The cultural perspective holds that health disparities are a result of culture and cultural differences. Culture and cultural difference impact the experience, the expression, and the explanation of trauma and its effect, as well as in the expectations about the course and outcome of the trauma and about the treatment process. All of these will be explained below. As is perhaps obvious, all people are cultural, to the extent that culture is not simply the domain of the “exotic other” but of all people. To that end the very conceptual foundation of cultural competence is predicated on the notion that clinicians are as impacted by their own culture, in terms of experience, expression, explanation, and expectations as are their patients.

In many respects, the race-based “side” of the equation is the most complicated and perhaps even controversial. Whereas the culturalist is easier to digest in as much as the focus is on different ways of being in the world, the race based is far more uncomfortable as it has to do with differential access to resources on the basis of an arbitrary feature that is usually physical, although not necessarily so. The race-based domain resituates the “issue” in psychiatric work in the psychiatrist, and not in the patient; the issue at hand is not the behaviour of the patient but of the filters through which the mental health professional experiences the patient. What the reports on health disparities left very clear is that certain patients receive a lower quality of care simply because they are perceived to be members of a particular “race”(Atdjian and Vega 2005; Institute of Medicine 2002; Mallinger and Lamberti 2010). Much has been written as to whether “race” exists or not, and there is sufficient research that clearly shows that it is of no interest biologically, nor does belonging to a given race mean anything about an individual’s behaviour (Betancourt and Lopez 1993; Helms et al. 2005). Race is meaningful in psychiatry as a social construct (Smedley and Smedley 2005). What this means is that being identified as a member of a given race can result in a certain sort of treatment.

The patient who is perceived as being racially different may well be treated differently, not on the basis of any characteristic specific to the patient, but rather due to prejudices that the therapist will project onto the patient (Fernando 2010). Race is a particularly complicating factor because even as it is visible, its impact often remains invisible. Researchers have routinely demonstrated that there is often a difference between what they term explicit and implicit race-related behaviour (Banaji et al. 1997; Penner et al. 2010). The former is that which is under the individual’s conscious control; the latter is not. Thus, although we may consider ourselves to be “colour-blind” and ignore race in our encounters with patients, there is a strong body of research which suggests that even those individuals who consider themselves to be antiracist themselves show an own-race preference (Dovidio et al. 2002; Quillian 2008).

The upshot of this is that most of us are under the influence of what could be termed unconscious racism, and as it is unconscious, we are blind to it, and nevertheless it impacts our interactions with patients. Clearly, then, it is incumbent on the clinician to develop awareness of this process in order to minimize the interference of prejudices in the therapeutic encounter.

Recent developments in the neurosciences have contributed to the notion of the “cultural brain” which notes that neural development is conditioned by the experiences that occur in a given cultural context (Chiao et al. 2010). This contributes to the overall understanding that experience is never “pure” but is always conditioned and/or mediated by culture, previous experience, context, and so forth. What this means, then, is that humans do not simply have experiences and then subsequently interpret them through their cultural filters, but rather the event itself is experienced culturally, so to speak. This does not presuppose determinism, that being from a particular culture will automatically result in certain sorts of experiences, but rather culture will set forth the parameters in within which experience occurs. What it really reminds of us is that experience can be highly variable, even if it would appear to be otherwise. The trauma experience is not pure either, nor is it simply a question of the initial pure trauma experience which is then conditioned by the cultural context and interpretation. Rather, what is and is not a “trauma,” as we shall see below, is very much culturally contingent, as is how the trauma is experienced.

