Many curricula have been developed to sensitize trainees to the needs of diverse populations (1). What we term the "traits" approach aggregates individuals by an ethnic or social characteristic to promote cultural competency for communities around training institutions (2–4). Sample curricula exist for gender, sexual, and racial minorities (5–11). Alternatively, the "skills" approach focuses on evaluating patients from any culture, probing explanatory models, acculturation, and culturally tailored treatments (12, 13). Critics of the traits approach suggest that clinicians may incorrectly extrapolate group attributes to individual patients (14). Moreover, clinicians may be confused when a patient identifies with many groups (15). Finally, this model ignores how cultures evolve, with travel and technology allowing for accumulation of unprecedented influences (16, 17). Another variable is the optimal pedagogy for cultural competency. Unlike specialties dependent on expensive technologies, cultural psychiatry utilizes clinician experience as data. Experiential learning may enhance professionalism because it joins learner experience with theory to improve performance of real-world tasks (18). Experiential-based learning inverts traditional instruction as learners determine the conditions (the What, How, and When) of learning (19). Experiential learning has also been used within residency programs to mentor trainees (20). The authors sought to combine experiential learning with small-group discussions in units of five to eight individuals, who exchanged answers as they debated toward consensus with facilitators. This article reports qualitative results of an experiential elective seminar on culture and mental health through the skills approach that sought to balance an instructor-driven syllabus with learner-determined education. We assumed that participants would learn about cultural competency and tensions between psychiatric and anthropological research if they surveyed historical themes, organized independent cultural assessments of patient histories, and read actively in the psychiatry and anthropology literature.
The course was offered as an elective through the Yale Department of Psychiatry for all students in health professions. The course departed from older models of cultural competency. First, instructors assigned readings for culture and a theme, rather than a minority group (for example, "Culture and Depression," "Culture and Anxiety," and "Culture and Psychosis," rather than "The African American Patient" or "The Bisexual Patient"). Second, instructors encouraged presenters to weave readings with clinical experiences. Several educational styles were used, such as the discussion of articles, presentations to the group, case discussions, and small-group discussions. Finally, participants devised independent methods for developing cultural assessments, and these were compared with the DSM-IV-TR Outline for Cultural Formulation. Participants met biweekly for 11 sessions (February 10, 2010, to July 21, 2010). Open attendance was allowed, given the challenging schedules of many trainees in medicine and public health. The course was advertised through e-mail: listserves from the Department of Psychiatry to all residents and the School of Public Health to all students interested in global health. No incentives were offered for participation. Each session met for 90 minutes, following the same format: 5 minutes of welcome and assignment of readings, 30 minutes for summary, and 55 minutes of discussion. Participants read material beforehand except for the week on the cultural formulation, when they were asked to construct an assessment tool based on previous intellectual themes. Readings on this topic were reviewed in class (see Table 1).
The authors of this article served as course facilitators. One is a PGY-4 in psychiatry who organized the syllabus around cultural psychiatry and psychiatric anthropology. The other is the residency program director, who advocated for experiential learning. The senior resident led sessions with adviser mentorship. Advanced residents may teach effectively because junior trainees can identify with them (12), and they can apply knowledge from their recent roles as medical learners in transitioning to medical teachers (21). The Human Investigation Committee deemed this study "minimal risk," and a waiver of consent was obtained since no identifying information would be disclosed.
Here, we present the results in two formats. First, we list themes of the course. Next, we include participant cultural assessments. Three of 32 trainees in the PGY-2 and -3 years (9%), two 4th-year medical students, and a sociologist formed the core group of virtually every session (1).
Hybridized cultural identities are an overlooked norm. The first session questioned the trait-based format that characterizes most literature on cultural competency. Participants introduced themselves, explained their reasons for taking the course, and attempted definitions of culture. Participants challenged each other by positing compounded selves as the norm of cultural identity. For example, discussions revolved around biracial children; unequal fluencies in several languages; immigration with varying degrees of acculturation; and ethnic minorities who identified as gay, bisexual, or transgendered. This process supported our hypothesis that a skills approach would be more helpful in assessment. Since hybridity posits that individuals actively synthesize identities from multiple reference-points, in contrast to inherited identities of origin (22), participants agreed that psychiatrists should discern how cultural meanings influence illness and treatment expectations of patients.
Anthropological research can guide cross-cultural mental health. Anthropologists have long argued that their discipline can detail mental disorders across cultures, highlight cultural dimensions of illness, examine translations of instruments, and critique the universality of knowledge produced in Western cultures (23, 24). Each participant had previous exposure to international experience through clinical rotations or personal travel, so this content may have found a sympathetic audience. The sessions on culture's interplay with various disorders delved into terrain familiar for anthropologists, such as the study of emotions and (ab)normality across societies. The idea that cognitions and psychoses could shift on the basis of language and culture also captivated the participants.
