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Resource Column | September 01, 2004

A Psychiatric Residency Curriculum on the Care of African American Patients

Herbert W. Harris, M.D., Ph.D.; Diane Felder, M.D.; Michelle O. Clark, M.D.

Academic Psychiatry 2004;28:226-239. 10.1176/appi.ap.28.3.226

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Drs. Harris, Felder, and Clark are with the Committee of Black Psychiatrists of the American Psychiatric Association. Dr. Clark is Chairperson of the Committee. Address correspondence to Dr. Clark, Westwood Medical Plaza, Suite 405, 10921 Wilshire Blvd., Los Angeles, CA 90024-4001; mcmd72@aol.com (E-mail).

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Abstract

Training psychiatric residents to address cross-cultural issues in their practice of psychiatry is a necessary objective of contemporary psychiatric education. Cultural issues play a critical role in the formation and expression of a patient's personality. In addition, they are a major determinant of the context in which mental illness develops. This proposed curriculum outlines a systematic progression toward cultural competence with populations of African descent. It begins with increasing the residents' awareness of their own cultural identity. The concept of achieving cultural competence as a continuum is utilized. Trainees should be prepared for any unfavorable reactions to this novel material. The curriculum must include accurate historic information about black culture, and general topics of diagnosis and treatment of African Americans must be covered. This should occur in congruence with trainees' development from students to residents to psychiatrists, as they move from inpatient to outpatient, hospital to community, close supervision to autonomous functioning, gaining both skill and confidence.

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Cultural background is well acknowledged as a factor that determines the course of mental illness and defines the nature of the doctor-patient relationship. Educators have long struggled with the problem of designing training experiences that would provide psychiatric residents with an understanding of cultural differences and the clinical skills necessary to communicate effectively with people of diverse cultural origins. In meeting this goal, the American Psychiatric Association (APA) has initiated the development of model curricula that would outline requisite training needed to improve transcultural clinical practice. For several years, component committees of the APA have completed and published several of these curricula. Training guidelines have been developed for American Indians and Alaska Natives (1), gay men and lesbian women (2), gender and women's issues (3), and patient's of Hispanic ancestry (4).

The development of these curricula marks the culmination of a process of gradual understanding of the clinical importance of intercultural understanding, variability, and recognition. The history of psychiatry is replete with examples of the consequences of the failure to achieve this recognition. One of the earliest examples of the misuse of psychiatric diagnoses in this context is the term drapetomania, which was used to describe a mental disorder that caused slaves to run away from their masters (5). In various studies of psychosis published in the early psychiatric literature, it was believed that mental disorders were rare under conditions of slavery but became more common following emancipation (6, 7). Many of these early studies attributed mental illness in African Americans to evolutionary and phylogenetic factors (8). Psychodynamic explanations of mental illness in this population invoked concepts of self-hatred, as exemplified by the work of Kardiner and Ovesey, who advanced the thesis that one of the characteristic features of African American identity is a self-directed contempt (9).

Because of these historical precedents, African Americans came to be viewed by mental health professionals as nonverbal, hostile, unmotivated, intellectually inferior, and possessing character disorders that were not suitable for a dynamic therapeutic intervention. African American family life and child rearing practices were viewed as chaotic and psychologically destructive (10—14). Social conditions such as poverty and crime have all too often been attributed to mental illness, biology, and genetics. This has created a kind of nihilism on the part of mental health professionals, which has proven to be an impediment both to research and health care delivery. These deterministic views of race-based psychology have continued to appear in the literature and continue to exert a pernicious influence (15).

With the rise of the Civil Rights Movement in the 1960s, African Americans and other minority groups demanded that American society become more responsive to their needs. During the same period, community mental health programs expanded to include economically disadvantaged populations that had never received professional mental health services. These social changes presented new challenges for the field of psychiatry. Traditional psychotherapies that were based primarily on Eurocentric models of behavior and psychology often proved ineffective or ill-suited to the needs of minority patients. In addition, the emergence of pharmacological treatments created new models and paradigms that made the treatment of mental illness more widely accessible than ever before. With these advances came recognition of the need for education, training, research, and treatments that focus on the psychiatric care of underserved groups.

