Although the ethical, social, and political importance of addressing cultural diversity in health care is widely recognized, the evidence for improved clinical effectiveness remains quite limited. There is a tremendous need for more research on all aspects of the interplay of culture and mental health, including models of psychopathology, health services, and recovery (1). This, in turn, requires a new generation of researchers trained to apply contemporary social science perspectives and diverse methods to the study of culture and psychiatry. To address issues of cultural diversity in mental health services, researchers require familiarity with a broad range of methodologies. The most sophisticated studies are multimethod, integrating both quantitative and qualitative approaches, and require teams of researchers who can work together closely.
In this article we summarize our experience training researchers in cultural psychiatry at the Division of Social and Transcultural Psychiatry of the Department of Psychiatry, McGill University in Montreal. Research training activities include a Master of Science (M.Sc.) degree in psychiatry, an intensive summer school, annual Advanced Study Institutes, and the McGill-Canadian Institutes of Health Research (CIHR) Strategic Training Program in Culture and Mental Health Services Research. We will outline our pedagogical approach and curriculum and present data evaluating the courses and training experiences. The social context and background for these programs is provided in a companion article on clinical training (2).
Institutional Setting and Unique Features of the Program
There is a long history of interuniversity research collaboration in Montreal through the Division of Social and Transcultural Psychiatry and Groupe interuniversitaire de recherche en anthropologie medicale et ethnopsychiatrie (GIRAME). Because Montreal is situated at the cross-roads of Anglo-American and French academic traditions, with a highly diverse population, the training environment provides a pluralistic approach both in terms of theoretical frameworks and intellectual styles (3). In recent years, academic work in cultural psychiatry has evolved from an emphasis on theory development to clinical research in several related domains: novel cultural consultation frameworks for mental health services and primary care (4); new intervention models with major psychiatric disorders (including psychoses) to introduce social and cultural dimensions (5–8); specialized transcultural child psychiatry (9); promotion and prevention programs for communities within schools (10–12); and research interaction with community organizations and policy makers around issues of immigrant and refugee health as well as the mental health of Aboriginal peoples (12–14).
One of the unique aspects of the program is the close link among clinical units actively engaged in developing new models for cross-cultural clinical work. These include the Transcultural Child Psychiatry Service of the Montreal Children’s Hospital (9) and the Cultural Consultation Service of the Jewish General Hospital (4). These services are involved in funded research projects including ongoing evaluations of effectiveness. We also have active research at community clinics that provide primary medical care and social services to an extremely culturally diverse population of immigrants, refugees, and ethnocultural communities. The close proximity of academic and clinical settings and involvement of clinician-researchers facilitates the clinical relevance of research and the translation of knowledge to the practice setting. Collaboration with front-line clinicians, the regional health planning board, and community organizations ensures an ongoing exchange of information on issues critical for policy and practice.
Research training in culture and mental health tends to follow disciplinary lines and programs are usually confined to a single discipline (typically psychology or public health). As a result, few programs give equal weight to qualitative and quantitative research methods. A particular strength of our program is the longstanding collaboration between scholars of medical anthropology, psychology, and psychiatry at McGill. Faculty members in our program have contributed to critical reconceptualizations of culture that can inform research and clinical practice (1, 16–22). Contemporary views of culture emphasize the heterogeneity, hybridity, and internal flux of cultural identities, institutions, and practices. The critical perspectives of anthropology allow the comparative study of health care systems and their fit with social parameters and cultural values. This critical anthropological approach is complementary to other approaches in health services research and training that emphasize epidemiological and clinical evidence.
Since 1973 the McGill Department of Psychiatry has offered an M.Sc. degree, which can be taken with a focus on cultural psychiatry. To our knowledge, this is a unique program in North America. The degree was originally designed for physicians seeking research training; however, at present it also admits students from other disciplines who wish to pursue lines of research and study found only within the psychiatry department. The program involves courses in cultural psychiatry, psychiatry epidemiology, as well as quantitative and qualitative research methods (described in later sections). Other courses are chosen to fit the specific needs of individual trainees. Training is centered on conducting original research under the mentorship of faculty, who include researchers from psychiatry, psychology, epidemiology, public health, neurosciences, anthropology, sociology, and philosophy. International students may spend one year at McGill and complete the degree by conducting field research in their home country.
