The Language and Culture of Psychiatry

She was an administrator at the rural branch of a county mental health system. A therapist by training.

On the classical scale in the hallowed paradigms of the twentieth century, a psychiatrist like me who had sacrificed (or in other cases, put on hold or marginalized) her biological destiny — well, a psychiatrist like me would have been the head of the team.  I would have sat at the head of the table with those who had not survived anywhere near as many years of authoritative education silencing each other to hear authoritative pronouncements. But she was the chief, not me.

The place does not much matter, although it is much like many rural agricultural places in California.  Back in the twentieth century based on even the most idealized of media portrayals, I saw California as a hotbed of anti-intellectualism, where one’s appearance in a bikini trumped the old {italics} curriculum vitae {unitalics} in all spheres.

The time does matter.  We were 15% of the way through the 21st century. If the last decade of the twentieth century was —  as some in my field have named it — the “decade of empowerment,” when minorities were being pumped up and made buff and made to exercise their rights, then this was the time of political correctness, when we were all supposed to be duking it out on a very level playing field.

I always leave the door to my office open when I am not engaged with a patient in confidential and sacred goings-on. She walked in.  She had seen one of my patients in the corridor unescorted, she said — a risk to patient confidentiality, the safety of records.  Doctors are supposed to escort their patients to and from the waiting room. I apologized profusely.  Of course, I would escort my patients in the future. I think what happened was that others, seeing I walked with a cane, had tried to protect me from this responsibility.  It mattered little; I walk just fine with my cane, and would profit from a little exercise.

Oh! She added — and had my superior spoken with me about running overtime?  It was not a good idea to spend too much time with patients.  Others would be made to wait, and get angry. Here I must add that the State of California has made it law that a non-doctor may not practice medicine without a license.  This is not only to give the patients the best care, but to keep people (such as administrator) from decreeing how many patients a doctor must see, how much time a doctor can spend with a patient, and what treatments the doctor may render, Yet, this is the way all clinics are run. The doctors are basically given treatment parameters in spite of state law.

I said I tried to give my patients the time I felt they needed and deserved.  But I told her, I had a special challenge in this job. The challenge was, and is usually in such clinics, getting people primary medical care.  Getting them to someone who will see them in a reasonable time and do what they need.  Also convincing them or the importance of following through.  After all a depression can disappear if diabetes is identified and treated.  The long-term side-effects of psychiatric drugs need to be monitored and mitigated with blood tests, prescriptions and sometimes even weight management with associated pharmacology or surgery. All administered by a general practitioner.

She told me that this was a cultural problem, and that this was well known in the Mexican-American culture from which she had issued.  Mexican Americans simply did not like to go to the doctor.  So the best one could do is to document this reticence and carry on. And don’t waste valuable time.

I was livid with rage but thought it wisest to say nothing at the time, although I did report the interchange to a higher administrator who is a friend.

It is not as if I have not worked with Mexican Americans before.  I have been up and down the state of California as a psychiatrist and am considered fluent in Spanish.  I have heard it estimated that 5/8 of the California population are either Hispanic or of Hispanic descent. I worked with Spanish Speaking folks starting long before.  When I was 18, the first medical employment of my lifetime was at the front desk of the emergency room of a major Boston Hospital.  I saw the Puerto Ricans who were linguistically challenged.  I crashed the “language lab” at my undergrad university, even though I had no time to actually take a course in Spanish, since I was overloaded with science courses and had already fulfilled my language requirement in French.

In those long-ago days, a benevolent librarian had to help me load reel-to reel tapes onto cumbersome machines, and give me desk copies of texts and dictionaries. All so that I could try to translate for a Puerto Rican in the emergency room, using some kind of archaic 19th century word for drugstore and kicking myself later for not knowing the far more accessible word “pharmacia.” After years of trying to help folks, I know they will often be more comfortable with native speakers and that the economics of the system encourages the usage of (and billing for) additional staff as translators. After all I still speak Spanish like a well-meaning redheaded Jewish lady from Boston and it shocks some Latinos the way it might shock you to be addressed in grammatically perfect English by Mr. Ed the talking horse. After years of having schlogged my way through some primo Spanish literature (I love Pablo Neruda) as well as a couple of books for and about “curanderas,” (female natural healers in Mexican culture) — well, this was one of my most profound insults ever. In a Los Angeles mental health system they said I was “trilingual,” meaning English, French, and Spanish.  My husband says it is more accurate to say “Try-lingual” — meaning I will try any language under the sun.  I have done some pretty exotic therapies (emotional freedom technique) in Jewish languages.  I have been brought patients when nobody can figure out what language they seem to be speaking.