RATIONALE FOR CURRICULUM ON THE TREATMENT OF AFRICAN AMERICAN PATIENTS

Given the factors mentioned above, it may seem self-evident that there is a need for ongoing commitment to transcultural education in psychiatric training. However, the consideration of culture in psychiatric practice is not universally accepted. Critics of multiculturalism view the recognition of minority culture as contributing to the erosion of the dominant values. Multiculturalism is believed by its critics to replace universally shared norms and ideals with a pluralism that fragments the society and undermines the basis for common experience. While most of the critique of multiculturalism has occurred within the humanities, psychiatry has not escaped scrutiny. In particular, it is argued that promoting a multicultural perspective in psychiatry is clinically destructive because it undermines the understanding of universally shared realities of mental illness (16). These critics argue that to approach mental illness in multicultural contexts is to neglect the essential features that make rational diagnosis and treatment possible.

While a full response to these arguments is beyond the scope of this article, we hold that the most universal goal of psychiatric practice is the achievement of empathic understanding. Empathic understanding requires many levels of interaction between the patient and the clinician. In general, communication between the clinician and the patient flows more easily when common references to shared realities exist. Transcultural recognition is a useful tool to begin the process of empathic understanding because the mutual understanding of race, culture, and ethnicity often create a sense of shared standards within those groups that can facilitate communication and empathy. Stereotypes, cultural biases, and misinformation tend to clutter our perceptions in the real world. Insofar as it breaks down these stereotypes and other obstacles to empathic understanding, transcultural recognition contributes to the clinical care of our patients (17).

The acceptance of the role culture plays in mental health service provision is reflected in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). This edition, in contrast to earlier versions, formally recognizes the "cultural relativity" of human behavior and the costly mistakes that can be made when norms of a person's cultural background are overlooked in applying psychiatric diagnostic criteria. There are now age, gender, and cultural consideration sections among the 90 diagnostic categories. Additionally, an outline for cultural formulation and a glossary of culture-bound syndromes are provided. For example, page 154 of the Quick Reference of the DSM-IV states that " …a symptom, if it is a culturally sanctioned response pattern, [should not be included]" when the criteria for a brief psychotic disorder are being applied.

GOALS OF THE CURRICULUM

The primary goal in developing a curriculum for the care of African Americans in psychiatry is to increase the quality and efficacy of instruction given to psychiatric trainees concerning African American patients. A necessary step toward achieving this goal is to increase cultural awareness and sensitivity among trainees, and provide a valid scientific knowledge base about African American populations. Developing a complete and comprehensive curriculum was an important aim. However, we recognize the increasing time constraints and limited resources available to many training programs. We have therefore attempted to identify learning objectives that are both essential to cultural competence and achievable within the limitations of most psychiatric training programs.

Specific learning objectives of such a program would include:

AREAS OF SPECIAL EMPHASIS

Within the framework described above, several focus areas emerge that deserve special consideration within any training program regarding African American populations. These areas include: child and adolescent development, violence and traumatic stress, substance abuse, the African American family, the African American "Elder," the diagnosis of mental illness in African Americans, and special issues in the biological and psychotherapeutic treatment of African American patients. A brief sample of the current literature on each of these topics is presented in the appendix.

Child and Adolescent Development

Child and adolescent development is one of the most intensely studied aspects of the psychological life of the African American. The extensive literature on this subject has been exhaustively reviewed (18—24). One area of particular importance is the impact of cultural influences, including effects of oppression and discrimination on development. The impact of these factors on the expression of mental illness is an area of tremendous controversy (5, 11, 21, 23, 25—28). A second area of intense investigation in the development of African American children and adolescents is the study of identity formation. An extensive literature exists on the development of racial identity in African American children (13, 22, 29—35). Much of the early work on the psychology of racial identity held that identification with one's own racial or ethnic group was normative and that out-group preferences and identifications expressed by black children reflected the psychologically damaging effects of racism (36, 37). However, social changes coinciding with the Civil Rights Movement resulted in a reexamination of the process of identity development. It could no longer be assumed that possibilities were limited to African Americans lacking a positive identity or aspiring to adopt the identity of the majority society (38—41), and thus identity development continues to be an important topic of research and scholarship.

