EDITORIAL Culture, Bias, and Understanding: We Can Do Better

Susan Hatters Friedman, MD

J Am Acad Psychiatry Law 45:136–39, 2017

There is much unrest in the current American polit- includes the behaviors, traditions, rituals, attributes, ical climate. Immigration bans, xenophobia, racism, and the meanings of a group.3 Race theoretically re- sexism (and sexual exploitation), and monocultural fers to genetic heritage, but in practice is often based attitudes evidenced by some in America have been on phenotypic traits and, in the United States, on the prominent in international news. We must be par- “one drop [of black blood] rule” (Ref. 4, p 21). ticularly mindful of this in our role as forensic psy- Similar to my argument about the importance of chiatrists tasked with explaining to the court behav- understanding women and criminality,5 an under- iors of defendants from various cultures. standing of culture is crucial for forensic psychia- Throughout the world, cultural and racial minor- trists. The same critical question of “misguided be- ities are overrepresented in forensic populations. neficence” can occur in our interactions with various Court participants (including forensic psychiatrists) nondominant cultures in forensic psychiatry.1 Fo- come with their values and preconceptions. We are rensic psychiatry’s goal is to advance the interests of absorbed in our attitudes, values, traditions, and be- justice.6 Our ethical mandate is to strive for objectiv- haviors. Kirmayer and colleagues noted: “Since we ity. Yet, if we are blind to culture, we cannot objec- are fundamentally cultural beings, cultural concerns tively understand a person’s situation, beliefs, and are ubiquitous and are not the sole province of people experiences. We risk misunderstanding, perpetuat- identified as ethnically different” (Ref. 1, p 100). ing fear with potential overestimations of risk and Almost two decades ago, Griffith2 discussed the cul- inappropriate testimony. tural formulation as useful in forensic psychiatry. Forensic psychiatrists of the “dominant” race and The Problem of Bias culture primarily evaluate persons of “nondominant” 7 races and cultures. Therefore, many forensic evalua- Parker recently discussed the criminal justice sys- tions occur cross-culturally. Forensic psychiatrists tem’s biases against black and poor defendants. I was may find increasingly greater distrust of their motives first struck by the presence of this bias as a young among those evaluees from marginalized groups. At medical student. During an adolescent medicine the same time, dominant privilege asserts itself insid- elective, I spent a day observing in juvenile court. I iously in many situations, perhaps in viewing non- recall a well-to-do, white, unemployed, teenage girl, dominant people as the “other” or with fear. Culture accompanied by an attorney, who had a breaking- and-entering charge and did well in court. A poor, Dr. Hatters Friedman is Associate Professor, Department of Psycho- black, teenage boy who had pocketed some money logical Medicine, School of Medicine, University of Auckland, Auck- from the cash register at his job did not fare as well. land, New Zealand. Address for correspondence: Susan Hatters Fried- Just as Parker described, I was trained to identify man, MD, University of Auckland, Room 12.003, Level 12, Auckland Hospital Support Building, Grafton, Auckland, New Zealand 1142. defendants’ age and gender but not their race or eth- E-mail: [email protected]. nicity in my forensic reports, and I have adhered to Disclosures of financial or other potential conflicts of interest: None. this teaching throughout my forensic work in the

