Culture encompasses the beliefs, values, customs, behaviours and assumptions shared by a community. All medical specialties require awareness of how cultural contexts inform (and sometimes distort) diagnosis and treatment. This is most true for psychiatry, where psychosocial judgements, rather than objective clinical measurements, constitute diagnostic criteria.
Cultural sensitivity is indispensable in the diverse sociocultural landscape of the UK. Research by the Mental Health Foundation 1 finds that mental health stigma within Black, Asian and minority ethnic communities restricts mental health services for ethnic groups, resulting in underdiagnosis, late diagnosis and undertreatment. We know little about the effects of a culturally diverse workforce. Proposed ‘ethnic matching’ is impractical in the current workforce crisis. Unlike most studies in transcultural psychiatry that focus on patients’ experiences, this article shines a light on challenges also faced by clinicians from diverse backgrounds and calls for more research into psychotherapy practices, as a pragmatic and economic method to address those challenges, as we have done in this pilot.
The peer group we describe comprises doctors who are competent in reading, writing and analysing professional literature in English, some of whom have worked in English-speaking settings outside the UK. Their linguistic mastery has sometimes instilled false expectations of smooth communication with colleagues and patients, overlooking Scotland’s idiosyncratic uses of language, metaphor and nuance.
Bhui and Bhugra Reference Bhui and Bhugra2 advocate for a deeper understanding and integration of cultural knowledge to enhance treatment engagement and efficacy. In a further analysis, Reference Bhui, Halvorsrud and Nazroo3 Bhui et al describe linguistic challenges, socioeconomic disadvantages and entrenched cultural misconceptions. Culturally considerate practices, environments and interventions could reduce stigma and inequity, delivering more effective mental healthcare even in a climate of austerity.
The compelling mental health literature in this field includes Fernando’s Reference Fernando4 condemnation of ‘institutional racism’ and Lago’s Reference Lago5 2011 handbook, which examines counselling and therapy in the context of transcultural boundaries and, in particular, ‘the dynamics of the White counsellor–Black client partnership’. Such approaches rightly uphold the cultural rights of patients, but regard these as posing ‘demands’ on clinicians rather than providing joyous opportunities for discovery and development.
The General Medical Council (GMC) reports that 63% of doctors joining the medical register in 2022 qualified overseas. Despite welcome efforts, culturally diverse doctors still face distrust and denigration from patients and even colleagues. Recent British Medical Association surveys found 58% of international medical graduates (IMGs) reporting ‘thinly veiled, everyday incidents of racism’ (micro-aggressions) in the National Health Service (NHS). Reference Lago5
Binary consideration of the pain and damage on each side of the consultation is unhelpful. Cultural diversity is a whole-system phenomenon, not a burdensome extra need of patients or a problem for overseas doctors to master. No-one is once and forever ‘trained’ in cultural competency. It is a dynamic social and interpersonal consideration, with both pitfalls and opportunities.
The psychotherapy supervision group
Since August 2022, the Certificate of Eligibility for Specialist Registration (CESR) Fellowship Programme at Aberdeen’s Royal Cornhill Hospital competitively appoints psychiatrists from across the globe to live and work in the UK, and to qualify by the Portfolio route for GMC specialist registration. All those in the supervision group graduated and trained overseas, specialising in general adult psychiatry, often in senior roles. There was an equal mix of male and female doctors, with a cluster of ages in the late 30s/early 40s.
Aberdeen’s CESR Fellows provide mental health services to a mix of native Scots, UK citizens from south of the border, islanders, immigrants, refugees, asylum seekers and a diverse student population. Fellows often came to this cultural diversity from settings they described as relatively homogenous. Jordan is highly homogenous in terms of ethnicity and language, with over 95% of its population identifying as Arab. Nigeria is culturally diverse, but that nation has localised, homogeneous cultural communities where people share language, religion and traditions.
Some of these CESR Fellows formed a psychotherapy supervision group after initial training in interpersonal therapy (IPT). Psychotherapy casework is a component of the Portfolio curriculum, but the group experience went beyond this and was described by members as ‘an acculturation haven’.
The building of trust in weekly meetings allowed discussion of previously taboo topics. Discussion of the sensitive subjects of race, religion and diversity, in general, felt particularly urgent following the tragic 2024 Southport killings and subsequent riots. Concerns about the widespread violence against immigrants and minorities culminated in a peer-led workshop on which this paper is based.
How different group members responded to the cultural challenges they faced.
All took proactive steps to bridge the cultural and linguistic gaps:
‘I began learning the Ukrainian language, recognising the need to better communicate with a growing number of Ukrainian patients.’
Another colleague actively sought feedback from colleagues about her personal style, and discovered that what was accepted as straightforward in her native country could be considered as too blunt, even rude, in Scotland:
‘At first we felt some experience of micro-aggression around communication difficulties, but this eventually settled as we Fellows better understood the culture and expressed ourselves better in a culturally appropriate/acceptable form.’