The study of the genetics of behavior and behavioral disorders has a long and controversial history. Within recent years, heated debate has erupted over issues such as the genetic basis for violence, antisocial behavior, and intelligence (15). This controversy has extended far beyond academic and scientific circles to polarize the lay public, journalists, and public policy makers. Within this context, relatively modest progress in the understanding of the molecular genetics of psychiatric diseases is viewed not only as a basis for discriminatory insurance and health care access limitations, but ultimately as part of a racist social agenda. In particular, minority populations have often been (and currently are) singled out as victims of misuse and misrepresentation of scientific data (42). Therefore, a central educational and scientific objective in psychiatry is the ongoing exploration of how scientific investigation into the genetic basis of behavior and psychopathology can proceed in a socially responsible way. A major focus of the proposed curriculum is to: 1) present an overview of the status of behavioral genetics with a realistic appraisal of its current limitations and future prospects; 2) discuss the social implications of advances in this field with respect to health care and public policy; 3) stimulate a discussion of what forms responsible science and clinical practice should take with respect to gathering and applying behavioral genetic data; 4) appreciate the role of scientists and clinicians in the psychiatric community in maintaining open dialogue with patients and the lay public and presenting scientific findings in ways that cannot be misinterpreted or misused.

Violence and Traumatic Stress

Crime and violence are a constant reality of urban life. High levels of exposure to violent trauma and interpersonal violence among African American inner-city youth may result from a combination of external stressors, developmental issues, and economic factors. Children exposed to traumatic stress are vulnerable to a variety of stress-related disorders (11, 26, 43,44). The prevention of interpersonal violence among urban African American youth and the management of its consequences are a major concern in mental health (45,46).

Substance Abuse

In a similar way, substance abuse is a pervasive problem that requires a culturally informed approach (47—49). Racial and ethnic differences have been reported in alcohol and substance abuse, including incidence and prevalence, treatment choice, and availability and outcome. Spirituality and involvement in community institutions such as church seem to be more relevant to prevention and treatment outcomes among African Americans. Prevention and treatment of these disorders are often enhanced by culturally-based substance abuse education and training.

The African American Family

The African American family has withstood a devastating series of assaults, from slavery to the present day. The integrity of African American families reflects a resilience that is indeed remarkable. The factors that contribute to this resilience, as well as the consequences of its breakdown, are central topics bearing on the expression of mental illness among African Americans (50—54). One special aspect of African American family life that has received extensive treatment in the mental health literature involves transracial adoption. A very controversial body of opinion has evolved around the impact of transracial adoption on identity formation (60) and mental health (61—64).

The African American Elder

Older African Americans represent a major sector of patients in adult and geriatric mental health settings. Because African Americans tend to be underrepresented in epidemiological studies, the prevalence of many psychiatric disorders in this group can only be estimated (65—67). However, the public health significance of mental health in this population is great. Improved treatment of this population requires a complete understanding of the context of their lives, including the historical events shaping their values, community, and family. Complicating factors that impact on the course of mental disorders among older African Americans include chronic general medical problems such as hypertension, heart disease, and diabetes (68). These conditions occur with greater frequency in this group and often contribute to the polypharmacy that complicates the management of their psychotropic drugs. In addition, an increasingly important stressor arises from the transformations taking place in many urban neighborhoods, particularly those involving high-crime areas (69, 70).

Diagnosis of Mental Illness in African Americans

Research findings indicate that significant racial and ethnic differences exist in the symptom presentations of psychiatric disorders (71). The magnitude of the impact of these differences on diagnosis has been controversial (72—75). However, it has been well established that both overdiagnosis and underdiagnosis of mental disorders in African Americans frequently occur with significant implications for treatment as well as the consequences of mistreatment (76—78). Misinterpretation of observations or failure to screen for certain factors have been cited as reasons for diagnostic error. Culturally sanctioned hair and clothing styles can be perceived by others as unusual (71). An evaluator's discomfort with affect or language perceived as hostile may abbreviate the interview process and prevent adequate information exchange (71). Lack of knowledge of the breadth of spiritual beliefs encompassing perceptual distortions as well as the increased incidence of substance abuse in this community are factors associated with misdiagnosis of psychotic illnesses (72).

