History of ethnopsychology:

The term Ethno psychology was initially coined by Moritz Lazarus (1824–1903) and Heymann Steinthal (1823–1899), and they were responsible for its initial conception. The spirit of a people was the principal subject of Ethno psychology, which had two components – ethno historical psychology and psychic ethnology. While the former dealt with the general psychological functioning of the spirit of a people, the latter dealt with its concrete embodiment. The materials that Ethno psychology studied were primarily textual: languages, mythologies, religions, customs, and so forth. In 1920, Wilhelm Wundt, Father of Psychology recalled that he had conceived the idea in 1860 of adding a superstructure to experimental psychology. The latter had to limit itself to studying the mental life of the individual. The task of Ethno psychology was to study the phenomena of communal life. He held that this was ultimately more important and represented the proper conclusion of psychology. For Wundt, Ethno psychology, the need for a separate discipline to study social life arose because of the restricted scope of experimental psychology, which was unable to study the “higher” mental functions. He deﬁned Ethnopsychology as dealing with the mental products which were created by communities. His ethnopsychology presented a psychological theory that encompassed history, linguistics, sociology, anthropology, and comparative religion. The progressive disciplinary development of each of these disciplines mitigated against their uniﬁcation under a more fundamental psychological discipline⁴.

Approaches of ethnopsychology:

There are 3 approaches of ethnopsychology. They are the symbolic approach, activity theory, and an individualistic approach⁷.

The Symbolic Approach:

The predominant approach to cultural psychology defines culture as shared symbols, concepts, meanings, and linguistic terms. These are socially constructed in the sense of being produced by individuals in concert. Cultural symbols are regarded as organizing psychological phenomena. They do so by labeling and categorizing information and directing responses in particular ways. A useful application of the symbolic approach is Olson's (1981) explanation of the rarity of child abuse among rural Turkish people. She traces the low incidence of child abuse to the prevalent beliefs that life is unpredictable and subject to the vagaries of natural and supernatural forces which transcend human will. Since humans have neither the power nor responsibility to control life, they do not seek to control their children. Nor do they set expectations for children's physical and emotional capabilities. Caretakers accept and indulge children's behavior. As a result, most misbehavior of children are not punished but tolerated as childish naughtiness. Thus, parents' benevolent treatment of their children is mediated by beliefs about the causes of events, the powers and responsibilities of people, and the capabilities of children.

Activity Theory:

Activity theorists (Vygotsky, 1997) argue that psychological phenomena are formed as people engage in socially organized activity. Practical, socially organized activity is the primary cultural influence on psychology. Activity theorists maintain that activities such as science, schooling, art, writing, and reading stimulate distinctive kinds of psychological phenomena - e.g., communicating stimulates thinking. Activities do not express pre-formed, natural cognitive, emotional, or personality characteristics of the individual. On the contrary, artistic, literary, scientific, educational, and recreational activities generate psychological functions.

The Individualistic Approach:

This individualistic approach defines culture as the outcome of a negotiated interaction between an individual and social institutions-conditions. In their negotiations, interpretations, selections, and modifications of institutions-conditions, individuals "co-construct" culture. These psychologists argue that culture is not imposed on passive subjects; rather individuals actively express themselves in the culture. Individuals create meaning in their interpersonal interactions. The individualistic approach to cultural psychology is correct in noting that individuals actively construct culture and assimilate cultural influences. Culture does not function apart from individuals. Terms such as culture, social institutions, social conditions, school, work, and government should be used with the understanding that they denote the activities (and the products of activities) of people rather than reified entities^{4, 7}.

Importance of ethnopsychology in health care:

· To heighten awareness of ways in which their own faith system encounters with illness, suffering and death.

· To foster understanding, respect and appreciation for the individuality and diversity of patients beliefs, values, spirituality and culture regarding illness, its meaning, cause, treatment, and outcome.

· To strengthen in their commitment to relationship-centered medicine that emphasizes care of the suffering person rather than attention simply more to the pathophysiology of disease, and recognizes the physician as a dynamic component of that relationship.

· To facilitate in recognizing the role of the hospital chaplain and the patient's clergy as partners in the health care team in providing care for the patient.

· To encourage in developing and maintaining a program of physical, emotional and spiritual self-care therapies⁵.