136 The Journal of the American Academy of Psychiatry and the Law Hatters Friedman

United States. I, too, understood that the intent is viduals in the case.3 We should be cognizant of that I evaluate the case on its merits and not set the language problems, communication styles (asking stage immediately with the fact that a defendant is a open-ended questions where possible), and cultural member of a minority group where prejudging might manifestations of distress, values, and power rela- enter in. Anecdotally, one might recall cases, such as tionships. Understanding cultural values and beliefs those of attractive white female embezzlers of the is important for completing a meaningful forensic same socioeconomic status as those in control of the assessment.9 Behaviors and reasoning processes, legal system, who received a slap on the wrist com- when considered in the context of the individual’s pared with the more serious outcome of nondomi- culture, may be understood better.1,10 nant group members with lower socioeconomic sta- Culture shapes how we perceive ourselves and in- tus who had taken much less money. From a research teract with the world. It is the lens through which we perspective, several studies have noted that clinicians’ organize our reasoning and our emotional response.1 prediction of inpatient violence tends to underpre- Motivation and criminal intent should be under- dict violence by white patients and overpredict vio- stood in the context of culture. Kirmayer and col- lence by black patients.4 leagues noted: “Supplying the cultural context of Scott, in his discussion of “forensic education and behavior changes its meaning and renders the indi- the search for truth” pointed out a plethora of poten- vidual’s reasoning more transparent. In effect, it al- tial biases in forensic psychiatry. He described bias as lows the judge to reconstruct imaginatively the affec- “a preference that influences impartial judgment” tive logic of the defendant’s cultural world” (Ref. 1, p (Ref. 8, p 27). Hicks noted: “. . . failure to consider 100). relevant ethnic factors, including potential biases, The meanings of both incarceration and mental may lead to inaccurate forensic formulations and illness in the individual’s culture bear discussing.10,11 opinions, with serious implications for all parties” Forensic psychiatrists should also ask about accultur- (Ref. 4, p 29). It is axiomatic that our legal system ation among immigrants.10 In other countries, jus- should treat all defendants equally, regardless of race tice systems, perhaps ruled by corruption and se- or culture. Forensic psychiatrists operate at the inter- crecy, may be perceived as less fair than our system. section of medicine and law, and in this role, must In still other countries, culture may be considered understand the cultural context of actions and more often. symptoms. Culture must be understood more inclusively; it New Zealand Experience does not merely equate with race. Cultural identity 9 I have previously written about working in New should be explored with our evaluees and patients. Zealand,12 noting that, unlike the treatment of Na- Often physicians do not ask about race or ethnicity 4 tive Americans in the United States, in New Zealand, and yet still record it, based on their presumptions. the Maori (indigenous) culture is embraced. Despite It is not an uncommon experience for me to see a new the small size of the country, there are many recent patient and ask about cultural and racial identity, immigrants and refugees. Experiences in this multi- only to find that she is not the “24-year-old Latina cultural society are relevant, offering a different per- woman” identified in previous psychiatrists’ notes. spective from the American experience. Cultural understandings are embedded in forensic Culture Affects Presentation psychiatry teaching and practice in New Zealand. Cultural competence is about much more than This is not to say that racial or cultural discrimina- memorizing the meaning of amok (and the “strange” tion does not occur. However, the system now makes actions of “other” people in faraway lands), as we did a conscious effort to combat it in forensic and legal in medical school. We are not neutral observers of practice. culture, but also products of the culture from which In New Zealand, culture is celebrated and in- we observe. Cultural competence includes self- cluded in forensic reports, an initial culture shock for awareness, core knowledge of other groups, recogni- Americans who practice there. Karakia (spiritual tion of the limitations of one’s cultural knowledge, prayers) are made at the start of meetings and some and application of forensic skills in a culturally ap- evaluations. Pepeha (lengthy introductions of the in- propriate way so that we may understand the indi- dividual, which include personal identifications with

Volume 45, Number 2, 2017 137 Culture, Bias, and Understanding the land and the people) are routinely given in youth detection-correction training, such as for racial bi- courts. Within each forensic psychiatry treatment ases. In such training, he suggested that vignettes be team (whether in the forensic hospital, the prison, or used to expose potential bias. Parker recommended community), cultural advisors are important mem- examining a database of one’s forensic opinions by bers. Cultural advisers help conceptualize mental race and gender, keeping in mind that there are many health ideas and thus aid in understanding the per- other variables at play, including the individuals who son’s experience. Kaumatua (esteemed cultural el- are referred to us.7 Self-assessment should be used to ders) are available to help clarify the cultural diffi- guard against one’s own cultural biases.9 Reflection is culties presented by the patient–psychiatry team critical. Only through examining ourselves can we interaction. honestly confront bias. Nearby Australia has a shortage of culturally ap- Striving for objectivity is paramount in forensic propriate mental health care for their Aboriginal fo- 13 ethics. We must avoid stereotyping evaluees and rensic patients. Regarding the Australian situation fight our own inherent biases. The first step is in (yet also relevant for North America), Shepherd and recognizing our potential for racial or cultural bias, Phillips suggested: “Part of the answer may lie with similar to how we recognize other instances of coun- the fact that both justice and health organisations are tertransference. The responsibility of identifying often mono-cultural institutions, where decision- countertransference toward evaluees of other cultural making and structural arrangements are grounded in groups is ours. Similar to other types of countertrans- western principles and western conceptualisations of ference, this type may be positive (as in the case of the health, law and the family” (Ref. 13, p 308). embezzler) or negative (as is often the case). We must Importance of Self-Reflection For Us All also keep in mind that we may have different coun- tertransference tendencies to various groups of “oth- In a recent case, there was concern that a defen- ers.” Griffith reminded us that “. . .mastery of the dant of the nondominant culture might have links to evaluation of members of certain minority groups ISIL. Suffice it to say that the way this case moved does not mean mastery of all minority groups” (Ref. through the justice system reminded me of the old 2, p 182). malpractice aphorism, “special treatment for special Aggarwal noted that “unconscious biases in emo- people leads to special results.” Stepping outside the tions, motivations, fund of knowledge, and informa- case and the questions raised about the applicability tion processing may prejudice the expert, as can eth- of risk assessment tools, I had to wonder if the col- nic, racial and cultural biases against the evaluee, lective fears of those in the courtroom (that is, fears of which an internal dialogue may limit” (Ref. 10, p terrorism and “others”) might influence such a case. 4 Diagnoses from forensic evaluations should 116). Hicks recommended careful monitoring for theoretically have less bias than general psychiatric our own biases, in addition to consultation with col- evaluations because of the wealth of collateral infor- leagues and regular open discussions. In New Zea- mation, length of forensic evaluations, and consider- land, forensic psychiatrists must participate in peer ation of multiple hypotheses.4 However, errors oc- review as a condition of medical licensure. Peer re- cur. Such errors in diagnoses potentially relate to view allows one time to consider potential biases and cultural differences in communication and belief sys- countertransference. My experience with peer review tems.9 Countertransference and other biases “can in- in New Zealand allows me to recommend routine fluence the way in which we gather, view, and value peer review, especially when considering cultural the data and arrive at a conclusion or opinion” (Ref. bias. 14, p 36) Preconceived notions about presentation Simply put, an approach that does not consider may lead to a skewed, albeit subconscious, belief culture oversimplifies life experiences and meanings about diagnosis. One must strive to recognize and and risks incomplete explanations to the court. manage these tendencies, else they result in misinter- Institutional racism and monoculturalism occur at pretation and continued cultural stereotyping.9 all levels of the criminal justice system. All indi- Scott8 and Parker7 have both encouraged forensic viduals cannot be evaluated in the same way, be- psychiatrists to examine their own practices for im- cause of differences in culture and our own poten- plicit bias. Scott discussed the potential for bias- tial for bias.

