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REGULAR | July 01, 2008

Training Clinicians in Cultural Psychiatry: A Canadian Perspective

Laurence J. Kirmayer; Cécile Rousseau; Jaswant Guzder; G. Eric Jarvis

Academic Psychiatry 2008;32:313-319.

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Received September 2, 2006; revised December 11, 2006, and March 27, 2007; accepted June 18, 2007. The authors are affiliated with the Division of Social and Transcultural Psychiatry of the Department of Psychiatry at McGill University in Montreal, Quebec. Address correspondence to Laurence J. Kirmayer, M.D., Institute of Community and Family Psychiatry, Sir Mortimer B. Davis-Jewish General Hospital, 4333 Côte Ste Catherine Rd., Montreal, Quebec H3T 1E4, Canada; laurence.kirmayer@mcgill.ca (e-mail).

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Abstract

Objectives: The authors summarize the pedagogical approaches and curriculum used in the training of clinicians in cultural psychiatry at the Division of Social and Transcultural Psychiatry, McGill University. Method: We reviewed available published and unpublished reports on the history and development of training in cultural psychiatry at McGill to identify the main orientations, teaching methods, curriculum, and course content. Student evaluations of teaching were reviewed. The training strategies and curriculum are related to the larger social context of Canadian society including the history of migration, current demography, and policies of multiculturalism. Results: The McGill program includes core teaching, clinical rotations, an intensive summer program, and annual Advanced Study Institutes. The interdisciplinary training setting emphasizes general knowledge rather than specific ethnocultural groups, including: understanding the cultural assumptions implicit in psychiatric theory and practice; exploring the clinician’s personal and professional identity and social position; evidence-based conceptual frameworks for understanding the interaction of culture and psychopathology; learning to use an expanded version of the cultural formulation in DSM-IV for diagnostic assessment and treatment planning; and developing skills for working with interpreters and culture-brokers, who mediate and interpret the cultural meaning and assumptions of patient and clinician. Conclusion: An approach to cultural psychiatry grounded in basic social science perspectives and in trainees’ appreciation of their own background can prepare clinicians to respond effectively to the changing configurations of culture, ethnicity, and identity in contemporary health care settings.

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In this article we summarize our experience over the last 15 years training clinicians in cultural psychiatry at McGill University in Montreal. This includes core teaching for psychiatric residents and clinical rotations for residents in psychiatry and family medicine, as well as medical students, interns in psychology, and social work students. For those seeking more advanced clinical and research training, we run an annual summer school, Advanced Study Institutes, and a Master of Science program, both of which are described in a companion paper (¹). Here we outline our pedagogical approach and core curriculum for clinical training in cultural psychiatry.

McGill has the longest standing academic program in cultural psychiatry, which began in 1955 as the Section of Transcultural Psychiatric Studies under the leadership of Dr. Eric D. Wittkower. Along with H. B. M. Murphy and Raymond Prince, Wittkower established the first specialized journal in the field (Transcultural Psychiatric Research Review, now Transcultural Psychiatry) and an active research and teaching program. At that time there were a large number of residents from developing countries (especially countries of the British Commonwealth) who came to McGill for postgraduate training and who posed questions about the relevance and appropriateness of psychiatric theory and practice in their countries of origin. In 1967 there were 120 residents, with about 50% from outside North America. Hence, the emphasis was on international psychiatry using cross-national comparisons to shed light on the impact of culture on psychopathology and the nature of traditional healing (²). Over the years, the focus has broadened and shifted to include an emphasis on providing mental health services for the diverse population in North America, with particular attention to the mental health of indigenous peoples, immigrants, and refugees.