Just as culture conditions and sets forth the parameters for experience, so too is it the case with expression. Most every aspect of human expression is culturally mediated, from style of communication to nonverbal communication to more complex aspects of interaction. This means that everything from eye contact (or its lack) to gestures to tone of voice can vary cross-culturally. In addition to the “how” of communication, culture influences the form and content. Thus, there is considerable variability in “how much” emotion is expressed, how directly one expresses oneself, and how much formality is used. In many European countries and in North America in particular, the notion that one should “say what one means” is relatively normative. The message is given “as is”. This is not always the case, particularly in more interdependent and collectivist cultures, in which human relationships often take precedence, and therefore the priority is maintaining those relationships, even if it means being flexible with the truth. As we will see below, this is particularly the case with trauma although not universally so. The central issue here is that in psychiatry the idea is that a specific cluster of symptoms are indicative of a specific diagnostic category. This generally holds in the Euro-American cultural context and may indeed hold universally, but at times it does not. At times there is what could be called a symptom miss-match, meaning that the disorder finds a different sort of expression.

Expression, then, is germane to the psychiatrist working with an immigrant or culturally different patient in two ways. One has to do with the interaction, always understood to be a two-way street. Each person will have her or his own normative communication style and their way of expressing themselves verbally, nonverbally, and stylistically. This process is generally rather automatic; neither are we conscious of how we communicate, nor are we conscious that we are interpreting the expression of the other and in the process making decisions about the other person. Thus as clinicians we may observe that the patient has “flat affect” or indeed is “emotionally labile”. Both of these evaluations are indeed predicated on what we implicitly consider normative for emotional expression. The other way in which expression is relevant is that the very expression of symptoms can vary considerably (Katz et al. 1988; Minsky et al. 2003). Perhaps the most “common” of these has to do with verbal or psychological versus somatic expression. As Western biomedicine developed in the context of mind-body dualism, mind and body are separated, and this separation means that the mind is treated by psychiatrists and the body by other medical specialists. Indeed, the very existence of “mental” health and its related healing traditions (psy) is predicated on this dualism. Indeed, in other parts of the world, there are not “mind healers” as differentiated from “body healers” (although the difference might be between body and soul). What this means, then, is that in the West we expect a differentiation of mental and somatic expression, with the latter being reserved for physical problems and the former for psychological or psychiatric problems. The very notion of “psychosomatic” is predicated on the notion that psyche and soma should be separated, and when they are not, this is symptomatic of a psychiatric problem.

The place of embodied expression in trauma is particularly relevant in this respect, and as we shall see below, this complex interplay of body and mind in trauma can be very highly influenced by culture.

Just as culture circumscribes expression of distress, that is, the symptomatology, it also circumscribes what Arthur Kleinman calls the explanatory paradigm (1976). This refers to how the person makes sense of their distress. As mental health professionals, we tend to accept the biomedical approach, even if it is tempered by this or that school of psychology. We tend to opt for a natural and internal sort of explanation, meaning that the cause is natural, be it biological, psychological, or social (as opposed to supernatural, magical, etc.), and that the origin of the problem lies “within” the individual (Bhui and Bhugra 2002). This will also mean that the “cure” lies “within” the individual, be it through their “internal” focus in psychotherapy or through altering their neurochemistry.

The explanation, for example, that we provide for the impact of trauma follows these lines.

The human response to psychological trauma is one of the most important public health problems in the world. Traumatic events such as family and social violence, rapes and assaults, disasters, wars, accidents and predatory violence confront people with such horror and threat that it may temporarily or permanently alter their capacity to cope, their biological threat perception, and their concepts of themselves. (Van der Kolk 2000)

What we see here is that the traumatic event is understood to have a psychological and perhaps biological impact and is framed as such. It is important to note that the question is not so much “which explanation is correct” but rather to recognize the different sorts of explanations that may emerge and that there may be considerable variability in the explanations.

On the other hand, there are multiple “ontological domains” (Hinton and Kirmayer 2013) such as economic and environmental context, judicial/political situation, spirituality and religion, and ethnopsychology, ethnophysiology, and cultural idioms of distress that may be involved in a given person’s explanation, particularly when they are not from a culture heavily influenced by Western biomedicine.

The fourth “ex” is related to the multiple expectations surrounding both the course and outcome of the distress as well as any treatment-related issues such as the nature of the doctor-patient relationship and the nature of the treatment itself. As with the other exes, culture is central.

