Culture is a factor that is closely intertwined with mental health, greatly affecting the way an individual conceptualizes and manifests distress. Hence, an awareness of the pervasive influence of culture on the clinical practice of psychiatry is an essential component of any program training future psychiatrists. Literature indicates that other training programs have used different approaches to meet this competency, such as introducing the topic through a clinical rotation (1), integrating it throughout residency (2), and using a skills approach, rather than a traits approach (3). Because of the density of the curriculum and the time constraints in our program, a brief course was designed in accordance with the ACGME educational requirements for graduate training (4).
The goals of this course are to increase the residents' familiarity with the following: 1) the concepts of culture and dynamic interactions of cultures; 2) the role of a clinician’s frame of reference in culturally-sensitive patient assessments and the interpretation of that information on a continuum ranging from normative to mental illness; and 3) the care of various cultural groups encountered in clinical practice.
“Mr. S,” a 57-year-old Korean man, was admitted to the trauma service after attempting to hang himself in his home. During the initial psychiatric interview, Mr. S denied any psychiatric symptoms and said that things were going fine with his finances and his family. He did not offer any explanation of what triggered his suicide attempt. He was transferred to the inpatient psychiatric unit. Over the next few days, Mr. S did not reveal much information and interacted minimally with others. No change was noted after his family visited him over the weekend. (This is one of several case vignettes used in this curriculum to illustrate various teaching-points and will be developed in this paper.)
Residents’ knowledge about cultural psychiatry and their expectations for this course were ascertained through informal discussions before the course. Goals and objectives for each module were distributed before each lesson.
Readings from reference materials introduced concepts outlined in the course description. Case vignettes were presented from both real life and from reference materials. The primary modes of instruction were didactic teaching and interactive discussion.
At the end of each module, residents’ ability to apply concepts outlined in the course to a clinical case was assessed through discussion. Course objectives were evaluated in a written format by the residents at the end of the course.
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Description of the Course
This course was divided into three modules (5): The first module, “Introduction to Culture, Acculturation, and Acculturative Stress,” introduced the concept of culture (6). The concept of cultural identity was introduced through a discussion using examples such as the following:
“Mr. K,” is a 64-year-old man who migrated over 40 years ago from India. His pre-immigration experience was one of discrimination due to the caste system in rural India. Working as an R.N. in Chicago, he experienced a sense of professional and personal satisfaction he had never dreamed possible. He identifies himself as American in every way possible, including his name, his way of life, and his social circle, celebrating the day he landed on the shores of the United States as his personal independence day.
Concepts of acculturation, acculturative stress, its outcomes, and the factors that influence these outcomes are presented through vignettes (6). For example, acculturation is described as a continuous change, spanning several generations; the process is affected by the interplay of the group/individual’s values of preserving cultural uniqueness and increasing involvement with the host culture. Outcomes of acculturative stress include 1) separation from the host culture (i.e., cults); 2) integration into the host culture while maintaining a firm sense of cultural heritage; 3) assimilation into the host culture while giving up unique characteristics of one’s culture of origin; or 4) marginalization, rejecting both one’s cultural heritage and the norms of the host culture. The residents then discussed vignettes like the above case of Mr. K who, having consciously and unconsciously given up unique characteristics of his culture-of-origin, had completely incorporated characteristics of the mainstream culture and had assimilated, as an outcome of his acculturative stress.
The second module, “Culturally Normative Behavior, Its Variations, and Culture-Bound Syndromes,” begins with a reading from a classic citation demonstrating cultural biases against Native Americans (7). The discussion following it addresses how one’s own cultural frame of reference can influence one’s perception of behavior as normal or abnormal:
The group discussed a resident’s experience when consulted by the trauma service for possible depression in a 65-year-old Vietnamese woman hospitalized with spinal cord injury. After the initial interview, the resident called the patient’s son, introducing herself as the consulting psychiatrist. The patient’s son expressed anger that his mother was being subjected to a psychiatric examination. The consulting team realized that they had approached the issue from their own cultural frame of reference, assuming that concern about depression would be expected, given the patient’s recent life-changing stressor. However, to this family, a psychiatric consult seemed to come “out of the blue,” and had no connection to the injury the patient had suffered. The team then met with family and explained the rationale behind the consult, reassuring them that the consult did not imply that the patient was mentally abnormal.
