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REVIEW ARTICLE Dis Manage Health Outcomes 2003; 11 (4): 233-248 1173-8790/03/0004-0233/$30.00/0 Adis Data Information BV 2003. All rights reserved. Importance of Cultural Sensitivity in Therapeutic Transactions Considerations for Healthcare Providers Oyedeji Ayonrinde Maudsley Hospital, Denmark Hill, London, UK Contents Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 1. Culture and Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 1.1 Health and Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 1.2 Therapeutic Transactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 1.3 Stereotyping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 2. Culture and Care Pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 2.1 Culture, Assessment and Diagnostic Bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 2.2 Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 2.3 Hospitalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 2.4 Prognosis and Treatment Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 3. Cultural Aspects of Sociodemographic Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 3.1 Migration and Acculturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 3.2 Social Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 3.3 Religion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 3.4 Children and Child-Rearing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 3.5 The Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 3.6 Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 3.7 The Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 3.8 Lifestyle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240 4. Symptom Presentation: Somatization and Pain Across Cultures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240 5. Physician–Patient Communication and Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240 5.1 Principles of Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240 5.1.1 The Interpersonal Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 5.1.2 Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 5.1.3 Non-Verbal Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 5.1.4 Decision Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 5.1.5 Psychological Privacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 5.1.6 Social Privacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 5.1.7 Physical Privacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 5.2 Language in the Cross-Cultural Clinical Encounter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 5.3 Translating Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 5.4 The Interpreter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 5.5 The Therapist in the Cross-Cultural Dyad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 5.6 ‘Color Blindness’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244 6. Culture, Ethnicity and Pharmacotherapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244 7. Organizational Sensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245 8. Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245 9. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246 234 Ayonrinde Abstract Culture influences all spheres of human life. It defines health, illness, and the search for relief from disease or distress. With increased mobilization of people across geographical and national borders, multicultural trends are emerging in many countries. This is reflected in the cultural diversity presenting to clinicians in their daily practice. With these presentations, patients bring their own world views, expectations, norms and taboos to the clinical transaction. Cross-cultural transactions occur when two or more of the participants are culturally different. Although it is impossible to be conversant with all cultures, clinicians should be sensitive to the role culture plays in their practice without stereotyping patients. Culture influences help-seeking or care pathways, and may bias the process of assessment and choice of management. The interplay of patient culture, clinical setting and clinician culture can pose significant challenges experienced against a backdrop of other factors such as age, gender, religion, and acculturation. Language, even when shared, does not ensure skillful clinician–patient communications as there are different culture codes for interpersonal relationships, disclosure, privacy, and non-verbal communication. Linguistic difficulties can be partially overcome with the use of an interpreter, a triangular relationship with its own dynamics requiring skill and sensitivity. The cultural matching of patient and therapist is complex and may be complicated by the emergence of other differences that may be equally challenging. However, awareness of this should serve to reduce the number of differences. Cultural sensitivity in patient care is associated with a number of positive health outcomes, including improved patient satisfaction. 1. Culture and Illness Culture can be defined as the symbolic and learned nonbiological aspect of human society, including language, custom and convention, by which human behavior can be distinguished. It guides how people live, what they generally believe and value, how they communicate, their habits, customs and tastes. It also organizes our cognitions, emotions and behaviors in both subtle and obvious ways that may be beyond awareness.[1,2] Culture is a non-static heterogeneous phenomenon with complex and fluid boundaries. With these characteristics, culture unavoidably impacts on the ways in which people interpret and perceive health and illness, and their choices in seeking and providing care (table I). The relationship between culture and illness is a close yet complexly interwoven one. This relationship impacts on all levels of illness presentation and treatment and can be summarized as follows: • defining ‘normality’ and ‘abnormality’ • etiological role in some disorders • influencing clinical presentation and its interpretation • influencing rates and distribution of illness • determining the recognition, labeling, and explanatory models of disorders • determining treatment options and care pathways within a society Adis Data Information BV 2003. All rights reserved. • influencing the outcome of treatment interventions. 1.1 Health and Disease Definitions of ‘normality’ and ‘health’ vary globally within and across national, geographical, cultural and subcultural boundaries, influencing societal perception of the appropriateness of social behavior, health, illness and disease. Disease is the malfunctioning of biological, psychological, or physiological mechanisms. Illness, however, represents personal, interpersonal, and sociocultural explanations of, and reactions to, diseases and their consequences.[2] In most cultures, society recognizes that there are certain situations when ‘abnormal’ behavior is permissible (usually conforming to recognized codes). For instance, during fancy dress parties, traditional festivals and carnivals, people may dress as animals or cross-dress. Occasionally, an apparently circumscribed behavior may be viewed differently within the same society. For example, diverse groups may see alcohol consumption as normal, taboo, immoral, a symptom of psychological disorder, or even a vital part of rituals or religious occasions.[4] Recognition of illness or disease is often followed by a quest for treatment or alleviation of distress. 1.2 Therapeutic Transactions Therapeutic transactions occur during all forms of interaction between health professionals and their patients. This process may Dis Manage Health Outcomes 2003; 11 (4) Cultural Sensitivity in Therapeutic Transactions Table I. The cultural formulation (adapted from the Diagnostic and Statistical Manual of Mental Disorders [4th edition], text revision[3]) Cultural identity Ethnic/cultural reference group(s) Degree of involvement with both culture of origin and host culture Language (abilities, use, preference, multilinguistic) Cultural explanation of the individual’s illness Predominant idiom(s) of distress Meaning of symptoms Perceived severity of symptoms in relation to cultural norms Perceived causes or explanatory models of illness Past experiences of care Current preferences Cultural factors related to psychosocial environment and levels of functioning Interpretation of social stressors Availability of social support Level of functioning/disability Cultural elements of relationship between individual and clinician Differences in cultural and social status Problems associated with these differences communication elicitation of symptoms cultural significance negotiating relationship Overview of cultural assessment and impact on diagnosis and care be conscious, partially conscious or even unconscious to both parties (figure 1). The transactions involve:[5] (i) a ‘healing agent’/‘healer’ (not necessarily a professional); (ii) a ‘sufferer’ seeking relief from the ‘healer’; and (iii) a healing relationship between sufferer and healer. Culture may influence any of the above variables. A cross-cultural therapeutic alliance is any therapeutic relationship in which two or more of the participants are culturally different. This intercultural interaction involves users of health services who bring their specific values, beliefs and expectations about health, illness and appropriate healthcare to the health system.[6] Global migration and demographic shifts have led to the multiculturalization of many countries, such as the US, UK, Australia, and Canada, with increasing diversity of ethnicity, customs, languages, and identities in all walks of life. This diversity is also reflected in the patient lists of family physicians and primary care practitioners, and inevitably poses challenges to healthcare providers, particularly in gateway cities, Adis Data Information BV 2003. All rights reserved. 235 points of debarkation, urban communities, and rural communities with migrant workers.[7] A study of 12 000 family therapists in California observed that, although 94% of the therapists were White, 66% of clients were from other racial and ethnic groups.