In politics and psychiatry, trust is the variable

It's been a blockbuster couple of days in terms of politics in the United States. First, Governor Scott Walker, from my home state of Wisconsin, announced that he will run as a Republican candidate for president, standing for "reform, growth, safety" and a desire to repeal so-called “Obamacare.” Also, President Barack Obama announced a tentative, but controversial, nuclear deal with Iran. These announcements also follow closely on the heels of the outcry over the comments of Republican presidential candidate Donald Trump on the risks of Mexican immigration.

As tempting as it is to analyze the psychological aspects of these political decisions and rhetoric, what it reminds me of the most is our work in cross-cultural psychiatry. Historically, our evaluation and treatment of patients from various minority cultural groups, including refugees, African-Americans, Muslim-Americans, and indeed the group of Trump's concern, Hispanic-Americans, has left much to be desired.

Take the challenge of treating refugees. When the comments from the Iranian president were being tentatively translated into English, I was reminded of the challenge of using interpreters in psychiatry. How could you be sure that the interpreter was translating accurately enough in both directions? An example of a common linguistic problem is in translating the English word "mad." Would that be understood as "crazy" or as “anger”?

On a seemingly more simple level, given the common use of English, how well do Democrats and Republicans understand, appreciate and respect their different values?

Of course, the crucial aspect of any political negotiation or care delivery encounter is the outcome. In the case of Iran, will this deal lead to more or less nuclear control, increased or reduced safety, or better or worse international relationships? In the conflict of American politics between Democrats and Republicans, how do they reach compromise on areas of mutual interest?

Trust is the variable

Then, in our field, how do we assess the outcomes of patients that come from various cultures? How do you discover what needs to be discovered when that may be consciously or unconsciously hidden in the hearts or in the minds of our patients?

This sort of political and psychiatric analogy will only go so far, however. Trust seems to be where we part ways.

For example, in the Iran negotiations, the major principle on the side of the United States is said to be that the deal is not built on trust, but on verification. However, our relationship with patients is built not only on verification, but also on trust. The relationship between patient and clinician has continually been found in research to be the most important variable in patient outcome.

It is why, without random drug testing, that we can easily be fooled by patients with substance abuse problems who self-report. Yet, patients from minority cultures—cultures that have suffered discrimination—may not so readily trust clinicians or our formal systems of care.

As Scott Walker stated, we want "reform, growth and safety," whether in politics or in psychiatry. In our field, we need reform of our mental healthcare system to better serve patients. We need growth in our resources. We need safety in terms of a reduction in suicide, homicide and violence. However, what that means to people of different cultures and values may vary. The challenge is to reach mutually beneficial consensus, is it not?