Several authors have analyzed the differences in judicial cultures around the world. In 1995, Ciccone and Ferracuti published an outstanding account of the differences between judicial systems of the United States and Italy and of the differing roles of forensic psychiatrists within these two systems. They emphasized the importance of the wording of relevant legal standards and the assumptions and reasoning used by forensic psychiatrists in both countries (1). Ciccone and Ferracuti also noted that judicial practices involving forensic psychiatric evaluations are quite different in Italy than in the United States. For instance, in Italy, unlike the United States, it is not uncommon for a judge to attend a forensic psychiatric evaluation.
In 1996, Chaleby discussed the importance of Islam and Islamic judicial history in the practice of forensic psychiatry in Islamic countries (2). He pointed out that "[c]onfidentiality is sacred under Islamic law; even judges cannot order a psychiatrist to break it" (2). The scope of the duty of confidentiality may be broader in Islamic countries than in the West, due to the religious interpretation of the duty in Islam.
Roth and Pruett (3) and Desai and Desai (4) discussed the importance of changing cultural concepts of gender hierarchy in the legal treatment of rape in modern-day India. In India, village councils, or panchayats, act as a type of traditional legal system parallel to the formal criminal justice system. Roth and Pruett (3) and Desai and Desai (4) reported a recent case in which a 14-year-old bride in a remote Indian village had been raped by her father-in-law and deserted by her husband. The bride’s own father ordered her to commit suicide to restore the family’s honor, as tradition dictated. In this case, the local panchayat decided that the bride’s husband, father-in-law, and father were all to be banished from the village for life. The bride was allowed to hit her father and husband in the head with a shoe to restore her honor. Recent progress made by Indian feminists has eroded traditional male dominance, even in some remote villages.
The aforementioned articles point out that judicial systems vary from country to country and attitudes toward legal issues within a given culture and country change with time. Several authors have studied cultural issues in forensic psychiatry within their own countries.
In 1990, Duncan (5) analyzed cultural issues in forensic psychiatry from a Canadian perspective. She listed the essential characteristics of a forensic psychiatric assessment and noted the importance of cultural issues in such assessments. For instance, she noted the importance, of recognizing the possibility that evaluees with a background among the native peoples of Canada may regard hallucinatory experiences as part of their traditional spirituality. Duncan also stressed the importance of a practitioner’s recognizing his or her own cultural set when performing a forensic evaluation within a particular legal system. She concluded, "There is no clear cut answer to the question of how the process of forensic assessment can best take cultural factors into account. It is, nevertheless, crucial to recognize that culture is at least as significant, if not more so, than any other factor considered in forensic assessment" (5).
In 1997, Bhugra (6) discussed the importance of cross-cultural issues in the planning and delivery of psychiatric services in the United Kingdom (United Kingdom). He pointed out that Western models are often used for the management of mental illness in non-Western ethnic communities in the UK. Bhugra also noted that the country’s forensic special hospitals in prisons contain many African-Caribbean males. He emphasized the considerable need for appropriate psychiatric treatment of black prisoners in the (6). Familiarity with Caribbean patois, for instance, is important for psychiatrists treating such prisoners.
The literature is scanty on cross-cultural issues in forensic psychiatry training programs, but many of the issues raised in articles on teaching cross-cultural general psychiatry apply to forensic psychiatric training as well. In 1989, Yager et al. summarized the experience of the University of California-Los Angeles (UCLA) Department of Psychiatry in training medical students, residents, and fellows in transcultural psychiatry (7). They described the importance of exposing their general psychiatry residents to various ethnic groups in the Los Angeles area, including African Americans, Latinos, and Southeast Asians. They described having developed an extensive curriculum, including weekly seminars and the showing of films such as "El Norte" and "The Color Purple," as part of their inculcating an atmosphere of ethnic sensitivity among their trainees. UCLA developed a yearlong PGY-V fellowship in transcultural psychiatry. Fellows in the UCLA program worked with minority patients and taught seminars in transcultural psychiatry to medical students and residents, along with psychologists, social workers, and nurses who were also interested in learning about transcultural psychiatry (7).
