Overcoming language, cultural barriers when treating the foreign-born patient
As populations are becoming more diverse, increasing numbers of foreign-born patients are entering psychiatric practices and emergency services.
At the same time, clinicians are having trouble navigating cultural roadblocks to treatment. Little research has been done in treating the foreign-born patient, and few studies exist to guide us in the standard of care.1,2 The following three hurdles are common when examining the foreign-born patient:
- Language. Many immigrant patients do not understand medical terminology, and some English terms, such as “depression,” do not translate exactly into other languages. Trying to understand a patient’s own words or hearing a family member or friend try to explain the problem often leads to misinterpretation, or the gravity of the situation may be lost in the translation.
- Fears of “loss of face.” For cultural reasons, the patient may perceive mental disorders as a sign of weakness and is loath to admit that a problem exists.
- Dependence on family. The patient is reluctant to accept help from someone outside the immediate family.
The following advice can help you overcome cultural barriers to treatment:
Learn about the patient’s culture. Picking up on cultural traits can help you gain the patient’s trust.
For example, many Asian people are stoic; they bow profusely as a gesture of respect, yet with minimal affect. In Africa, some tribal members introduce themselves not only with their names but by reciting their entire ancestry. To interrupt this recitation is considered disrespectful. Westerners tend to be bold and more direct, whereas Easterners are more philosophical, vague, and abstract.
Cultural practices can be researched on the Internet. (For example, typing “Asian” and “cultural differences” into a search engine located a “primer” on Japanese culture.) Discussions with the patient’s family may also help.
Take a patient’s request seriously, no matter how frivolous it sounds. Some foreign-born female patients may ask to be assigned to a female clinician in your group or to be referred to another psychiatrist. For example, Islamic women cannot have male therapists because their religion and culture forbid close contact with men without the accompaniment or approval of a male relative. Indian women also have trouble talking to male doctors because of deep-seated cultural restrictions.
Foreign-born patients often do not come forward for help unless their condition becomes desperate. Your sensitivity to issues that seem trivial and far from your own experience may be initially difficult, but your openness enhances and strengthens the therapeutic alliance.
Make sure the patient understands you. Some foreign-born patients may agree with the doctor at all times, mostly because they do not wish to offend someone they hold in high esteem. In contrast, a curt or short response may reveal a guarded attitude or indicate a lack of understanding.
To ensure understanding, get specific answers. If necessary, politely rephrase the question. Be very patient.
Use a qualified interpreter, either a mental health professional or a resident or practicing colleague who speaks the patient’s language.
Qualified interpreters should be professional and precise in relaying your concerns and cautions to the patient. You will need to communicate medication options carefully and to express that you understand the stigma the patient’s culture attaches to mental illness.
Many hospitals today have interpreters available on staff—either volunteers to be called in emergencies or on-call contract personnel.
1. Lam A, Kavanagh D. Help seeking by immigrant Indochinese psychiatric patients in Sydney, Australia. Psychiatr Serv 1996;47(9):993-5.
2. McPhee S. Caring for a 70 year-old Vietnamese woman. JAMA 2002;287(4):495-504.
Dr. Sakhrani is a third-year resident at St. Francis Medical Center, Pittsburgh, Pa.