Why is it when we talk to God, we’re said to be praying, but when God talks to us, we’re said to be schizophrenic? Who decides right or wrong, and normal or abnormal? Why two people raised in same stressful environment turn out differently? One might become reasonably successful and maintain a satisfying marriage and family, while the other might get isolated, depressed, and lonely; divorced. What brings these differences? Studies successfully come to a conclusion that, person’s responses are influenced by certain personal, interpersonal, and cultural factors. Nursing philosophies often describe the person as a biopsychosocial being, who possesses unique characteristics and responds to the world in diverse ways. There is increasing recognition among health care professionals that culture may influence patients’ communication styles, their beliefs about health, and their attitudes towards health care. Culturally sensitive care acknowledges these influences and requires that healthcare professionals show cultural sensitivity when making health interventions.
Culture has been defined as the generalized organized way of life, including beliefs, values, thoughts, communications, actions, customs, and institutions of racial, ethnic, religious, or social groups, that is passed on generation to generation (Bjarnason et al., 2009). It is not a past value or practice or a finished product, but it is active and dynamic. Culture is a way of perceiving, behaving, and evaluating (Scrimshaw, 2006). Members of human species are trained in the family and in their education, formal and informal, to behave in ways that are conventional and fixed by tradition.
Aamir (a pseudonym), admitted voluntarily, a 32 year old male, jobless, married at the age of thirty, and a father of an eight year old boy. Family reported that Aamir showed drastic bouts of aggression, alternating with depressed episodes, increasing thoughts of suspicion and paranoia, and felt possessed by jin. Symptoms increased in 2 -3 years. Aamir had a strong believe in traditional medicines, faith healers, and wore many amulets ‘taweez’. During his treatment at AKUH psychiatric inpatient setting, Aamir was asked by the psychiatrist to remove one amulet every week and said that it is part of his treatment. Aamir accepted the psychiatrist’s order unwantedly. Later, it was reported by his wife that Aamir does remove amulet, but then puts it in the pocket and is still not ready to put it away. The next day, psychiatrist took away all the amulets against Aamir’s will. Aamir didn’t react to the situation but the desire to get discharged from the hospital increased. This clinical scenario compelled me to write about the violence of the ethical principle, autonomy. The notion that the patient’s autonomy is and ought to be the predominant principle of medical ethics is entirely consistent with the enlightenment ideal of individual rights. The principle of autonomy recognizes the rights of individuals to self determination (Rodrigues de Almeida, 2010). This is rooted in society’s respect for individuals’ ability to make informed decisions about personal matters. Autonomy has become more important as social values have shifted to define medical quality in terms of outcomes that are important to the patient rather than medical professionals. This essay will discuss the violation of ethical principle: autonomy under the shadow of paternalism, discuss concept of transcultural nursing and psychiatry, and the ways of provision of culturally sensitive care by integration of models.
World admits distinction between animals and human beings on the “capability to think symbolically, to represent and to project contents of conscience, using them in creation of human culture” (Rodrigues de Almeida, 2010, p. 383) therefore, conscience is the prerequisite to qualify humans as moral beings. But, if it is conscience that is related to autonomy, how can we classify those mentally incompetent as incapable to exert their autonomy? Would they stop being humans because they cannot fully use their mental abilities? Would we stop respecting their values and treat them as non-humans? Eike-Henner (2008) argues that mental processes behind behavior derive from cognitive capability. Cognition, a mental process of knowing, including awareness, perception, reasoning, and judgment, is lost partially or totally due to mental illness; hence this fact labels mentally ill patients as incapable to make choices and decisions (Eike-Henner, 2008). But, is this reason sufficient enough to take away their autonomy? Rodrigues de Almeida (2010) objects and pressurizes that mentally deprived patients must be treated as human beings, that is, carriers of inherent dignity that confers to all and anyone, simply because they are people, one can imagine that this includes the right of not to be discriminated. Many patients are considered incompetent in consequence of their clinical condition but, Eike-Henner (2008) teaches that even in their incompetence there must be a way to understand and respect their autonomy. Very often “patient autonomy is set aside by a principle of beneficence when patients are thought to be a risk to themselves or othersâ€¦Today’s asylum architect therefore proceeds in limiting patients’ freedom within ethical boundaries established not by patient autonomy but by a principle of beneficence” (Sine, 2008, p. 1061). If positive beneficence is an insufficient justification to override autonomy, then to restrict a patient’s freedom we enter the area of paternalism. Paternalism, the intentional overriding of a person’s known preference, is justified by a goal of preventing harm to that person and others (Sine, 2008). But, were those amulets harming Aamir or others? Wasn’t his religious practice, a coping mechanism which he chose to get himself out of this devastating illness? Or was it a maladaptive behavior? Is it justified, not to allow patients to make their own choices and threaten their autonomy? Existentialism, a philosophic theory, emphasizes the existence of an individual as a free agent in determining his or her own development, purpose and meaning (Eisenhauer, 1998, p.1047). Is it acceptable, for the health practitioners to make value judgments about what is best for their patients, not just in a medical sense, but as a whole? Is it wrong to let patients make their own choices until it doesn’t harm them or society?
Madder (1997) states:
“By taking responsibility for decisions which affect our lives, we maintain our discreteness as self and enable self-realisation. It is the act of making a decision which promotes self-being. I will call this view ‘existential autonomy’â€¦By promoting the doctor as the judge of what is all-things-considered best, it encroaches upon the patient’s responsibility for his own life decisions. Undermining patient responsibility for choice can only frustrate existential autonomy.”
Debate still goes on, yet the concept of autonomy, particularly in mental health realm, seems to be recovered by inaccurate meanings (Rodrigues de Almeida, 2010).