Expectations about the impact of the distress, how long it will last, indeed, what it means, can vary considerably according to how the distress is experienced, made sense of, and explained. This determines, in part, what needs to be done in the face of the distress. Thus, for example, one might expect that not thinking about a problem will be the optimal way of managing it, if it is understood that the problem has its origins in factors beyond one’s control such as the will of God, as there is then nothing that the individual can do about it, and God will remove the negative experience when he or she so sees fit. Such a perspective could also impact the expectations about what is needed to effectively deal with the problem. If it is a result of God’s will, then perhaps what makes most sense is to appease God or engage in some activity that will facilitate God removing the distress. To that end, engaging in individually centred talk therapy that assumes an internal locus of control and that involves engaging with the distressing experience would make little sense (Kirmayer 2007).

Cultural norms also dictate expectations about the nature of human interaction. Cultures differ considerably in how hierarchical they are, in how credibility is ascertained, in how formal or informal interactions are, in how much self-disclosure is normative, and so forth. Most modes of mental health treatment require that the individual reflects honestly on their psychoemotional experiences and shares these with the mental health professional. It is also expected that people speak clearly, directly, and to the point. All of these are simply “Western norms” and are by no means universal and, for many, could be considered to be rather strange and even uncomfortable (Qureshi and Collazos 2011). Further, the mental health professional may be expected to provide expert advice; any sort of exploratory talk therapy may be seen as rather strange. Many times we have heard comments such “enough with this talk, Doctor, please tell me what I must do” or something to that effect. Many Western psychotherapy modalities seek a collaborative type of relationship in which power differentials are minimized. This makes perfect sense in the context of a Western, Educated, Industrialized, Rich, and Democratic (WEIRD) culture (Henrich et al. 2010), but it does not with patients who have rather different cultural backgrounds.

As one of the key components of cultural competence, the knowledge domain has generated some controversy and indeed considerable criticism surrounding the notion that clinicians need to have knowledge about a given culture (Kleinman and Benson 2006). This notion is problematic for a variety of reasons, to the extent that some commentators reject the very notion of cultural competence for the cultural reductionism that such a notion implies (ibid.). Cultural knowledge is problematic for a few reasons. For many clinicians it is simply unreasonable to expect that they will have the time and energy to inform themselves about the cultures of the many different patients they see. But more importantly, cultural knowledge is a deceptive notion. In addition to the very important observation that culture is “distal” from the actual therapeutic interaction (Sue and Zane 1987), “knowing” a culture is a decidedly complicated notion. Cultures are complex, heterogeneous, and indeed contradictory and every changing. Thus to make any clinically relevant comment such as “Spaniards are emotive” or “Swedes hide their pain” is dangerous because although this may apply to some or indeed many people in a given culture, it does not apply to all. The very idea that “Swedes” or “Spaniards” are psychologically meaningful categories is inherently problematic. It assumes that all members of a given culture will share certain psychologically relevant characteristics. Not even addressing the complex issue of what defines a culture and distinguishes it from another (“Spain”? or should it be broken down to autonomous regions? Or specific linguistic groups? Or?), the idea of cultural knowledge runs a very serious risk of subjecting patients to stereotypes that simply may not be applicable and can lead to inadequate treatment.

But this is not to say that knowledge is not an important part of cultural competence. Knowledge that the four exes impact mental health and its treatment is essential. What should be clear is that all we can know is that the four exes are important for all humans; however, how this is the case is something that is not clearly known.

One of the central tenets of transcultural psychiatry is that, one way or the other, all explanations are cultural explanations, which means that all understanding of “trauma” is cultural, indeed, “trauma” itself, is a cultural construct. This is not to say that trauma does not exist, nor is it to descend into irrationalism, but rather to recognize that Western biomedicine is not, as Richard Rorty would say, “the mirror of nature”, but rather an explanatory model that serves us very well (1981). Thus, to put it more concretely, it is important to know that trauma in general and PTSD more specifically are understood in psychiatry according to the specific epistemological basis of Western biomedicine, and as such trauma and its consequences may show up very differently in different cultural contexts. Again, it is important to note that we can only say “may” precisely because of the considerable human diversity that exists even within the same culture.

