It is a swanky restaurant in Scottsdale, Arizona, during the 2004 meeting of the American Academy of Psychiatry and the Law (AAPL). Two diners, seated separately, vaguely recognize each other as being associated with AAPL. It is for them the work of an instant to decide to share a table, and, fueled by good food and wine, the conversation flourishes. Soon, the topic moves to the day's proceedings at the conference.
“So you're from Nigeria?”
“Yes, but I live and work in England now.”
“Oh, a colleague of yours did an interesting presentation today on culture…. he presented a remarkable case of cannibalism.”
“Er…that was actually I.”
“Oh (expletive deleted)!”
I hastened to reassure my colleague that no offense was taken, and that, for what it was worth, several other people whom I had known for years, but who had never seen me dressed in the native Nigerian garments that I had donned for my presentation, had walked straight past me at the meeting venue without the slightest flicker of recognition. My dinner companion was gracious enough to say, at the end of the evening, that the incident had taught him something about himself.
As forensic psychiatrists, we are perhaps now more aware than ever of the need to take the cultural sensitivities of our evaluees into consideration. However, as this episode demonstrates to some degree, we may be less aware of how our own cultural norms and values can affect our evaluations.
The Collins Shorter Thesaurus1 offers, among others, the following definition of culture: “…civilization, customs, lifestyle, mores, society, stage of development, the arts, way of life.” By way of illustration, what is regarded as acceptable and civilized behavior in Boise, Idaho, may be viewed quite differently in Ibadan, Nigeria. Handing something to an older person with your left hand will cause grave offense in Ibadan, but is unlikely to raise eyebrows in Boise (as far as I am aware). Similarly, the mores and way of life that a British army sergeant major regards as wholly normal may not necessarily strike the pacifist from Sydney, Australia, in quite the same way. Thus far, none of this is rocket science, and it all seems self-evident. How, then, can we explain the failure of my dinner companion to associate the speaker dressed in African garb with the more conventionally dressed person sitting across the table from him, and thereby put himself at risk of causing offense?
It will be no surprise to anyone reading this that human beings are social animals and that they therefore seek out some form of acceptance by a group. This is much easier to do if there is something about the group that he or she identifies with (color, gender, sexual orientation, military service, mode of dress, or even simply being a forensic psychiatrist). The corollary of identifying with a group, whatever that group might be, is that it excludes all who do not belong to the chosen group. It might also mean that a departure by a member of the chosen group from what the group regards as acceptable norms of behavior is viewed more dimly than it otherwise would be, on the grounds that “he or she should know better.” A colleague recently described to me his evaluation of a defendant who also happened to have been dishonorably discharged from the military for trying to shift his responsibility for an offense to a subordinate. The forensic psychiatrist, who was an ex-military man himself, confessed to a lingering feeling of contempt for the evaluee, which he found difficult to prevent from coloring his professional opinion.
We are all more comfortable with that with which we identify. When faced with the less familiar, we may fail to register what is before us (as happened at the AAPL meeting described earlier), or, as an instinctive reaction, may become somewhat defensive. Neither position is a comfortable one for a forensic psychiatrist to be in nor, in my opinion, is either conducive to promoting professional effectiveness. Few would dispute that any evaluation that involves one party's feeling contempt for or causing offense to the other is unlikely to be robust or objective. There is also a risk of this being true when dealing with the familiar. I have myself, on the occasions when I am asked in the United Kingdom to evaluate one of my countrymen whose language I speak, had to guard against a temptation to be carried away by the rare opportunity to conduct the evaluation at least in part in my own mother tongue and to strain objectivity by being overly sympathetic (or, indeed, hostile).
Simply put, the stakes are much higher for us, especially when we get it wrong. A faulty evaluation of competence to stand trial could result in the fundamental injustice of an incompetent person's being tried (and possibly punished). It could also mean that a competent person avoids a trial at the bar of his peers, and thus also avoids the retribution that society demands of those who break its laws. A deficient assessment of risk could create a victim (or victims) in the future and could also result in a disproportionate loss of freedom (or even life) on the part of the evaluee. There is the danger of loss of credibility on the part of the profession arising from the specific clinico-legal situations cited herein. In addition, we can all think of examples of the “hired gun” phenomenon. Is this simply a character flaw on the part of the individuals concerned? Could this phenomenon thrive in part as a result of cultural values that exalt material possessions over professional integrity?
As with all things, the first stage of dealing with a problem is recognizing that it exists. It is suggested that training in cultural sensitivities forms an integral part of fellowship training in forensic psychiatry, as should training in recognizing how the cultural norms and values of the forensic psychiatrist can influence his or her professional judgments. More radically, this training should also be an integral part of the recertification process for established forensic psychiatrists. If you cannot teach an old dog new tricks, you can at least periodically reinforce the old ones (assuming, of course, that they were ever learned in the first place). By so doing, we would hope to minimize one potential source of bias and inaccuracy in our evaluations and also to close off one avenue of assault on our credibility as a profession.
To return to our cozy scene at the restaurant in Scottsdale, I must confess to a small feeling of smugness (culturally permissible?) when, on departing the restaurant, my companion failed to recognize the former NBA star Charles Barkley, who had been sitting at an adjoining table. I did, even with Sir Charles not wearing a Phoenix Suns or Houston Rockets vest. I resisted, with some difficulty, the temptation to ask for his autograph.
- American Academy of Psychiatry and the Law
