22 - Communication with patients from other cultures: the place of explanatory models

Summary

Summary We discuss the complicated nature of communication between people from different cultural groups, perhaps using a second language. We focus on the fact that mental health practitioners and service users often have in common neither their cultural backgrounds nor their explanatory models of illness. Even in a shared language, communication can be less than optimal as words carry multiple meanings. Consequently, consultations that involve culturally grounded explanatory models of illness challenge the professional. We give examples showing that reconciling different explanatory models during the consultation is a core task for psychiatrists and mental health practitioners working in multicultural settings.

It is nearly two decades since Kleinman (1980) proposed the wider acceptance of the role of explanatory models in the assessment and management of mental disorders. The ‘explanatory model’ concept was intended to draw on social-anthropological approaches to understanding subjective experiences of distress and to apply them to psychiatric practice (Bhui & Bhugra, 2002). Pleas to recruit ‘understanding’ and ‘empathy’ into the clinical method have been with us since Jaspers’ early writings on general psychopathology (Broome, 2002). The tension between identifying and understanding abnormalities of mental state persists into current psychiatric practice. Consultations are increasingly regarded, mainly by nonpsychiatrists but also by some psychiatrists, as a technological enterprise. Checklists, clinical guidelines, clinical protocols, risk assessment tools, local implementation plans for the National Service Framework, governance requirements, appraisal and CPD portfolios, teaching portfolios and membership of learned institutions all include lists of activities, objectives and achievements. These documents regulate our practice by ensuring that minimum standards are met, and they demonstrate that our work includes more than sound clinical practice. Nonetheless, less attention is now paid to the more human aspects of psychiatry, which rely on sound clinical practice and include ‘quality in the clinical method’, consultation dynamics, effective history-taking, understanding, empathy and building a therapeutic alliance taking account of transferential and countertransferential issues.

Practising in a multicultural context

Drenan & Swarz (2002) remind us that psychiatric practice in multilingual settings involves various people acting as interpreters, which often leads to different conclusions about the significance of expressions of distress; for example, whether they indicate psychopathology or are culturally grounded and therefore not abnormal.