The Telepsychiatry Advantage: Episode 20

Lost In Translation: How Culture Shapes Mental Health In Telepsychiatry

 

Cultural Nuances In Patient Reporting

Let me tell you a story. I had a patient who was Mexican American. When I asked her, “How are you doing?” she would say, “Muy bien, muy bien,” which means very good, very good. But then when I started asking her more specific questions about what was going on in her life, I discovered that things weren’t going so well at all.

Things were going real bad. I mean, not to get into specifics, but we’re talking about severe trauma. And she was going through one of the most difficult times in her life. But I had to ask a lot of questions—open-ended questions and specific questions as well—to get to the bottom of that, because when I first asked her how she was doing, she would minimize and say “muy bien.”

And she wasn’t the only one who would do that. I noticed that people of Mexican American background more often than other backgrounds would minimize. I don’t want to sit here and say that they all do that, but I’ve noticed more of a tendency to say everything’s okay when things are not okay. And what does that mean?

In some Latino cultures, there is an emphasis on being pleasant, agreeable, avoiding friction, and kind of going along with things. That concept is called simpatía. That means they might say things are okay when things are not okay. In these cultures, I’ve noticed that there is a tendency to want to really respect the doctor, defer to the doctor, and go along with things. That is a term called respeto. So they may say that they’re taking their medications when they’re not, and they may be saying that because they don’t want to appear disrespectful to the doctor or appear that they’re not following the doctor’s orders.

Stigma may be part of this as well. They may feel shame about their mental illness more so than in other cultures. Honestly, what I’ve noticed in Caucasian culture these days is there is less stigma than in some other cultures, and people are much more open, on average, to talk about their mental illness. You are seeing these days people openly discussing their mental illness online, like posting on social media. For example, people like Lady Gaga talk about PTSD, depression, anxiety, and the trauma she’s experienced. Dwayne “The Rock” Johnson has talked about his depression, Ryan Reynolds about his anxiety, and Michael Phelps is an example of somebody who’s talked extensively about his depression, suicidal thoughts, and substance use. So I think that there is a gap between certain cultures in terms of their tendency to be open or discuss their mental illness, and what I’ve found is in Latino cultures, they may be less open about it.

This can actually be gender-specific as well. In Latino men, there’s this idea of machismo, where the expectation is that they’re strong, in control, providers, and not weak. This is something that you should think about: Is your patient being open about their mental illness, and is there a cultural element to that? As psychiatrists and mental health providers, we may misinterpret a lot of things because of cultural reasons—like eye contact, the way that they communicate with us, their interactions with family members, or how they describe their symptoms. All of this stuff can be different depending on the culture.

In today’s episode, we’re going to talk about how to approach culture on camera, what kind of questions to ask, what you shouldn’t assume, and how we make an effort to better understand our patient and the cultural factors that are making them present a certain way.

Observing the Home Environment via Telehealth

Let’s start with one of the advantages that I’ve talked about several times in past episodes: an advantage of telepsychiatry is that you can see the patient’s environment, and oftentimes that’s their home. That is rich with information about their culture. Take a look at the background and see: Are there family photos or religious objects? Are there several generations of family living in the same home? Pay attention as much as you can to the environment, because that could give you cultural clues.

But you need to be careful about how you interpret the information. For example, if in the background you notice that they are in a house with many family members (multigenerational), you might assume that the patient doesn’t have any privacy and that this is a problem. But it may or may not be a problem; it might be completely normal to live with lots of people in the same house. I’ve had patients who I know sleep in the same bedroom as their parents, or multiple people sleeping in the same bed. That is something that may actually be normal for certain cultures, so how you interpret that needs to be sophisticated.

What you want to do is observe and ask questions—don’t assume anything. If you see things in the background that have a religious significance potentially, ask the patient: “Are there any spiritual or religious things that are important to you that would be helpful for me to understand?” You might get them to open up about things that you would not have gotten in a regular office because you wouldn’t have the opportunity to see the background.

And maybe the background has nothing to do with them. Maybe it’s somebody else’s room in the house, and the things in the background don’t really reflect any of the values of the patient. We also have to understand, especially in younger patients, that maybe they don’t share the same values as their parents. Maybe they are the first generation that was born in America, and they identify more with American values than the values of their parents. So that’s something to consider as well.

Family Dynamics and Gender Roles on Camera

Another thing to consider is who is in the room with the patient and what that means from a cultural standpoint. For example, in Latino or Hispanic families, there may be involvement from parents, spouses, or adult children. There may be an expectation that they’re going to be involved in the healthcare decisions, and the patient may not want to discuss serious problems without a family member present. But it could actually go the other way, where there is a reluctance to involve family members out of a sense of shame. So it can be kind of complicated trying to understand the cultural aspects of how the patient involves family members or doesn’t involve them, and it can be contradictory. That’s why you should pay attention and ask some questions about that.

