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CULTURAL INFLUENCES

As mentioned earlier on, cultural, ethnic and religious impacts should be considered during an appointment with your patient when you are using the services of an interpreter. The section to follow highlights any cultural differences or implications which need to be addressed sensitively.

Culture, religion and ethnicity are not necessarily fixed influences but your understanding as a practitioner, of how they might impact on health behaviour is essential to successfully providing a service to all patients from different groups.

Cross-cultural communication is one of the biggest barriers preventing patients receiving quality mental health care. Non-verbal communication, such as gestures and eye contact can often be interpreted differently between cultures causing confusion during an appointment. For example, less eye contact in some cultures is a sign of respect. In psychological therapy eye contact is more likely to increase as the power differential between patient and therapist equalises, which happens when the patient gets to know the therapist more. This non-verbal communication is just as important as the spoken words between people, especially in this particular setting. Any information provided by the interpreter should be treated as one possible interpretation of culture, and not as a fixed absolute.

Culture can account for variations in how some patients communicate their symptoms and which ones they report. Some aspects of culture may also underlie culture-bound syndromes – this means, sets of symptoms much more common in some societies than in others, for example what may be deemed an issue of mental health in one culture may be perfectly normal behaviour in another. More often, culture bears on whether people even seek help in the first place, what types of help they seek, what types of coping styles and social supports they have and how much stigma they attach to mental illness. Culture also influences the meanings that people impart to their illness. [1]

All cultures have a system of health beliefs which they use to explain illness’s, how they can be cured or treated and who should be involved during this process. The extent to which patients perceive patient education as having cultural relevance for them can have a profound effect on their reception to information provided and their willingness to use it.

Western industrialised societies such as the UK, which see disease as a result of natural scientific phenomena, advocate medical treatments to diagnose and treat disease. Some societies however, believe that illness is the result of supernatural phenomena and promote prayer or other spiritual interventions that counteract the presumed disfavor of powerful forces. This showing just how largly cultural issues play a major role in patient compliance.[2]

You may find that in most cultures, there is a stigma attached to any diagnosis of Mental Health issues. From the examples we can see that each culture differs from one to the next and not all share the same values of Western medicine and diagnosis. Is it important to remember that with these differences in culture not all patients will conform to the Westernised concepts on mental health which you practice. Their beliefs and cultures’ will impact their understanding of what you are diagnosing or medicating. This is why it is so important to make use of your interpreter as a cultural advisor and not just an interpreter.

It is clear that the cross-cultural differences faced by many mental health care professionals working with patients who have a lower level of English proficiency, can lead to communication problems. Interpreters serve as a very important cultural adviser in the mental health environment and can greatly improve the quality of health care for patients with limited English proficiency.

Interpreters have unique knowledge and experiences in the cultures and languages of the patients for whom they are interpreting, allowing them to convey health information to both parties in a way that considers cultural traditions, belief systems, understandings of health and sensitivity to both Western and non-Western views on medicine. Because of this specialised skill, interpreters are able to fulfil a very important role in the medical visit. [3] It is important to remember that culture is not homogenous or fixed and is subject to different interpretations depending upon religion, caste and class etc.

These skills provide an important role for the interpreter as often the interpreter will have to explain traditional beliefs and practices to the professional and specifically communicate what the patient’s view of their illness may be. In the case where the patient comes from a place where there is no comparable mental health system, the interpreter will be required to use culturally appropriate substitutions in replacement of this.[4]

Interpreters can help practitioners to understand what may or may not be offensive to certain patients. Another challenge to communication is differences in styles. Medical terminology often doesn’t exist in other languages the way it does in English.[5] Finding ways to express and understand these differences often creates challenges in the medical encounter. Interpreters can bridge these differences by presenting information to each party in a way that is culturally appropriate which also meets the medical standards presented by the provider.

You should consider any current cultural issues which may be relevant to your patient, for example is there any unrest in their country of origin or political dilemmas going on which could be affecting them in any way. I.e. do they have family members which are still in their home country which they may be concerned about.

Here are some interesting points about certain cultural values that might have a bearing on how patients may engage mental health services. It is important not to assume, but to have an open discussion with your patient about their cultural values to find out how specifically their values interact with the service you are providing. Below you can find a brief list of what some main stream cultures value:

  • Asian/Pacific Islander culture:
    • Some patients will only report their somatic symptoms for example: dizziness or headaches whist not reporting any emotional symptoms.
    • Extended family has a large influence upon decision making.
    • The oldest male of the family may be the decision maker or spokesperson for their family.
    • If a male is present your patient may not open up as much or explain in detail their feelings out of respect for the male.
    • Interests of honour towards the family are more important than that of the individual.
    • Older family members are highly respected and their decisions are rarely questioned.
    • Harmony is an important value within Asian culture, therefore a strong emphasis is placed on avoiding conflict and confrontation. This can mean a patient agrees with you at the time of diagnosis, however rejecting any kind of treatment once they have left the appointment.
    • Respect for authority will mean disagreements with health professionals will be avoided, however this lack of disagreement does not always mean that the family will follow what the health professional has set out for them to follow. (As above).
  • Chinese culture:
    • Behaviour of one individual reflects upon their family, therefore any diagnosis of mental illness, or behaviour that represents a lack of self-control can produce shame and guilt for that family.
    • This culture hold high regard for ensuring moral order is up kept, often meaning any mental health issues are ignored.
  • Indian and Pakistani Culture:
    • Some sub-populations from these cultures will not accept mental illness diagnoses as they believe it can seriously damage their chances of other members of their family getting married.
    • Mental illnesses are deemed shameful, therefore being rejected as a diagnosis.
  • Vietnamese Culture:
    • Mystical beliefs explain mental illnesses.
    • Health is viewed as a harmonious balance between poles that govern the bodily functions.
    • Western mental health is not readily accepted however if trust is gained, it may be possible for Vietnamese to accept assistance.
  • Russian Culture:
    • Many people within the Russian culture distrust medical care from other countries.
    • They are used to being told what to do and what is wrong rather than asked their view on how they feel.
  • Hispanic culture:
    • A strong heritage for family and religion is encompassed within the Hispanic culture.
    • Older family members are respected and consulted before any decision making is done.
    • Illness of any sort is viewed as God’s will, or divine punishment from sinful acts of behaviour.
    • Some Hispanics may prefer home remedies and may consult a folk healer.

(Information on specific cultures found above have been sourced from Euromed Info).[6]

It is important to note that the above are discussed as cultures collectively. There will be variances and individualist differences dependent upon area and region.

[1] Department of Health and Human Resources, Mental Health: Culture, Race and Ethnicity, a supplement to mental health – a report of the surgeon general, 2001.

[2] Euromed Info, [online], [Accessed] 24th March 2014.

[3] University of Minnesota, Working with interpreters, 2009, pg 7.

[4] Connel, J. The Intersection of Language, Culture and Mental Health: Considerations for Training in Mental Health Interpreting, 2008.

[5] Hudelson, P. Improving patient-provider communication: insights from interpreters, Family Practice, 22(3), 2004, pgs 311-316.

[6] Euromed Info, [Online], [Accessed] 24th March 2014.