Incorporating cultural issues

Postindustrial societies are ethnically diverse. Clinicians have the opportunity to regard each patient as an informant from a culture that is, in some way, foreign. The physician's curiosity about each patient's beliefs and background will be rewarded with more information about the patient's culturally influenced explanatory models of illness.(45) It is a mistake to assume that all members of a culture hold the same belief. Recent immigrants often hold beliefs different from their children. On the other hand, some generalizations may apply. In several American studies, for example, different cultural groups had vastly different responses to pain. Italian-Americans were most concerned with the immediate experience of pain, Jewish-Americans were concerned more about the meaning or prognosis implied by the painful state; both considered it dangerous not to report pain. (46> In contrast, 'old Americans' (of English descent) are expected to be more stoical in response to pain. Knowledge of Asian cultures' expectations of stoicism may be useful, for example, to the clinician caring for an 'emotionally flat' Laotian woman recovering from breast cancer surgery.

In Chinese culture, exposure to wind is thought to be harmful.(47) Disorders of a specific organ system may carry complex meanings and fear for members of a particular culture; patients fear 'heart distress' in Iranian culture, (48> and Puerto Ricans are fearful of loss of even small amounts of blood. Chinese patients will often report somatic symptoms rather than psychological ones due to the stigma that psychological distress places on the patient as well as the family. (49> Peptic ulcer disease may carry positive connotations in Japan, where it is seen as a sign of diligence and hard work. In Mediterranean cultures, it is considered healthy to express emotions, and some illnesses are attributed to 'not having cried enough' after a loss. Antidepressant or anxiolytic treatment in such cases can be counterproductive.

Patients from different ethnic groups place different emphasis on the role of the family in medical decision making. Northern European cultures value individual autonomy; many of the ethical principles are based on an individual patient-physician relationship without considering the influence of the family. Conversely, some

Mediterranean/50) Latino, and Asian(51) cultures use a family-centred model of decision making, including a preference to inform the family, not the patient, of his or her diagnosis and/or prognosis. These models of medical decision making are of paramount importance in mental health care, as family involvement and support of a treatment plan can make the difference between success and failure. In addition, traditional healers can play an important and adaptive role in the healing process if the clinician can maintain an open mind.

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