One feature of the McGill program has been very close links between medical anthropology and psychiatry, with shared teaching, research collaborations, and consultation. This ongoing dialogue has fostered a critical approach to concepts of culture, race, and ethnicity in medicine (³, ⁴). In recent years, the focus has been less on the culture of the other but on the professional cultures of biomedicine and psychiatry itself (⁵—¹¹). This focus on the cultural assumptions of psychiatric theory and practice is a central element in our training activities. We believe this reduces the tendency to construct ethnic stereotypes and helps to prepare clinicians for working with changing populations by providing conceptual tools for the critical rethinking and negotiation of diagnostic assessments and interventions.

The majority of Canadian psychiatric residency programs offer very limited exposure to cultural psychiatry (¹²). This reflects the fact that, to date, psychiatry residency programs in Canada have not developed specific guidelines for training in cultural psychiatry. The only mention of cultural issues in the Royal College accreditation standards states: "Learning environments must include experiences that facilitate the acquisition of knowledge, skills, and attitudes relating to aspects of age, gender, culture, and ethnicity appropriate to psychiatry" (¹³). There must also be facilities for supervised experience in community consultations. There is no mention of any other specific topics including immigrants, refugees, Aboriginal peoples, ethnocultural communities, or the use of interpreters. An accreditation committee background paper on teaching and assessment of communication skills notes only that "Areas that residents may need to develop include the ability to communicate with patients where there is a language or physical communication barrier" (¹⁴). A Canadian Psychiatric Association position paper on training for work in rural and remote areas makes brief mention of the importance of attention to local culture and of Aboriginal mental health issues (¹⁵). Earlier position papers on training in emergency psychiatry and substance abuse both acknowledge the relevance of sociocultural factors; however, no detail on curriculum is provided (¹⁶, ¹⁷).

The Social Context of Training

Cultural diversity is conceptualized in markedly different ways in different countries depending on local histories of migration, ideologies of citizenship, and patterns of ethnic identity (¹⁸—²¹). The Canadian context is distinctive in some respects and this usefully highlights what is idiosyncratic about models of training based on the configurations of cultural identity in the United States, which tend to dominate the medical literature. The five ethnoracial blocs that are commonly used to organize research, training, and sometimes services in the United States do not make sense in the Canadian context (¹⁹). Canada has an Aboriginal population of First Nations, Inuit, and Métis, who comprise about 3.8% of the population, and two original colonizing peoples, the British and the French, who have contributed to a bilingual nation, with ongoing tensions that have demanded serious attention to the nature of the larger social fabric that can respect differences and local autonomy (²²). The bilingual dialogue between two "founding peoples" provides the backdrop for a high level of ongoing immigration over the last 100 years. Canada also receives large numbers of refugees so that, at any given time, an average of one in six people in Canada are foreign born.

Since 1976, Canada has had an official policy of multiculturalism (²³). This policy formally acknowledges and promotes recognition of the diversity of Canadian society as a shared feature of collective identity (²⁴). It contributes to a social milieu in which talking about cultural difference is acceptable, even required, in order to respect and respond to individuals and ethnocultural communities. In a compelling metaphor, Canada has been called "the house of difference" (²⁵). However, this commitment to diversity has its roots in an ethnic composition that was dominated by large groups of European immigrants and has not yet come to terms with a long history of racist policies and exclusionary practices toward non-Europeans and Aboriginal peoples in Canada (²⁶).

The geographic origins of newcomers to Canada have changed in recent years with enormous impact on the demography of the major cities. At present, most of the more than 250,000 people who come to Canada each year are from Asia, Africa, the Middle East, and Latin America—societies with great internal diversity and significant differences from the European cultures prevalent in earlier waves of migration. This new migration has challenged the complacency of multiculturalism, drawing attention to the history of racism and to more subtle forms of inequality that affect the mental health and access to services of Canada’s population. Understanding these issues is crucial for the training of psychiatrists and other mental health professionals.

