Psychiatrists entering medical practice are increasingly likely to provide services to culturally diverse patients. Data from the last census (1, 2) show that the minority populations in the United States are increasing at a faster rate than the majority population. From the years 2000–2050, the proportion of whites in the United States is projected to decrease while the proportion of other racial and ethnic groups (i.e., black, Asian, Hispanic) is projected to increase. Because of the multifaceted, multicultural, and fluid nature of contemporary society, there are often significant challenges to providing culturally competent mental health services for culturally dissimilar as well as culturally similar therapeutic dyads.
In the United States, the results of these challenges can be seen in the existence of health care disparities (3–8). In 2001, the Office of the Surgeon General determined that in comparison to whites, ethnic minorities in the United States had less access to mental health care, were less likely to receive quality or expert care, were more likely to be misdiagnosed, and reported less effective mental health treatment (5). Physician cultural competence and responsiveness may be the key to meeting the “diverse needs of all patients” (5) and may contribute toward the reduction of health care disparities (9).
Leaders in health care and in psychiatric residency accreditation have noted the importance of cultural competence training. The Office of the Surgeon General and APA have recommended training curricula that address the impact of culture, race, and ethnicity on mental health and mental health services (5, 7, 10–15). The 2007 Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for Psychiatry Residency recognize sociocultural factors relevant to psychiatry training (16, 17). Training curricula that encourage an appreciation of diverse health care values and self-examination of one’s own world view as well as supervised clinical experience with multicultural populations are likely to foster patient-centeredness (3). The ACGME encourages training psychiatrists to learn case formulation that “…includes sociocultural issues involved in diagnosis and management of cases” (16, 17). The DSM-IV-TR Outline for Cultural Formulation has previously been used as a clinical tool to highlight culturally relevant issues in psychiatric care (8, 18).
Cultural factors often impact communication between psychiatrists and their patients. Patients whose individual or group histories include oppression or discrimination are sometimes reluctant to disclose information to or follow the advice of providers who represent mainstream culture (9). Effective history-taking and clarification of symptoms may be difficult when the patient and psychiatrist do not share the same language (verbal and nonverbal) (19). Psychiatrists who are trained to use interpreters and who appreciate culture-based patterns of communication may be better able to serve a multilingual patient population. Moreover, the ability to identify and empathically respond to sociocultural factors relevant to the treatment relationship may improve patient care and satisfaction.
Cross-cultural education experts widely recognize a tripartite model of cultural competence education that is a foundation for multicultural proficiency (9, 20–23). The tripartite model involves three dimensions: knowledge, skills, and attitudes. Many cross-cultural psychiatry programs focus primarily on the knowledge pillar of the model and only a few have empirically evaluated their programs (24). However, imparting knowledge about other groups without an attendant exploration of attitudes can actually serve to intensify and harden stereotypes and biases (25). Furthermore, developing the ability to introspect about one’s cultural assumptions is a highly transferable ability. It is useful when working with any cultural group, including one’s own.
We present a psychiatric multicultural training course that is designed to increase resident training in knowledge of sociocultural factors relevant to clinical practice; awareness of their own world view, values, biases, privileges, etc.; and clinical skills that foster the application of these principles. We hypothesized that after the course residents would report an increase in the extent of training that they had received in multicultural knowledge, skills, and attitudes as well an increase in the application of multicultural practice skills. We present precourse, postcourse, and 9-month follow-up data on residents’ knowledge, attitudes, and clinical application of multicultural practice skills.
The course was offered at an academic public sector hospital that features a large immigrant, multiracial, multiethnic population who represent various levels of socioeconomic status. The course was designed to introduce trainees in the department of psychiatry to central concepts important in culturally sensitive mental health practice. The course used the DSM-IV-TR Outline for Cultural Formulation as a framework for introducing these concepts. Several educational approaches were used to maximize participant learning, personal awareness, and skill development: brief large group lectures, discussion of case vignettes, small group discussion, and in-session demonstration of clinical skills.
Trainees from multiple disciplines met weekly for the 9-week program, which took place during the initial training months (July 6, 2005–August 31, 2005). There were 35 course attendees comprised of postgraduate years 2–4 (PGY-2-4) residents as well as psychology predoctoral interns and social work trainees. They met each week for an hour and 15 minutes in a small auditorium. Each trainee was assigned to a small group with an average of six trainees and two facilitators. There were six groups in total. Group assignments were made to create the maximum diversity in terms of ethnicity, gender, and discipline. Each session had the following general format: 10 minutes to review material presented in the previous session, 30 minutes to present new concepts in a brief lecture format, 25 minutes for clinical application either in large or small group discussion settings, and 10 minutes to summarize the session and to review reading material for the next week (Table 1
). Participants were asked to read literature related to the topic for the next week between sessions. During this time they also completed personal awareness exercises (e.g., a cultural genogram) or attempted new clinical skills (e.g., culturally sensitive interviewing).