Of course I know there is more to culture than just language. In a medical career that has (so far) spanned three countries (France, Canada and the U.S.) and had me dealing with cultures originating in all continents except Antarctica, I am still reeling from the shock of this administrator’s visit to my office.

Despite a lifelong interest in the tapestry of endless color and fascination that is world culture I cannot cite a single culture where people actually enjoy going to the doctor.

We have, in America, a serious problem with access to medical care.  To write it off as a cultural difference that need be documented and not acted upon is as profound a crime against humanity as the holocaust.

I love my Mexican patients — yes, even the undocumented ones. The State of California has decreed that they are as deserving of my care as natural citizens, and that is plenty good enough for me. In their stories, I hear the same stories I heard from my grandmother of blessed memory and her contemporaries.  I hear the stories of men and women who left situations of great poverty wanting their future generations of offspring to have opportunities which they did not.  I hear a quasi-delusional belief in the opportunities and wonders of America.  My grandmother really did believe the streets were paved with gold.  They believe that in America they will have access to education and to jobs.

From the clinics where the poor are treated, I see the difficulties in accessing their dreams.  Perhaps the greatest compliment I have had of late was from someone, herself of Mexican origin, on the front lines treating poor Mexicans.  She told me I was a doctor who was like a “campesina,” someone of their earth.  In the Jewish language of my grandmother of blessed memory, it would have been the word “landsleit,” which also means “people of my earth.”

I cannot do a very good job of getting angry with that administrator.  She is the campesina who has become so acculturated that she is an entrenched bureaucrat.  She is acculturated to worry about the clinic running on time and having the appearance of maintaining confidentiality and bringing in money.

My anger is reserved for a system where cultural literacy in confused with ineffective and seemingly inaccessible medical care.

I am certainly no bureaucrat.  I love my Mexican patients when unencumbered by bureaucratic restraint, they hug and kiss me and sometimes move me to tears.  They are sometimes telling me things in a way that is “muy emotionante;” very emotional in their expressions, reminding me of patients I have especially enjoyed who were of Mediterranean origins.  They are like my Eastern European Jewish “landsleit,” more than the acculturated bureaucrats.

So how has the world gone wrong?  I knew better than to confront my administrator.  Her criticism came from a power bigger than me.

Although my delays became less egregious as I learned their particularly unhelpful and ridiculously complex computer system I was never able to stay perfectly on schedule.  I have told every patient, “Sometimes I am a little behind because I spend all the time with each patient that they need.”  No patient ever complained to me about it. As a matter of fact they usually tell me not to be too apologetic.

I think the real problem here has something to do with politics and labels.  “Right” and “left” and “politically correct” and other oversimplifications of philosophy have generated reactions of a very emotional nature.  Anger runs high and easily from trigger-words. Understanding takes schlogging it away in the trenches.  My higher administrator friend has taken the lead in programs that entail getting police to talk to mental health professionals.  In this kind of a dialogue each side comes not just with their prejudices, but with their language their expressions that are “emotional triggers.”

“Cultural competency” is an emotional trigger for me.  I am glad I was able to subdue my anger.

I am reminded of a schizophrenic patient I saw many years ago.  He told me he only wanted to be seen by a psychiatrist who was schizophrenic.  Only such a person he told me, could possibly understand what the daily life of a schizophrenic was, and takes care of a schizophrenic with understanding. I remember taking a lot of time trying to explain that folks with schizophrenia usually did not go through medical school. I told him I would try my best, and promised him he would be getting the best I could do.

He ended up patting me on the back and telling me not to feel bad for not being schizophrenic. I cannot be all cultures. Not everything is a cultural issue.

Being idealistic, humanistic, is a lonely path which has little reinforcement. It is difficult for me to avoid sounding trite. My view on patient care is independent of both religion and politics.   Everybody should have as much as they need. Of course they can choose to decline it.  But it has to be a personal choice that has been made by someone who is in possession of the facts. But it is wrong for people to decline care because access is difficult.

I could not change the system; I could only do my best within its constraints. It is no wonder that I move onward and seek places where my experience, training and talents can help the most.