[8] Rates and distribution of cross-cultural clinical transactions are invariably influenced by epidemiological trends, manpower, help-seeking behaviors, and health service structure. Practically speaking, it is impossible to be familiar with the cultural norms of all ethnic and social groups. Neither will all cultural issues presented be relevant. The challenge for the health professional is to effectively screen clinical and cultural information for their significance in patient management. How does culture influence the patient, therapist, and therapeutic process? How should the therapist deal with cultural differences? Literature on the influence of culture on therapeutic processes has focussed on issues such as group characteristics, values, norms, taboos, needs, strengths, and weaknesses of cultural groups.[1,2,6-8] Culture-bound syndromes have also been of interest.[9] Although the general consensus is that there is a need for awareness of cultural differences, there are differing opinions on the significance of this awareness and its therapeutic benefits. Some authors[10] stress that ethnicity is just one of a number of influences in therapeutic transactions, and a strong focus on ethnicity may overestimate other differences between therapist and client. Other authors[7,8] emphasize that a lack of awareness of cultural or ethnic issues may compromise the therapeutic process. Another view is that there is a need for therapist awareness of their own ethnicity, and the impact or limitations of this on their relationship with clients[11] as other variables come to play within and across cultures. Some clinicians contend though that ethnicity is not as important as therapeutic skill in understanding clients. The view held by some health professionals that if each patient is treated with respect cultural problems will be averted[12] is fraught with problems, although well meant. Others advocate a posture of ‘cultural naiveté’ and ‘respectful curiosity’ as being as important as acquiring skills about specific cultural groups.[13] 1.3 Stereotyping A danger of emphasizing cultural differences in clinical practice and research is that of stereotyping people or reinforcing racial views. Stereotyping is the ascription to an individual of characteristics associated with a group of people, or extending to a group characteristics attributed to a single individual.[14] Both the professional and patient may find themselves drawing on stereotypes in unfamiliar or challenging situations, regardless of their culture.[15] However, one must caution that ethnoracial group labels may Dis Manage Health Outcomes 2003; 11 (4) 236 Ayonrinde Patient Clinician 1. Assumptions about illness 2. Expectations of clinician role 3. Preferences for treatments 4. Expresses symptoms in culturally determined way 5. Communicates construct of disorder to clinician 6. Accepts/rejects proposed treatment 7. Appraises outcome against cultural constructs 1. Assumptions about nature and control of illness 2. Expectations of patient role 3. Preferences for treatment modalities 4. Examines for signs/symptoms of illness 5. Communicates decisions to patient 6. Implements treatment 7. Appraises outcome against medical constructs Individual variables 1. Age 2. Gender 3. Sexuality 4. Ethnicity 5. Identity 6. Social class 7. Religion 8. Health system 9. National and local policy Fig. 1. The patient–clinician cultural interface. erroneously suggest attributes that may therefore be clinically 2. Culture and Care Pathways misleading. • An Asian patient checks his watch during a routine medical consultation with a locum practitioner. Noticing this, the locum asks if he needs to return to the ‘family business’. The patient replies ‘I am a doctor too and running late for my clinic’. Selective perception can perpetuate stereotypes in clinical transactions. Unlike stereotypes, generalizations may be a useful framework in some situations.[12] So while stereotypes are ending points (such as conclusions about persons and their background or way of life), generalizations serve as a starting point about common trends within a group (with recognition that further information would be required as applies to the individual).[12] Although these processes are inherent to medical training, further sensitivities are required across cultures. This review aims at providing principles while cautioning against the clinical and therapeutic risks of generalizing. Table II provides a glossary of terminology used. Adis Data Information BV 2003. All rights reserved. Definition and expression of disease, illness and distress vary across cultures.[2] Culture influences help-seeking behaviors and ultimately affects care pathways.[16] Numerous descriptions of pathways to care have been reported in the scientific literature for different ethnic groups, for instance the Turkish in the UK,[17] African Caribbeans in the UK,[18] Russians in the US,[19] Asians in the US,[20] Bedouin Arabs,[21] and Vietnamese in Australia;[22] these studies consistently demonstrate differences between majority and minority groups. Researchers in the US[23] observed ethnic and cultural differences in the use of alternative therapies among women with breast cancer. Chinese women preferred herbal remedies (22%), Latino women used dietary therapies (30%) and spiritual healing (26%), Black women preferred spiritual healing (36%) and White women preferred dietary (35%) and physical (21%) methods. Treatment delay in some groups, e.g. Asian Americans, may be associated with conceptualization of distress as a manifestation of underlying medical problems amenable to indigenous, alternative, or home remedies.[24] Past experience of discrimination or prejudice may Dis Manage Health Outcomes 2003; 11 (4) Cultural Sensitivity in Therapeutic Transactions 237 Table II. Glossary of terminology Term Definition Culture The symbolic and learned non-biological aspect of human society, including language, custom and convention by which human behavior can be distinguished. It guides how people live, what they generally believe and value, how they communicate and their habits, customs, and tastes Race The phenotypic features of a group that distinguish it from others, e.g. skin color, eyes Ethnicity The cultural practices and outlooks of a given community of people that sets them apart from others. Different characteristics such as language, history, ancestry (actual or perceived), religion, and nationality may serve to distinguish these groups. Ethnic differences are wholly learned with individual awareness of group membership Cultural identity The extent to which an individual endorses and manifests the cultural traditions and practices of a particular group White In the broadest sense, members of a light-skinned race. Loosely used to refer to people of European ancestry Black In the broadest sense, members of a dark-skinned race. Loosely used to refer to people of African descent. Individuals of Black African origin have been described as colored, Negro, Black and African American in the US, while in the UK persons of similar ethnic heritage have been described as Black, Afro-Caribbean, African Caribbean and Black British Asian Used differently in American, British and Australian literature. For example, Asian American (Japanese, Chinese, Philippine, Korean), South East Asian (Vietnamese, Cambodian), and Asian Pacific Islanders (Hawaiian, Samoan). On the whole, ‘Asian’ in the UK refers to the Indian subcontinent (India, Pakistan, Bangladesh) Hispanic Represents language (Spanish speaking), family name (Spanish surname), ancestry (Hispanic American), Latino (country of origin). Being Hispanic does not necessarily mean the individual speaks Spanish People of color Persons whose ostensible ancestry is at least in part African, Asian, or indigenous, and/or combinations of these groups and/or White or European ancestry Transference The patient’s thoughts and emotional response to the therapist Countertransference The therapist’s thoughts and emotional response to the patient (this may impede clinician objectivity or enhance the transaction) result in suspiciousness, mistrust and avoidance of health services.[25] Physician awareness, stigma, and availability of other treatment modalities also play a role. Ethnic and cultural differences may also influence referral patterns to specialist services.[26,27] The majority of patients and their caregivers select from a wide array of therapeutic options available to them, of which medical services are only one. 2.1 Culture, Assessment and Diagnostic Bias Studies (for example, Cooper et al.[28]) have described varying rates of diseases and disorders across ethnic and cultural groups in community, primary care, and hospital populations.[29-31] Although some disorders, e.g. cystic fibrosis and sickle cell disease,[32] show higher prevalence rates in ethnic groups with a genetic predisposition, racialization of these disorders may neglect persons lacking overt phenotypical features. Interethnic variation has been reported in the interpretation and expression of pain.[33] In the US and the UK, overdiagnosis of schizophrenia and underdiagnosis of affective disorders has been observed among African American and African Caribbean populations, and Asian Americans with mood disorders are more likely to be misdiagnosed with schizophrenia.[29] It is crucial for accurate detection Adis Data Information BV 2003. All rights reserved. and monitoring of disorders that when rating scales are used for cross-cultural assessments they should be standardized, validated, reliable, specific, and sensitive to the culture. Literacy can also influence assessment outcomes. 2.2 Expectations Expectations about treatment influence help seeking, discontinuation of therapy, compliance with medication and its effectiveness.[30,31,34] Both clinician and patient have their own expectations of the consultation (figure 1). Cultural differences, prejudicial or stereotyped expectations may create therapeutic misalliance.[35] 2.3 Hospitalization Regardless of culture, the experience of hospitalization may be stressful. The culturally different individual, already anxious, experiences a new community, loss of liberty, privacy and a change in daily routine, e.g. waking, meal, medication and visitor times. The hospital, like other subcultures, has its own codes and encourages conformity. Hence, the patient may feel doubly alien. In hospital, patients are occasionally exposed to patients or caregivers of different backgrounds who may be ignorant, repugnant, or perplexed about their differences.