Author reply to Letter to the Editor regarding: ‘East is East and West is West’: The meeting of cultures

Teo and colleagues, in their letter, have rightly acknowledged the role of personal reflexivity in culturally appropriate psychiatric practice and have highlighted immediate consequences of such cognizance. Naturally, they advocate in favor of a fuller, nontokenistic exploration of cultural factors, their belief being rooted in the appreciation of the dynamic nature of culture. With this approach, they hope, psychiatry will emerge in a more meaningful avatar.

It is a safe assumption that no two human minds are alike, and a large proportion of these differences is not of a biological origin. If the mind is the gestalt of bio-psycho-social interactions happening at the level of the brain, then psychiatry perhaps constitutes the last bastion of clinical medicine in allowing for such interactions to be deciphered through nonlaboratory-based assessments. And in understanding and formulating our patients’ sufferings, language remains our most reliable ally.

When culture is defined loosely as ‘the way of life, especially the general customs and beliefs, of a particular group of people at a particular time’ (https://dictionary.cambridge.org/dictionary/english/culture, accessed 13.09.2022:0900), we can immediately see the role language would play in setting its norms and expectations, and in modeling its realities. This is borne out well in psychiatry, where psychological distresses are often expressed and elaborated through distinctive idioms and metaphors (Desai and Chaturvedi, 2017). These usages are almost always stipulated and illustrated in the context of the specific cultural milieu, are idiosyncratic within a delineated group, and they may or may not be translatable into the commonly understood parlance of the majority culture. The latter could be a language (English, for example), or the technical diagnostic descriptions. By being untranslatable into another language and by defying familiar logical norms, such expressions may baffle an external observer. During rushed clinical encounters, therefore, misconstruing actualities through misinterpreted idioms and metaphors becomes a real possibility in psychiatry.

Consequently, during cultural explorations, a key factor to consider is the risk of a ‘cultural faux pas’. Cultural formulations are double-edged swords. By allowing us to reasonably explain the man and his symptoms within a ‘framework’, they empower clinical encounters with a semblance of validity. However, the reliability of this veneer is heavily dependent on the construct validity of that unique constitution which is presumed to be understood by the clinician. It is generally proposed that empathy enables oneself to appreciate some of the cultural references. It is also likely that empathy itself has its own cultural underpinnings (Atkins et al., 2016) and variabilities which plague encounters. Adding to the complexity is the fact that this construction is likely to have bidirectional influences, reflecting the dynamism of cultures. Through the unfolding of this intricate drama, the tedious nature of this whole task makes it fraught with false hopes and reassurances.

Under these circumstances, if a psychiatrist tries to emulate competence, the risk remains that s/he is carried away by the power of the ‘narrative’. This power of narratives is well recognized in anthropological literature. As highlighted by Said (2003) through his exploration of the concept of ‘Orientalism’, narrative-dominated frameworks which introduce one to cultural nuances may be dangerous in allowing for a false sense of complacency which could then rapidly spiral into a reductionist-prescriptive, often discriminatory, approach. By reducing variability and allowing for cognitive biases and heuristics, these narratives encourage stereotyping—which is the antithesis of cultural competency. In a multicultural society, the perils of such misapprehended narratives may be much higher.

Thus, there can be no doubt that cultural competency is a core skill which should form the cornerstone of psychiatric practice, especially in our modern multicultural world. There is also no arguing that the relevant bodies—the RANZCP in Australia, for example—should have the responsibility to institute such measures as would be appropriate to develop a culturally proficient workforce. However, as I have tried to explain in this letter, actual competency requires a basic adaptation in our understanding of what we are aiming to achieve. Instead of mechanical and theoretical expertise, I recommend a state of curious bewilderment. It may be a counterintuitive proposal, but it is likely that if cultural competency is enforced through institutionalized rhetoric, instead of being encouraged to grow organically, this may lead to false stories. The repercussions may lead to cosmetic clinical encounters, with little actual benefits.

I believe a practical way would be to cultivate a sense of wonder, the realization of which would certainly go beyond the narrowly defined medical-anthropological field, and would ideally encompass the whole society.

“If there is a knower of tongues here, fetch him;

There’s a stranger in the city

And he has many things to say”.

—Mirza Ghalib*