Pedagogical Approach

While issues of political representation, voice, and equity for ethnocultural groups demand serious attention, the influence of culture on psychopathology, illness behavior, and healing is also a scientific issue. There is a great deal of evidence that the brain is "designed" to acquire culture and that human behavior (and psychopathology) depends on culture for its complexity (²⁷). Cultural psychiatry therefore involves both practical issues of equity in health services and fundamental scientific questions about the nature of psychopathology. Our approach to training both clinicians and researchers strives to balance experiential learning that changes attitudes and enhances skills with more didactic and conceptual teaching that emphasizes theoretical models, clinical methods, and research findings.

A crucial focus is on the personal and professional identity of the clinician as this is one constant across encounters with people from different backgrounds. Clinicians who understand something of their own cultural background and how it contributes to their values, perceptions, and personal style are in a better position to learn from the clinical encounter with others. Issues of power and position are central when considering the relationship between clinician and patient (²⁸). The historical legacy of colonialism, slavery, and the ongoing impact of other forms of structural violence provide a larger context for the clinical encounter that may lead to "cultural transference" and countertransference (²⁹). Among existing models in psychiatry and allied mental health disciplines, the perspectives of family systems theory are most readily adapted to understanding the particularity of migrant individuals and ethnocultural communities. The emphasis on systems or networks of relationships fits well with the values of people from many backgrounds, but this relational perspective must be extended to include attention to wider social and political issues that affect relationships between ethnocultural groups.

A second emphasis is on the ways in which contemporary identities are heterogeneous, fluid, mixed, or hybrid (³⁰). Owing to the forces of globalization, migration, mass media, and the intermixing of peoples, many individuals have multiple cultural roots and most find themselves at the confluence of different cultural streams. As a result, they may experience specific tensions that may complicate psychiatric disorders or present as additional clinical problems.

Respecting the cultural background of the other involves attitudes of interest and of modesty or humility. While there is a common core of human experience that allows empathy across cultures, important details of each individual’s background remain difficult to fully appreciate without extensive exposure over time to his or her social realities (³¹). Thus, trainees who tend to be focused on mastery, acquiring professional authority and competence, must learn to tolerate ambiguity, uncertainty, and not knowing—and develop the confidence to allow patients a measure of control over their own social positioning and gradual self-disclosure. The intercultural clinical encounter is a mirror of similar encounters in the larger society and brings with it all of the cultural and historical assumptions, tensions, and expectations that freight such everyday interactions. Clinicians must learn to use their own identity, both in terms of self-understanding and, with an awareness of how they appear to others given this social historical background, as a tool to explore patient identity, illness meanings, the social context of illness and adaptation, and the clinical relationship itself (³²).

Another important aspect of our program is its approach to ethnocultural diversity in terms of the broader notions of culture in contemporary medical anthropology. The term "culture," as we use it here, refers not only to the ethnocultural backgrounds of patients and clinicians, but also to the professional knowledge and practices of health care providers and to the implicit values and ideologies that structure health care systems and other social institutions (⁴, ³³, ³⁴). The clinical setting must be conceived of as a space of negotiation between different systems of knowledge and practice and different value systems.

Clinical Training

In the early 1990s, a national survey of residency training programs found that neither formal traning nor degree of exposure to patients of different cultures significantly influenced psychiatry residents’ perception of their transcultural practice. Instead, residents’ perceptions varied according to their own cultural origins (³⁵). These findings underscored the need to revise the curriculum to address the challenges of clinical practice in Canada’s increasingly multiethnic cities, focusing especially on clinical skills. In the following years, we have developed new training methods that emphasize the following:

1. Intensive case studies. The case study method, which is standard in medicine, is used to analyze the complexity of cultural influences on patient presentation and evolution and also to identify the cultural dimensions of clinicians’ own practices and to address their implicit biases and tacit assumptions.

2. Education in pluralism. This approach, based on the work of the Russian philosopher Mikhail Bakhtin, is more prevalent in the fields of education and social work. It emphasizes a dialogic negotiation of difference that goes beyond the dichotomy of "us-and-them." This pedagogical approach has proved very helpful in building therapeutic alliances and addressing individual and institutional prejudice or racism.