To serve diverse needs of patients, it is imperative that the healthcare professional have sound knowledge about various cultural practices and beliefs. In Pakistan Shaman, popularly known as “baba” or “pir”, explains mental illness on the basis of possession by the evil spirit, by jinni or by magical influences cast by enemies. The treatment given includes amulets, spiritually treated water, burning incense or reciting incantations. “In Pakistan, where there is a dearth of psychiatrists, prevalent stigma for mental illness, poor socio-economic conditions and vast majority of population living in rural areas depend more on shamanic treatment who have conferred benefits to patients” (Muhammad Gadit, 2007, p. 101). Shamans enjoy the acceptance of large masses of people who approach them for their mental health problems (Muhammad Gadit, 2007). Not only Islam but in innumerable religions, amulets are worn with a belief that it protects from evil spirits or hard times of life (Scrimshaw, 2006).But can we decide to disapprove the belief of our patients? Scrimshaw (2006) emphasizes that culture significantly impacts health, influences health-seeking behaviors, treatment decisions, and how individuals cope with and interpret illness. Each culture creates its own responses and attitude to health, illness, pain, impairment and death. Then why do we forget to respect our patient’s culture and beliefs? It’s impossible to know which individual adheres to the beliefs described for his or her culture and what shape his belief system takes. This complicates the task. It means a practitioner working with a Mexican population does not have to memorize which foods are hot and which are cold in Mexico, but the practitioner does need to know that the hot/cold belief system is important in Mexican culture and be able to understand and respond when people bring up the topic (Scrimshaw, 2006).
Paul (as cited in Scrimshaw, 2006) writes:
If you wish to help a community improve its health, you must learn to think like the people of that community. Before asking a group of people to assume new health habits, it is wise to ascertain the existing habits, how these habits are linked to one another, what functions they perform, and what they mean to those who practice them (p.41).
Biopsychosocial (BPS) model, accounts for biological, psychological, and sociological interconnected spectrums (Lakhan, 2006). The model explains that illness behaviors and recovery are influenced by its physical nature ‘bio’, which in turn is affected by the beliefs and understandings of the condition, and the state of mind of the person ‘psycho’. All of this is affected by the influence of family, friends, community, culture, and work context ‘social’. But today how much do we, as healthcare professionals pay attention to social part of this model? To arrive at rational treatments, we must take into account the patient’s social context in which he lives and the complementary system devised by society to deal with the disruptive effects of illness (Lakhan, 2006). What about Aamir’s social environment? Why he was forced to act against his beliefs and practices? Restricting ones religious practices during treatment, is it what brings health? Undoubtedly, developing interventions to improve health is virtually impossible if this exercise is stripped of cultural knowledge.
Transcultural Psychiatry deals with the management of all psychiatric conditions as they reflect and are subjected to the influence of cultural factors in a biopsychosocial context while using concepts and instruments from social and biological sciences to advance a full understanding of psychopathology and its treatment (Lim, 2002). Madeleine Leininger creatively developed Sunrise Model to depict the theory of culture care: diversity and universality with the goal to provide culturally congruent holistic care (Leininger, 2002). Worldview refers to the way people tend to look at the world or universe in creating a personal view of what life is about. Cultural and social structure dimensions is a huge umbrella which includes factors related to religion, social structure, political/legal concerns, economics, educational patterns, the use of technologies, cultural values, and ethno history that influence cultural responses of human beings within a cultural context. Health care professional’s culturally sensitive actions and decisions, can preserve or maintain, accommodate or negotiate, and repattern or restructure cultural care. Cultural care preservation or maintenance helps people of particular cultures to retain and use core cultural care values related to healthcare concerns or conditions. Cultural care accommodation or negotiation helps people of a particular culture to adapt to or negotiate with others in the healthcare community in an effort to attain the shared goal of an optimal health outcome for client of a designated culture. Cultural care repatterning or restructuring refers to therapeutic actions taken by culturally competent professionals or family. These actions enable or assist a client to modify personal health behaviors towards beneficial outcomes while respecting the client’s cultural values. In addition, mental healthcare practitioners have a particularly challenging role of providing care that is culturally competent. “The Process of Cultural Competence in the Delivery of Healthcare Services”, is a model presented by Campinha-Bacote in 1998 (Campinha-Bacote, 2002). Model views cultural awareness, cultural knowledge, cultural skill, cultural encounters and cultural desire as the five main domains of cultural competence (Campinha-Bacote, 2002; Flowers, 2004). Cultural awareness is the self-examination of one’s own culture, which includes recognition of one’s biases, and prejudices. Cultural knowledge is the process of seeking sound educational foundation about diverse cultures. Cultural skill is the ability to collect relevant cultural data regarding the client’s problem. Cultural encounter is the process which encourages the healthcare professional to directly engage in cross-cultural interactions with clients from culturally diverse background. Cultural desire is the motivation of the healthcare professional to ‘want to’, rather than ‘have to’ engage in the process of becoming culturally aware. Healthcare practitioners must have expertise in the delivery of culturally competent care in order to provide best possible care.
Although the days of asylums have dissipated, the moral issues of psychiatry remain entangled between the biomedical ethics principle of patient autonomy, existentialism and the good of paternalism. Socio-cultural factors shapes psychological constructs that determine how people respond to health messages and then use their social support networks and cultural beliefs to deal with it. Increasing the understanding of the role of culture in health and illness would help developing culturally sensitive and effective ways of preventing and curing disease. Existing models need to be tested cross-culturally and modified accordingly. Despite attempts to collect the vast amount of knowledge accumulated in the disconnected fields of cultural and health psychology, more research is certainly required which will help practitioners, and lay people acquire a better understanding of how the psychological experiences of illness and health are shaped by individuals’ socio-cultural environment.
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