The large group lecture format was adapted not only to disseminate information but also to facilitate a participatory and revelatory atmosphere. By structuring a check-in and wrap-up in the large group format, there was an opportunity for participants to address clinically sensitive material and/or intense emotional experiences they had in the small groups and/or in the previous session. Facilitators modeled attentive listening, attended to verbal and nonverbal communication among small group participants, and encouraged all participants to contribute to the discussion. Facilitators encouraged participants to offer their understanding of the concepts presented as well as the way in which aspects of their cultural background shaped the meaning they gleaned from the concepts under discussion.
Two of the authors served as instructors for the course: one is an instructor in psychology (TLH) and the other was a PGY-4 psychiatry resident (JM). The instructors presented lectures about basic constructs in cross-cultural psychiatry and also modeled humility, empathy, curiosity, respect, sensitivity, and awareness with regard to multicultural issues in clinical practice (9). The modeling involved the demonstration of cross-cultural skills (e.g., culturally sensitive interviewing) as well as strategies used to manage difficult feelings (e.g., shame experienced with cultural insensitivity) and mistakes made in the process of applying cultural competence skills. Moreover, it was hoped that having the instructors represent both the training faculty and the trainees would foster identification. In addition, the resident instructor served as a small group facilitator and the faculty instructor served as a floating facilitator to trouble-shoot and provide additional support to small group facilitators.
Volunteers from faculty across disciplines (psychiatry, psychology, and social work) in the department of psychiatry served as facilitators for the small group discussions. There was diversity (race, gender, sexual orientation, discipline, immigration history, acculturation experience, practice setting, and prior knowledge of multicultural issues) among faculty involved. Involvement of faculty representative of several minority groups was encouraged to minimize the pressure that minority trainees sometimes feel to carry the so-called “minority position” in the large and/or small group discussions. While all of the facilitators had experience doing group work, they had a range of multicultural knowledge from novice to expert. Small group facilitators who were self-identified novices were partnered with those with more multicultural training experience. The instructors developed a facilitator’s guide and held three training meetings: one prior to the small group work, one mid-course, and one toward the end of the course. The meetings were timed to prepare for and to debrief from small group sessions that were anticipated to be particularly challenging. The instructors met weekly and communicated with facilitators via e-mail to discuss the preceding session and to titrate the course content to be appropriately challenging. Any revisions were then incorporated into the upcoming facilitator’s guide and disseminated via e-mail to all of the facilitators.
Fifteen of the 22 psychiatry residents who attended the course decided to participate in the study. Of the study participants, 53% were male (N=8). The group was 67% Caucasian (N=10), 13% Asian (N=2), 7% black (N=1), 7% Latino (N=1), 7% other (N=1). Forty percent of the group were PGY-2 (N=6), 27% were PGY-3 (n=4), and 33% were PGY-4 (N=5). Seven residents did not attend the first day. In the group that did not attend, there were no significant differences in gender or ethnicity. In the group that did not attend, 29% were PGY-2, 57% were PGY-3, and 14% were PGY-4. The study was approved by the Institutional Review Board of the Cambridge Hospital/Harvard Medical School as a “minimal risk study,” including a waiver for informed consent since no identifying data were obtained.
In order to assess the impact of the course, we adapted items from the Boston Survey of Culturally Competent Residency Training Practices in Psychiatry (26); this survey was originally drawn from the work of Weiss and Minsky (27). Readers may contact the authors to see a copy of the questionnaire. The first part of the questionnaire asked residents to rate their current training in multicultural knowledge (items 1–10) and awareness of their cultural background and position(s) of privilege (items 11–12). A 5-point Likert scale was used, with 1=none and 5=a lot. The second part of the questionnaire asked residents to rate their application of multicultural training in several practice areas, such as diagnostic assessment and treatment planning (items 13–19). Another 5-point Likert scale was used, with 1=never and 5=all the time.
We distributed the questionnaire was distributed immediately before and after the 9-week session. Participants also completed a 9-month follow-up questionnaire using either an online survey mechanism or by hand using the paper survey distributed at one of the monthly residents’ meetings. In the follow-up questionnaire (which included items 11–19 of the original questionnaire), residents were asked to rate the awareness training they received throughout the 2005–2006 year as well as their application of multicultural training. Study participants were instructed to create a unique identifier to ensure their anonymity and to allow their pre-, post-, and 9-month follow-up responses to be matched. All data were entered and analyzed using the participants’ unique identifiers and were never linked to the participants by name. Data were entered twice and mismatches validated by referencing original surveys. We used paired t tests to compare mean scores on the precourse, postcourse, and 9-month follow-up questionnaires.
Of the 22 residents (PGY-2–PGY-4) who completed the course, 15 residents completed the preassessment and 11 residents completed the postassessment. Ten residents completed both the pre- and postcourse questionnaire (Table 2
). While 11 residents completed the 9-month follow-up, only six of those had also completed the pre- and postcourse questionnaires.
Following the course, residents indicated an increase in the multicultural knowledge/skills section in seven of the 10 items of the questionnaire and in both items assessing attitudes. Residents also reported an increase in four of the seven clinical application items. Residents’ pre- and postcourse mean scores also indicated significant improvement in their multicultural knowledge and clinical application. Table 2
presents the descriptive statistics for residents who completed both the pre- and postcourse questionnaires.
