‘East is east,and West is west’: The meeting of cultures

To the Editor

It is a well-known fact that the practice of psychiatry is heavily influenced by culture. Australia is a diverse country, and people from a multitude of backgrounds call it home. Furthermore, a significant proportion of its psychiatric workforce is born overseas – which often means a two-way cultural interaction in clinical encounters. The prejudices (and presuppositions), which form a natural accompaniment of culture, are inadvertently introduced into the clinician–patient relationship, adding an extra layer to its effects on the manifestations of psychopathology (Moleiro, 2018).

Before immigrating to Australia 2 years ago, my exposure to different cultural milieus as a psychiatrist in India had sensitised me to the nuanced influences of societal values and expectations on psychopathology, treatment and therapeutic relationships. This understanding is a prerequisite to using modern diagnostic systems (International Classification of Diseases [ICD] and Diagnostic and Statistical Manual of Mental Disorders [DSM]), which call for culturally informed assessments. But nothing could dissuade me from chasing the (very elusive) mirage of a ‘single Australian culture’ in my clinics until the futility was amply evident, and ensuing reflections generated valuable insights.

Beyond the theoretical understanding of the influences of culture on psychiatry, what is likely to be more daunting for a clinician is the maintenance of objectivity while facing counterintuitive deductions and unknown cultural variables. Culture usually provides templates for (almost) a semi-automatic understanding of psychiatric presentations – by defining norms and providing necessary contrast to identify psychopathology. Thus, adapting to a new society entails generation of newer versions. These could originate in bottom-up (effort-intensive) or top-down (error-prone) processes, but a third alternative is to construct them through (unconscious) Bayesian probabilistic learning. By identifying patterns, mixing-and-matching pre-existing templates, testing and correcting from feedbacks, this forms an active project for lifelong learning, with reinforcements provided by (unpredictable) gratifying rewards. In my experience, exposure to cinemas and fictions – not necessarily about one particular culture – is often a useful way of acquiring such models and for understanding our limitations. The latter is important, as it brings about humility.

The practice of psychiatry – differentiating between normative and non-distressing experiences from psychosis to appreciating the meaning of trauma within particular societies – requires an openness of mind. It is humanly impossible to know about all cultures, but it is important that we know how to generate an approximate template, if need be, and remain flexible and self-critical with this exercise. This is particularly useful for clinicians, who are adapting to the demands of a new society, to ensure good clinical outcome and self-satisfaction.