Dowdall described the significance of including training in cross-cultural issues in behavioral therapy education in South Africa circa 1982, a period of transformation for the country (8). He emphasized the importance of linguistic difficulties as a problem for psychiatrists and psychologists, most of them from white, middle-class backgrounds. A number of them spent a good deal of clinical time treating African patients from rural areas, many of whom did not speak English or Afrikaans. Dowdall also emphasized the need to take into account the cultural patterns and beliefs of patients of various South African cultures. He noted that authority is closely linked to age and sex in traditional African culture and pointed out that communication is frequently ritualized in a pattern unfamiliar to white therapists. Dowdall cited H. Mkhize, a student of indigenous healing systems in South Africa, who in 1982 pointed out that assertiveness training could effectively be undertaken with traditional black clients in rural South Africa, but should be geared toward channels appropriate to their community (8). Dowdall stated that "… if one were dealing with a woman whose depression seemed linked to assertiveness problems, one might first ask: ‘Within the Mthembus, how does a woman fight for her rights?’ A serious stand on her rights might involve the woman walking up and down inside the yard of her house and calling out her grievances to the dead ancestors, in the hearing of her husband, which would have an effect on him. Assertive training may be aimed at helping the woman to achieve this, and thus asserting herself appropriately without exceeding cultural limitations" (8).
In 1994, Minas et al. reported their survey of mental health professionals from a variety of disciplines on their knowledge of cultural issues relevant to the large immigrant population of the Australian state of Victoria (approximately 30%), where these mental health professionals worked (9). In the survey, psychiatric professionals in Victoria cited the language barrier as a significant factor to them in their daily work with immigrant patients, and they discussed their training in cultural issues relevant to treating three important ethnic, immigrant groups in Victoria: Turkish, Vietnamese, and Italian. Approximately one-third of their sample considered that their professional training had not prepared them at all for cross-cultural clinical work. Data showed that 42.5% of respondents reported that on the job experience was their major source of knowledge about cross-cultural issues relevant to immigrant groups in Victoria. More than 90% of the survey respondents indicated that they were quite interested or very interested in attending staff education sessions for improving cross-cultural knowledge (9).
In 1995, Griffith discussed the importance of experts’ sensitivity to black and white cultural issues in evaluations conducted in the course of transracial adoption disputes in the United States. He also emphasized the need for experts in such cases to make clear to courts the limitations of science-based data on the outcome of transracially adopted children (10).
Moffic and Kinzie reviewed the history and features of cross-cultural psychiatric services in 1996 (11). They emphasized the broad range of culturally identifiable groups for whom psychiatric care needed to be tailored, reaching beyond traditional definitions of cultural groups by including foreigners and those who are "different" from the Caucasian American majority to a definition that takes into account individuals of various ethnic minorities, religions, genders, the poor, the elderly, the deaf, the disabled, individuals in the public eye, and other groups (11).
In 1988, Lefley emphasized the importance of training in cross-cultural issues for psychiatry residents and other mental health professionals who treat chronically mentally ill patients from a variety of backgrounds. She discussed how important it is for psychiatry residents to learn about differences in attitudes toward families and the role of family in the treatment of chronically mentally ill patients between practitioners using a Western healing model and those using indigenous healing models in treating outpatients with schizophrenia and other chronic mental illnesses who lived in southern Florida (12). Psychiatrists who learned about such differences would be expected to become more effective in their relationships with other caregivers and families of chronically mentally ill patients.