In Asian cultures, there may be a tendency for children to defer to a parent about discussing treatment options and even how they feel. Sometimes you might ask the patient, and then the parent answers, but you don’t actually know what the patient thinks, and the patient may withhold that information. So maybe you need to ask the patient directly without the parent being there to see if there is an actual difference in how the patient feels about the situation.

Gender can actually make a difference as well. In some cultures, the expectation is that the man, like the father, is going to make the major decisions. Therefore, if you have a female patient who’s a child sitting there, they may not feel like they can express themselves because the father is doing most of the talking, and you may get a skewed impression about what’s happening with the female patient.

Nonverbal Cues Across Cultures

The next thing that I want you to consider is eye contact, facial expression, and body language when dealing with cultural differences. As psychiatrists, we’re constantly watching the patient’s behavior. We’re seeing if they’re maintaining good eye contact, their affect, their posture, their gestures and mannerisms, and how animated somebody is. All of that tends to be really useful information that we’re trying to pay attention to, but the problem is that these behaviors don’t necessarily mean the same thing across cultures.

For example, in Western settings, particularly in the United States, we are taught to maintain eye contact as a form of respect and engagement. If you maintain eye contact, that shows that you’re being honest, confident, and not looking away. But that does not necessarily hold in other cultures. Prolonged avoidance of eye contact by a Western patient can be interpreted by the psychiatrist as evidence of anxiety, depression, social discomfort, guardedness, or evasiveness. But that doesn’t mean the same thing in other cultures. In certain East Asian cultures, for example, prolonged eye contact can actually be very uncomfortable and can be a sign of disrespect toward an authority figure.

Facial expression is another example of how cultures can differ in presentation. In some East Asian cultures, like in Japan and China, emotional restraint is socially valued. Someone experiencing significant distress may still maintain a neutral facial expression. So if someone has a flat or restrained presentation, you shouldn’t automatically interpret that as depression or another mental health problem; it could be their cultural values.

In certain cultures, such as in Thai culture, smiling may actually signify embarrassment, discomfort, or social tension. The opposite is true as well: if the patient is smiling, does that mean that they’re happy? Maybe not; maybe they’re uncomfortable.

In certain Mediterranean cultures, communication can be much more animated. If somebody is really animated, a psychiatrist may think they’re agitated or overly emotional with a big, expressive personality. But that could just be a cultural norm. Some Middle Eastern and Mediterranean cultures value greater emotional expression, which may have nothing to do with mental illness. If you understand what the culture values, then if the patient is doing the opposite of what their culture expects, that could be a sign of a problem.

And now, a quick word from Orbit Health. Orbit Health is a telepsychiatry company that provides services to California County Behavioral Health. If you’re a psychiatrist interested in working with a company that will support you and put you in the best position to succeed, there’s no better choice than Orbit Health. If you want to learn more, go to Orbit Health. Thanks.

Communication Styles and Technology Delays

The next thing to consider is the significance of the patient’s communication style. For example, if they are really silent, just nod, or don’t say anything, that could be influenced by their culture. In a lot of Western countries like the United States, Canada, European countries like Germany and the Netherlands, or places like Australia and New Zealand, patients may communicate with a more direct style. They will more likely tell you exactly how they feel.

In contrast, East Asian cultures (like Japan, South Korea, and China) or South Asian cultures (like India) may not communicate as directly. The context of the situation really helps you understand what the patient is going through because they may not directly tell you. A patient from Japan, for example, may be reluctant to tell you directly that they disagree with your recommendation or are unwilling to take medication. They may find other ways to communicate that you need to pay attention to.

Let me give you an example: I was seeing a patient from Japan, and when I was talking about my treatment recommendations for his depression, he didn’t tell me directly that he didn’t want to take the medication. It was more like, “Well, I’ll think about it. I’ll talk with my family”—seemingly reluctant, but never directly saying he was unwilling. What I noticed was the patient didn’t get his prescription filled. It was only after several appointments that I was able to get to the bottom of it, but I should have recognized his indirect reluctance sooner.

What about long pauses? Sometimes we think of long pauses as a mental health symptom—for example, thought blocking, anxiety, or even a sign of psychosis. But in some East Asian cultures, a long pause is comfortable and normal in conversation. In contrast, in Western, Mediterranean, or some Latin American cultures, there may be a tendency to overlap in conversation, speaking right after or slightly over you, which can be completely normal depending on the cultural context. But you have to differentiate that from mania or agitation.

Also, keep in mind that a pause might have nothing to do with either culture or mental health status; it could be the technology. There can be a delay in the Wi-Fi signal causing a lag, which makes it look like the patient has a delay in their speech or thinking.

