If the patient feels their beliefs, values, and practices are understood and respected by the practitioner, there is an increased likelihood a good relationship will be established and the patient will trust the doctor and the clinical procedures. Cultural sensitivity in consultations is ultimately about the same parameters that make for good practitioners in any situation – self-awareness, rapport, evidence-based medicine, health promotion, respect, collaboration and good communication. Keeping these values in mind will ensure that a strong therapeutic alliance will develop with more successful outcomes for both you and the patient.

Dr. Jill Benson MB.BS.DCH.FACPsychMed

Jill has been a GP in Adelaide for about 25 years. She is the Director of the

Health in Human Diversity Unit in the Discipline of General Practice. Dr Benson also sees refugees at the Migrant Health Service and Aboriginal people at Nunkuwarrin Yunti. She is the Australasian representative for the WONCA (World  Organisation of GPs) Working Party in Mental Health.