Biological and Psychotherapeutic Treatment of African American Patients

Recent research and clinical experience have shown that African Americans may be at greater risk to receive less than optimal psychopharmacological treatment (79). There is a great deal of variation in prescribing patterns with racial and ethnic minorities resulting in overuse and needlessly high dosages of antipsychotics and higher rates of involuntary treatment (80). Alternatively, physicians may underutilize psychotropic medications, especially for anxiety and affective disorders, which are underdiagnosed in minorities. Recent advances in pharmacokinetics, pharmacogenetics, and pharmacodynamics have led to a rapid expansion of our knowledge of drug effects in minority populations (81). Studies have disclosed many potentially significant differences in drug distribution (82) and metabolism (83—85) that may affect treatment responses of African American patients.

The efficacy of psychiatric work is dependent not only upon the competence of the clinician but the cooperation of the patient. For African Americans, accessing and utilizing psychiatric services is distinct. In addition to factors related to the subject areas above, patients' attitudes, beliefs, and expectations play a major role. Spiritual or religious beliefs and practices impact a patient's health maintenance and treatment participation. Alternative treatments and healers are often involved before or during clinical services. Understanding the African American patient's spirituality is critical for effective intervention.

IMPLEMENTATION OF CURRICULUM

Cultural Sensitivity Experiential Groups

Insight into one's attitudes, reactions, and biases toward others has always been an important aspect of residency training. Residents often gain better understanding of themselves and increase their empathic interactions with their patients. Sensitivity groups can allow residents the opportunity to discuss and explore their own ethnic backgrounds. This is a necessary beginning in their ability to approach their assumptions and stereotypes toward others. Since cultural information needs to be geared toward residents' level of understanding of assessment, diagnosis, and treatment skills, the experiential groups could be introduced in PGY-1. Focus on identity can further be expanded during PGY-2. Residents and faculty can identify their own cultures-of-origin by presenting their own family tree. They can identify issues and conflicts in their own family and life experiences that may influence their interactions with patients, especially those of different cultural groups. A particularly useful framework is the Pinderhughes model of intragroup dynamics, which has become a highly successful vehicle for understanding race, ethnicity, and power (17).

Didactic Courses

In many traditional training programs, didactic course material is presented during PGY-2 and PGY-3. Each of the topics discussed should be scrutinized and updated to include data relevant to transcultural psychiatry. This is particularly relevant in courses such as interviewing, psychopathology, and psychopharmacology.

These can also be incorporated into a community psychiatry lecture series within the structure of a seminar block. Residents should have enough basic psychiatric knowledge to integrate cultural influences. The focus must shift to theoretical material and practical issues in patient care. The course should integrate the anthropological, spiritual, biological, and psychosocial approaches as an integrative model for assessment, diagnosis, and treatment of the African American patient. As residents enter PGY-4, they should gain more autonomy and assume administrative roles as they provide services to African American patients from all socioeconomic groups. The incorporation of an African American patient in case study seminars will enable residents to apply their expanding knowledge base during various points in their training.

Clinical Experiences

The didactic course should be accompanied or followed by an opportunity to apply clinical knowledge to a clinical setting. The community site should be at a location that serves a large percentage of African American patients of varying ages and social classes. All residents must have the opportunity to treat patients from cultural backgrounds different from their own, and one of these cases should be presented at a continuous treatment seminar. The residents might initially profit from supervised experiences in interviewing patients from different cultures, and one of these cases should be presented at a diagnostic conference. This supervision should focus on developing a style that is free of implications that may reflect cultural biases or stereotypes.

The authors recognize that many programs lack faculty with the skills necessary to implement the proposed curriculum. In situations where clinical faculty does not exist in the African American community, there should be an investment in continuing medical education training such as that provided by the APA at their annual meetings. Referral for case review or curriculum development is also available through the APA Committee of Black Psychiatrists, the Black Psychiatrists' Caucus list server, or the Black Psychiatrists of America.

There should be training in therapies utilizing a systemic approach to treatment as well as an individual approach. Emphasis should be placed on training the resident to learn to work in a multidisciplinary system since African American patients often require assistance from many disciplines.