[32,34] Alienation serves to hinder therapeutic response with variable outcomes. Dis Manage Health Outcomes 2003; 11 (4) 238 • Ayonrinde A female Somali refugee from a rural farming background was admitted to a maternity unit shortly after arrival in the UK. She found fetal monitoring and examination by the male physician a terrifying experience. Unable to share her anxieties with staff, she kept to herself. She found the food unfamiliar and was stared at by other patients with discriminatory curiosity. Her previous successful pregnancy had been under the skillful supervision of her elderly aunt, a joyous experience. 2.4 Prognosis and Treatment Outcome Although the patients’ right to know should be respected, in some cultures the norm is for the patient’s family to be initially informed of a poor prognosis, after which decisions are made on how to notify the patient.[12] Relatives may perceive the physicians breaking difficult news to the patient as insensitive and even hastening death. Clinicians face the risk of unwittingly colluding with family members against the wish of their patients, and ultimately need to be guided by the ethics of confidentiality. 3. Cultural Aspects of Sociodemographic Issues 3.1 Migration and Acculturation Psychological and physical morbidity have been widely reported in immigrant groups.[36,37] Migration is associated with disequilibria of social networks, family, community, and physical environment[37] which are all major contributors to individual identity. There are four stages of migration trauma: (i) pre-migration; (ii) transit; (iii) asylum seeking/resettlement; and (iv) substandard living and minority persecution.[37] Clinicians must not ignore the effects of post-traumatic stress disorder resulting from war, torture, or witnessing conflict. Presentation may differ during stages of acculturation (the process by which a new culture is acquired), even within the same ethnic group.[37,38] Patients of uncertain immigration status may find medical interviews probing, intrusive and may be cautious or withhold information for fear of adverse outcomes. 3.2 Social Structures Different social structures and hierarchies exist within and between cultures. Across these structures, social class, caste, and educational differences may emerge between the clinician and patient. For instance, a traditional African chief may face status contradiction when addressed by first name by a clinic receptionist. Many immigrants experience a conflict of, or decline in, status during the period of acculturation. Patient communication and behavior may also show deference towards the authority figure of the clinician. Adis Data Information BV 2003. All rights reserved. 3.3 Religion Religion is an integral part of culture in many societies. In fact, some cultures are defined by their religious practices such as diet, prayer routine, sacred days, prohibitions, rites, dress codes, and even attitudes. Religion may lead to disagreement over value systems, power brokering, denial or even collusion between therapist and patient.[34,39] A lack of awareness or sensitivity about the patients’ religion may be perceived as offensive. For instance, a Sikh person may feel insulted being referred to as Hindu,[39] as would an Irish Protestant referred to as Catholic. On a similar vein, a seemingly innocuous question such as ‘what is your Christian name?’ may be perceived as insensitive if asked of a Muslim patient. The pitfalls of pathologizing normal religious experience cannot be underestimated. • A member of a Black Pentecostal church presents to his family practitioner reporting that he had heard ‘the voice of God’ directing him to seek help for his distress. The practitioner remembers discretely observing him several weeks earlier speaking incoherently with head shaking and swaying motions while visiting his sick child. He promptly requested a psychiatric opinion. In Pentecostal faith it is not uncommon to ‘hear God’ and to ‘speak in tongues’[40] as opposed to the experience of auditory hallucinations with abnormal stereotyped movements. ‘Stereotype-looking’ behavior may also be observed in other forms of worship. Religious awareness without sensitivity could undermine therapeutic relationships as well. • A devout Sikh man was offered chemotherapy/radiotherapy for the treatment of cancer. The attending oncologist painstakingly explained possible adverse effects and their relative risks. He also cautioned that the patient would have global alopecia from the treatment. One of the founding tenets of Sikhism is that males must not cut their hair. Although the physician had explained the procedure in detail, the patient was left in a quandary: faith with cancer, or diminished adherence to his faith and treatment. Although the oncologist was aware that hair loss would be difficult for the patient, he was insensitive to the emotional impact. In close-knit communities, stigmatization of illness may lead people to seek care from other cultural or religious groups, in order, for example, to avoid jeopardizing opportunities for marriage.[34] As a religious safeguard against improper sexual behavior, two people of opposite sex are not permitted to be alone in a potentially intimate situation in Orthodox Jewish and some other Middle Eastern faiths. Similarly, casual touching or handshaking (taken Dis Manage Health Outcomes 2003; 11 (4) Cultural Sensitivity in Therapeutic Transactions for granted in some cultures) is prohibited between men and women in other cultures.[34] In such interactions, interpersonal distance should be respected and may require for doors to be kept unlocked or ajar in some situations and immodest dress avoided. 3.4 Children and Child-Rearing Practice Child-rearing practices not only differ between families but across cultures. Children imbibe family values and their parents’ culture as well as that in which they live. Health service usage by children is greatly influenced by decision-making adults in the household.[28] Adolescence, a period of physical and psychological change, is characterized by a need to identify with the peer group. This may be challenging for ethnic minority children who experience ‘identity confusion’ and requires sensitive attention.[39,41] Children may be treated using cultural remedies before presentation, e.g. the Asian practice of ‘coining’, in which a coin, heated or oiled, is rubbed on the patient’s back to extract illness; the ensuing welts are evidence of a successful procedure.[12] Such traditional remedies may be mistaken for physical abuse and may lead to the initiation of child protection proceedings.[42] 3.5 The Elderly The roles of the elderly are dictated by tradition and strong cultural beliefs[43] that also influence attitudes toward aging. Elderly migrant persons are more likely to seek help in primary care than through specialist services.[19] They also have greater physical morbidity than younger persons. Unique issues of the older migrant include acculturation difficulties, e.g. dietary changes, financial limitations (less likely to be able to compete in the job market) and narrow social networks. Cross-cultural impact on symptom presentation, behaviors and caregiving style have been described among the elderly, e.g. different rates of Alzheimer’s disease between African American and African groups.[44] The clinician should not be surprised if families from some groups express reluctance to relinquish support for their elderly to ‘outsiders’, as this contravenes traditional care values.[12,38] 3.6 Gender Gender roles and their significance vary across cultures. In many less industrialized cultures men have a traditional provider role while women are responsible for child rearing. Gender role reversals in therapeutic encounters could pose problems for some patients. Transgenerational cultural deference to men is encouraged in some Asian (and African) societies; from daughters to fathers, wives to husbands and in old age, mothers to sons.[45] Adis Data Information BV 2003. All rights reserved. 239 Cultural variables influence various spheres of female service utilization. In the UK, investigators found that spoken English and social class influenced patterns and quality of maternity services, with reduced satisfaction amongst ethnic minority groups.[46] In The Netherlands, immigrant women (Surinamese, Antillean, Turkish and Moroccan) were heavier users of social work facilities and crisis centers than were local counterparts.[47] Multicultural contraceptive service provision is complex.[48] Muslim opinion with regard to contraception ranges from prohibition to acceptance.[49] This is reflected by the different rates (5% to over 50%) of contraceptive use in some Muslim countries.[49] Clinicians should clarify individual opinion and knowledge about contraception in such services. The practice in some rural West African cultures of prolonged breastfeeding also serves a contraceptive role, as does adults sharing sleeping quarters with children in some Asian societies. Menstruation exempts Muslim women from important religious rites, and may explain reluctance in some quarters to seek help for gynecological symptoms, cervical smears or intrauterine devices for fear of bleeding. Women unaware that traumatic bleeding is distinct from menstrual bleeding may unknowingly impose religious restrictions.[49] Cultural sequelae of menstruation have also been described in Jewish populations. [50] 3.7 The Family In many non-Western cultures, identity is entrenched in interpersonal family relationships[39,49] with family obligations overriding personal ambition. If successfully negotiated, this brings pride to the family – otherwise, shame.[51,52] Culture interacts with the family life cycle at all stages, defining roles,[53] transitions, tasks and rites of passage appropriate to each stage. In some groups, the head of the family is crucial to help-seeking decisions and is consulted (sometimes in the country of origin) in matters of distress.[39] Immigrant families may initially be of lower socioeconomic status or educational achievement than the general population; hence, health needs are prioritized against other requirements. It is suggested that family therapy may be more acceptable than previously thought to those from family-oriented countries.[54] Treatment approaches emphasizing family and community have been effective in Western cultures by encouraging sociocentric family practices as therapeutic tools. Alternatively, treatment strategies may be doomed to failure if they are viewed by family members as threatening to family integrity.