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Culture and Psychiatric Education

Received February 21, 2008; accepted March 26, 2008. Dr. Lim is affiliated with the Department of Psychiatry and Behavioral Sciences at the University of California Davis School of Medicine; Dr. Lu is affiliated with the Department of Psychiatry at the University of California San Francisco. Address correspondence to Russell F. Lim, M.D., Psychiatry and Behavioral Sciences, UC Davis School of Medicine, 2230 Stockton Blvd., Sacramento, CA 95817; rflim{at}ucdavis.edu (e-mail).

The editors of Academic Psychiatry are proud to be able to bring to their readers the latest developments in teaching in culture and psychiatric education. We would like to introduce this special issue with a brief historical overview of the development of cultural psychiatry as a subspecialty area. Transcultural, or cross-cultural, psychiatry was recognized by APA in 1969 (1) and has since expanded and evolved as a field of study. Cross et al.’s (2) seminal work in defining cultural competence, describing it as a continuum between cultural destructiveness and advanced cultural competence, was a key step in operationalizing cultural competence conceptually and systemically.

Important regulatory milestones in the development of the field include the Title VI Civil Rights Act of 1964 (3), which forbade discrimination on the basis of sex and race in hiring, promoting, and firing. The Americans with Disabilities (ADA) Act was passed in 1990 (4) and prohibits private employers, state and local governments, employment agencies, and labor unions from discriminating against qualified individuals with disabilities in job application procedures, hiring, firing, advancement, compensation, job training, and other terms, conditions, and privileges of employment. In 1993, the State of California began a process that became known as the California Cultural Competence Plan, which asked each of the 58 county administrative bodies in California to assess the languages spoken of their mental health patients and providers and required that they provide services and brochures in any language spoken by 3,000 non-English-speaking Medi-Cal members or 5% of the Medi-Cal population in that county (5). New York initiated similar requirements of its providers in 1997, publishing the New York State Cultural and Linguistic Competency Standards (6).

Professional organizations such as the American Counseling Association (7), the American Psychological Association (8), and the National Association of Social Workers (9) issued their own guidelines on how to implement cultural competence standards. APA published the DSM-IV in 1994, which included a groundbreaking Outline for Cultural Formulation, and cultural factors were included in APA’s Practice Guidelines of the Psychiatric Assessment of Adults, published in 1995 (10).

Further development of the integration of cultural competence in training was seen in the Association of American Medical Colleges’ initiative for Cultural Competence in Medical Education (11), which requires medical schools to provide instruction on culturally competent assessment and treatment. Following a pair of conferences sponsored by the Center for Mental Health Services, the Accreditation Council of Graduate Medical Education Residency Review Committee incorporated cultural competence requirements into its Guidelines for Psychiatry Residencies (12).

Other national agencies supported cultural competence as well, including the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Office of Minority Health (OMH), as well as the Office of Civil Rights (OCR). In 2000 SAMHSA published Cultural Competence Standards in Managed Care Mental Health Services: Four Underserved/Underrepresented Racial/Ethnic Groups (13), which details mental health treatment standards, as well as objectives for training. The OMH produced the National Standards on Culturally and Linguistically Appropriate Services (CLAS) (14), which are 14 standards for providing mental health services to ethnic minorities. Finally, the OCR, empowered by an executive order from the White House, required that all federal agencies formally address how they would provide access to their services to those clients with limited English proficiency (15).

Four other documents were critically important to raising the mental health community’s awareness of the disparities that ethnic minorities experience. The supplement to the Surgeon General’s Report on Mental Health, Culture, Race, and Ethnicity (16) established that ethnic minorities do not utilize services as much as the majority population and that "culture counts." The president’s New Freedom Commission Report on Mental Health (17) highlighted the need for serving ethnic minorities’ unique needs with culturally competent services, which would improve access and decrease disparities. The Institute of Medicine’s (18) report Unequal Treatment showed that across all illnesses, ethnic minorities received a lower standard of care than the mainstream population when controlling for socioeconomic status. Finally, the Agency for Health Care Research and Quality (19) published the National Health Care Disparities Report in 2006, which confirmed that disparities based on race, ethnicity, and socioeconomic status continue to exist and have a devastating personal and societal cost. The report emphasized the reduction of barriers to care, the need for preventive care, and the need for further research in the area of health disparities.

