Why is culture so important in Psychiatry?
And why is there a trend towards teaching culture predominantly from the perspective of the cultures of Indigenous Australians?
To answer these questions I believe that its firstly important to reflect on how in medicine but in particular in psychiatry it is important to take a holistic approach to individuals presenting with mental health concerns. A common approach to this is of course the Biopsychosocial Model*.
*The biopsychosocial model is a broad view that attributes disease outcome to the intricate, variable interaction of biological factors (genetic, biochemical, etc), psychological factors (mood, personality, behavior, etc.), and social factors (cultural, familial, socioeconomic, medical, etc.).
There is no one single Indigenous culture in Australia but several differing cultures of Aboriginal and Torres Strait Islander peoples and a rich history of culture going back tens of thousands of years.
By studying cultures in mental health using the cultural perspectives of Aboriginal and Torres Strait Islander people we can inform our approach to mental health to a range of differing cultural perspectives and in fact also reflect on how our own particular cultural experience affects our view of mental illness.
Or as an Aboriginal doctor put it to me once:
“If we can get mental health services right for Aboriginal people. They will probably be right for all people.”
There are of course some quite fascinating culture bound syndromes in psychiatry and I would encourage you to discover more broadly about this as well.
For this post I will be borrowing heavily from the work of the Royal Australasian and New Zealand College of Psychiatrists and its Aboriginal and Torres Strait Islander Mental Health Committee as well as the work of Professor Helen Milroy.
For students and junior doctors interested in improving their approach to culture in mental health I would encourage you to read through the rest of this post.
The post is broken into 3 sections:
- A description of the “Dance of Life”, a way of visualizing aspects of Aboriginal culture
- A link to the RANZCP eLearning module on interviewing an Aboriginal or Torres Strait Islander patient
- A case presentation of an aboriginal person presenting with a mental health problem
By Helen Milroy
The Dance of Life
The Dance of Life painting is the last in a series depicting a multi-dimensional model of health and wellbeing from an Aboriginal perspective.
The final painting in the series brings several dimensions together to reflect the delicate balance of life within the universe. These dimensions include the biological or physical dimension, the psychological or emotional dimension, the social dimension, the spiritual dimension and finally but most importantly, the cultural dimension.
Within each dimension there are additional layers to consider, including the historical context, the traditional and contemporary view as well as our gaps in knowledge.
The potential solutions for healing and restoration of wellbeing come from considering additional factors encompassing issues of symptom presentation and service delivery, such as education and training, policy, the socio-political context and international perspective. As the final painting suggests, we can only exist if firmly grounded and supported by our community and spirituality, whilst always reflecting back on culture in order to hold our heads up high to grow and reach forward to the experiences life has waiting for us.
The stories of our ancestors, the collective grief, as well as healing, begin from knowing where we have come from and where we are heading. From the Aboriginal perspective, carrying the past with you into the future is, as it should be. We are nothing if not for those who have been before us and the children of the future will look back and reflect on us today.
When we enable a person to restore all of the dimensions of their life, then we have achieved a great deal. When all of the dimensions are in balance, within the universe, we can break free of our shackles and truly dance through life.
Read more about the Dance of Life
“If we can get mental health services right for Aboriginal people. They will probably be right for all people.”
Click here to take the RANZCP module.
In order to supporting health professionals in improving knowledge and understanding of Aboriginal and Torres Strait Islander mental health care to achieve better outcomes the RANZCP has developed a series of 4 eLearning modules in collaboration with aboriginal experts and aboriginal communities.
Module 1 is entitled “Interviewing an Aboriginal or Torres Strait Islander patient”
This module is highly recommended for medical students and junior doctors. It takes about an hour to complete and focuses on improving your skills and knowledge in relation to engagement and communication with Aboriginal and Torres Strait Islander peoples in a culturally appropriate and safe way.
A Case
Introduction
Young aboriginal male brought by ambulance to hospital with a past history of psychosis
Concern about odd behaviours in community:
- talking to self
- annoying strangers on the street
- stopping cars in the middle of the road
No next of kin available to interview
Is “guarded” on interview at hospital but denies any symptoms of mental illness, mild thought disorder noted
Nursing staff report:
He has seen the Aboriginal Mental Health Worker who reports that his beliefs are ‘cultural’ … ‘black magic’.
Suggestion is that he should be discharged
Further Information
Appears distracted by unseen stimuli
Talking about cultural ceremonies and secret mens’ business
Reports having been at a recent ceremony and in trouble for a breach of tradition
Aboriginal Mental Health Worker
Has not seen patient yet but when asked for opinion had indicated:
it could be cultural and he may not be mad
Has spoken to family who report:
- Has been smoking lots of “yandi”*
- Had not been at the ceremony, had not broken cultural lore
- Strong family history of psychosis
*A form of cannabis
Family
The doctor asks the family if they can come to the hospital to help with corroborating the history.
The man’s family members indicate that it may be difficult for them to come to the hospital.
Diagnosis
The differential diagnosis in this case includes:
- Was there a cultural transgression?
- Is this ‘just’ a culture issue?
- Did a breach of cultural lore induce stress and precipitate a psychotic break
- Has psychotic illness resulted in ‘wrong’ behaviour
- Expected punishment for wrong doing part of a delusional picture in a psychotic person of aboriginal background
Discussion
A number of issues are highlighted in this case:
First, the issue of diagnosis. It is important to be aware of specific cultural factors that may explain behaviours BUT it is also important not to attribute such behaviours to cultural factors without sufficient evidence at the cost of excluding someone from treatment for mental illness.
Second, the “guarded behaviour” of the young man and his “denial of symptoms”. “Denial of symptoms” is a perjorative statement to make in relation to any person and should be avoided. Like most observed behaviours in mental health “guardedness” could have a range of explanations, one of which is obviously related to effect of psychosis. Another possible explanation is that the man is not very comfortable with his current environment or the approach of the doctor.
Third, the importance of family. Family is of particular importance in Aboriginal cultures and can act as a protective factor. However, it may not be obvious who the most appropriate next of kin is and this may not necessarily be the person’s mother or father. In most circumstances it is appropriate to ask and seek clarification. Aboriginal Mental Health Workers can also be of assistance in clarifying family relationships.
In working with Aboriginal people and their families it is important also to be aware of the recent history of trauma that has occurred within Australia to generations of Aboriginal people. The majority of Aboriginal families will have experienced some sort of traumatic experience in relation to health services, for example a family member dying in hospital. Sadly, Aboriginal people have not always been treated with respect and dignity in our hospitals. It is therefore possible that Aboriginal people and their family members may be reluctant to visit hospital settings due to intergenerational trauma or not feeling safe. In some cases it may be possible to offer alternatives, such as been seen outside the hospital or at an Aboriginal health service.
Fourth, communication. It is not uncommon in busy services for communication to go awry. It is always better to speak to someone directly when you can rather than relying on the reports of others.
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