[55] Where families present with a ‘spokesperson’ this may compromise presentation of sensitive issues, e.g. sexual abuse.[56] One should caution that cultural sensitivity to the extent of collusion Dis Manage Health Outcomes 2003; 11 (4) 240 Ayonrinde with families or against medical ethics could be counterproductive, if not damaging. The decision to exclude ‘significant others’ should also be given careful consideration. • A Somali couple present with their young daughter requesting advice on local services for female circumcision. The female practitioner finds this request abhorrent and attempts to counsel them on the hazards and implication of such a procedure. The girls’ father explains ‘It is our culture! It has been the practice of our mothers, wives and daughters over generations.’ The practitioner replies ‘I must also warn that it is illegal.’ Although culturally sanctioned, this practice is not condoned in many countries.[57-59] Marriage between partners of different ethnic groups, religious communities or castes (e.g. Muslim-Christian, Hindu-Sikh, African-Chinese) presents families with the task of redefining their identity.[38] Presentation of such couples or their offspring would require sensitivity to their transitions or renewed identity. 3.8 Lifestyle Lifestyle is diverse within and across culture, and includes diet, clothing, sexual mores, education, recreation, and spirituality. Hence, health information leaflets with pictures of golfers or graduates in academic gowns may alienate some patients. Advice on diet and exercise should also be alert to diversity, e.g. halal and vegetarian.[60] Many relished traditional dishes and ingredients do not have translatable English equivalents. The unemployed migrant looking to provide for his family may find medical advice to register with a gymnasium impracticable or not a priority. There is clear evidence that with acculturation lifestyle trends such as patterns of alcohol use change in migrant groups.[61] Lifestyle changes can increase the risk of other health problems. 4. Symptom Presentation: Somatization and Pain Across Cultures At all levels of care, physicians see patients presenting with somatic symptoms such as headache, weakness, and pain. The perception of pain and psychological distress varies from culture to culture.[60] Presentation of somatic symptoms is widespread among patients with depression.[62-64] Earlier reports depicted somatic symptoms as an alternative idiom of distress, prevalent in cultures where illness carried great stigma[65] and that this was more common in patients from non-Western countries.[66,67] Other authors[17] proposed that in cultures where the body-mind dichotomy is not as salient as in Western societies, it would be natural to express distressing emotions through bodily complaints. Interestingly though, these views were not supported by a 14-country international study.[68] Researchers argue that the concept of soma Adis Data Information BV 2003. All rights reserved. tization rests on the culturally determined assumption about the secondary nature of somatic symptoms.[68] Idiomatic expressions of somatic complaints vary across cultures,[17] e.g. ‘heat in the head’ in some African cultures,[69] and ‘heartbroken’ in Western societies. Current evidence demonstrates the term ‘somatization’ refers to a variety of phenomena,[68,70] with different research and clinical definitions[65,71-73] as follows: (i) patients who report only somatic symptoms as the reason for visiting the physician;[71] (ii) reporting of medically unexplained somatic symptoms as a presentation of depression;[72] and (iii) denial of psychological symptoms of depression on direct questioning. Rates were inconsistent and not associated with technological development. Only 4% of patients met all three definitions, therefore raising doubts on some research in this area. Somatic complaints may not reflect reluctance or an inability to acknowledge psychological distress.[68] In some cultures, the reporting of somatic symptoms may seem a more appropriate route for seeking help from the primary care therapist. This ‘facultative somatization’ thus provides a ‘ticket of admission’ to the primary care service.[71] Given the frequency of somatic complaints during cross-cultural consultations, the clinicians’ challenge lies in unraveling what is being communicated by the patient[74] as presentation of a ‘headache’ may also bring fear, anger, worries, and frustrations.[17] Or, in the case of traditional Chinese medicine, an association between internal organs and individual emotional states, e.g. happiness in the heart, anger in the liver, worry in the lung, fear in the kidney, and desire in the spleen.[75] 5. Physician–Patient Communication and Culture 5.1 Principles of Communication Communication between physicians and patients is one of the most complex interpersonal relationships. The principle is the use of communication as a tool in the identification of health problems with a view to achieving a health solution. It involves individuals in non-equal positions, often non-voluntary, concerns issues of vital importance, is emotionally laden and requires close cooperation,[76] and is all the more complex when across a cultural gradient. Intercultural communication occurs whenever a message produced in one culture has to be processed in another culture. Clinical communication influences patient satisfaction, treatment adherence, understanding of medical information, well-being, and quality of life.[77] The following sections consider key elements in physician–patient communication. Dis Manage Health Outcomes 2003; 11 (4) Cultural Sensitivity in Therapeutic Transactions 241 5.1.1 The Interpersonal Relationship approaches[78] Advocates of patient- or client-centered stress the importance of empathy, respect, genuineness, unconditional acceptance, and warmth. Others[79] suggest an amalgamation of both ‘patient-centered’ and ‘physician-centered’ approaches whereby the patient is the expert regarding their symptoms, preferences and concerns and the physician in diagnosis and treatment. Both techniques are applicable in cross-cultural transactions. 5.1.2 Information Information is the key to diagnosis and to the formulation and implementation of a treatment strategy. Regardless of culture, all patients want to feel understood, as do clinicians. This may present a number of challenges, particularly across linguistic barriers (see section 5.4 on language and interpreters). To engage the patient the therapist must explicitly educate him/her about the purpose of questions[55] Cultural differences occur in clinician attitudes and communication style, e.g. the word ‘cancer’ may be substituted with words such as ‘growth’, ‘unclean tissue’ or ‘blood disease’.[80] Patient communication styles also influence the amount of information clinicians give to patients;[81] particularly, female patients[82] tend to express more concerns, ask more questions, be more anxious, and receive more information. Linguistic and socioeconomic factors may compound the ability to acquire medical information, the amount of which may range from minimal to overload via the Internet.[83] Different illness models between patient and therapist can also lead to etiological dispute, e.g. the belief by a Bangladeshi man that lack of sweating in the UK was a cause of diabetes mellitus.[84] 5.1.3 Non-Verbal Communication Non-verbal communication has even greater salience in transactions with limited linguistic ‘bridging’. Although it has been reported[85] that only 7% of emotional communication during medical interviews is conveyed verbally, 22% transmitted by tone of voice and 55% by visual cues (e.g. eye contact or body posture), little has been done to evaluate this across cultures. Mediterranean cultures, for instance, are more explicitly physical in everyday interactions, and body language may say more than verbal communication in some situations.[17] The ready smile of some patients from African cultures may mask underlying distress. Culture influences the emotional tone of interpersonal exchange such as tone of voice, gaze, posture, facial expressions, laughter, touch, gesticulations, and physical distance.[77,86,87] Reduced eye contact in a number of cultures communicates respect or deference and not ‘shiftiness’. As therapeutic encounters are often emotionally laden with anxiety or even fear, patients scan for subtle cues to the seriousness of their illness. Inconsistencies Adis Data Information BV 2003. All rights reserved. between therapists’ verbal and non-verbal communication may suggest a lack of genuineness to the wary patient.[77] 5.1.4 Decision Making Decision-making in contemporary medical practice encourages clinician and patient involvement. The authoritarian, ‘paternalistic’ or controlling physician may be perceived as threatening, yet authoritative or directive communication is seen as a sign of competence by others.[38,55] Transactions with traditional healers are often prescriptive, with clear definition of tasks, and their competence is evident in their ability to effuse authority.[88] 5.1.5 Psychological Privacy Psychological privacy[89] includes the right to determine with whom and under what circumstances thoughts and feelings are shared. Black and Asian groups may be reserved or even reluctant to discuss problems outside the family.[39,55] A lack of appreciation of cultural aspects of self-disclosure may lead to patients being perceived by therapists as guarded, concealing information, or even paranoid. Mistrust due to genuine or perceived racial or discriminatory experiences also influences patient disclosure to clinicians.[90] 5.1.6 Social Privacy Social privacy involves the control of social contacts in order to manage interactions or maintain status divisions. Across cultures, formality, conversational topics, and language are determined by social codes. ‘Platica’ – the need to talk informally about irrelevant topics before proceeding to the more serious and relevant – has been described among Hispanics.[40] Patients may feel uncomfortable being addressed on first name terms. 5.1.7 Physical Privacy Physical privacy, accessibility to others and the definition of personal space are influenced by culture, ethnicity, and gender. The physicians’ ‘caring’ proximity may seem threatening. Some cultures are ‘touch oriented’, e.g. some Turkish patients have little faith in physicians who do not touch them,[17] whereas others, e.g. Islamic and Orthodox Jewish, discourage this, particularly across genders. 