138 The Journal of the American Academy of Psychiatry and the Law Hatters Friedman

Conclusions 3. Simpson AIF, Friedman SH: Culture and forensic psychiatry, in Principles and Practice of Forensic Psychiatry (ed 3). Edited by If we as forensic psychiatrists ignore or misinter- Rosner R, Scott CL. CRC Press, 2016, pp 785–92 pret cultural differences, we risk errors in our cases 4. Hicks JW: Ethnicity, race, and forensic psychiatry: are we color- blind? J Am Acad Psychiatry Law 32:21–33, 2004 and misunderstanding of more important matters. 5. Friedman SH: Realistic consideration of women and violence is Blindness to culture is never the answer. We each critical. J Am Acad Psychiatry Law 43:273–6, 2015 must consider our own potential biases, such as by 6. Appelbaum PS: A theory of ethics for forensic psychiatry. J Am seeking peer review. At the same time, we must iden- Acad Psychiatry Law 25:233–47, 1997 7. Parker G: Come see the bias inherent in the system! J Am Acad tify our own knowledge gaps about culture and seek Psychiatry Law 44:411–14, 2016 appropriate remedies, such as additional learning op- 8. Scott CL: Believing doesn’t make it so: forensic education and the portunities and cultural consultation. We must com- search for truth. J Am Acad Psychiatry Law 41:18–32, 2013 plete culturally appropriate forensic assessments and 9. Glancy GD, Ash P, Bath EP, et al: AAPL practice guidelines for the forensic assessment. J Am Acad Psychiatry Law 43:S3–S53, be prepared to correct misconceptions in courtroom 2015 testimony. Finally, we must remember that culture is 10. Aggarwal NK: Adapting the cultural formulation for clinical as- part of us all, not only the defendant in front of us. sessments in forensic psychiatry. J Am Acad Psychiatry Law 40: 113–18, 2012 Acknowledgments 11. Kapoor R, Dike C, Burns C, et al: Cultural competence in correctional mental health. Int J Law Psychiatry 36:273–80, The author thanks Drs. Sandy Simpson, Andrew Howie, and 2013 Wendy Bevin for their thoughtful reviews of drafts of this editorial. 12. Friedman SH: No worries, mate: a forensic psychiatry sabbatical in New Zealand. J Am Acad Psychiatry Law 41:407–11, 2013 References 13. Shepherd SM, Phillips G: Cultural ‘inclusion’ or institutional 1. Kirmayer LJ, Rousseau C, Lashley M: The place of culture in decolonisation: how should prisons address the mental health forensic psychiatry. J Am Acad Psychiatry Law 35:98–102, 2007 needs of indigenous prisoners? Aust NZ J Psychiatry 50:307–8, 2. Griffith EEH: Ethics in forensic psychiatry: a cultural response to 2016 Stone and Appelbaum. J Am Acad Psychiatry Law 26:171–84, 14. Ciccone JR: Commentary: forensic education and the quest for 1998 truth. J Am Acad Psychiatry Law 41:33–7, 2013

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