Reasons for emerging concept of ethnopsychology:

Ethno Psychology needs to equally involve both intellectual and practical components, as we live in a country consisting of many different cultures, religions and levels of development. Many people in rural parts of the country may be perceived as not being intellectual, but this does not mean that they don’t have the mental abilities. Ethno Psychology should take into account indigenous people’s languages, philosophies and worldviews. It is through these worldviews and philosophies that people make sense of themselves and the world. It is essential to identify the cultural processes such as beliefs and values, or worldview, which are enforced by power elements such as political and economic factors, and behavioral practices⁴.

Cultural beliefs and values about illness:

· The ideology or worldview of a culture refers to the available symbols, meanings, and values about what is important and what behaviors are right and correct. These beliefs and values are convictions about how a person should be, what is the right way to behave, and how one should be in the world. This is the link between the larger worldview of a culture and the individual psychological functioning of any given person. Mental health can be said to be the degree to which a person is able to fulfill the cultural expectations of his or her society (Fiske, et al, 1998; Markus and Katayama 1991; Saint Arnault, 1998).

· Illness and disease occur within a cultural and social context. Culture provides the framework within which the meaning of the illness, and the necessary care or cure, is determined. Explanatory models are the ways that the culture and community people explain the source of distress or the cause of the illness. One such explanation for problems is the concept of imbalance or harmony. Physical, social, emotional and spiritual imbalance can be caused by a variety of factors. The balance between ones diet and ones current biological state is important in some cultures. For them, states such as menstruation, childbirth, and illness represent changes in the heat of the body. In cases such as these, dietary or environmental changes are warranted to restore balance. Social behaviors can also cause social imbalance. Immodesty, excessive sex or drinking, jealousy and greed can upset the social balance and are believed to cause illness. Finally, energy can become blocked and /or concentrated creating an imbalance in energy flow.

· Other important beliefs about sources of illnesses are spiritual. Spiritual sources can be further subdivided into those involving human and non-human spirits and supernatural forces. There are many different cultural beliefs about the nature, location and character of the human spirit. Some cultures believe that the spirit can be captured, dislodged, or lost. These spiritual events can occur because of witchcraft, or as a result of some kind of traumatic experience. Non-human spirits include the spiritual nature of plants, animals, mountains, water and other non-human forms. Many non-western healing systems consider respect and recognition of these non-human spiritual forces essential for health. Disrespect and disconnection from them can lead to illness. Supernatural forces or spirits can include ancestors. They might also be Gods, which may be benevolent, evil or changing. Often, humans are called on in these systems to give offerings to ancestors or supernatural spirits, to act in ways that are pleasing to them or to protect the spirits from capture with rituals or amulets. In most of these cases, there is a relationship between social conduct and spiritual sources of illness, such that people need to maintain good relationships with both other people and the spirits.

· Another belief about the source of illness is that it comes from the outside or the environment. These external forces might be bad winds, ghosts, spirits, negative energies, germs, and elements such as cold, impurities, or negative or jealous thoughts. People holding these beliefs hold that inner strength, resistance and purity are important protections against invasion from these outside forces. This set of beliefs is related to the balance concept, because imbalance can make one vulnerable or weak, and therefore susceptible to these outside forces².

Political and economic factors:

· The political/economic aspects of culture include the social structure of the society, including how families, groups and political institutions distribute resources, divide labor, and acquire and distribute wealth. These are the ways that people organize themselves, who has the power to control whom, and who “should” have less or more. The political/economic dimension of culture, therefore, incorporates cultural beliefs and values about “good” and “right” to justify who will hold power over whom. Finally, this aspect of culture includes how those in power define proper social conduct and how public behavior will be regulated. Stigma is an example of the use of social structure to uphold an ideal. In many cultures, a person with mental illness is considered frightening and abnormal. However, if one examines the cultural values more closely, one finds that on what basis the society defines “abnormal,” “immoral” or “unnatural. society, for example, the mentally ill were historically seen as one who was controlled by evil forces, morally weak and economically unproductive. Therefore, these people were feared, stigmatized and ostracized. These beliefs about the mentally ill have also historically been seen in the public’s treatment of people with tuberculosis, cholera, syphilis and AIDS.

· Other aspects of political and economic dimensions include social power. Social power is reflected in the dominant language used. People who are unable or unwilling to use the dominant language are shut out of avenues of power. They may not be able to work, use needed services, read public information, shop, drive, bank, obtain legal representation, and obtain health care.

· Another cultural feature of daily life is the familiarity with technology. Besides the additional information and conveniences that technology can afford, people may feel that technologies are against their traditions or may not access health related services because of the strange and frightening technological use. While many young people from diverse cultures may be interested in technologies, older people are often less so. Combining an unknown language with an environment that is dominated by technology can make accessing health care an impossibly frightening and alien experience. Finally, the infrastructure of a region may make use of technology impossible. If there is no electricity, phone lines and passable roads, it is unlikely that one will seek out or value technological advances².