5.2 Language in the Cross-Cultural Clinical Encounter Unique to all cultures are the denotations, connotations, grammar, accents, dialects, and functionality inherent in their languages. Even when the ‘same language’ is being spoken, educational, class and regional differences emerge.[6] • A young African-Caribbean boy tells a health worker that his uncle is ‘wicked’, with flagellating and flicking motions of his fingers. Concerned that the boy was being physically hurt, child protection proceedings are initiated. A family crisis follows. Dis Manage Health Outcomes 2003; 11 (4) 242 Ayonrinde The word ‘wicked’ was used to describe this ‘favorite’ uncle using street parlance and the hand motions emphasizing how special he was. Clinicians should seek to contextualize and clarify narratives before concluding therapeutic interventions, as misunderstood communication may have harmful outcomes. Across the clinical spectrum, there are multilingual persons who speak no English, to the grammatically correct who speak with a heavy foreign accent. Clinicians must be aware of the intrinsic risk of prejudice in these situations. Essentially, physicians are bilingual in that they speak ‘everyday language’ and ‘medical language’. Patients, on the other hand, are most conversant and fluent in everyday language.[91] A study examining knowledge of common health terms by physicians, nurses and patients found highest correlation between physicians (70%), and lowest (36%) for patients.[92] The widest discrepancy was found with respect to psychological terms, e.g. depressed, paranoid and confused. Greater discrepancies are expected with non-clinical linguistic differences. The bilingual patient speaking a second language can experience anxiety or pervasive discomfort during clinical presentation.[37] The monolingual clinician must take care not to misinterpret the pauses, sparse words, and emotional preoccupation of the struggling bilingual.[37] Linguistic inaccessibility may actually add to a sense of helplessness in the distressed patient.[93] The clinician’s alertness to non-verbal cues is usually invaluable. 5.3 Translating Language Table III demonstrates the challenge of translation from languages in which subtle inflections in tone can significantly change the meaning of words or phrases. As an exercise, readers are encouraged to substitute each of these meanings in response to the question ‘What is the problem?’ In Chinese, the pronunciation of the character for the number ‘four’ is similar to that of the character for the word ‘death’.[12] Table III. Challenge of translating from Yoruba Yoruba English Ógùn Medicine Ogún Twenty Ògun War Ògún God of iron/war Ogun Inheritance Ōgùn Name of a river Ōgun Sweat Ogun The person was stabbed Ogūn It is long/(s)he is tall Adis Data Information BV 2003. All rights reserved. Although unintentional, this can be distressing for a Chinese patient hospitalized in ‘room 4’ and in some communities health facilities avoid use of this symbol. Arguably, few superstitious people would opt to undergo high-risk surgery on ‘Friday the 13th’ in some Western cultures. 5.4 The Interpreter It is impossible to be fluent in all languages. A common language between clinician and bilingual patient may seem the logical option,[94] but this may abbreviate or hinder free flow of communication. The anxious patient can be even less adept when speaking a second language.[95] As language of assessment impacts on symptom presentation, dual assessments in each of the bilingual patient’s languages have been advocated.[37] However, this may not be practical. Where either clinician or patient lack adequate proficiency in the language of communication, an interpreter is required. The triangular relationship between the patient, interpreter and clinician needs skillful harmonization to maximize verbal and non-verbal communications. This involves task definition, mutual dependence and appreciation,[94] therefore requiring the combined experience of the clinician and the competence of the interpreter (figure 2). Patients may refuse interpreter services because:[94] (i) the interpreter may be from a conflicting ethnic group; (ii) the interpreter may be from the same community as the patient, causing the patient to be anxious about confidentiality; (iii) the patient may feel insulted by questioning of their language skills; or (iv) the patient may want to impress with their ‘command’ of the language. Furthermore, medical and psychological terms can be difficult to translate, particularly scientific or unfamiliar concepts.[96] Translation is the ability to exchange words from one language to another while retaining the meaning. Additional skills are required for interpretation, the transmission of connotative as well as denotative meaning. Working with interpreters is an acquired clinical skill. The clinician should observe experienced clinicians with different interpreters, be comfortable with others speaking an unfamiliar language, empathize with the interpreter, ask translatable questions, seek clarification, educate the patient in translatable terms or contexts, manage mutual dependence in the clinician–interpreter dyad, and recognize incongruity in verbalnon-verbal cues. Good interpreter skills are: • familiarity with general medical and social care systems • sensitivity • general awareness of the physician–patient relationship, e.g. confidentiality Dis Manage Health Outcomes 2003; 11 (4) Cultural Sensitivity in Therapeutic Transactions 243 Clinician spirit, heart nor self are here’ detracts from the implicit meaning ‘I am homesick’. In emergencies it may be necessary to use any translator available. Telephone language services provide translation but may be limited by their impersonal nature and missed non-verbal cues. This can be reduced with the use of video conferencing facilities. 5.5 The Therapist in the Cross-Cultural Dyad Interpreter Patient Verbal and nonverbal communication Non-verbal and para-verbal communication Fig. 2. Working with an interpreter (the triangle of communication). • • • • ability to work as a team member reasonable fluency in both languages literacy in both languages ability to use different interview techniques e.g. facilitation, clarification • awareness of non-verbal communication[97] • skill in asking about issues not common to ordinary conversation, e.g. sexual problems, finances, suicidal intentions • an understanding of the task, its purpose and the means of achieving success. Potential problems with interpretation include: (i) inaccurate translation to and from clinician to patient; (ii) the interpreter may be directive or provide unsolicited editorial input; (iii) the interpreter may lack the corresponding vocabulary in either language; (iv) non-verbal cues may be missed or misunderstood; (v) transference/counter-transference issues may be present in the dyad and triad of communication; (vi) the interpreter may collude with the patient to withhold information, or the patient may withhold taboo or embarrassing information from the interpreter; and (vii) the interpreter may be unacceptable to the patient because of gender or conflicting ethnicity. Effective interpretation requires didactic, culturally aware, and on-the-job training.[94] For instance, fluency in classroom Spanish does not ensure awareness of Hispanic cultural norms or healthrelated behaviors and attitudes. Similarly, a skilled family practice interpreter may experience difficulties in a specialist oncology clinic. There is also the risk of over-interpreting symbolic meanings beyond linguistic translation, hence distorting communication.[17] Literal translation of the Yoruba phrase ‘neither my body, Adis Data Information BV 2003. All rights reserved. Cultural difference between patients and professionals is often inevitable in multicultural societies. Some authors[98] imply that cross-ethnic dyads pose insoluble problems and may even be destructive to clients, while others[99] express the opinion that ‘it is not the race of the clinician but the acknowledgment of race that is crucial to the therapeutic interaction’. Some ethnic organizations advocate that their experience cannot be understood unless the clinician has first-hand experience[100] and some groups argue that ‘if the physician does not share their etiological and pathophysiological model how can he fully understand or relieve the problem?’[17] The selection of clinicians for patients on the basis of the degree of cultural similarity has been advocated as a means of reducing clinician-patient misalliance and cross-cultural difficulties.[100] However, health professionals who share the same ethnicity as a patient may share little with that patient’s culture.[101] Furthermore, the patients may not be ‘typical’ of the cultural norm.[38] Discussions about the clinician-patient relationship across cultures often neglect variables such as previous experience of other cultures, contact with less familiar cultures, and socio-economic status.[100] Other influential factors are the experience and personality of the clinician, their style of information gathering, gender, race and age.[11] Across cultures there may be transference and countertransference issues between the patient and health professional associated with race,[11,102-104] a powerful trigger for the projection of unacceptable impulses. • An alcohol-dependent man seeing an Arab physician confronts him by saying ‘how can you understand me when you are not from a drinking culture?’ Should the therapist’s countertransference feelings match those of the client (‘Do you doubt my competence because I don’t drink?’), frustration and resentment may impair the therapeutic alliance.[105] Nafsiyat, an intercultural psychotherapy center in London, UK, opposed ethnic matching except where issues of language left no option.[106] Critics[107] are of the opinion that such culturally specific services only distance ethnic minorities from the other less culturally specific services. Dis Manage Health Outcomes 2003; 11 (4) 244 Although ethnic pairing is a combination sometimes advocated on the basis that it allows for freer communication, this is not always the case. Differences often emerge within ‘homogeneous’ groups,[11] e.g. the observation that although a large number of Russian refugees to the US are Jewish, they are both ideologically and culturally different from the American Jewish population.