3. Interinstitutional and intersectorial work. Addressing systemic issues can be taught effectively through seminars discussing interinstitutional cases. If the composition of the group is stable, trust develops among the participants, who are then able to address and partially resolve institutional differences.

4. Fostering reflection on ethical issues. The predicament of refugees, ethnocultural minorities, and other groups raises complex ethical issues involving individual versus group rights as well as frequent situations in which professionals must consider modifying standard procedures and adopting positions of advocacy without appropriating the voice or experience of the other (³⁶).

Most of our clinical training occurs in interdisciplinary settings and the training of clinicians from different disciplines is an explicit objective of our program. We receive undergraduate medical students and graduate students in social work, psychology, art therapy, and psychiatry from local, national, and international universities for clinical rotations. This interdisciplinary training setting is an important asset that fosters cooperation among the professions and contributes to trainees’ ability to integrate diverse perspectives in their clinical work.

In addition to individual and group clinical supervision, we have formal clinical teaching activities presented by faculty from adult and child psychiatry, clinical psychology, family medicine, social work, and nursing. Nonclinical faculty from social sciences and humanities (anthropology, sociology, bioethics, philosophy) also contribute to clinical teaching through participation in case conferences and seminars. The main didactic activities include:

The core teaching for residents in cultural psychiatry comprises 9 hours of didactic sessions presented in postgraduate year 3 (PGY-3), including 3 hours of introduction to basic conceptual issues in cultural psychiatry. These include cultural influences on the causes, course, and outcome of major psychiatric disorders; culture-related syndromes and idioms of distress; cultural concepts of person, self, and emotion; and patterns of helping. There are also 3 hours of teaching on immigrant and refugee mental health, which focus on the specifics of migration in the Canadian context and compares this with the international literature. This helps residents grasp the clinical relevance of the migration history and postmigratory challenges in the host country. Core teaching on religion and spirituality comprises an additional 3-hour block. The history of the relationship between religion and secularism is reviewed with special attention to the tendency of the behavioral sciences to disparage or neglect religion and spirituality. Recent trends toward a rapprochement between psychiatry and religion are discussed, and case material illustrates the interplay among religion, spirituality, and psychopathology.

Over the past 10 years, about 80 residents from McGill and other universities have participated in these training activities. Resident evaluations of this core teaching over a 5-year period (2000 to 2004) rated the presentations very positively, with a mean of 3.6 (SD=0.18) on a 4-point scale with 3=satisfactory and 4=outstanding. The most consistent feedback from residents’ qualitative evaluations has been concern about how to incorporate the material into everyday work given the constraints of time and resources in clinical practice. This dilemma is consistent with findings from a recent survey of residency training in the United States (³⁷).

Residents in PGY-1 to PGY-3 who choose to spend one of their clinical rotations at the Jewish General Hospital take part in monthly seminars in cultural psychiatry. These begin with an introduction to the DSM-IV cultural formulation and go on to cover topics including migration, religious experience, cultural identity, cultural explanations of illness, the clinician-patient relationship, working with interpreters, legal aspects of migration, and a series of clinical cases (³²). Residents also prepare a cultural formulation of a case for presentation to the group and invited experts from the community act as discussants to help to situate the patient’s behavior and experience in cultural context (³²).

Residents or fellows who wish to acquire more advanced training can elect to spend 3- to 12-month rotations on the Cultural Consultation Service or the Transcultural Child Psychiatry Service (³⁸, ³⁹). These rotations involve specialized inpatient, outpatient and community consultations, and time-limited treatment (⁴⁰, ⁴¹). These rotations consist of clinical activities in three major domains: direct patient contact, consultation with referring clinicians, and outreach to community referral sources. The primary purpose of consultation work is to increase the competence of nonspecialist clinicians in their work with social and cultural issues affecting a broad range of patients, including migrants and refugees. To this end, residents work in teams made up of interpreters, cultural experts or culture-brokers (who can help mediate and explain the cultural models and expectations of both patient and clinician), and referring clinicians. Outreach to community referral sources is an important part of the Cultural Consultation Service, in which consultants use case conferences to highlight aspects of the relevance of culture for diagnostic assessment and treatment. Because it emphasizes consultation to other professionals and requires openness to questioning the assumptions of standard psychiatric practice, the cultural consultation rotation is most appropriate for senior trainees (PGY-3 to PGY-5). Group supervision and the self-disclosure of experienced clinician-mentors are crucial to assist the residents to understand the impact of their own cultural identity and to develop clinical skills and an effective professional style.