Practice or Behavioral dimension:

· The practice domain includes the rituals, spatial organization, and interpersonal behaviors used in a culture. The practice aspect of culture includes both power and ideas—these two forces are acted out in even the smallest gestures, speech patterns, manners of dress, social distances, food choices, etc. Practice is the embodiment of “tradition.” Thus, cultural practices are the enactments of the cultural ideology at the personal or small group level.

Help seeking and healing options:

· The type of healing a person seek depends largely on one’s beliefs about the cause of the illness. The practice of healing aims to remove the cause of illness or protect people from these causes².

Health practices in different culture:

· Use of Protective Objects:

Protective objects can be worn or carried or hung in the home- charms worn on a string or chain around the neck, wrist, or waist to protect the wearer from the evil eye or evil spirits.

· Use of Substances:

It is believed that some food substances can be ingested to prevent illness. People from many ethnic backgrounds eat raw garlic or onion In an effort to prevent illness or wear them on the body or hang them in the home.

· Religious Practices:

Practices such as from a divine source the burning of candles, rituals of redemption, and in many instances a heritage consistent person may prayer.

· Traditional Remedies:

The use of folk or traditional medicine is seen among people from all walks of life and cultural ethnic back ground. Many plants are used by specific communities.

· Healers:

Within a given community, specific people are known to have the power to heal. These approaches may originate in culture, ethnicity or religion.

· Immigration:

Every immigrant group has its own cultural attitudes ranging beliefs and practices regarding these areas.

· Gender Roles:

In many cultures, the male is dominant figure and often they take decisions. The female usually is passive. In some other cultures females are dominant.

· Beliefs about mental health:

In the traditional belief system, mental illnesses are caused by a lack of harmony of emotions or by evil spirits. Another belief that problems in this life are most likely related to transgressions committed in a past life.

· Economic Factors:

Factors such as unemployment, underemployment, homelessness, lack of health insurance and poverty etc prevent people from entering the health care system.

· Time orientation:

It is varies for different cultures groups. People from different cultures have their own time management plans^18-19.

Impact of culture in psychiatric practice:

· Cultural considerations in clinical practice

· Clinical assessment and diagnosis

· Culture and psychopathology

· Culture and psychiatric treatment

Cultural considerations in clinical practice:

Folk concepts and stigma of mental disorders:

Even though modern psychiatry has made significant progress in its scientific understanding of the nature of psychiatric disorders, many people still believe various folk concepts about mental illness. Loss of soul, intrusion of illness objects, the wrongdoing of ancestors, deficiency of vitality, and an imbalance of yin and yang are some examples of folk interpretations of mental illness (Tseng 2001). An individual holding these beliefs might resist taking psychotropic medications. Although increased knowledge and improvements in clinical care are changing peoples’ attitudes toward mental disorders, there are still broad cultural differences in these attitudes. For instance, in Arab societies and in India, the mentally ill are respected and tolerated because of the historical notion that divine messages are sent through them. In contrast, in many societies, there is a general fear of and a strong stigma attached to "insane" people. These negative views of mental disorders obstruct the practice of psychiatric care⁷.

Cultural differences in therapist-patient relationships:

Interpersonal relations are closely defined and regulated by social etiquette and cultural norms. This is particularly true for attitudes toward authority, which encompass the physician-patient relationship. In the United States, the predominant form of physician-patient relationship is egalitarian, based on a contractual agreement between the two and heavily influenced by an ideological emphasis on individualism, autonomy, and consumerism. In contrast, in many Asian cultures, the relationship is modeled after the ideal hierarchical relationship. The physician is seen as an authority figure who is clearly endowed with knowledge and experience. The ideal doctor should have great virtue and should be concerned, caring, and conscientiously responsible for the patient’s welfare. In return, the patient must show respect and deference to the physician’s authority and suggestions (Nilchaikovit et al. 1993).

Ethnic/racial transference and counter transference:

Ethnic or racial transference is a situation in which a patient develops a certain relationship, feeling, or attitude toward the therapist because of the therapist’s ethnic or racial background. Ethnic or racial counter transference is the reverse phenomenon, in which a therapist’s feelings and interventions are influenced by the patient’s ethnic or racial background. Similar to personal transference or counter transference, ethnic or racial transference or counter transference can be positive or negative and can severely influence the process of therapy. It is therefore critical to recognize when treating the patient. Ethno cultural transference may be manifested as denial of ethnicity and culture; mistrust, suspicion, and hostility; ambivalence toward the therapist; or over compliance and friendliness (Comas-Díaz and Jacobsen 1991). Likewise, counter transference may be manifested as denial of ethno cultural differences; excessive curiosity about the patient’s ethno cultural background; and excessive feelings of guilt, anger, or ambivalence toward the patient⁷.