This issue of Academic Psychiatry covers a variety of topics in psychiatric education in its 10 articles, ranging from a comprehensive overview of strategies that stimulate a culture where diversity is an integral part of the educational environment to descriptions of various psychiatric residency curriculums at the Oregon Health Sciences University, the University of Toronto, and McGill University in Montreal. It includes specific techniques such as using nonfeature films to teach diversity, an individual lecture in the undergraduate curriculum at UC Davis on interpreting, and a seminar in the psychiatric resident curriculum at the Cambridge Health Alliance in Massachusetts. Approaches in supporting research through the use of training at McGill University are covered, as well as a pilot course on spirituality and religion at the University of British Columbia. Finally, there is an article looking at the negative impact of TV on racial identity development of African American children and how to mitigate its effects by instilling in them positive images of African Americans. Taken as a whole, these articles offer many suggestions on how best to implement a cultural psychiatry education program from the top down and the bottom up. Further resources for developing cultural curriculum can be found in American Psychiatric Publishing’s catalog, such as Lim’s Clinical Manual of Cultural Psychiatry (20), the Group for the Advancement of Psychiatry’s Cultural Assessment in Clinical Psychiatry (21), and Tseng and Strelzer’s Culture and Psychotherapy (22). Lu’s Annotated Bibliography on Cultural Psychiatry and Related Topics (23) is available online. However, the reader should be aware that these articles and resources represent only the tip of the iceberg in terms of the varieties of training approaches. The editors hope that other institutions will submit articles for publication in Academic Psychiatry detailing their innovative approaches.

REFERENCES

TOP REFERENCES

 

1. American Psychiatric Association: Position Statement on the Delineation of Transcultural Psychiatry as a Specialized Field of Study. Am J Psychiatry 1969; 126:453–455.[Abstract/Free Full Text]
2. Cross TL, Bazron BJ, Dennis KW, et al: Towards a Culturally Competent System of Care, vol 1. Washington, DC, CASSP Technical Assistance Center, Georgetown University Child Development Center, 1989
3. Civil Rights Act of 1964, Public Law 88-352
4. Americans with Disabilities Act, 1990, Public Law 101-336, 1990
5. California Department of Mental Health: DMH Information Notice No:02–03. Addendum for Implementation Plan for Phase II Consolidation of Medi-Cal Specialty Mental Health Services—Cultural Competence Plan Requirements; 2003, superseding (California) DMH Information Notice No: 97-14. Addendum for implementation plan for phase II consolidation of Medi-Cal specialty mental health services—cultural competence plan requirements;1997. Available at http://www.dmh.cahwnet.gov/DMHDocs/docs/notices02/02-03_Enclosure.pdf
6. New York State Office of Mental Health: Cultural and Linguistic Competency Standards. New York, Office of Mental Health, 1997
7. American Counseling Association: Cross-Cultural Competencies and Objectives, 1992. Available at http://www.counseling.org/Publications/
8. American Psychological Association: Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist 2003; 58:377–402.[CrossRef][Medline]
9. National Association of Social Workers: Standards for Cultural Competence in Social Work Practice, 2001. Available at http://www.socialworkers.org/sections/credentials/cultural_comp.asp
10. American Psychiatric Association: Practice Guidelines for the Psychiatric Evaluation of Adults. Washington, DC, American Psychiatric Publishing, 1995
11. Association of American Medical Colleges: The AAMC Initiative for Cultural Competence in Medical Education, 2000. Available at http://www.aamc.org/meded/tacct/culturalcomped.pdf
12. Accreditation Council for Graduate Medical Education: Residency Review Committee, Guidelines for Psychiatric Residencies, 2007. Available at www.acgme.org/acWebsite/downloads/RRC_progReq/400pr07012007.pdf
13. United States Center for Mental Health Services: Cultural competence standards in managed care mental health services: Four underserved/underrepresented racial/ethnic groups (Publication No. SMA00-3457). Washington, DC, Substance Abuse and Mental Health Services Administration, 2000. Available at http://mentalhealth.samhsa.gov/publications/allpubs/sma00-3457/default.asp
14. National Standards on Culturally and Linguistically Appropriate Services, 2001. Available at http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15
15. Overview of Executive Order 13166. Federal Interagency Working Group on Limited English Proficiency, 2003. Available at http://www.lep.gov/
16. US Department of Health and Human Services: Mental Health: Culture, Race, and Ethnicity. A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md, DHHS, 2001
17. New Freedom Commission on Mental Health: Achieving the Promise: Transforming Mental Health Care in America. Final Report. DHHS Publication SMA-03-3832. Rockville, Md, DHHS, 2003
18. Smedley BD, Stith SY, Nelson AR (eds): Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC, The National Academies Presses, 2002
19. Agency for Healthcare Research and Quality: National Healthcare Disparities Report, 2006. Rockville, Md, Agency for Healthcare Research and Quality, 2006. Available at http://www.ahrq.gov/qual/nhdr06/nhdr06.htm
20. Lim RF: Clinical Manual of Cultural Psychiatry. Arlington, Va, American Psychiatric Publishing, 2006
21. Group for the Advancement of Psychiatry: Cultural Assessment in Clinical Psychiatry. Washington, DC, American Psychiatric Publishing, 2002
22. Tseng WS, Strelzer J: Culture and Psychotherapy. Washington, DC, American Psychiatric Publishing, 2001
23. Lu FG: Annotated Bibliography on Cultural Psychiatry and Related Topics-February 2005. Available at http://www.nami.org/Template.cfm?Section=Fact_Sheets1&Template=/ContentManagement/ContentDisplay.cfm&ContentID=22156

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