A total of 158 students have taken part in the M.Sc. program, with 29 (18%) focused on social or cultural psychiatry; more than 50% come from psychiatry, about one third from psychology, and the remainder from other health and social science disciplines (general internal medicine, nursing, art therapy). Of the 29 students with a focus on cultural psychiatry, 22 have graduated; 13 (59%) have academic appointments in medical schools, two work in health policy, two are working as research assistants, and five are continuing on to an advanced degree. Overall, 18 (82%) were actively involved in research, 15 (68%) were doing clinical work, with 13 clinician-researchers. An ad hoc Ph.D. program in cultural psychiatry is currently under development. Description of the graduate training program can be found on our website (http://www.mcgill.ca/tcpsych/training/msc/).
McGill Summer Program and Advanced Study Institutes in Cultural Psychiatry
In 1994 we organized an annual summer program in social and cultural psychiatry to strengthen the academic program for trainees at McGill and to make it more feasible for students and professionals from outside Canada to participate. The program includes three core courses:
This seminar surveys recent theory and research on the interaction of culture and psychiatric disorders. Topics covered include the history of cultural psychiatry; cross-national epidemiological and ethnographic research on major and minor psychiatric disorders; culture-bound syndromes and idioms of distress; culture, emotion, and social interaction; ritual and symbolic healing; mental health of indigenous peoples; mental health of immigrants and refugees; models of mental health services for multicultural societies; psychiatric theory and practice as cultural constructions; and methods of cross-cultural research. A key element is the use of films to illustrate ethnographic material and provide a basis for discussion of basic issues.
This course provides an overview of the applications of epidemiology in the field of psychiatry. Topics include instruments and methods used in community studies; major recent national and international population surveys of psychiatric disorders; study of treatment-seeking behavior, pathways to care, and use of services; the interaction between psychological distress and physical health; methods used in specific populations (elderly, children and adolescents, homeless); and evaluation of treatment and services.
This course is described in the companion paper on clinical training (2).
Additional courses, modules, and workshops address key issues in culture and mental health research, including:
Qualitative Research Methods
This course provides an overview of the main qualitative research methods relevant to culture and mental health service research. Topics include epistemological assumptions, conceptual frameworks, and sources of bias. The core of the course focuses on ways of coding and analyzing narrative data, qualitative interviewing skills, and key features of fundable qualitative research proposals. Students practice qualitative interview skills in the classroom using a generic semistructured ethnographic interview schedule (23). A combination of lectures, case presentations, group discussions, and class exercises are used and students develop or refine their own graduate research project during the course.
Quantitative Methods in Cross-Cultural Research
This course provides an overview of the design of cross-cultural quantitative studies as well as population and community surveys. Topics include problems of cultural validity and levels of psychometric equivalence of instruments across cultures; statistical methods for cross-cultural comparison with large and small samples; and cultural considerations in the measurement of symptomatology, diagnosis, need for services, service utilization, functional status, quality of life, and treatment outcome.
Participatory Action Research with Communities
This workshop addresses the ethics and pragmatics of participatory research, which is crucial for work with Indigenous peoples as well as ethnocultural groups, consumers, and community organizations (24). Topics include participatory research theory; building and maintaining healthy and respectful partnerships; developing collaborative project strategies from design through dissemination; ownership of research data; maximizing benefits and minimizing community risks; and capacity building and sustainability. The workshop is conducted in an Aboriginal community and illustrates how community groups can use research results to influence health policies.
Over the last 12 years, over 350 people from 34 different countries have taken part in the summer school courses. Participants include psychiatric residents and graduate students in health and social sciences as well as more senior academic faculty and researchers. About 30% come from outside North America, making for a very diverse learning environment. Reflecting the enthusiasm of faculty and students, the courses are consistently rated in the very good to excellent range. Qualitative evaluations by participants comment on the interactions among faculty and students that the courses in cultural psychiatry are unique educational experiences characterized by a high level of respect for diversity. The main criticism is the need for more discussion time.