The attitude domain is perhaps the most complex of the three, precisely because it is the most intangible and is the antithesis of a more standard, “objective” concrete domain such as that of knowledge. This is because both the skills and knowledge domains of cultural competence require a willingness on the clinician’s part to approach patients and their cultures openly, to put their preconceived notions on hold, and to allow themselves to be challenged. Although this is clearly a positive characteristic of any clinician, it is particularly challenging in as much as it requires the clinician to acknowledge not only that he or she may not know, but also that he or she may indeed be disposed to prejudices. In this respect, clinician countertransference is of particular importance. The so-called racial countertransference has to do with how we unconsciously deal with uncomfortable racial material. In large part because most clinicians are socialized in a context that rejects racism, racist and racialist thoughts and feelings are dealt with by relegating them to the unconscious where they show up indirectly and implicitly (Altman 2002; Comas-Díaz and Jacobsen 1991; Gorkin 1996). Researchers and theorists have identified a number of ways in which clinicians can do this, which include both “positive” and “negative” explicit responses. The former are ones in which we lose sight of the patient himself or herself and see the patient as a sort of specimen of the culture in question. We can end up exoticizing the patient, adopting a patronizing attitude in which we feel compelled to “save” the patient, convince ourselves that although there may be racism occurring in the world at large, we are different from others, and provide our patients with a different sort of experience. We can tell ourselves that we are colour-blind and do not see the person’s race, just them. Conversely, we can end up seeing the patient as a “problem”, and we can see their religion (if it is different from ours) as perhaps explanatory for their problematic ways of dealing with their problems. We can see them as somehow “primitive” and backwards with their quaint “cultural explanations” of their distress.

Thus an essential attitude is one of openness in every sense of the word, both to the patient but also to how one approaches the patient. This further requires that the psychiatrist be willing to adopt that very uncomfortable position of “not knowing” and of approaching the patient interaction with as open a mind as possible.

In the context of trauma, this means in effect suspending what we think we know about trauma, its symptoms, its impact, and its treatment. Further, it demands that we are willing to question our interpretive filters and our attitudes towards the patient.

The skills domain focuses on the application of knowledge and all aspects related to the interaction with the patient or the “doing” side of things. In the graphic above, it encompasses both the race-based and the culturalist approaches and involves having the competence to effectively manage cultural differences in interaction as well as to attend to and deal with prejudices and with cultural filters. In addition, and perhaps most importantly, it consists of communication and relationship development skills. There is a considerable research base that shows that the therapeutic relationship is the substrate upon which therapeutic effectiveness is built (Clemence et al. 2005; Lim et al. 2006; Suchman 2006) and that communication forms an important part of the development of the relationship. Further, just as culture is present in explanations and expression, so it is in understanding and empathy (Rasoal et al. 2011). Thus taken together, this means that the culturally competent clinician is skilled at engaging with her or his culturally different patient, with the ability to adapt to the relational and communicative style of the patient. But it is not only “culture” here, but also race, in as much as prejudices, stereotypes, and transference may well be involved. This means that clinicians are skilled at identifying how racial prejudices and transference may interfere with good communication and the development of the therapeutic relationship.

In the context of trauma, this also means that the clinician has the capacity to detect what sort of relational dynamic will be optimal for the particular patient in question, given his or her cultural context, and will be one that facilitates trust. In particular this means that the clinician is sufficiently open to “where the patient is at” to not impose the received relational model but rather to adapt to the specifics of the patient. It may mean, for example, adopting a more formal tone, in which honorifics (Mrs.; Mr.; Ms.; Miss) and surnames are used. It most certainly also involves adapting to the cultural communication style of the patient. It is beyond the scope of this chapter to address this in detail, and indeed, there is no shortage of excellent material available that delineates different aspects of intercultural communication.