DSM-IV-TR’s cultural formulation and its components were discussed, including the influence of the individual’s cultural identity, cultural explanations of illness, cultural factors related to psychosocial environment and level of functioning, cultural elements of the relationship between the individual and the clinician, and overall cultural assessment for diagnosis and care (8). Each component was introduced using vignettes, such as the case of “Ms. G,” a 37-year-old Hispanic woman who believed her nervous tremor, heart-racing, and anxiety were due to “the evil eye” — an example of a cultural explanation of illness. The concepts of cultural norms, culturally-accepted deviation from these norms, and, finally, culture-bound syndromes, were introduced (9). Systems of classification were presented, with a few examples of culture-bound syndromes (Table 1) (10, 11).
Questions adapted from Kleinman’s model explaining patients’ cultural understanding of their illness (12) were presented as follows:
What do you call your problem? What name does it have?
What do you think caused your problem?
Why do you think it started when it did?
What does your sickness do to you? How does it work?
How severe is the sickness? Will it have a short or a long course?
Residents’ discussions included a continuation of the case of Mr. S:
At a family meeting, Mr. S’s wife related that she had had an argument with Mr. S about an ex-boyfriend she had in Korea prior to her marriage with Mr. S. When asked about this, Mr. S dismissed this incident as trivial. He did, however, report a chronic burning feeling in his upper abdomen and painful defecation. This was addressed, and the treatment plan discussed with Mr. S. He then began to show improvement in mood and energy. A family meeting was scheduled, wherein Mr. S was allowed to take the lead in the discussion. He then showed a rapid return to a euthymic state and was ready for discharge within the next few days.
Discussion of the Above Case “Hwa-byung” is a Korean somatization disorder literally meaning “anger disease,” manifested by a feeling of heat in the abdomen, palpitations, or other GI complaints. When further interviewed, patients endorse symptoms of emotional distress such as sad mood, suicidal ideas, and guilt. Various life-events involving their spouse (extramarital affairs, domestic violence, etc.), or children (leaving home, academic failures) are identified as triggers for a subjective psychological state explained as a feeling of having been treated unfairly or unjustly (9). Mr. S appeared to be going through a similar state, which manifested as somatic complaints. Building rapport, eliciting collateral information in a culturally-sensitive manner, and respecting Mr. S’s position as head of the family were some of the components that led to a successful outcome. Of note, these aspects of the treatment team’s approach were significantly more important than actually making a diagnosis of a culture-bound syndrome.
The third module, “Cultural Groups Encountered in the Clinical Practice of Psychiatry,” addresses individual cultural groups. Cultural explanations or models of illness and variations in manifestations of psychiatric illnesses in each cultural group were discussed (13, 14). Clinical examples include the following case:
“Mr. D,” is a 42-year-old Native American man who appeared at first to have blunted affect and poor eye contact. He later revealed to his interviewer that it was considered disrespectful in his tribe to make direct eye contact with an authority figure. He also explained that, despite going through emotional problems, it was important for him to put up a “brave face,” thus explaining his stoic facial expression.
Residents then explored issues a clinician would be likely to face when treating patients from different cultural groups, such as transference and countertransference and compliance with treatment and systems of care (13). Residents discussed examples from their experiences with patients such as the following case:
“Mrs. Z,” is a 65-year-old Chinese woman who nodded in understanding throughout the clinician’s explanation of a procedure, only to reveal later to her daughter that she had not understood a single word, but had wanted to be polite and be seen as “the good patient.” Finally, the importance of appreciating the uniqueness of each individual patient and the dangers of assuming sameness based on a patient’s cultural background were discussed.
This course was reviewed by the program director, who determined that it met ACGME’s training requirements for psychiatry residents in the area of cultural aspects of psychiatry.
Evaluations were designed on the basis of the objectives of each module, with residents rating achievements of each objective on a 5-point Likert-type scale (1: Strongly Agree to 5: Strongly Disagree). Most items were rated as “Strongly Agree” or “Agree,” and none were in the “Disagree” range (Table 2).
This curriculum attempts to deliver a concise and clear picture of the concept of health as essentially a cultural product. The authors hope that this program will improve the quality of health and mental health care delivery by raising the residents’ level of awareness of this important core concept in mental health. This curriculum can be adapted to other residency and health/mental healthcare training programs requiring education in cultural diversity and its applications to patient care. Future research should examine the impact of this course on trainees’ knowledge and attitudes and thus address its effectiveness in enhancing residents’ cultural competency in clinical care.