The Medical College of Wisconsin (MCW) opened a forensic psychiatry training program in 1996, the same year in which accreditation was first offered to such programs. As part of MCW’s successful program to achieve accreditation by ACGME, its faculty designed a clinical and didactic curriculum to give trainees a wide exposure to forensic psychiatric experiences in diverse populations. The need for cross-cultural training as part of the curriculum was clear from the beginning, when the yearlong clinical and didactic experience in forensic psychiatry was designed. The program trains up to two fellows at a time, each of whom spends 6 months based in two very different settings: 1) an outpatient setting, at the Wisconsin Forensic Unit in Milwaukee and the Milwaukee County House of Correction, performing outpatient criminal forensic evaluations and providing correctional care to a population reflecting the multiethnic makeup of a large urban area in Milwaukee; and 2) in an inpatient state hospital, on the forensic service of the Mendota Mental Health Institute in the much smaller city of Madison, Wisconsin’s state capital, 70 miles west of Milwaukee. During their clinical time, trainees in the program interact with Milwaukee population that is primarily comprised of members of ethnic minorities, including African Americans, Hispanics (especially Mexican Americans and Puerto Ricans), and a substantial number of members of Southeast Asian immigrant groups. The largest Southeast Asian populations encountered by the forensic psychiatry fellows include the Hmong (members of hill tribes who constitute a minority in their native Laos), lowland Laotians, Cambodians, and Vietnamese. Most of the patients treated by the forensic psychiatry fellows at the Mendota Mental Health Institute in Madison come from less urbanized areas of Wisconsin and include mostly Caucasian Americans, many from rural backgrounds. At both the Milwaukee and Madison sites, the fellows also evaluate and treat some of Wisconsin’s Native Americans.
Fellows working at the two sites meet weekly with MCW faculty for a didactic program of seminars and case conferences. Throughout the fellowship year, faculty members of the program emphasize fellows’ sensitivity to the diverse patient populations seen by trainees at MCW’s two forensic clinical sites. The fellows see a disproportionately minority population in performing evaluations for the courts in criminal forensic psychiatry, including evaluations of defendants’ competency to stand trial and their criminal responsibility. They likewise treat a disproportionately large minority population in their correctional psychiatry experience at the Milwaukee County House of Correction.
In 1998, the imprisonment rate for non-Hispanic, African American males in the United States was more than 8 times higher than that for non-Hispanic whites (13). In Wisconsin, the ratio was more than 19 times higher in 1999 (14). In the United States as a whole, Hispanic-American men were incarcerated at a rate more than three times higher than non-Hispanic white men in 1998 (13), while in Wisconsin, the rate of imprisonment of Hispanic men was more than 5-1/2 times that of non-Hispanic white men in 1999 (14). In the United States as a whole, Native-American men were incarcerated at a rate of more than twice that of non-Hispanic white men in 1998 (13), while in Wisconsin, Native-American men were incarcerated at more than 6 times the rate of non-Hispanic whites in 1999 (14) (t1).
While the reason for the even greater over-representation of disadvantaged minority groups in the incarcerated population of Wisconsin compared with that of the rest of the United States is beyond the scope of this article, the data show that, although the degree of disproportionality may not be as great in other parts of the country as in Wisconsin, it is nevertheless the case that members of minority groups are very substantially over-represented in the incarcerated population throughout the United States. The incarcerated population is the population treated in correctional psychiatry, which is one of the major areas covered in didactic and clinical settings in forensic psychiatry training programs. Hence, the MCW experience of forensic trainees seeing a diverse population is reflected in forensic training across the United States.
In case conferences and clinical supervision, MCW forensic psychiatry faculty members emphasize to fellows the importance of taking into account the cross-cultural issues of language, culturally different notions about unusual perceptual phenomena, and culturally different expressions of major mental illness in evaluating criminal defendants’ competency to stand trial and criminal responsibility for their actions.
For instance, Hispanic defendants and Southeast Asian defendants often bring their limited skills in everyday English to their roles as criminal defendants, and their language difficulty is compounded by their difficulty understanding the English words used in the American criminal justice system (e.g., judge, jury, prosecuting attorney, defense attorney, and witness). Trainees are expected to perform evaluations of such defendants with competent interpreters of Spanish, Hmong, Cambodian, or whatever language the defendant speaks. Faculty members emphasize to trainees the importance of insuring that the interpreter employed feels comfortable in his/her ability to translate legal terms, which may require a search for a particularly skilled interpreter for the conducting of an adequate forensic evaluation.
