Cross-Cultural Crises

Working in the emergency care setting takes choice out of the equation when dealing with cross-cultural issues for both clinicians and patients. As clinicians, we need not have had any prior scientific interest in a patient's particular culture, and the patient has not cautiously selected us to trust. We are thrown together.

Emergencies also take pure intellectualism out of the equation. If a session with an introspective, articulate patient is like running alongside an open boxcar and grabbing an outstretched hand that hoists us into the train, then dealing firsthand with cross-cultural issues in an emergency situation can feel like missing the train altogether and being stranded in strange territory. The territory may seem uncharted. Even if someone has been there before and written about it cogently, emergency clinicians seldom have time to read about it beforehand; even then, to read about it is not to feel its immediacy. Perhaps that is why there is so little written about cross-cultural issues in the emergency setting.

The elements of surprise and unpreparedness in the emergency department (ED) are strong and not uncommon to either clinicians or patients. Dealing with these elements, however, may be easier for us as clinicians because at least we are in familiar surroundings, whereas patients are having to process both the experience that brought them to the ED and the often unfamiliar ED environment. The psychiatric crisis with a cross-cultural component can often itself be a crisis of culture, in which our culture clash with a patient is paradigmatic of the reason we are seeing them.

Having trainees from different cultures in our midst is a special plus. As they learn psychiatry, they realize the importance of underlying issues that they had never before appreciated and can share their realizations with the faculty. Through these trainees, we can learn the finer points of the world's view of our country and cultural dynamics. Even a resident who has borderline English skills is your closest ally when he or she speaks the language and can navigate the social system of a non-English-speaking patient in psychiatric crisis who is quite ill and completely unknown to the ED staff.

It is interesting how we tend to highly prize the subtleties of our own cultural identity and forget that persons who hold a different cultural identity do the same thing. It is so much easier to see cultural incompetence in others. Developing cultural competency thus involves increasing not only our external knowledge base but also our self-knowledge. Gaining emotional poise in responding to our own cultural clashes in the emergency care setting is a lifelong process. We have layers of sensitivity that influence how we react to personal attacks. For example, crisis practitioners often become experienced in dealing with personal attacks on their race before learning to deal with the more unnerving affronts to their (presumed) religion.

These verbal attacks may be a patient's way of getting us to feel what he feels. The best possible outcome is that attempting to bridge the culture gap with a patient will interest him in bridging the gap with us. Gaps are not all bad. Cultural competence should include developing interest and skill in forming good relationships with people who are different than we are; this kind of competence is good for patients too.

Naturally, safe de-escalation is a paramount objective in the emergency setting. Having culturally sensitive and informed staff on hand will lessen the risk of violence. However, there is a point at which oversimplifying reality for a person hinders his ability to learn to cope better with the complex world in which he finds himself.

Clinical gaffes are inevitable, but they force us to get up to speed and we can usually recover from them. Even failures serve a purpose if they challenge us to be better prepared next time. The interplay of culture in the formation or destruction of identities and families and helping relationships is one of the most interesting things that we see and deal with every day.

Dr Glick's commentary nicely puts the feature article and subsequent case presentations into perspective. Drs Alarcón and Hart's overview article articulates the cultural perspective and its clinical importance, and their case presentations show some real-life crisis vignettes that drive their message home. I think that this issue of Psychiatric Issues in Emergency Care Settings will increase our knowledge base of emergency presentations and heighten our understanding of the cultural perspective. It will also sensitize us to everyday aspects of the clinician-patient interaction that, when handled well, make us more effective with our clients, both diagnostically and therapeutically.