Several members of the group had young family and were able to compare parenting practices with others at the school gates:
‘I delved into writings on Scottish and English subcultures, and found this immensely eye-opening and enriching. It led me to explore a vast array of literature on cultural competency that I had previously not been exposed to.’
Contact with young people (including students) was especially helpful in learning cultural expressions, idioms and colloquialisms that were initially unfamiliar:
‘I have learned to recognise the limitations of my initial training and the importance of continually adapting to meet the needs of a diverse patient population.’
Group members began to routinely consult with interpreters, advocacy workers and each other, making the most of local expertise and diversity. One CESR Fellow had a patient from the same country of origin as another member of the group. Their discussion revealed cultural context that had not been provided by the translator.
IPT: a psychotherapy model fostering cultural awareness
IPT is a well-researched, structured, time-limited approach addressing difficulties associated with four common issues linked to mental health disorders, particularly depression. Reference Iacobucci6 It was a first choice of psychotherapy model for a group where cultural curiosity and self-awareness are central to the work.
The IPT model.
IPT is a well-researched, structured, time-limited approach aimed at addressing difficulties associated with four common issues often linked to mental health disorders, particularly depression. Reference Cuijpers, Donker, Weissman, Ravitz and Cristea7
The therapy is underpinned by two core principles.
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(a) Depression (or other disorder) is a treatable illness and not the individual’s fault.
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(b) A reciprocal relationship exists between the disorder and interpersonal problems.
Choice of a focus (grief, interpersonal disputes, role transitions or social isolation) ‘fine-tunes’ the middle stage of therapy to select the most relevant skills for that focus, but there is a common stem of four early sessions during which IPT uses an ‘illness model’ to give mental illness equal validity with physical illness, and to prescribe culturally sanctioned respect for the recovery process.
Emotions are explored, described and tolerated, acknowledging the need to discard the maladaptive behaviours commonly used in response to overwhelming feelings. For instance, it is culturally normative for Scots to self-medicate with alcohol, and some young people in UK culture turn to deliberate self-harm.
The IPT therapist represents the patient’s history as a timeline, highlighting significant life events – sharing understanding of the patient’s cultural interpretations of what is significant. Finally, an interpersonal inventory is mapped out so that all the interacting relationships of family, work, friendship, study, leisure and belief groups can be considered. Fellows found this technique to be ‘of inestimable value’ and considered drawing up an inventory with patients, even when they were not offering IPT.
Both the transitions and grief focus areas examine how interpersonal resources can be mobilised to mitigate losses and revitalise the next stage of the patient’s life. When the focus is on disputes (also called role conflicts), the spotlight is on how mutual expectations are mismatched in the relationship between the patient and an important other.
Champion, a leading IPT theorist, writes:
‘The approach reflects the pragmatism, a plea for simplicity of language, an interest in the patient’s real experiences and interactions with others, issues that have been reflected in the writings of both Meyer and Sullivan. In this way, IPT can be culturally sensitive too as it should take into account the cultural context in which the patient exists, including the norms and expectations of the specific culture. In this way, the IPT therapist needs to be aware of the patient’s real experiences and expectations that may be very different from the therapist’s own, if therapist and patient are from different cultural backgrounds.’ Reference Champion8
Cultural awareness ‘highlights’
During supervision, group members shared some key observation points they had found helpful, both clinically and in application to their own lives.
Language is more than words
The GMC requires that IMGs practising in the UK hold an English language proficiency qualification. Even allowing for Scottish accents, Fellows found words spoken by a UK national can completely differ in meaning from the same words in the mouths of different IMGs. The English language is not just a lingua franca, but has enmeshed itself in each of the rich cultures in which it is used.
Understanding cultural aspects of communication was found to be essential for effective clinical practice, integration into multidisciplinary teams and career progression.
Language is politically sensitive. A Ukrainian patient claimed that Russians were pursuing him to Aberdeen, but an interpreter was needed to investigate this belief. Unfortunately, a Russian interpreter was provided on the basis that ‘all Ukrainians understand Russian’.
Expression of emotion
Culture imposes expectations on how much and in what way feelings are expressed. Reference Cowen, Brooks, Prasad, Tanaka, Kamitani and Kirilyuk9 One individual weeping at a funeral may be merely meeting cultural expectations, whereas a tight-lipped mask might hide unbearable sorrow. Northern Europeans are characterised as being more emotionally reserved, with African, southern European and Caribbean people being considered more emotionally expressive. Reference Lago5 The IPT model endorses skills of emotional awareness and culturally appropriate emotional communication.
Patients’ expressions sometimes baffled clinicians. One patient said she ‘saw red’ – a common British way to describe sudden fury. The clinician’s native culture used the colour red as a symbol for fear of danger, so it was important to clarify this.