Cultural Manifestations of Symptoms and Belief Systems

Now let’s get to how different cultures express psychiatric symptoms. In one culture, depression may manifest itself with sadness, hopelessness, and anhedonia (“I don’t enjoy doing anything anymore”). In another culture, they may not tell you any of that; they may just report headaches, fatigue, stomach problems, or dizziness—somatic complaints.

Culture makes a big difference in how symptoms present. In Latino culture, if you hear a patient talk about nervios, it could mean excessive anxiety, feeling overwhelmed, or psychological distress, or it could even mean they are experiencing trauma or depression. There’s also the term susto, which refers to symptoms resulting from a severe, frightening, or traumatic event where a person feels they have “lost their spirit.”

In East Asian cultures, depression and anxiety frequently present as somatic complaints like fatigue, headaches, and dizziness. Primary care physicians seeing patients with these complaints should ask directly about mood and stress rather than assuming it’s purely a medical issue.

It can get very specific: in Cambodia, there is kyol goeu (a “wind attack”), which involves dizziness, palpitations, and shortness of breath, attributed to a disruption of the wind in the body. In some cultures, distress may relate heavily to social relationships, community, or spirituality rather than an isolated psychiatric disorder.

When you see a patient from a culture you’re not familiar with, remember that they may present differently than what the DSM describes.

Regarding religion and spirituality: if a patient tells you they saw a ghost, that may not necessarily be a hallucination or delusion if they come from a culture with a strong belief in ghosts. When patients report hallucinations, ask whether this is consistent with their religious or spiritual beliefs rather than immediately assuming it’s a psychotic disorder requiring antipsychotics.

The way a patient describes hearing voices matters too. If they hear the voice of God, in some cultures that is a normal spiritual experience. The most helpful clinical marker is a change from baseline alongside social and occupational dysfunction. If the patient is at their baseline and has no social or occupational dysfunction, hearing a spiritual voice may not be psychopathology. But if someone without those cultural beliefs suddenly believes God is speaking to them, claims to be a prophet or Jesus, experiences a marked change from baseline, and suffers functional impairment, they may be in the middle of a manic or psychotic episode.

Your job is not to judge the patient’s belief system; your job is to understand their experience and determine whether it falls outside of their cultural norms to the degree of psychopathology.

Risk Assessment, Language, and Avoiding Stereotypes

Culture also impacts suicide risk assessment. In some cultures, patients may be reluctant to disclose thoughts of suicide or self-harm and prefer to keep them concealed, whereas others are more expressive.

Cultural attitudes toward suicide vary significantly. In some cultures, suicide might historically be viewed as an honorable act under certain circumstances. We want patients to understand that suicide is not the answer, but in cultures where suicide is viewed differently, we may need a higher index of suspicion to properly assess risk.

Gender dynamics and power structures also vary. In some cultures, women have significant independence to advocate for themselves; in others, advocating for oneself is discouraged. If a female patient is not speaking up or advocating for herself, it may be a cultural dynamic, and you need to figure out how to advocate for her interests effectively.

When working with interpreters, remember that language is more than literal translation. Words may carry different cultural meanings than what the direct translation suggests (like nervios). Always look at and speak directly to the patient, not the interpreter. Let the interpreter translate, and ask for their context if a phrase doesn’t translate cleanly, but maintain your role as the clinician.

Avoid stereotyping. While cultures have general patterns of expression, individuals within a culture vary widely. Culture provides context, not a definitive diagnosis.

Super-communicators excel at asking thoughtful questions to understand the patient rather than making assumptions or telling them what to feel.

The Cultural Toolkit: 10 Key Takeaways

1. Observe before interpreting: Pay attention to facial expressions, communication style, and background environment.
2. Culture should generate questions, not conclusions: Do not assume how a patient will behave based solely on their background.
3. Ask what the behavior means to the patient: Determine if the behavior is a problem or out of the ordinary for them.
4. Don’t assume agreement means compliance: A patient saying “yes” out of respect (respeto) may not mean they intend to follow the recommendation.
5. Don’t assume silence means pathology: Long pauses or silence may be a cultural norm or a technological delay.
6. Identify who is in the room: Understand who is present, their relationship to the patient, and the family’s decision-making dynamics.
7. Ask how the patient and family understand the illness: Explore their framework for what is happening.
8. Distinguish cultural/religious beliefs from psychopathology: Look for a change from baseline and social or occupational dysfunction.
9. Use interpreters appropriately: Speak directly to the patient and recognize that literal translations may miss cultural nuances.
10. Never let a cultural formulation replace a psychiatric assessment: Treat the individual, not just the culture.

Don’t assume that something unfamiliar is automatically psychopathology, and don’t assume that a patient who appears okay on the surface is actually doing fine. Always seek to understand what culture means to your specific patient.

Thank you for joining me. Until next time, keep raising the standard.

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