Therapist-patient matching:

Although the matching of therapist and patient by ethnicity, race, or cultural background sounds reasonable and desirable, it is not a simple matter. Such matching may not only be impractical, but clinically it does not necessarily guarantee success. Successful therapy relies on professional competence reflected in knowledge and experience. It also depends on the therapist’s personal ability to establish a positive relationship with and show empathy toward the patient. In addition, therapists with the same ethnic or racial backgrounds as their patients may sometimes be at a disadvantage. This can occur, for example, if the patient does not want to reveal his or her personal background to a therapist with the same background for fear of being judged harshly, or if the therapist does not offer a proper figure for ethnic identification.

Language and meanings in cultural context:

In psychiatric practice, it is important to grasp meanings expressed explicitly, tacitly, or in a symbolic way. Cultural idioms may invoke subtle or symbolic meanings of words. For instance, if someone says, "My house is far away," it might mean that you are not welcome to visit it. If someone asks whether you have already eaten, it might not mean the person is concerned about your eating or interested in offering you a meal, it may simply be a social greeting, like asking "How are you?" Even when a patient reveals a wish to kill himself, it should not necessarily be taken literally but requires a clinical judgment about the patient, his psychopathology, and the possible motivation for such a revelation. In addition, a cultural judgment is needed: an understanding of the general custom among people in the patient’s culture of revealing a wish to end their lives, its common implication, and the possible message that the person wants to communicate. For example, if a Muslim person, whose faith forbids self-killing, expresses the wish that God would "take back" his life, the person may be indicating that he has suicidal thoughts, which must be taken seriously⁶.

Styles of problem presentation:

A patient might make a somatic complaint not because she actually has a somatic problem but simply because it is a culture-patterned behavior to initially present somatic problems to a physician, or even to a psychiatrist. Sensitive probing, however, often reveals the more important emotional problems (Tseng 1975). In contrast, a patient might present a psychologized complaint—such as how much he hates his father or a trauma he encountered in his early childhood—at his first session with the therapist, as if he were very psychologically minded and aware of his psychological problems. However, as the therapy goes on, it might be shown that the patient learned to present such "psychoanalytical" material from the mass media or from his friends, whereas he actually knows nothing about his own psychological problems.

Disclosure of personally sensitive information or taboo subjects:

In general, a therapist would like to have the patient disclose as much personal information as possible so that a proper, in-depth understanding of the patient can be achieved. There are many cultural variations, however, regarding how much internal information a person should reveal to an outsider and what issues are taboo. For example, in many cultures (including Asian cultures) it is taboo to discuss imminent death from a terminal disease. In such a circumstance, breaking the social taboo and helping the person face reality and prepare for the end of life has to be done delicately and subtly, rather than discussing the subject openly and liberally. Otherwise, the patient might conclude that the therapist wishes him to die soon.

Culture and psychopathology:

Culture substantially influences psychopathology (Tseng and Streltzer 1997). The various ways that culture contributes to psychopathology have been termed pathogenetic, pathoplastic, pathoelaborating, pathofacilitating, pathodiscriminating, and pathoreactive effects (Tseng 2001). Culture has less influence on organic mental disorders and major psychiatric disorders (functional psychoses) than on minor psychiatric disorders (neuroses) or substance abuse. Culture has a profound influence on culture-related specific syndromes or epidemic mental disorders ³.

Clinical assessment and diagnosis:

Psychiatric assessment results from a dynamic process that involves multiple levels of interaction between the patient (and sometimes the patient’s family) and the clinician⁷.

Experience of distress by the patient:

A person experiences pain when he is hit; feels anxious if he is worried about something; becomes paranoid if he suspects that he is being persecuted by others; or feels sad if he has lost something significant to him. All these reactions to distress—which may be manifested as symptoms or signs—are subjective, experiential phenomena. However, it is clear that the source of the distress can be influenced by sociocultural factors. For instance, stress can be produced by culturally demanded performance. Stress can be created by culturally maintained beliefs. Stress can be generated by cultural restrictions of behavior, culture-supported attitudes, or other culture-related factors

Perception of problems by the patient:

After the experience of distress and the emergence of symptoms, the patient perceives and interprets the distressing experience. This psychological phenomenon is subject to the influence of cultural factors in addition to other variables, such as the patient’s personality, knowledge, and psychological needs. Depending on how the problem is understood and perceived by the patient, he will show a secondary process of various reactions to the distress. In other words, the patient’s perception of and reaction to the primary symptoms will add secondary symptoms that compound the clinical picture. The process of forming secondary symptoms is usually subject to cultural influences.

