Fagie Mandel Greenberg, M.Ed., CDT.
Dyslexia and behavior specialist, EdMind LLC; Professor of Literacy and Special Education, Kean University, NJ.
Ms. Mandel Greenberg has disclosed that she has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
Hien, your 8-year-old Vietnamese American patient with autism spectrum disorder, is referred to you for “assault” and “elopement.” The school psychologist describes Hien hugging peers (“assaults”) during reading (“non-preferred task”), leaving his desk (“elopement”), and coming to the teacher and leaning into her chest (“sexual misconduct”), despite IEP goals for “quiet hands and body” and “manding” (asking appropriately). The school hopes that adjusting medication will improve his compliance. Hien’s parents are a soft-spoken couple who tell you that he causes no trouble at home. They encourage Hien to come to them with any worries and are alarmed over his difficulties at school. You are concerned that the school has misinterpreted Hien’s anxiety as misbehavior and schedule a call, resisting the pressure to try to solve this with more medication.
Our assumptions about children shape diagnosis and treatment; we may interpret a given behavior entirely differently based on the setting in which it occurs. We want to avoid inadvertent participation in a treatment plan that fails to bridge cultural differences and thus is ultimately unhelpful. This article builds on our recent interview with Dr. Andres Pumariega about cultural issues in child and adolescent psychiatry (CCPR, July/Aug/Sep 2020) to improve your awareness of how culture impacts assessment and treatment.
Cultural differences in communication Communication styles vary from culture to culture, impacting how we interpret a person’s meaning and intent. For example, Western European culture uses intentional eye contact to convey care and presence, yet in Japan and Southeast Asia, sustained eye contact connotes aggression. Silence also is perceived differently in various cultures. In China, silence connotes agreement and acceptance; in many aboriginal cultures, sustained introspective silence is the norm before responding to a question; and in North America and the UK, silence between people implies distance or disinterest. Facial cues also vary between cultures. It can be difficult to read subtle facial cues in patients from cultures that tend to avoid facial expressions of negative emotions, as is common in Japan (Huang Y et al, Psychiatry Clin Neurosci 2001;55(5):479–483). In addition, individuals from Native American and some European cultures may perceive direct questioning as rude. In our case example, Hien’s behavior of “flocking” to peers and adults is communicating anxiety in a manner consistent with his family’s culture.
One month later, you learn that Hien has been moved to a new school for children with conduct problems. After several restraint episodes, his behavior is “much improved”; however, there is a report that older peers have gotten Hien to “talk funny Asian” for them. When you speak to him, Hien is quieter than during the previous appointment. His affect is flat and he is less responsive. You worry that Hien’s compliance comes from a sense of helplessness. You tell Hien’s parents that you are concerned Hien is too compliant, which might make him vulnerable to being mistreated by his peers, and that you wish to work together to see if there are other possible approaches to care. They reply, “Yes, of course; we will do whatever you say so that Hien will be a good boy.” Two weeks later, you receive an online review about yourself that states, “The doctor said that he didn’t want our child to behave.”
Adjusting your assessment style Despite our best efforts to offer respectful care, any of us might misstep. For instance, collaborative therapeutic relationships can confuse clients from hierarchical cultures who expect explicit direction, something common among Latino communities. Similarly, clients from cultures with an emphasis on humility, such as Asian and Native American cultures, may benefit from being asked to think about their strengths in terms of the perspectives of others.
Be aware that mental health is more stigmatized in some populations, and this can have a significant impact on the patient. Families may distrust mental health providers, may view problems in terms of being good or bad, or may disregard them entirely. For example, a Western patient with anxiety or depression might experience psychological distress, but a patient from a Filipino culture with anxiety or depression might experience and interpret that distress solely as physical symptoms. Some families will avoid treatment; others may decline medication, particularly in favor of culturally congruent remedies or practices.
Research supports open, therapeutic environments for diverse clients (Asnaani A and Hofmann SG, J Clin Psychol 2012;68(2):187–197). Within your working relationship with both patients and families, you may evoke a range of responses: compliant deference, egalitarian partnership, or even outright fear or hostility. Here are some ways to guide your assessment:
Remain non-judgmental. We all have preexisting ideas about cultural groups different from our own, and these assumptions can cause patients to feel misrepresented or marginalized. Treat those assumptions as hypotheses. If you assume many patients from a certain culture will somaticize, remember that an individual patient from that culture might not.
Don’t play the expert. You may be tempted to demonstrate your knowledge of your patient’s culture, leading patients and families to feel prejudged. Instead, it is better to acknowledge your limitations. For example, you might say, “I know about learning problems, and I also know you are the expert in how you and your family think about learning.”
Get input and stay humble. Ask patients, “Help me understand how you think these problems happened.” Inquire how they usually like to work with doctors and other professionals. Listen for and ask about how they communicate at home. The Cultural Formulation Interview (APA, 2015) is a useful tool for identifying client cultural identity, cultural explanations of mental illness, cultural factors, and cultural communication (APA allows this supplemental tool to be reproduced for clinical and research purposes; see www.tinyurl.com/19sdrkr7).
Be aware of developmental enculturation. Teens will often request mental health care as they become enculturated into the dominant Western culture, even if their parents and families do not share or support this view. Mediate this topic, allowing all parties to voice their opinions. You could say, “It seems that there are different ideas about what is happening at school—let’s list them all so we can think about them together.”
Adjusting treatment During your next family appointment with Hien and his parents, you try an authoritative tack, mirroring the parents’ language about being “good” and recommending placement in a small, emotionally supportive school now that Hien’s behavior is “better.”
Once you have a better understanding of how your patient culturally experiences the world, you can shape a better care plan. Here are some strategies for adjusting care to your patient’s cultural context:
Employ a communication style that fits with the family’s needs. For example, with some families you may need to take a more authoritative stance; others might call for being more egalitarian and collaborative; and still others might necessitate cultivating the role of humble service.
Frame your treatment plan from your patient’s perspective. Some families may not be comfortable with discussing emotions during a therapy session. Some may prefer a more indirect approach like meeting regularly with the child’s teacher. Similarly, some families find hospitalization extremely stigmatizing and may do better if their children receive intensive outpatient care. You may also want to obtain permission to talk with important figures, perhaps a patriarch or matriarch, about medications and other treatments.
Seek empirical data on treatment adaptations identified for various cultures. The U.S. Department of Health & Human Services’ Office of Minority Health sponsors a helpful website called Think Cultural Health (www.thinkculturalhealth.hhs.gov/about). It contains an online library with resources on integrating cultural competence into therapeutic practice. See also CCPR Summer 2020 for examples, such as CBT for depression in teens modified for Puerto Rican culture and brief strategic family therapy developed for Latino families in the Miami area.
Keep learning from your families. With every family, you will become more effective over time as you learn more about how the patient and family members express themselves, how they interpret others, and what the family’s ongoing expectations are of the child, the school, and you. Use that information to inform your approach and problem solving. A helpful PDF called “Understanding the Families You Work With: Reflective Questions to Uncover Cultural Differences” is available at www.tinyurl.com/dosveu2u.
Six months later, Hien is thriving on no medication. However, he is having trouble with the boisterous recess environment where there is no organized play. You learn that at home there is a structured schedule of activities much like what Hien’s parents had as children. You work with the school to offer optional semi-structured facilitated playground activities. A few days later, you read a new online review that says, “This doctor is very wise.”
CCPR Verdict: Autism itself has a culture of care, and yet, like for all conditions, cultural aspects can create an entirely new clinical picture. Through information and tools, we can adjust care to better meet the needs of our patients and their families in their cultural context.