Field Experiences

There are a number of opportunities for residents to gain a deeper appreciation of the social environment from which the patients they are treating come. Field experiences may include home visits, visits to neighborhood centers and other meeting places, resident and halfway homes, emergency shelters, and local schools and churches. Introduction to local clergy, administrators, and political leaders, who serve in supportive roles in the African American community, can greatly add to residents' knowledge base. Other activities that may assist the resident in providing comprehensive and quality services to African American patients include local cultural entertainment, lectures by local and national leaders, and museums and galleries that offer exposure to African American literature and art.

Supervision

Throughout cultural psychiatry training, supervision should be provided by people who are experienced and knowledgeable of the African American population and appreciate both the positive and negative aspects of the African American experience. Throughout training, there should be supervision of the resident with an openness and willingness to discuss cultural issues. Faculty in these programs must have opportunities to obtain requisite training and experiences in transcultural psychiatry as well. Utilizing both full-time and part-time faculty has enabled programs to expand the pool of faculty with experience working with African American populations.

Program Evaluation

There must be an evaluation process throughout residency training to ensure that residents progress in an empathic and competent fashion. This can be accomplished through a written evaluation that addresses cultural issues and should be performed by the supervisor who provides constructive feedback to the resident. It is necessary for residents to participate in the evaluation of the service and supervision with feedback to the residency training director. Particular attention should be paid to residents' positive and negative experiences in working with African American patients. The evaluation process must address the needs and experiences of the patients and their perception of how they can be better served.

ACKNOWLEDGMENTS

The Committee of Black Psychiatrists thanks Dr. Herbert Harris for guidance and support in the preparation of this article. The authors gratefully acknowledge the assistance of Drs. Walter P. Bland, F.M. Baker, Ezra E.H. Griffith, Tana Grady-Weliky, William B. Lawson, Carl Bell, the late Jeanne Spurlock, and the Council on National Affairs, Committee on Graduate Education and the Council on Medical Education and Career Development. The Committee also thanks the following past chairpersons and Committee members for researching, compiling, and editing this important document: Michelle O. Clark, M.D. (Chair); Patrice Harris, M.D. (Immediate Past Chair); Gloria Pitts, D.O. (Past Chair). This project is the work of many since its beginning in 1987.

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: APPENDIX 1. Selected Bibliography

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Lindsey, K.P. G.L. Paul, Involuntary commitments to public mental institutions: issues involving the overrepresentation of blacks and assessment of relevant functioning. Psychol Bull, 1989. 106(2): p. 171—83

Lawson, W.B., Clinical issues in the pharmacotherapy of African-Americans. Psychopharmacology Bulletin, 1996. 32(2): p. 275—281

Lawson, W.B., The art and science of the psychopharmacotherapy of African Americans. Mt Sinai J Med, 1996. 63(5—6): p. 301—5

Lin, K.M., D. Anderson, R.E. Poland, Ethnicity and psychopharmacology: Bridging the gap. Psychiatric Clinics of North America, 1995. 18(3): p. 635—647

Johnson, J.A. T.N. Livingston, Differences between blacks and whites in plasma protein binding of drugs. European Journal of Clinical Pharmacology, 1997. 51(6): p. 485—488

Marinac, J.S., et al., Determination of CYP2C19 phenotype in black Americans with omeprazole: Correlation with genotype. Clinical Pharmacology & Therapeutics, 1996. 60(2): p. 138—144

Evans, W.E., et al., Genetic basis for a lower prevalence of deficient CYP2D6 oxidative drug metabolism phenotypes in Black Americans. Journal of Clinical Investigation, 1993. 91(5): p. 2150—2154

Thomasson, H.R., J.D. Beard, T.K. Li, ADH2 gene polymorphisms are determinants of alcohol pharmacokinetics. Alcoholism, Clinical & Experimental Research, 1995. 19(6): p. 1494—1499

Bradshaw, W.H., Training Psychiatrist for Working with Blacks in Basic Residency Programs. American Journal of Psychiatry,1978 101:1520— 1524

Clark, M.O. Case: You Can Keep the Yacht. DSM IV Casebook

Jones, B. Misdiagnosis of Blacks

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APPENDIX 1. Selected Bibliography