Psychiatry Race and Culture
- Posted by Editor JPR
- Posted in Editorials & Commentary
Journal of Psychiatry Reform vol. 10 #2, February 2023
Alan Eppel MB, FRCPC
Psychiatry at its core concerns the relationship between people. All diagnostic and therapeutic interventions converge on the dyad: the physician-patient relationship.
But each member of the dyad is formed and influenced by the social, cultural, economic and political environment in which he/she grew up and within which he/she practices medicine. This is exemplified in its clearest form in the practice of individual psychotherapy. For it is in this that both overt and subtle influences come into play in the relationship between patient and therapist.
These factors are seen most acutely among refugees who have lived through the most horrendous and brutal experiences of war, government oppression, and unspeakable loss. But it is there also in those who have grown up within a society that denigrates them because of their race, religion, colour of skin, sexuality, or gender. This has been made more publicly evident with access to global media and the Internet.
All of these factors impact on the developing child and shape the quality of attachment relationships. They shape the individuals sense of self and expectations and perceptions of others.
Cultural factors may not be obvious. Western and particularly North American cultures emphasize individualism, autonomy, and personal goals .
Cultures differ with regard to the boundaries of the person. In some cultures certain inner experiences cannot be expressed overtly because this would violate the societal internalizations. These experiences then are not contained within the boundaries of a self but rather reside within the realm of a social and cultural identity.
Kirmayar describes that many African and Asian cultures are “sociocentric” rather than individualistic . The experience of “personality” embodies a social aspect entailing family and social relationships. This determines values, obligations and duties that are different from those derived by an individualistic self concept. Instead the self representation is embedded in relationship to others. Relatedness to a social group overrides individualism.
An African perspective is described by Mukuku  who points out that the practice of psychology (and by extension psychiatry) is not universally applicable:
“…the dominant discipline-defining knowledge base of psychology (organizing principles, scientific habits, exemplars, and social outcomes) is biased toward the cultural and historical realities of some people and not others …
for psychology to serve humanity, there is a need to explicate the defining aspects of the ‘psyche’ of any culturally and experientially distinctive group of people. Put differently, what each culturally and experientially distinctive group of people considers important and necessary for human authenticity should be the point of departure” .
In contrast he describes the Ubuntu philosophy which is much more relevant than Western concepts in the African context:
“ …collective identity has been amply identified in existing Afrocentric scholarship. Collective identity underpins Mbiti’s (1970) most-quoted epitome: ‘I am because we are, and because we are, therefore I am’” .
Ubuntu philosophy emphasizes [4,5]:
- collective identity,
Understanding these cultural differences can open the door to appreciating how cultures of all types may require different approaches in psychiatry, psychology and related disciplines.
The experience of racism influences all aspects of human development and identity formation. This is evident among native and immigrant populations. The impact is multigenerational as evident in the indigenous experience of cultural genocide in Canada, the United States and Australia.
Psychotherapeutic interventions based on European and North American psychiatric and psychological principles have limited relevance without the deeper contextual understanding of racism and discrimination.
Prior to the 1980s questions about sexual abuse and trauma were not part of psychiatric history taking and assessment. These problems were felt to be uncommon. It was only when it was demonstrated that these problems had a very high prevalence that clinical practice and diagnostic classifications changed. As well as clinical assessment structured assessment questionnaires and rating scales were introduced. Perhaps it is time that the same approach be used for the assessment of racism and cultural factors in the practice of psychiatry. Numerous scales already exist . Use of scales can make it easier to broach sensitive topics and conveys the therapist’s interest in providing appropriate care.
One such scale the “Race-related events Scale” includes questions about unfair treatment, verbal, physical aggression, threats and harassment [7, 8].
Salman Akhtar, a renowned Indo-American psychoanalyst, has made recommendations for the practice of psychotherapy. This is based on his own experience as an immigrant from India to North America and becoming aware of both obvious and subtle impacts of culture. He recommends asking the patient for the correct pronunciation of his or her name and to learn something about the culture, history, and geography of the person’s country of origin .
He says one must validate the minority and cultural dislocation status:
“how does it feel living in a country where you are part of a minority? I am white you are black. It may become an issue between us. If something comes between us – talk about it and we can work together”.
Akhtar identified a need to recognize different elements of countertransference in the therapeutic relationship based on the cultural and ethnic roots of the therapists themselves.
Akhtar distinguishes cultural conflicts from psychological conflicts. A cultural conflict is the result of a clash between differing expectations or norms of one culture versus another. A psychological conflict results from internal psychological dynamics .
Psychiatric practice needs to be modified to take account of the impact of racism and cultural differences on psychological development, wellbeing, and illness experience. Modifications to assessment and therapeutic practices should include structured questionnaires and rating scales.
- Kirmayer L. Psychotherapy and the cultural concept of the person. Transcultural Psychiatry 2007: 232-257
- Mukuka R. Ubuntu in S. M. Kapwepwe’s Shalapo Canicandala: Insights for Afrocentric Psychology Journal of Black Studies 2013; 44(2) 137–157
- Mbiti, J. (1970). African religions and philosophy. Garden City, NY: Anchor Books.
- Hanks T. The ubuntu paradigm: psychology’s next force? Journal of Humanistic Psychology, vol. 48 (1) 2008; 116-135 DOI: 10.1177/0022167807303004
- Chigangaidze, R, Mafa, I, Simango, T, Mudehwe, E. (2023). Establishing the relevance of the Ubuntu philosophy in social work practice: Inspired by the Ubuntu World Social Work Day, 2021 celebrations and the IFSW and IASSW’s (2014) Global Definition of Social Work. International Social Work, 66(1), 6–20.
- Atkins R. Instruments measuring perceived racism/racial discrimination: review and critique of factor analytic techniques. Int J Health Serv. 2014;44(4):711-34. doi: 10.2190/HS.44.4.c.
- Waelde L. Pennington D. Mahan C et al.(2010). Psychometric Properties of the Race-Related Events Scale. Psychological Trauma: Theory, Research, Practice, and Policy. 2. 4-11. 10.1037/a0019018.
- Hall R. Anti-black Racism: trauma informed allyship. Grand rounds Department of Psychiatry & Behavioural Neurosciences; February 22, 2023.
- Akhtar S. Cultural difference in the therapeutic dyad OPA Psychotherapy Section Fall Conference. October 17, 2020