Presentation of complaints or illness by the patient:

The next step is the presentation of the complaints or illness by the patient to others—the process and art of "complaining." For instance, patients of certain ethnic groups tend to make somatic complaints to their clinicians in their initial sessions at mental health clinics. This tendency requires careful understanding. There may be several alternative implications: a physical condition is the patient’s primary concern; somatic symptoms are being used as socially recognized signals of illness; the symptoms constitute a culturally sanctioned prelude to revealing psychological problems; or the symptoms are a reflection of hypochondriacal traits that are shared by the group (Tseng 1975). Therefore, the nature of the somatic complaint needs to be carefully evaluated and understood rather than simply dealt with or labeled as a somatoform disorder.

Perception and understanding of the disorder by the clinician:

A clinician, as a cultural person and a professional, has his or her own ways of perceiving and understanding the complaints that are presented by the patient. The clinician’s psychological sensitivity, cultural awareness, professional orientation, experience, and medical competence all act together to influence his or her assessment of the problems a patient has presented (Streltzer 1997). The cultural background of the clinician is a significant factor that deserves special attention, particularly when he or she is examining a patient with a different cultural background or one with which the clinician is unfamiliar. The clinician’s style of interviewing, perception of and sensitivity toward pathology, and familiarity with the disorder under examination all influence his or her interaction with the patient, which in turn influences the outcome of the clinician’s understanding of the disorder.

Diagnosis and categorization of the disorder by the clinician:

The final step in the process of evaluation is making a clinical diagnosis. Determination of the appropriate clinical category for the diagnosis is influenced by the professional orientation of the clinician, the classification system used, and the purpose of making the diagnosis (Cooper et al. 1969; Jilek 1993; Tseng et al. 1992). In many societies, a clinician needs to take into consideration the social impact of diagnostic labeling on the patient and the family. Recognising patients with clinically significant functional fatigue or weakness often seek help from various care-givers, prevalence of this condition was studied in four specialty clinics of Sassoon Hospital, Pune, India. Overall prevalence of 5.02% with higher rates in the dermatology and ayurved clinics than in psychiatry and medicine clinics⁸.

Culture and psychiatric treatment

Psychiatric treatment in general:

In addition to socioeconomic and medical factors per se (including knowledge and theory), the mode of psychiatric treatment is also directly or indirectly influenced by cultural factors. For instance, the decision to follow a more biologically or a more psychologically oriented treatment model is subject to the patient’s and the therapist’s views on the usefulness of these models, and these views are based on their cultural attitudes and beliefs. Decisions regarding whether the patient should be treated in a closed institution with custodial care or in an open system in the community are greatly influenced by the family’s and the community’s attitudes toward mental illness³.

Culture and psychotherapy:

Psychotherapy is greatly influenced by cultural factors (Tseng and Streltzer 2001). This is true of both the technical aspects and the theoretical and philosophical considerations of psychotherapy (Tseng 1995).

Ethno psychopharmacology:

Genetic and other biological factors affect pharmacokinetic and pharmacodynamic processes. In addition, significant psychological factors—closely associated with social and cultural factors—influence the giving and receiving of medication⁶.

Ethnopsychology in relevance to modern psychiatric treatment:

· Herbs such as St John’s wort and valerian are excellent for mild to moderate depression, anxiety and insomnia. Other useful herbs for restlessness and sleep disorders include hops, lemon balm, passion flower and lavender.

· Gingko biloba is another useful herb, especially in the treatment of cognitive deficits (cerebral deficiency disorders) due to organic brain disorders

· Flower essences subtly influence mood, leading to greater balance and stability. Mustard, for example, is given for depression and deep gloom.

· Aromatherapy: Just the smell of many oils is extremely relaxing. A few drops of lavender placed near the bed of a restless child will often help him or her fall asleep quickly. Clary sage, bergamot, lavender and neroli have uplifting, antidepressant effects. A drop of rose oil rubbed onto the hands and held over the face soothes grief.

· Diet and Nutrition: Adjusting both diet and nutrition may help some people with mental illnesses manage their symptoms and promote recovery. For example, research suggests that eliminating milk and wheat products can reduce the severity of symptoms for some people who have schizophrenia and some children with autism.