Even when excellent linguistic interpretation is available, the background of some defendants seen in criminal forensic evaluations in Wisconsin poorly equips them for an understanding of the American criminal justice system. For example, many of the Marielito Cuban refugees who came to the United States at the beginning of the 1980s, despite having some familiarity with the criminal justice system and mental health system of Castro’s Cuba, arrived in the United States with very little understanding of how those systems differ in this country from the ones they knew in their homeland. Likewise, many Hmong refugees, who lived in the margins of society in their native Laos and whose native language did not even have a written form until recent years, arrived in the criminal justice system in Wisconsin singularly ill-prepared to understand concepts such as the right to remain silent or to call witnesses at their trial. However, the relevant issue in an evaluation of a defendant’s competency to stand trial is not the defendant’s current understanding of the legal system, but rather his capacity to understand it, given enough education. Hence, fellows in the program are trained to educate evaluees from different cultures, who find themselves charged with a crime in the American legal system, so as to be able to give an opinion to the court on the evaluees’ capacity to understand their legal predicament and assist in their defense counsel.
Some of MCW’s forensic fellows come to the program without having had much exposure to the culturally acceptable phenomenon of religious ecstatic experiences in certain African American patients (particularly those from Pentecostal backgrounds), which evaluees in the forensic setting sometimes report, and which can be very similar to the experiences mentioned previously in the context of the native peoples of Canada. In the seminar setting, MCW faculty members educate fellows about the necessity of evaluating reports of ecstatic experiences such as a vivid experience of seeing and hearing Jesus Christ, within the context of a defendant’s entire mental status. A Pentecostal African American man who reports that he was comforted by an image of Jesus at a time of difficulty is not necessarily describing a true hallucinatory experience indicative of psychosis. The ability to interpret such a phenomenon within the context of a Pentecostal man’s religious and cultural background is essential to arriving at a proper diagnosis and giving the court accurate information about the criminal defendant’s mental state. The Medical College of Wisconsin’s forensic fellows are also educated about the tendency of some Mexican American families to downplay the significance of what may be genuine major mental illness, including schizophrenia, and to ascribe serious psychotic disturbance to "nervios," that is, "nerves." Jenkins described in a 1988 paper the use of the term "nervios" to reduce the stigma associated with mental illness in Mexican American families (15). Mexican American families can better accept a schizophrenic family member by pointing out that, "everyone has ‘nerves’ from time to time." The family may then ascribe the symptoms of schizophrenia to merely a bad case of "nerves," which Jenkins believed was an adaptive strategy to lessen stigma, rather than a denial of the seriousness of the symptoms (15). When forensic fellows take family histories from Mexican American criminal defendants or inmates, it is important for them to determine whether the case of "nerves" that a patient reports having experienced is an anxiety disorder or a major psychotic mental illness. (t2.)
Because of the significant impact that a forensic evaluation may have on the lives of criminal defendants, it is essential that the information submitted to a court about a defendant’s competency to stand trial or criminal responsibility be as accurate as possible. Hence, issues of cultural psychiatry such as sensitivity to an individual’s native language, religion, and country of origin are important throughout the field and are particularly crucial in criminal forensic psychiatric evaluations. Likewise, the ethnically diverse inmate populations seen in jails and prisons represent a group of patients requiring the utmost cultural sensitivity for proper diagnosis and treatment of mental illness. Forensic psychiatry fellowships confront many of the same challenges in educating trainees about cross-cultural psychiatry as general psychiatry residencies, but they face an even greater need to expose fellows to cross-cultural issues. Forensic psychiatry fellowship programs should address these issues in didactic form through seminars, case conferences, readings, and in the clinical supervision of forensic fellows’ work in outpatient and inpatient settings, with individuals being evaluated for the courts as well as in correctional settings where prisoners are treated. The authors hope this paper will encourage research on how forensic psychiatry fellowship programs are currently addressing these challenges.
This paper is based in part on a workshop presented at the Annual Meeting of the American Association of Director’s of Psychiatry Residency Training, March 2000.