"We must meet our patients where they are," psychiatrist Joe
Neidhardt, M.D., told listeners at a special session of the National
Association for Rural Mental Health in Albuquerque in June.
Joe Neidhardt, M.D.: "It's important to give credence to
parapsychological experience in people who are part of cultures where those
experiences are normal."
Credit: Aaron Levin
He was not talking so much about geography of place as about a landscape of
the mind, a landscape where mountains and valleys are sculpted by a
community's shared history and traditions, values and beliefs, ethnicity and
sometimes race, attitudes, rituals, and
For Neidhardt, appreciating that cultural landscape can only improve his
chances of helping his patients at the Santa Fe Indian Health Service Hospital
in New Mexico.
Neidhardt doesn't reject Western, evidence-based medicine by any means, but
he does take a nuanced view of it. He's grateful for the data and guidance it
provides. He's also conscious of its limits. He has learned through experience
that the application of science must rest inside the cultural context where
his patients live.
The culture that most of Neidhardt's patients traverse is that of the
Jicarilla Apache, San Felipe Pueblo, or Ramah Navajo in northwestern New
Mexico. However, "culture" isn't a term that applies only to
racial or ethnic minorities. Everyone grows up in some cultural context, he
said in a follow-up interview.
"There are limits to evidence-based medicine," he said, citing
numerous examples. Effect sizes in trials may be statistically significant but
not produce clinically important differences in practice settings. Patients
recruited and retained in clinical trials are often very different from the
people who walk through a clinician's office door. His patients in Santa Fe
often don't look or think anything like the patients recruited for STAR*D, as
far as he's been able to find.
"A study of bipolar disorder will exclude alcoholics, while a lot of
our patients are heavy drinkers," he said. "Or patients with
substance abuse are excluded from studies of disorders other than substance
abuse despite high addiction rates seen in clinical practice." High
dropout rates also make it hard to translate clinical trial results to
everyday office practice.
"Too often, the 50 percent of subjects who drop out are the ones
sitting in your office," he said.
Adapting the benefits discovered through randomized, controlled trials
means understanding a patient's background, too.
"I do evidence-based medicine, but I also do mental-, physical-,
cultural-, and spiritual-based psychiatry," he said. "Spiritual
deprivation looks like depression so it's important to address all those
issues in the first diagnostic interview."
In addition to applying the logic, intuition, and empathy used in any
psychiatric encounter, his work often requires an awareness of culturally
determined states of consciousness, whether waking or dreaming, and an
accommodation of phenomena dismissed as irrelevant or psychotic in Western
culture and medicine.
He told the story of a patient who dreamed that her son would die after
surgery. She called Neidhardt, who suggested that she discuss her fears with
the surgeon and anesthesiologist, who could explain any risks involved with
the procedure. When her son later succumbed to postoperative complications,
the woman's belief in the veracity of her dreams was more than confirmed.
The lesson to Neidhardt is not that Western medicine must agree that dreams
predict the future, but that psychiatrists must accept the fact that some of
their patients do hold such beliefs, said Neidhardt.
"It's important to give credence to parapsychological experience in
people who are part of cultures where those experiences are normal," he
said. "We would be short-sighted if we failed to accept this form of
knowing and failed further by not supporting its use for our patients."
However, a clinician should not assume homogeneity beneath the blanket of"
culture," he said. "Make it specific to where you
For example, northern New Mexico has a Hispanic culture distinct from that
of the southern part of the state, he noted. And among Navajos, some live on
reservations, are fluent in Navajo, know little English, and prefer tribal
medicine. Others may look like that cohort but may be devout Christians and
disdain native medicine.
Such understanding carries over into the mechanics of patient management,
too. Neidhardt's Navajo patients may extrapolate their expectations of his
clinic from their experience in their own cultural system, he said.
"They go to the medicine man to be cured, so if they don't get full
remission from a psychiatrist's treatment, they won't come back," he
That doesn't rule out the tiered, multi-step approach found in general
clinical practice, but it does mean that discussing treatment effects in
advance requires an added layer of awareness by the clinician. A simple
recitation of potential medication side effects to a Navajo patient may be
interpreted as an intention to harm rather than a precaution.
In sum, Neidhardt advocates using a breadth of expertise, no matter what
its origins. Medications have their place, but an added referral to a tribal
healer may relieve a patient's distress.
"Develop your practice within your expertise and within the culture
of your patient," he said. ▪