· Art Therapy: Drawing, painting, and sculpting help many people to reconcile inner conflicts, release deeply repressed emotions, and foster self-awareness, as well as personal growth. Some mental health providers use art therapy as both a diagnostic tool and as a way to help treat disorders such as depression, abuse-related trauma, and schizophrenia.

· Dance/Movement Therapy: Those who are recovering from physical, sexual, or emotional abuse may find these techniques especially helpful for gaining a sense of ease with their own bodies. The underlying premise to dance/movement therapy is that it can help a person integrate the emotional, physical, and cognitive facets of "self."

· Music/Sound Therapy: Music stimulates the body's natural "feel good" chemicals (opiates and endorphins). This stimulation results in improved blood flow, blood pressure, pulse rate, breathing, and posture changes. Music or sound therapy has been used to treat disorders such as stress, grief, depression, schizophrenia, and autism in children, and to diagnose mental health needs.

· Acupuncture: The Chinese practice of inserting needles into the body at specific points manipulates the body's flow of energy to balance the endocrine system. This manipulation regulates functions such as heart rate, body temperature, and respiration, as well as sleep patterns and emotional changes. Acupuncture has been used in clinics to assist people with substance abuse disorders through detoxification; to relieve stress and anxiety; to treat attention deficit and hyperactivity disorder in children; to reduce symptoms of depression; and to help people with physical ailments.

· Cuentos: Based on folktales, this form of therapy originated in Puerto Rico. The stories used contain healing themes and models of behavior such as self-transformation and endurance through adversity.

· Scientific research on transcendental meditation programme has shown effectiveness of meditation on reducing neuroticism improving learning improving academic achievements, prevention of alcohol and drug abuse

· Prekshyadhyan a combination of meditation and relaxation technique has been found useful in improvement of concentration, memory and anxiety reduction. Effectiveness of vipassana meditation as a therapeutic tool in psychological and psychosomatic illnesses.

· Some Ayurvedic combinations have been used as anti-anxiety and anti-depressants, reports of which are available from National Institute of Ayurvedic, Jaipur. Vacha (Acorus calamus) and Jyotishmati (Celastrus Panniculatus) were found useful in treatment of depression (Bahetra). Unmad Bhanjan Ras a combination of 24 compounds was found to have anti-psychotic effect equivalent to chlorpromazine.

· While communicating with cancer patients it was found by Gautam and Nijhawan that Indian patients tend to accept the diagnosis of cancer rather easily. The concept of death prevalent in Indian culture based on philosophy of Gita where soul is accepted as immortal and it is believed to transfer through death from one to another human/species plays a significant role in the easy acceptance of the diagnosis and the planning for the rest of the life. The understanding of human psyche in vedantic model is more acceptable to Indian patients because of transfer of attitudes from generation to generation. Anecdotes from Bhagwat Gita as a psychotherapy of dying patient is virtually a tradition in Indian culture. Even now in many families when death is anticipated preaching of Lord Krishna stating that thoughts at the time of death determine the species of next birth help the individual to accept the death in a more gracious manner²³.

Application of psychiatric nursing practice:

· This multidimensional model of culture allows nurses to examine culture in a variety of places—the things people do the structure of their social organizations, and their beliefs and values. Nurses have a responsibility to understand the influence of culture, race and ethnicity on the development of social emotional relationship, child rearing practices and attitude toward health².

Nursing assessment:

· The nurse should have an understanding of the general characteristics of the major ethnic groups, but should always individualize care rather than generalize about all clients in these groups.

· Before assessing the cultural background of a client, nurses should assess how they are influenced by their own culture.

· Nursing assessment must be sensitive to the common ways that distress is experienced and communicated. To determine relevant aspects of folk or traditional healing that can be incorporated into nursing care. Based on beliefs about spiritual causes, for example, the appropriate spiritual healer should attend to the spiritual aspects of the illness without sanction or evaluation by the nurse. This is more than respect for diverse traditions, but rather an incorporation of other methods of healing into the biopsychosocialspiritual care of the patient and the family. In addition, the safety and compatibility of folk remedies and therapies must be evaluated. For example, herbal remedies often contain biochemicals with powerful pharmacological effects. If the patient is using herbal remedies, these may interact with medical therapies.