[19] Patients from ethnic minorities may attribute differences in quality of care to clinician ethnicity.[108] The matched professional may also be perceived as distant from the street subculture of the group. Furthermore, patients who wish to disclose and discuss acts or events that are taboo within their own culture may refuse to see a therapist from the same ethnic background and culture.[38,101] • A British-born Bangladeshi adolescent girl developed a close alliance with her white therapist, sharing anxieties about traditional gender role issues and her fear of an ‘arranged marriage’.[109]Should the therapist attempt to encourage independence and self-sufficiency in such a patient, this may conflict with cultural norms and so needs to be managed with great sensitivity. A clinician who is of the same ethnic group as the patient may also strongly identify with the patient and collude with, or go to great lengths to support, them.[102] On the other hand, the sameculture therapist ignoring or disrespecting sacred ground may face conflict with patients who might have given ‘diplomatic immunity’ to cross-cultural exchange.[110] • A Yoruba West African health worker in an ‘African dyad’ with an elderly Shona African patient waits to be offered a handshake when introduced, in keeping with Yoruba traditional respect for elders. The older man feels insulted and disrespected by this ‘African’, because in Shona culture the younger party offers his hand as a show of respect to elders. In a US study that evaluated the impact of psychoeducation and culture brokerage across five ethnic communities (African Americans, Bahamians, Cubans, Haitians, and Puerto Ricans), best outcomes were associated with ethnic matching.[111] Another study of Asian clients matched for ethnicity, language, and gender observed that common language or ethnic background between urban clients and therapists increased client sessions with reduced discontinuation rate. However, it had no beneficial effect on the eventual outcome.[112] Other research indicates that persons of color in race-concordant dyads participated more in their medical care than dissimilar dyads.[113] It has been argued, though, that it is actually the clinicians’ collaborative style that actually facilitates Black client satisfaction with treatment.[114] On the other hand, good outcomes have been reported in other inter-cultural services.[106] The lack of consistency in research findings highlights the complexity of these transactions,[115,116] further complicated by racial bias in the recommendations of some studies.[99] Adis Data Information BV 2003. All rights reserved. Ayonrinde Canadian researchers found inhibition and activation of stereotypes depending on the desirability of outcomes. Hence the Black physician was viewed as ‘a physician’ when the outcome was positive and ‘Black’ when adverse.[108] Problems of studies of therapy across cultures[117] include inadequate randomization of the race/ethnicity of clients and therapists, inadequate appreciation that treatment seekers may not be representative of the cultural group and the role of variables such as gender, social class, and age. Outcome measures may also lack cross-cultural validity. 5.6 ‘Color Blindness’ ‘Color blindness’ has been described as the illusion of sameness of cultures.[99] Core problems of such approaches are that: (i) they disregard the central importance of the client’s ethnicity/ culture; (ii) they ignore the impact of the therapist’s culture on the patient; and (iii) they abstract the patient from the social realities of their experiences as a member of the group, e.g. ChineseAmerican. In claiming that all patients are the same, we take away any special differences they may have. Importantly, these differences are essential for sense of identity and self esteem. As Davids wrote, “… we are very susceptible to persuasion that ‘differences don’t matter’ … and have no psychological meaning on our professional work. We spare ourselves a painful struggle … however, in so doing we undermine our therapeutic efficacy.”[118] While ethnic matching may enhance some transactions, it may prove problematic in others. Awareness of these complex issues enhances sensitivity in same or cross-cultural dyads. 6. Culture, Ethnicity and Pharmacotherapies Although there are widespread differences in pharmacological practices across geo-cultural boundaries, the general consensus is that they are efficacious in patients of diverse ethnic and cultural backgrounds. Physical treatments, such as oral and parenteral medication and surgery, carry different symbolic representations to individuals based on past experience and culture. Illness models, which include physical causations, may be more amenable to the acceptance of physical treatments to alleviate symptoms. On the contrary, where patient and therapist have different belief systems,[119] difficulties may be experienced. Allowance should therefore be made for ‘holistic’ care, with a non-critical stance, particularly if there is minimal risk of adverse effects (e.g. sacrifices or rituals).[120] Researchers[121] have reported racial differences in community patterns and preferences of over-the-counter medications, nutritional supplements, and psychotropic, gastrointestinal, and analgesic medications. In this US study, African Americans were less Dis Manage Health Outcomes 2003; 11 (4) Cultural Sensitivity in Therapeutic Transactions likely to use medication than were Whites. However, the strongest predictor was health insurance status and use of health services, with only 6% of the variance associated with race.[121] Trends in the use of complementary therapies highlight the growth in popularity of alternative therapies. The wide variety, availability, and indications for herbal remedies (e.g. St John’s Wort and ginseng) and their complementary use with other medication is often neglected in clinical practice. However adverse effects and interactions, such as hypotension and depression secondary to amine depletion with Rauwolfia serpentina or unfamiliar dietary composition and the use of monoamine oxidase inhibitors, pose a significant risk. It is good practice to enquire if other remedies (traditional or over the counter) are being used concomitantly and caution on the risk of interaction. Recent advances in pharmacogenetics, pharmacokinetics (determining bioavailability to target organs) and pharmacodynamics (determining response to agent) have revealed mechanisms that may explain variations in responses, doses and adverse effect profiles across ethnic groups.[122-124] This ethnic and genetic diversity probably reflects adaptation to the metabolism of different substances by different groups. For instance, genetic differences in the cytochrome P450 isoenzymes CYP2D6 and CYP2C19 are reflected in the metabolism of hypnosedative, antidepressant and antipsychotic agents in Asian, African and Caucasian groups[125] as the distribution of alleles varies substantially. In addition, ethnic variations in body size and distribution of fat and fluid have been observed to impact on the conjugation, plasma protein binding, enzyme induction, and distribution of drugs;[124] for example, Black Africans have higher red cell/serum lithium ratios than Caucasians, and hence a greater risk of CNS-related adverse effects.[125] On the whole, variations in metabolism best explain differences in response across groups.[126] Cultural differences in diet and lifestyle also influence metabolism e.g. induction of the isoenzyme CYP1A2 by eating cabbage, charbroiled beef or smoking tobacco. A high protein diet accelerates the metabolism of theophylline, whereas a carbohydrate diet reduces this. It is worth noting that significant dietary changes following migration may affect therapeutic response to medication. Although acknowledging the role of pharmacotherapy, it has been suggested that sociocultural transactions and contextual issues may actually play a more important role than pharmacodynamics and pharmacokinetics in determining medication prescription and compliance.[126] The accessibility of medication across national and cultural regions is influenced by availability, cost, licensing, prescribing practice, marketing, and political factors. Invariably, restricted treatment options affect health outcomes. Client expectations or Adis Data Information BV 2003. All rights reserved. 245 therapist characteristics may result in a placebo effect or even treatment failure in a number of patients. Compliance or treatment adherence can be compromised by differences in illness beliefs, inadequate explanation, or lack of understanding of the rationale for the treatment. Sometimes treatment interventions are against the patient’s spiritual or cultural beliefs e.g. blood transfusion to a Jehovah’s Witness. • A Muslim man with insulin-dependent diabetes mellitus had been compliant with treatment and monitoring of his blood sugar over 10 years. On reading the fine print of the drug information leaflet, a family member realizes it is a pork insulin preparation. The man stops use of all his medication with ensuing metabolic derangement. He also describes feeling poisoned and rendered impure by health professionals. He became depressed but emphatically refused all forms of formal medical intervention. In Islamic faith pork is ‘haram’ (forbidden). The implications for a Muslim of daily injections of a pig extract are significant. The clinician had not been aware of this and had also not discussed the type of insulin with the patient. 7. Organizational Sensitivity As with the individual therapist, health services should be culturally sensitive to the needs of their clients by implementing appropriate and relevant structures and policies. Organizations may be subject to governmental, political, care system, policy, staffing, and financial influences, to mention but a few. This macro-interplay impacts on the cross-cultural consultation with marked variability. Ultimately, services should be tailored to demographic characteristics, epidemiology, and the needs of individual clients. Lessons can be learnt from other service models, but the cultural relevance of health programs is dependent on their specificity and not their generalization.