Since 1996 we have held a series of annual Advanced Study Institutes to focus on emerging issues in culture and mental health research and practice. These involve groups of four to six senior scholars and four to six junior scholars chosen for their active involvement in an emerging research issue. Along with the postdoctoral fellows and other trainees, they meet for 3 to 5 days in an intensive workshop format to present current work, discuss methodological issues, develop a critical perspective, and advance the field. The themes of these institutes have included the politics of trauma; the mental health of Indigenous peoples; models of training in culture and mental health; body, memory and identity; models of mental health services in multicultural societies; culture and psychotherapy in a creolizing world; stigma and the dynamics of social exclusion; and refugees and forced migration. Details on the summer program and the Advanced Study Institute can be found on our website (http://www.mcgill.ca/tcpsych/training/summer/).
Strategic Training Initiative in Culture and Mental Health Services Research
In 2003 we received a 6-year grant from the Institute of Neuroscience, Mental Health and Addictions of the Canadian Institutes of Health Research to develop a strategic training program in culture and mental health services research. The aims of the program are to train researchers to do the following:
integrate epidemiological and ethnographic (quantitative and qualitative) research methods to produce more accurate and valid information on the mental health status and service needs of immigrants, refugees, Aboriginal peoples, and ethnocultural communities (25, 26);
identify the influence of cultural and social factors on the pathways and barriers to care, mental health service design and delivery, and the response to treatment of individuals with psychiatric disorders (1);
evaluate the effectiveness of culturally responsive mental health services (27);
critically evaluate and study ethical issues in cross-cultural mental health research and clinical practice (28, 29);
develop community partnerships for participatory research (24, 30);
engage in effective knowledge translation of research findings to policy makers, cultural communities, primary care institutions and practitioners, and other stakeholders (31). The program also aims to develop innovative curriculum and training methods for training researchers.
The program includes postdoctoral fellowships as well as training at M.Sc. and Ph.D. levels for researchers with a background in psychiatry, psychology, social work, nursing, public health, bioethics, or social sciences applied to medicine (e.g., medical anthropology). Graduate work can be taken within one of the departments or disciplines involved in the program at McGill University. Emphasis is on conducting research in collaboration with the program faculty and their collaborators across Canada and internationally.
Faculty from anthropology, bioethics, epidemiology, family medicine, health economics, law, psychology, public health, social work, sociology, and philosophy participate in seminars and jointly supervise trainees to ensure exposure to multiple disciplinary perspectives. A weekly integrative research seminar fosters interdisciplinary thinking about research questions and methodologies. Topics for this seminar include current concepts of culture and ethnicity; racism and postcolonial theory; migration and mental health; cultural competence; cultural concepts of self, person, and identity; social capital and social suffering; stigma and social integration; ethical issues in cross-cultural research, and research on clinical ethics in multicultural health care.
The training program has an advisory board comprised of representatives from other mental health disciplines (family medicine, nursing, social work) as well as community organizations involved in work with immigrants, refugees, Aboriginal peoples, and ethnocultural communities. A network of international scholars acts as mentors and guest faculty.
In all, 54 trainees have taken part in the Canadian Institutes of Health Research (CIHR) program from its inception to August 2006, of whom 21 are health professionals. Participants from the program come from psychology (44%), psychiatry (22%), anthropology (22%), and other health (6%) and social sciences (6%). In addition to residents and medical students doing research rotations, the program has included 13 postdoctoral fellows, 13 doctoral-level students, 15 masters students, and five visiting scholars. Trainees have produced a total of 95 peer-reviewed publications, 64 other publications, and approximately 100 presentations (62 conference presentations). Of the 21 who have completed the degrees in association with the program to date, seven have faculty appointments as assistant professors (in medical anthropology, medical sociology, and social psychology), five are clinician-researchers, four are clinicians, and the remainder are pursuing further graduate or postdoctoral study. A recent external review of the research training program by the granting agency rated it excellent and a model for interdisciplinary research training. The McGill-CIHR training program is described in more detail on our website (http://www.mcgill.ca/tcpsych/training/cihr/).