With the exception of one item, residents’ postcourse and 9-month follow-up scores were not statistically different from one another. However, they did indicate a significant decline in the item assessing training in awareness of privilege (N=6; postcourse mean=4.67; 9-month follow-up mean=4.00; t=-3.74; p<0.05; effect size=0.37). Although not reaching statistical significance, several other item scores were lower at the 9-month follow-up than scores immediately following the course.
We presented a psychiatry multicultural training course that used the DSM-IV-TR Outline for Cultural Formulation as a framework. The course incorporated a tripartite multicultural training model (9, 20–23) and used a combination of pedagogical methods (lecture, small group discussion of personal world view, and clinical application) (9, 11, 12, 24). In contrast with a previous multicultural training initiative (24), we also included between session exercises to reinforce clinical application. Current ACGME Program Requirements for Resident Education in Psychiatry (16, 17) require competence in six core areas, five of which include sociocultural issues. Our course provided multicultural training in four of the five core competences: patient care, medical knowledge, interpersonal communication skills, and professionalism (16, 17).
Using a tripartite, multimodal multicultural education model seemed not only to increase resident training in multicultural knowledge, skills, and attitudes but also to influence resident application of multicultural practices. Although there were overall gains in multicultural knowledge and application, residents did not seem to gain significant knowledge in areas such as spirituality or belief systems, or in clinical application domains such as eliciting cultural history or culture-informed treatment planning. Our course presented a general framework from which to understand patients of various cultural backgrounds and did not present culture-specific information. It may be that specific information regarding cultural groups is needed to effect resident knowledge in areas like spirituality and belief systems (24). We did not assess the adequacy of instruction received and residents may simply have needed more or better didactics to increase their clinical application. Despite the experiential nature of the small group discussions, residents may need individual reinforcement through supervision to achieve wider gains in clinical application (11, 12).
Leaders in multicultural medical education have also recommended follow-up assessments to determine whether change in residents’ knowledge about culture and clinical behavior is long lasting (9, 24). Nine months following our course, residents reported a significant decline in their awareness of privilege training. There was also a decrease in the gains made in several areas of clinical application originally seen immediately following the course. For example, residents were less likely to incorporate the cultural views and strengths of patients in the formulation of treatment plans. Despite this trend, residents generally maintained the gains achieved from precourse to postcourse. Continued acknowledgment of privilege may have stirred up feelings of shame (28). Without an opportunity to process these emotions throughout their training experience, residents may have experienced decreased ability to use their awareness of privilege. When supervisors and supervisees avoid discussion of culturally relevant material they are not likely to recognize cultural issues central to the patient’s presenting problem(s) (29). However, supervision that incorporates culturally relevant issues may not only support continued empathic understanding of one’s cultural values and position of privilege, but may also increase the likelihood that residents integrate the cultural values and strengths of the patient into mental health services planning. Tummala-Narra (29) suggests that supervisors can improve their ability to explore race and culture by increasing their cultural knowledge, initiating discussions of culture with their supervisees, attending to transferential responses, and engaging in multicultural education. By using such strategies supervisors may be more successful in preparing residents for the intellectual, practical, and emotional aspects of multicultural competence development.
There are some limitations to our study. First, participation in the study was voluntary and may have led to selection bias. Second, there was significant attrition between the postcourse and 9-month follow-up. Perhaps only those residents interested in increasing their cultural competence training chose to participate in the initial and subsequent assessments. Third, our study design did not include a comparison group. As such, it is difficult to determine whether the changes noted immediately and 9 months following the course may have occurred without taking the course. Fourth, the small sample size may have hindered our ability to determine statistically significant results (e.g., the 9-month follow-up assessment). A larger sample may be obtained in future studies by designing a multisite, controlled intervention model.
Furthermore, the measure we used assessed the respondents’ report of increased training in multicultural knowledge/skill, attitudes, and clinical application and may be subject to social desirability factors. The study could also have been improved by using a paired-question format for the pre-, post-, and follow-up assessments to avoid possible bias incurred when responding to the same items over time. In addition, this measure only assessed exposure to the topics, not mastery of the topics. Future studies may also use brief examinations to determine actual knowledge acquisition. Supervisor assessments, patient satisfaction ratings, and medical record reviews may be used to monitor the extent of clinical application as well as the effectiveness of that application.
This multicultural training course resulted in modest gains in resident training in multicultural knowledge, skills, and attitudes. Further research with a larger sample and a comparison group is needed to determine the curricular and supervisory support required to ensure that residents practice cultural psychiatry empathically, effectively, and consistently.
This study was conducted at the Department of Psychiatry, Cambridge Health Alliance/Harvard Medical School, in Cambridge, Mass. This study was supported by the American Psychiatric Association/Minority Fellowship/Substance Abuse and Mental Health Services Administration. The authors thank Drs. Teresita Camacho-Gonslaves and Stephen Leff of the Human Services Research Institute for their support in the design of this project and for their assistance in manuscript preparation. We also thank Drs. Jack Burke and Marshall Forstein who supported the development of the Multicultural Competence Core Seminar.