[109] Service models should therefore meet the demographic and epidemiological needs of the area provided for. This multidimensional and dynamic process incorporates both objective and subjective assessment of cultural realities.[109] It is worth noting that health resources exist in individual cultures which, if not preserved, may destabilize some members of these groups. 8. Outcomes There are wide cultural differences on what constitutes ‘good medical care’. At times, patient expectations may be completely divergent from those of the healthcare provider. This understandably influences subjective and objective perception of health outcomes. Good outcomes from the perspective of cross-cultural communicative behaviors are patient satisfaction, compliance, and understanding of information. However, these do not necessarily Dis Manage Health Outcomes 2003; 11 (4) 246 Ayonrinde result in improved health or reduction in morbidity. Lifestyle, care options, and support systems also influence disease risk and health outcomes. On the whole, there is a dearth of empirical data on the impact of culture on outcomes relevant to the physician–patient relationship.[127] It is recognized, though, that positive physician–patient relationships can have important consequences for physical health outcomes, whereas patient dissatisfaction is associated with higher psychological morbidity (depression and anxiety). Cultural sensitivity reduces this dissonance in therapeutic transactions. 9. Conclusion Neither physicians nor patients are homogeneous groups. There is great diversity between patients and physicians within and across cultures. The interplay of world views, culture, and individual traits influences the physician–patient dyad in the care of different diseases. Cross-cultural clinical transactions are commonplace.[128] Cultural sensitivity involves a balanced awareness of both patient and treatment cultures. Successful negotiation of these interactions improves patient information, compliance and satisfaction with services, with significant consequences for physical and psychological health outcomes. The inculcation of cultural awareness, sensitivity, and competence in the training and practice of clinicians cannot be overemphasized. Acknowledgements The author had no sources of funding or conflicts of interest directly relevant to the content of this review. He would like to acknowledge Dr Akolawole Ayonrinde for his comments on the original manuscript. References 1. McGoldrick M, Giodarno J, Pearce B. Ethnicity and family therapy. 2nd ed. New York: Guilford Press, 1996 2. Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med 1978; 88: 251-8 3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington, DC: American Psychiatric Association, 2000 4. CG Helman. Cross-cultural psychiatry. In: CG Helman, editor. Culture, health and illness: an introduction for health professionals. Oxford: Butterworth-Heinemann Medical, 1994: 246-95 5. Frank JD, Frank JB. Persuasion and healing. 3rd ed. Baltimore (MD): John Hopkins Press, 1991 6. Robinson L. Intercultural communication in a therapeutic setting. In: Coker N, editor. Racism in medicine: an agenda for change. London: Kings Fund, 2001: 191-210 7. Goldstein MZ, Griswold K. Cultural sensitivity and aging. Psychiatr Serv 1998; 49 (6): 769-71 8. Green RJ. Race and the field of family therapy. In: McGoldrick M, editor. Revisioning family therapy: race, culture, and gender in clinical practice. New York: Guilford, 1998: 93-110 9. Prince R. The Brain Fag Syndrome in Nigerian students. J Mental Sci 1960; 106: 599-70 Adis Data Information BV 2003. All rights reserved. 10. Nichols MP, Schwartz RC. Family therapy: concepts and methods. 4th ed. Boston: Allyn & Bacon, 1998 11. Ayonrinde O. Black, white or shades of grey: the challenges of ethnic difference (or similarity) in the therapeutic process. Int Rev Psychiatry 1999; 11: 191-6 12. Galanti G. An introduction to cultural differences. West J Med 2000; 172 (5): 335-6 13. Dyche L, Zayas LH. The value of curiosity and naivete for the cross-cultural psychotherapist. Fam Process 1995; 34: 389-99 14. Hinton P. The psychology of interpersonal perception. London; Routledge, 1993 15. Bowler I. They’re not just the same as us: midwive’s stereotypes of South Asian descent maternity patients. Sociol Health Illn 1993; 15 (2): 157-78 16. Lin K, Inui TS, Kleinman A, et al. Sociocultural determinants of the help-seeking behavior of patients with mental illness. J Nerv Ment Dis 1982; 170: 78-85 17. Yazar J, Littlewood R. Against over-interpretation: the understanding of pain amongst Turkish and Kurdish speakers in London. Int J Soc Psychiatry 2001; 47 (2): 20-33 18. Burnett R, Mallett R, Bhugra D, et al. The first contact of patients with schizophrenia with psychiatric services: social factors and pathways to care in a multiethnic population. Psychol Med 1999; 29 (2): 475-83 19. Chow JC, Jaffee KD, Choi DY. Use of public mental health services by Russian refugees. Psychiatr Serv 1999 Jul; 50 (7): 936-40 20. Lin K-M, Cheung F. Mental health issues for Asian-Americans. Psychiatr Serv 1999; 50: 774-80 21. Al-Krenauri A. Mental health service utilization among the Arabs in Israel. Social Work Health Care 2002; 35 (1-2): 577-89 22. Phan T, Silove D. The influence of culture on psychiatric assessment: the Vietnamese refugee. Psychiatr Serv 1997; 48: 86-90 23. Lee MM, Lin SS, Wrensch MR, et al. Alternative therapies used by women with breast cancer in four ethnic populations. J Natl Cancer Inst 2000; 92 (1): 42-7 24. Okazaki S. Treatment delay among Asian-American patients with severe mental illness. Am J Orthopsychiatry 2000; 70 (1): 58-64 25. Coker N, editor. Racism in medicine: an agenda for change. London: Kings Fund, 2001 26. Akutsu PD, Snowden LR, Organista KC. Referral patterns in ethnic-specific and mainstream programs for ethnic minorities and whites. J Couns Psychol 1996; 43: 56-64 27. Littlewood R, Lipsedge M. Aliens and alienists: ethnic minorities and psychiatry. London: Routledge, 1997 28. Cooper H, Smaje C, Arber S. Use of health services by children and young people according to ethnicity and social class: secondary analysis of a national survey. BMJ 1998; 317: 1047-51 29. Flaskerud JH, Hu L. Relationship of ethnicity to psychiatric diagnosis. J Nerv Ment Dis 1992; 180: 296-303 30. Borkan JM, Morad M, Shvarts S. Universal health care?. The views of Negev Bedouin Arabs on health services. Health Policy Plan 2000 Jun; 15 (2): 207-16 31. Rashid A, Jagger C. Attitudes to and perceived use of health care services among Asian and non-Asian patients in Leicester. Br J Gen Pract 1992; 42 (358): 197-201 32. Maxwell K, Streetly A, Bevan D. Experiences of hospital care and treatment seeking for pain from sickle cell disease: qualitative study. BMJ 1999; 318: 1585-90 33. Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA 1993; 269: 1537-9 34. Sublette E, Trappler B. Cultural sensitivity training in mental health: treatment of Orthodox Jewish psychiatric inpatients. Int J Soc Psychiatry 2000; 46 (2): 122-34 35. Balabil S, Dolan B. A cross-cultural evaluation of expectations about psychological counselling. Br J Med Psychol 1992; 65: 305-8 36. Harris MI. Racial and ethnic differences in health care access and health outcomes for adults with type 2 diabetes. Diabetes Care 2001; 24 (3): 454-9 37. Perez Foster R. When immigration is trauma: guidelines for the individual and family clinician. Am J Orthopsychiatry 2001; 71 (2): 153-70 38. Khisty K. Transcultural differentiation: a model for therapy with ethno-culturally diverse families. Aust N Z J Fam Ther 2001; 22 (1): 17-24 39. Wali R. Working therapeutically with Indian families within a New Zealand context. Aust N Z J Fam Ther 2001; 22 (1): 10-7 Dis Manage Health Outcomes 2003; 11 (4) Cultural Sensitivity in Therapeutic Transactions 40. Ruiz P. New clinical perspectives in cultural psychiatry. J Pract Psychiatry Behav Health 1998; 4: 150-6 41. Goldberg D, Hodes M. The poison of racism and the self-poisoning of adolescents. J Fam Ther 1992; 14: 51-67 42. Ahmad Y, Woolaston S, Patel S. Child safety in Indian families. Social Work Now 2000; 15 May 13-9 43. Da Canhota CMN, Piterman L. Depressive disorders in elderly Chinese patients in Macau: a comparison of general practitioners’ consultations with a depression screening scale. Aust N Z J Psychiatry 2001; 35: 336-44 44. Hendrie HC, Osuntokun BO, Hall KS, et al. Prevalence of Alzheimer’s disease and dementia in two communities: Nigerian Africans and African Americans. Am J Psychiatry 1995; 152: 1485-92 45. Vaz L, Kanekar S. Predicted and recommended behaviours of a woman as a function of her inferred helplessness in dowry and wife beating predicaments. J Appl Soc Psychol 1990 May; 20: 751-70 46. Hemingway H, Saunders D, Parsons L. Social class, spoken language and pattern of care as determinants of continuity of carer in maternity services in east London. J Public Health Med 1997; 19 (2): 156-61 47. ten Have ML, Bijl RV. Inequalities in mental health and social services utilisation by immigrant women. Eur J Public Health 1999; 9 (1): 45-51 48. McAvoy BR. Contraceptive services for Asian women in the UK: a review. Fam Pract 1990; 7: 60-4 49. Dhami S, Sheikh A. The Muslim family: predicament and promise. West J Med 2000 Nov; 173 (5): 352-6 50. Brooks MH. Beliefs of Orthodox Jewish girls about menstruation. Fam Pract 1984; 1: 113-6 51. Maitra B. In giving due consideration to the family’s racial and cultural background. In: Reder P, Lucey C, editors. Assessment of parenting: London: Routledge, 1995: 151-66 52. McGoldrick M. Ethnicity and the family life cycle. In: Carter B, McGoldrick M, editors. The changing family life cycle. 