· Accurate assessment of health related beliefs and values often necessitate the collaboration with a cultural translator. A cultural translator does more than translate language. They can assist the nurse in understanding the health related concepts that are specific to that culture. The cultural translator should also closely resemble the patient with regards to geographical region, social class and gender. Using information gained from work with patients, families and cultural translators, the nurse can use concepts of health and illness to understand the meaning of the illness to the person and their community. Often, beliefs about the causes of illness reveal feelings of failure, concerns about social problems, spiritual distress or other negatively sanctioned problems

Nursing diagnosis:

The nursing diagnosis for clients should include potential problems in their interaction with the health care system and problems involving the effects of culture.

· The planning and implementation of nursing interventions should be adapted as much as possible to the client's cultural background. Discussing cultural questions related to care with the client and family during the planning stage helps the nurse understand how cultural variables are related to the client's health beliefs and practices, so that interventions can be individualized for the client.

· Psychiatric nursing care is a culturally derived set of interventions designed to promote verbalization of feelings, teach individually focused coping skills, and assist clients with behavioral and emotional self-control consistent with Western cultural ideals. However, consideration should be given to providing psychiatric nursing care that is not bound to specific cultural ideologies but aimed at general mental health goals. Cultural competence has been defined as the nurses' ability to achieve ethno relativism so as to work within the cultural context of patients and to know, assess, and integrate the beliefs, values, and practices, practices, and problem solving strategies of the patients' cultures in the care provided to patients .This process requires health care providers to see themselves as becoming culturally competent rather than being culturally competent.

· A related concept focusing on nursing intervention is that of the nurse as a culture broker. This framework incorporates advocacy, negotiation, mediation, and sensitivity to patients' and families' needs. Culture brokerage, as a nursing intervention, is a strategy that is intended to assist nurses, to "bridge" the gap between the orthodox health care system and the health belief systems of clients and their families who are from "different" cultures.

· Language and communication are central in the accessibility of health care. The choice of language affects the perception of the people, including some and excluding others. The need for nurses to minimize barriers to access to health care directly. Nurses can work on behalf of the community to translate materials, make videotaped materials for those who cannot read, provide translators, and create health care settings that include familiar symbols, objects and that are delivered in an environment that resembles one that is familiar and understandable.

· Nurses must work at the community level to remove aspects of the environment that may cause illnesses. Nurses should identify respected community leaders and cultural translators, and work in partnership to identify health related priorities. These are likely to involve political action on the part of the nurses to change elements of the environment, such as the infrastructure, environmental safety and security.

· Nurses are in the position of advocate for the underserved and the disenfranchised. In the advocate role, they should determine what social and structural factors create illness, cause barriers to health and prevent access to health care. However, understanding these political and economic factors forces is not enough. Nurses must work to change these systems of power. Often this means first giving up power gained from alignment with medicine, science and psychology.

· The ways that families care for each other and sick roles of patients are culturally defined and enacted. Care giving roles of various family members must be ascertained and incorporated in all aspects of care, from acute care to outpatient care. The nurse can designate the appropriate recipient for teaching based on their roles in the care giving process.

· Community health promotion centers on working with the intersection of beliefs, recognizing political and economic forces and helping community members alter or enact health related practices.

Evaluation should include the nurse's self-evaluation of attitudes and emotions toward providing nursing care to clients from diverse sociocultural backgrounds. Evaluation continues throughout the nursing process and should include feedback from the client and family. Self-evaluation by the nurse is crucial as he or she increases skills for interaction. The client’s educational level and language skills should be considered when planning teaching activities.

Different studies related to culture and mental health:

Presentation of symptoms in different cultures:

· Gautam and Kapur, in a study of psychiatric patients presenting with somatic complaints reported that more patients from Muslim ethnic group presented with somatic symptoms in South Indian population. Headache followed by nauseating sensation and vomiting were the prominent somatic complaints of the neurotic disorders. Gautam et al. repeated the study in north Indian population and found that the predominant somatic complaint was constipation and feeling of gas in the abdomen⁹.

· Kulhara and Chakrabarti, studied “Culture and schizophrenia and other psychotic disorders” and observed that there is certain uniformity to the way schizophrenia presents globally; there are equally significant cultural differences. The outcome of schizophrenia appears to be better in developing, than developed cultures; reasons for this are far from clear, nevertheless, it can be safely assumed that culturally-determined processes, whether social or environmental, are partly responsible¹¹.

· Jacob KS., reported in their study, “The cultures of depression.” that there are many cultural issues that need to be resolved. Clinically, there is a need to look beyond symptoms and explore personality, life events, situational difficulties and coping strategies in order to comprehensively evaluate the role of vulnerability, personality factors and stress in the causation of depression. In a review, “Depression among women in the South-Asian region: The underlying issues.” ^12,13.