Future Directions

With the increasing diversity of Canadian society and the visibility of the McGill program, there has been increased interest from residents and fellows seeking more in-depth training. To address this need, we plan to expand the program in several ways. First, we plan to develop additional curriculum on specific topics that can be presented within the core-curriculum or as self-study modules under the guidance of faculty (see Table 1 ). These topics cut across other topics in the core curriculum and can provide a supplement to existing training that has not adequately integrated cultural issues. Second, we want to develop a mandatory half-day workshop on working with interpreters, including video-training materials and exercises. A lack of training in working with interpreters was the most frequent deficit in cultural competence training identified in a recent survey of residents across the United States and contributes to the underutilization of interpreters in clinical settings (⁴²). Third, we plan to organize additional clinical rotations for junior and senior residents; these will involve specific "modules" that can be assembled into a 3-, 6-, or 12-month rotation, including a mix of cultural consultation, community consultation, short-term treatment with refugees and survivors of torture, child and family assessment and intervention, and cultural psychiatric research. Mentoring during these clinical rotations is a crucial avenue to address issues of cultural attitudes and the use of self, and to consolidate clinical skills. Finally, we would like to develop methods of clinical competence assessment in the areas of working with interpreters, preparing a cultural formulation, and negotiating diagnosis and treatment plans in intercultural work.

Despite longstanding concern with the issue of diversity, there are currently no national standards in Canada for training in cultural psychiatry. The section on transcultural psychiatry of the Canadian Psychiatric Association is currently working on developing curriculum guidelines and training materials. This initiative will build on the work at McGill, the University of Toronto, and other Canadian universities to advocate national standards in training and accreditation and to provide resources to assist programs across the country to more fully address issues of cultural diversity in their training activities.

Conclusion

Abstract | Conclusion | References

The foundation of our approach to teaching cultural psychiatry is a process of reflection on the cultural, social, and historical origins and contemporary meanings of culture in psychiatric theory and practice. This involves interrogating the assumptions of psychiatry that may be rooted in limited datasets that ignore cultural context and the values and notions of self and person that are rooted in Euro-American traditions. Clearing a space where one can begin to think about alternative ways of being allows for more open dialogue and negotiation with patients in clinical settings as well as suggests fruitful topics for research and clinical innovation. The issues explored by cultural psychiatry have implications for psychiatric theory and practice more generally (², ⁴³—⁴⁶).

Although it utilizes tertiary care settings and services for training, our program emphasizes the integration of cultural competence in primary care mental health. In particular, the Cultural Consultation Service is a unique "clinical laboratory" in which psychiatric and ethnographic modes of inquiry are brought to bear on practical issues pertaining to migrants and refugees from around the world (³¹). The consultation-liaison model allows us to emphasize the transfer of knowledge and skills to clinicians, encouraging them to work with cultural diversity in their own settings.

Training in cultural psychiatry leads to increased awareness of social, cultural and political issues that can enhance the effectiveness of clinical work. Attention to culture in psychiatric care also serves to articulate a vision of a pluralistic community that respects diversity. The effects of globalization on increased flows of knowledge and the confrontation of different value systems heighten the importance of cultural psychiatry both as an academic discipline and as a central pillar of clinical training.

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TABLE 1. Outline of Topics for an Introduction to Cultural Psychiatry

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