2nd ed. New York: Guilford Press, 1989: 69-90 53. Cabrera NJ, Tamis-LeMonda CS, Bradley RH, et al. Fatherhood in the twenty-first century. Child Dev 2000; 71 (1): 127-36 54. Di Nicola VF. Family therapy and transcultural psychiatry: an emerging synthesis: II. portability and culture change. Transcultural Psychiatric Res Rev 1985; 22: 151-80 55. Tsui P, Schultz GL. Failure of rapport: why psychotherapeutic engagement fails in the treatment of Asian clients. Am J Orthopsychiatry 1985; 55: 561-9 56. Waldegrave C. Mono-cultural, mono-class and so called non-political family therapy. Aust N Z J Fam Ther 1895; 6 (4): 197-209 57. Omer-Hashi, Kowser H, Entwistle M. Female genital mutilation: cultural and health issues, and their implications for sexuality counselling in Canada. Can J Hum Sex 1995; 4: 137-47 58. Lightfoot-Klein H. Disability in female immigrants with ritually inflicted genital mutilation. Women Ther 1993; 14: 187-94 59. Williams L, Sobieszczyk T. Attitudes surrounding the continuation of female circumcision in the Sudan: passing the tradition to the next generation. J Marriage Fam 1997; 59: 966-81 60. Hartog J, Hartog EA. Cultural aspects of health and illness. West J Med 1983; 139 (6): 910-6 61. Gutmann MC. Ethnicity, alcohol and acculturation. Soc Sci Med 1999; 48 (2): 173-84 62. Simon G, Gater R, Kisely S, et al. Somatic symptoms of distress: an international primary care study. Psychosom Med 1996; 58: 481-8 63. Ebert D, Martus P. Somatization as a core symptom of melancholic type depression: evidence from a cross-cultural study. J Affect Disord 1994; 32: 253-6 64. Marmanidis H, Holme G, Hafner RJ. Depression and somatic symptoms: a crosscultural study. Aust N Z J Psychiatry 1994; 28: 274-8 65. Kleinman AM. Depression, somatization and the ‘new cross-cultural psychiatry. ’ Soc Sci Med 1977; 11: 3-10 66. Kleinman A. Neurasthenia and depression: a study of somatization and culture in China. Cult Med Psychiatry 1982; 6: 117-90 67. Mezzich JE, Raab ES. Depressive symptomatology across the Americas. Arch Gen Psychiatry 1980; 37: 818-23 Adis Data Information BV 2003. All rights reserved. 247 68. Simon GE, VonKorff M, Piccinelli M, et al. An international study of the relation between somatic symptoms and depression. N Engl J Med 1999; 341 (18): 1329-35 69. Ayonrinde A. Heat in the head or body: a semantic confusion. Afr J Psychiatry 1977; 1: 59-63 70. Kirmayer LJ. Three forms of somatization in primary care: prevalence, co-occurrence, and sociodemographic characteristics. J Nerv Ment Dis 1991; 179: 647-55 71. Goldberg DP, Bridges K. Somatic presentations of psychiatric illness in primary care setting. J Psychosom Res 1988; 32: 137-44 72. Lipowski ZJ. Somatization: the experience and communication of psychological distress as somatic symptoms. Psychother Psychosom 1987; 47: 160-7 73. Kroenke K, Spitzer RL, Williams JBW, et al. Physical symptoms in primary care: predictors of psychiatric disorders and functional impairment. Arch Fam Med 1994; 3: 774-9 74. Turk DC, Okifuji A. Assessment of patients’ reporting of pain: an integrated perspective. Lancet 1999; 353: 1784-93 75. Lin TY. Mental disorders and psychiatry in Chinese culture: characteristic features and major issues. In: Tseng WS, Wu DYH, editors. Chinese culture and mental health. Macau: Academic Press, 1985: 369-93 76. Chaitchik S, Kreitler S, Shaked S, et al. Doctor-patient communication in a cancer ward. J Cancer Educ 1992; 7: 41-54 77. Ong LML, De Haes JCJM, Hoos AM, et al. Doctor-patient communication: a review of the literature. Soc Sci Med 1995; 40 (7): 903-18 78. DiMatteo MR, Taranta A, Friedman HS, et al. Predicting patient satisfaction from physicians non-verbal communication skills. Med Care 1980; 28: 376-87 79. Smith RC, Hoppe RB. The patient’s story: integrating the patient and physiciancentered approaches to interviewing. Ann Intern Med 1991; 115: 470-7 80. Holland JC, Geary N, Marchini A, et al. An international survey of physician attitudes and practice in regard to revealing the diagnosis of cancer. Cancer Invest 1987; 5 (2): 151-4 81. Street RL. Information-giving in medical consultations: the influence of patients’ communicative styles and personal characteristics. Soc Sci Med 1991; 32: 541-8 82. Waitzkin H. Doctor-patient communication: clinical implications of social scientific research. JAMA 1984; 252: 2441-6 83. Ayonrinde OA. Patients in cyberspace: information or confusion?. [editorial]. Postgrad Med J 1998; 74: 449-50 84. Greenhalgh T, Helman C, Chowdhury AM. Health beliefs and folk models of diabetes in British Bangladeshis: a qualitative study. BMJ 1998; 316: 978-838 85. Ong LML, De Haes JCJM, Hoos AM, et al. Doctor-Patient Communication: a review of the literature. Soc Sci Med 1995; 40 (7): 903-18 86. Smith CK, Polis E, Hadac RR. Characteristics of the initial medical interview associated with patient satisfaction and understanding. J Fam Pract 1981; 12: 283-8 87. Larsen KM, Smith CK. Assessment of non-verbal communication in the patientphysician interview. J Fam Pract 1981; 12: 481-8 88. Odejide AO, Olatawura MO, Sanda AP, et al. Traditional healers and mental illness in the city of Ibadan. J Black Stud 1977; 9: 195-205 89. Parrott R, Burgoon JK, Burgoon M, et al. Privacy between physicians and patients: more than a matter of confidentiality. Soc Sci Med 1989; 29: 1381-5 90. Bhugra D, Ayonrinde OA. Racial life events and psychiatric morbidity. In: Bhugra D, Cochrane R, editors . Psychiatry in multicultural Britain. London: Gaskell, 2001: 91-111 91. Bourhis RY, Roth S, MacQueen G. Communication in the hospital setting: a survey of medical and everyday language use amongst patients, nurses, ad doctors. Soc Sci Med 1989; 28: 339-46 92. Hadlow J, Pitts M. The understanding of common health terms by doctors, nurses and patients. Soc Sci Med 1991, 6 93. Javier RA, Alpert M. Re effect of stress on the linguistic generalisation of bilingual individuals. J Psycholinguistic Res 1986; 15 (5): 419-35 94. Westmeyer J. Working with an interpreter in psychiatric assessment and treatment. J Nerv Ment Dis 1990; 178: 745-9 95. Nicassio PM, Solomon GS, Guest SS, et al. Emigration stress and language proficiency as correlates of depression in a sample of Southeast Asian refugees. Int J Soc Psychiatry 1986; 32: 22-8 Dis Manage Health Outcomes 2003; 11 (4) 248 96. Berkanovic E. The effect of inadequate language translation on Hispanics’ responses to health surveys. Am J Public Health 1980; 70: 1273-6 Ayonrinde 116. Snowden L, Hu T, Jerrell J. Emergency care avoidance: ethnic matching and participation in minority-serving programs. Community Ment Health J 1995; 31: 463-73 97. Uchigama K, Lutterjohn M, Shah MD. Crosscultural differences in frontalis muscle tension levels: an exploratory study comparing Japanese and Westerners. Biofeedback Self Regul 1981; 6: 75-8 117. Sue S. Psychotherapeutic services for ethnic minorities. Am Psychol 1988; 43: 301-8 98. Dalal FN. Race and racism: an attempt to organize difference: group analysis. Vo;. 26. London: Sage, 1993 118. Davids F. Two accounts of the management of racial difference in psychotherapy. J Social Work Pract 1988; 2: 40-51 99. Liggan DY, Kay J. Race in the room: issues in the dynamic psychotherapy of African Americans. Transcultural Psychiatry 1999; 36 (2): 195-209 119. Slattery G. Transcultural therapy with aboriginal families: working with the belief system. Aust N Z J Fam Ther 1987; 8 (2): 61-70 100. Bhugra D, Bhui K. Clinical management of patients across cultures. Adv Psychiatr Treat 1997; 3: 233-9 101. Bhui K, Bhugra D. Cross-cultural competencies in the psychiatric assessment. Br J Hosp Med 1997; 57 (10): 492-6 120. Baker FM, Bell CC. Issues in the psychiatric treatment of African Americans. Psychiatr Serv 1999; 50: 362-8 121. Hanlon J, Fillenbaum G, Burchett B, et al. Drug use patterns in black and nonblack community dwelling elderly. Ann Pharmacother 1992; 26: 679-85 102. Holmes DE. Race and transference in psychoanalysis and psychotherapy. Int J Psychoanalysis 1992; 73: 1-11 122. Kalow W. Race and therapeutic drug response. N Engl J Med 1989; 320: 588-9 103. Comas-Diaz L, Jacobsen FM. Ethnocultural transference and countertransference in the therapeutic dyad. Am J Orthopsychiatry 1991; 61: 392-402 123. Kalow W. Pharmacogenetics: its biological roots and the medical challenge. Clin Pharmacol Ther 1993; 54: 235-41 104. Tan R. Racism and similarity: paranoid-schizoid structures. Br J Psychother 1993; 10: 33-43 124. Wood A, Zhou H. Ethnic differences in drug deposition and responsiveness. Clin Pharmacokinet 1991; 20: 1-24 105. Coll X. Importance of acknowledging racial and cultural differences. Psychiatr Bull 1998; 22: 370-2 125. Strickland T, Ranganath V, Lin K, et al. Psychopharmacologic considerations in the treatment of Black American populations. Psychopharmacol Bull 1991; 27: 441-8 106. Kareem J, Littlewood R. Intercultural therapy: theory and practice. Oxford: Blackwell, 1992 107. Gordon P. Keeping therapy white? Psychotherapy training and equal opportunities. Br J Psychother 1993; 10: 44-9 108. Sinclair L, Kunda Z. Reactions to a black professional: motivated inhibition and activation of conflicting stereotypes. J Pers Soc Psychol 1999; 77 (5): 885-904 109. Barrio C. The cultural relevance of community support programmes. Psychiatr Serv 2000; 51 (7): 879-84 126. Lin KM, Smith MW, Onitz V. Culture and psychopharmacology. Psychiatr Clin North Am 2001; 24 (3): 523-38 127. Comas-Diaz L. The future of psychotherapy with ethnic minorities. Psychotherapy 1992; 29: 88-94 128. Lopez SR. Cultural competence in psychotherapy: a guide for clinicians and their supervisors. In: Watkins CZ, editor. Handbook of psychotherapy supervision. New York: Wiley, 1997: 570-88 110. Lappin J. On becoming a culturally conscious family therapist. In: Hansen JC, editor. Cultural perspectives in family therapy. London: Aspen, 1983: 51-67 111. Lefley HP, Bestman EW. Public-academic linkages for culturally sensitive community mental health. Community Ment Health J 1991; 27: 473-88 112. Flaskerud JH, Lui PY. Influence of the therapists’ ethnicity and language on therapy outcomes of southeast Asian clients. Int J Soc Psychiatry 1990/1991; 36: 18-29 113. Cooper-Patrick L, Gallo J, Gonzales JJ, et al. Race, gender and partnership in the patient-physician relationship. JAMA 1999; 282: 583-9 114. Comas-Diaz L. Building a multicultural private practice. Independent Pract 2001; 21 (4): 220-3 115. LaFromboise TD, Trimble JE, Mohatt GV. Counseling intervention and American Indian tradition: an integrative approach. Couns Psychol 1990; 18: 628-54 Adis Data Information BV 2003. All rights reserved. About the Author: Dr Ayonrinde is a Consultant Psychiatrist with the South London and Maudsley National Health Service Trust in the UK. He has clinical responsibility for an adult psychiatric service as well as a regional psychosexual clinic. His research and academic affiliation is with the Cultural Psychiatry Section of the Institute of Psychiatry in London and his interests are in health services research, cross-cultural aspects of mental health, migration and mood disorders. Correspondence and offprints: Dr Oyedeji Ayonrinde, Maudsley Hospital, London, Denmark Hill, London, SE5 8AZ, UK. E-mail: [email protected] Dis Manage Health Outcomes 2003; 11 (4)