Culture-bound syndromes:

· Chaturvedi SK et al. in their work, “Dissociative disorders in a psychiatry institute in India - A selected review and patterns over a decade” emphasized that unlike in the West, dissociative identity disorders were rarely diagnosed; instead, possession states were commonly seen in the Indian population, indicating cross-cultural disparity¹⁰

· Sumathipala A et al. in their study “Culture-bound syndromes: The story of dhat syndrome.” explored the possibility of the presence of similar symptoms and syndromes in different cultures and historical settings. And concluded that the presence of similar symptoms and syndromes in different cultures and historical settings^14-16.

Cultural attitude to treatment:

· Nunley M,in his study, “Why psychiatrists in India prescribe so many drugs?” offered the need to “sell” psychiatry as a legitimate kind of medicine by satisfying client expectations, and psychiatrists’ relationship to other actors in India’s pluralistic medical system, as factors that encourage a reliance on pharmaceutical or somatic interventions in psychiatric settings¹⁷.

Belief system influencing course and outcome:

· Shankar BR et al while studying “Explanatory models of common mental disorders among traditional healers and their patients in rural south India”, found that different terms, concepts and treatments were used by traditional and faith healers. 42.3% satisfied the International Classification of Diseases-10 Primary Care Version criteria for Common Mental Disorders. Mixed anxiety depression was the most common diagnosis (40%). they concluded that an understanding of local patient perspectives of common mental disorders will allow modern medicine to provide culturally sensitive and locally acceptable health care²⁰.

· Bhugra D described “Sati: A type of non-psychiatric suicide” and illustrated cultural factors, which may be seen as contributing to the act of suicide. Loganathan and Murthy SR. studied “Experiences of stigma and discrimination endured by people suffering from schizophrenia” and found significant differences between rural and urban respondents. They concluded that mental health programs and policies need to be sensitive to the consumer need and to organize services and to effectively decrease stigma and discrimination^21-23.

Psychiatric Nursing Studies:

· Wilson DW explored the perceptions of clients with mental illness regarding the overall effectiveness of psychiatric nursing care in meeting their cultural needs, and psychiatric nurses' perceptions of how and to what extent they provided culturally competent psychiatric mental health nursing care to diverse client populations. This descriptive study employed a qualitative research design using a multi-method data collection approach consisting of in-depth individual client interviews and a self-administered nurse questionnaire. Client participants tended to minimize the importance of receiving care related to their cultural needs. They described (1) encouraging and reassuring me; (2) speaking up for me; and (3) praying a lot as essential to their care. Nurse participants perceived their psychiatric nursing care to be culturally competent; however, few described specific strategies for incorporating cultural beliefs and practices into nursing care. Client participant lacked awareness of their cultural needs and had difficulty identifying and describing specific nursing interventions that contributed to positive mental health outcomes. Nurses perceived that they provided culturally competent care but actually lacked specific knowledge and skills to do so effectively²⁴.

· Hoke MM, LK. Described an exemplar educational approach used to teach cultural competency to beginning graduate psychiatric mental health nursing students. Using interactive strategies delivered within the 4 phases of the curriculum, the approach has been shown to facilitate students' ongoing journey to cultural competence. Building on baccalaureate nursing competencies, the course addresses attitudes, knowledge, skills, and cultural humility to strengthen cultural self-assessment, cross-cultural clinical practice expertise, and the use of culturally appropriate research for graduate students²⁵.

CONCLUSION:

Finally, cultural psychology data to date suggest that interdependent cultural models exist in relation to stress roles, relationships, interpersonal harmony, and authority. These values can inform nursing practice when the nurse incorporates the sociocultural factors into the plan of care. Curiosity, negotiation, compromise, and flexibility are attributes that can help the nurse provide culturally relevant care. It would be appropriate to conclude with the words of Dr. Radhakrishnan: “India has seen empires come and go, has watched economic and political systems flourish and fade. It has seen these happen more than once. Recent events have ruffled but not diverted the march of India’s History. The culture of India has changed a great deal and yet has remained the same over three millennia. Fresh springs bubble up, fresh streams cut their own channels through the landscape, but sooner or later each rivulet, each stream merges into one of the great rivers which has been nourishing the Indian soil for centuries.”

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Received on 08.07.2016

Modified on 29.07.2016

Accepted on 28.10.2016

Research J. Humanities and Social Sciences. 7(4): October- December, 2016, 325-336.

DOI: 10.5958/2321-5828.2016.00051.6