Anthropology suffers from the same limitations as its critiques of psychiatry. Many participants were frustrated that anthropologists critiqued psychiatry without applying the same analysis to their own work. For example, participants claimed that anthropologists who attack the power of psychiatrists to invoke involuntary commitment have no responsibility toward suicidal or homicidal patients. Participants also countered that anthropologists critiquing psychiatrists for applying Western diagnoses and treatments apply Western social theories to non-Western populations. This tension between a critical anthropological and a clinically-applied perspective was unanticipated.
Despite differing frameworks, anthropologists and psychiatrists use interviewing techniques with the cultural formulation dovetailing common interests. After reviewing theories in psychiatry and anthropology, the facilitators sensed that participants grew restless at ongoing critiques that assessments did not account for culture. After the 4th week, participants began to offer their own ways of evaluating culture. Recognizing that we had not yet addressed the cultural formulation, the facilitators therefore asked participants to fashion their own method for cultural assessments. Participants were advised not to read the formulation in DSM-IV-TR or conduct literature reviews about the topic.
Despite the observation's limited sample size, there are interesting trends, which can be seen in Table 2. All participants asked about explanations of illness and social networks to gauge levels of support and functioning. There were also key differences, potentially due to training. Only one resident considered how cultural factors affected the patient–clinician relationship (on the basis of his experiences in second-language settings). No participant inquired about cultural identity, since many felt awkward and uncomfortable asking about this directly. The readings on the cultural formulation produced such interest that participants extended discussions for another week. Participants agreed that devising a formulation solidified the need for a general cultural assessment. Participants: were also surprised to learn that the cultural formulation reflected collaboration among anthropologists and psychiatrists. Psychiatrists involved in the 1991 NIMH Group on Culture and Diagnosis convened for DSM-IV have publicized how the cultural formulation originated from a literature review converging anthropology's focus on patient experience with psychiatry's focus on patient recovery (25, 26). All participants welcomed the ethnographic approach to the history, wherein the patient's viewpoint supplemented the various DSM criteria of symptoms.
Our experiential seminar yielded many benefits. First, by tracing the histories of general and cultural psychiatry, participants grasped methodological challenges in clinical care and research. For example, attendees disputed anthropological criticisms of psychiatry, but appreciated the ethnographic approach of the cultural formulation. Second, participants felt comfortable sharing emotional material in a small-group format, suggesting that the readings imparted knowledge and stimulated conversation. Third, the experiential format invited participants to contemplate their clinical styles by debating scenarios such as the need for translators during a busy call or the translation of unfamiliar idioms of distress into DSM-IV-TR criteria.
Nonetheless, our elective has several limitations. First, participation was voluntary and led to selection bias, since all participants had expressed interest in cultural psychiatry, whose prior knowledge-base we did not evaluate. Future courses could collect more fine-grained information on participants. Second, public health students stopped attending after the fourth session, the final month of their semester. Future courses could restrict participation to medical students or better account for calendar discrepancies. Third, some sessions attracted more attendees than others, given the open attendance. Therefore, we could not effectively administer pretest and posttest questionnaires. Future courses could require attendance for regular assessment or evaluate every session. Fourth, our seminar only addressed culture in affective, anxiety, and psychotic disorders—those most prevalent in an adult-psychiatry residency. However, the syllabus could easily fit other topics like personality disorders. Fifth, our questionnaire tested course attitudes, not clinical skills. Finally, our course did not benefit from the curricular space and intense resources of required courses in the residency program, reducing participation, educational materials, and session number. More generally, the facilitators also recognized limitations of a strictly skills-approach to cultural assessment. When clinicians applied the cultural formulation to individuals from unfamiliar reference groups, they could not detect whether beliefs and practices were culturally shared. In this manner, the traits-approach can complement the skills-approach if clinicians accessed the ethnographic record (27). Just as clinicians contact social collaterals for patient information, clinicians can view the ethnographic record as a "cultural collateral." This may optimize a skills-approach of process with a trait-approach of content. Despite these drawbacks, this seminar presents an alternate pedagogy for cultural psychiatry. Interventions with better samples and assessments are required, but qualitative data demonstrate constructive feedback about our course. The topical format may help other programs incorporate cultural themes within existing curricula or as topics for journal clubs. The extent to which instruction within cultural psychiatry alters practice remains an open question that may benefit from future systematic research.