Developing and Sustaining Research Training in Cultural Psychiatry
The McGill program offers a unique environment for training in cultural psychiatry. We believe the growth and success of this program reflect several deliberate choices as well as fortuitous circumstances. First, it is due to a commitment on the part of the Department of Psychiatry to support cultural psychiatry as an academic discipline and the corresponding provision of salary, space, and administrative support. The tradition of transcultural psychiatric research at McGill has focused on basic science questions of social and cultural influences on psychopathology and treatment. This focus ensures that the whole field is viewed not only as a matter of equitable health service delivery, or “political correctness,” but also as an arena for exciting scientific research.
Second, it reflects a long history of engagement in international training and research, and more recently of strong links with local ethnocultural communities and advocacy groups. These links to consumers, as well as policy and practice settings, provide the basic rationale for cultural psychiatric research training and opportunities for clinically and socially relevant projects and knowledge translation activities.
Third, an open attitude among colleagues from medical anthropology, social sciences, and psychiatry has fostered interdisciplinary research collaboration and co-supervision of students and, related to this, a relative lack of interest in defending disciplinary boundaries or competing over scarce resources. This has allowed trainees to receive training and mentorship from colleagues based at many different academic departments and universities, both locally and internationally;
Finally, our growth and success is due to some unique funding opportunities. The McGill teaching hospitals have supported the development of research units and clinical services devoted to work with immigrants, refugees, and Aboriginal peoples. Although many of our training activities have been self-funded (through course fees and faculty contributions of time) and we have consistently avoided seeking any support from the pharmaceutical industry, the innovative vision of Quebec and Canadian health research agencies committed to building research capacity has made it possible to obtain team grants and, most recently, funding for a strategic training initiative, that have greatly expanded the training environment.
The same attitudes of respect, intellectual curiosity, and social concern that make for creative collaborations among colleagues from diverse backgrounds contribute to a training environment in which young researchers can begin to acquire and integrate methods and perspectives from multiple disciplines, toward the long-term goal of putting cultural psychiatry on firm conceptual and empirical footing.
Cultural psychiatry is an emerging field of research that provides an essential complement to the body of psychiatric research that is usually conducted without systematic attention to cultural context or generalizability. Transcultural research requires both methodological rigor and the ability to question the cultural assumptions built into conventional mental health theory and practice. In this transdisciplinary training program, we strive to find a balance between rigor and openness to novel ways of thinking. Four strategies have been useful in this process:
introducing the student to multiple disciplinary perspectives by ensuring they have mentors from different backgrounds, while being careful not to place the student in a quandary with supervisors who make contradictory demands or present unresolvable differences in approach;
exposing students to a transdisciplinary perspective that emphasizes the value of multiple methods to address critical research questions. In particular, students are encouraged to understand the complementarity of methodological approaches, especially quantitative-epidemiological and qualitative-ethnographic methods, through research seminars and exposure to the faculty’s own work;
encouraging students to carry out original projects that fit their interests. Often, students will choose a subject that has some relation to their own identity or personal trajectory. This ensures personal relevance and commitment but poses challenges for maintaining the critical stance essential for research;
providing a supportive learning environment where students are part of an interdisciplinary research team that works in partnership with community organizations, schools, or clinicians. This partnership is an important way to address the essential need for knowledge translation in health research.
Our research training activities include summer studentships for medical students, research electives for residents, an M.Sc. and ad hoc Ph.D. in cultural psychiatry, postdoctoral fellowships, and a summer program with courses and workshops that can be taken for professional development. Available follow-up data are limited but suggest that these activities have been successful in influencing career directions, producing new independent investigators, and promoting productivity in terms of publications and grants. Additional methods of outcome assessment are needed to determine whether these training activities have increased the interdisciplinarity of cultural psychiatric research, as well as the conceptual sophistication and methodological rigor of a new generation of studies.
The movements toward patient-centered, narrative-based, and values-based medicine are all consistent with increased attention to cultural issues in health care. Attention to culture has also been driven by increased representation of ethnic minorities and international medical graduates within the health professions (32). Research in social neuroscience and on the social determinants of health provides clear evidence of the importance of culture in the basic biological, psychological, and social processes of health and illness (33). At the same time, given the forces of globalization and dynamics of communities, culture itself is a moving target that demands innovative models and methods to research (25). Transdisciplinary research training of the sort we have described is an essential step in building the capacity to identify the links between culture and the social determinants of health, as well as the design and implementation of effective mental health services and interventions for our increasingly diverse societies.