Collectivist and individualistic cultures
A ‘collectivist’ cultural norm emphasises the values of group harmony, emotional control and ‘saving face’, encouraging coping by accessing family, religious institutions and community wisdom. By contrast, individualistic cultures prioritise self-reliance and behaviour based on personal goals and interests. Local White Scots most often apply individualistic coping strategies and prefer confidential mental health services in circumstances where an African community would trust family and religious groups. There is overlap and complexity: notably both types of culture experience shame and stigma, whether saving face for the group or losing self-esteem at an individual level.
The IPT model supports patients and therapists with cultural challenges. The ‘role transition’ focus helps address relocations from one culture to another. CESR Fellows in the group held rich recent experience of their own recent relocations, informing a range of potential feelings and reactions. A ‘disputes’ focus can consider mismatched expectations from different cultures. Therapists acknowledge and respect patients’ cultural expectations while pointing out different expectations in different communities. This promotes healthy questioning of assumptions.
For instance, a British Pakistani woman in Scotland might face conflicting expectations on marriage and career. A ‘disputes’ focus explores both her parents’ and her own expectations, acknowledging the associated feelings while seeking resolution. The therapist – a male doctor from the Middle East – could benefit from acknowledging his own society’s expectations, and discussing in supervision how this might potentially affect the therapeutic alliance.
Family rules and roles
Culture profoundly shapes family expectations and roles. Collectivist societies prioritise family honour and respect for elders. Marriage may carry sacred connotations, with divorce heavily stigmatised. By contrast, Western cultures often prioritise individual needs, influencing how transitions such as marriage and divorce are perceived and managed.
Authoritative, even authoritarian, parenting, where parents make the majority of decisions for their children, is more common in some societies. Some cultures and subcultures apply pressure to excel in formal education, whereas others prioritise maintaining family businesses or acquiring practical skills.
‘Traditional’ societies often define gender roles strictly. Women are typically seen as nurturers, men as financial providers. Whereas modern Western cultures are more fluid around gender roles, Scottish men often still experience unemployment as a threat to their masculinity. Scottish women may choose to be ‘child-free’, but infertility invokes concerns in Glasgow as well as in Africa. Even in modern Scotland, care for children, elders and the disabled falls mainly to women.
Most societies prescribe rituals marking successes, partnerships, transitions and losses. These are a rich resource for IPT, offering opportunities to express and tolerate strong feelings and fostering healthy feelings of ‘belonging’. Group discussions of the different ways of managing and honouring a death were particularly helpful. Without prescribed rituals, or where patients cannot access these, they struggle to healthily process deep feelings. In such cases, both therapist and patient may collaboratively create ceremonial, perhaps with significant others. In another ‘borrowed’ ritual, patients often appreciate a ‘graduation from therapy’ as part of termination of therapy. Significant others may be invited to add their testimony, and documents such as letters or copies of outcome measures can be handed over.
NHS culture
Awareness of the unique structural and managerial context of the NHS is essential for quality mental healthcare. CESR programme coordinators helped navigate these bewildering pathways, and support from previously integrated senior doctors was particularly helpful. Fellows now ‘pay forward’ the support to cushion the culture shock for new IMGs.
Hallmarks of cultural competence: recommendations for practice
One widely used framework of provider-level cultural competence is Sue’s Reference Sue, Sue, Neville and Smith10 tripartite model:
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(a) cultural attitudes – sensitivity to how one’s own values and biases impact on the client’s presentation and the therapeutic relationship;
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(b) cultural knowledge – about one’s own and the client’s background;
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(c) cultural skills – cultural humility and appropriate, sensitive strategies.
Our supervision group extended the concept of individual cultural competence to a vision of culturally diverse teams, explicitly built into service design in multicultural communities such as the UK. Just as a multidisciplinary team acknowledges and exploits the particular skills of different professions, so members of a multicultural team could be explicitly tasked with promoting rapport with patients from diverse backgrounds, fostering inclusive workplace practices, validating culturally diverse psychiatrists and reducing stigma.
Meanwhile, our own CESR programme is offering a second iteration of the IPT peer supervision group, with the aims of training fellows in the art of psychotherapy, satisfying curriculum demands and also providing opportunities to work through their own transition into the role of psychiatrist in north-east Scotland. Like the authors of this paper, they find that the accounts of peers validate their own experiences and accelerate the learning needed to function at their professional and personal best. We have evidence of acceptability, but have not gone beyond anecdotal evidence of better outcomes for staff and patients.
We recommend that other centres experiment with similar pilots and that this model be subjected to formal study, so that if its effectiveness is formally confirmed, this relatively inexpensive intervention may be offered routinely to IMGs in psychiatry.
Author contributions
Each author provided several paragraphs of the first draft of the paper, based on presentations given within the supervision group. The lead author then fashioned these into a coherent draft, which was modified and finally approved by all authors.
Funding
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
None.
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