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“People won’t wake up after Labor Day and think, ‘Everything is different.’” - Rochelle Walensky, MD

On Wednesday, August 31st, the US Food and Drug Administration (FDA) authorized the new bivalent COVID-19 booster shots. In 2 days, my wife and I will receive them. I hope you can too, and that the appointments pour in, but I doubt it. It seems like the country as a whole has been operating this past summer with some denial, as if the pandemic is over. It is not. More than half of Americans eligible for boosters have not received even one. There are still hundreds of deaths a day, long-term “brain fog” with difficult-to-diagnose mood changes, and the uncertainty of falling back in the fall.

Just 2 weeks before the FDA authorization, and just after celebrating its 75th anniversary, director Dr Walensky announced that the United States Centers for Disease Control and Prevention (CDC) needed culture change. In comparison to earlier times in the pandemic, she wants the agency to move faster in public health crises, and emphasized easier collaborations and communication internally and externally.

On being questioned in the most recent TIME magazine, she said

“I don’t think that moving boxes around on an organizational chart alone will fix the problem. What we’re talking about is a culture change. Reorganization is hard, but I think this is even harder than that.”

How refreshing to hear from a leader who admits mistakes, does not scapegoat others, and makes plans to move ahead.

Perhaps other medical organizations and leaders can do the same. Clearly, with the epidemic of physician burnout continuing at the same pace for about a decade now, culture change that engages clinicians and removes obstacles to their healing abilities is even more necessary.

Just like people, organizations cannot just assume they are doing the right things. That includes large organizations like the CDC and smaller ones, like families, who themselves may need family therapy to make a culture change. It includes whether businesses should force employees to return to offices after Labor Day, and with that comes the possibility of getting a COVID infection.

Soul searching and accountability, just like Dr Walensky apparently has done, is the emotional and mental labor that needs to be emulated. In her desire for collaboration, perhaps the American Psychiatric Association can work more closely with the CDC to better address one of the biggest problems in medicine today: misinformation. Collaboration means we care about one another.

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

1. Park A. Dr. Rochelle Walensky knows the CDC made ‘dramatic mistakes.’ Now she’s trying to fix them. TIME. August 23, 2022. Accessed September 6, 2022. 

https://time.com/6207887/cdc-covid-19-revamp-rochelle-walensky-interview/

This major medical organization is making an effort towards changing their culture. Here’s why more of us need to emulate these actions. 

From the CDC to a Family: Organizational Culture Change is Hard, But Often Necessary

I feared the worst when my ordinarily reliable patient did not respond to my emails. No, not the worst, since suicide is definitely the worst, and suicide was very low on my differential, given this individual’s unwavering will to live, even under the direst circumstances. Still, doctor discussion boards frequently comment about ways to cope with a patient’s suicide, so this dreaded outcome is clearly high on the radar of many psychiatrists. Earlier in the pandemic, it was not uncommon to hear my residents detail their distress from witnessing so many patients succumb in New York City, which suffered far more than its fair share of pandemic fatalities. Back in the 1980s, and even into the 1990s, I myself lost several patients—as well as medical colleagues—during the AIDS epidemic.

Perhaps there is something about epidemics and mass fatalities that either inures one to such losses or at least leads one to brace for them and prepare for them. Consultation-liaison (C-L) psychiatrists who work in hospital settings no doubt confront end-of-life issues and patient deaths on a regular basis, as do psycho-oncologists, geriatric psychiatrists, and psychiatrists who work in hospice and palliative care settings. But for me, as an outpatient psychiatrist in private practice, it is rare to follow a long-term patient through a life-threatening medical illness that required extensive treatment, but which eventually ended—not 2 weeks after the original diagnosis, as predicted by a surgeon at a general hospital—but 2 years later instead, thanks to aggressive medical interventions available at a specialty hospital known for its “Hail Mary” approaches to otherwise incurable medical conditions.

During those years, this patient shared far more of their hopes and fears, their achievements, and their aspirations than they had disclosed in the years before when they confronted psychiatric symptoms alone, without any hint of what was to come. The last appointment focused on the escalating pain that they endured during their recent hospital stay—yet this individual retained their dignity and humanity just the same.

When this punctilious patient did not confirm their biweekly appointment despite repeat emails, a veil of dread descended on me. Eventually we reconnected, and they told me of a 2-week hospitalization admission that impeded access to cellphones. Hearing of a 2-week stay in a tertiary care hospital was ominous enough, but not hearing back from the patient after their last appointment was even worse. At the patient’s request, I had forwarded contact information for 2 pastoral counselors, but did not get the expected acknowledgement from this typically gracious individual who recently asked me to pray for them—even though they knew that we practiced different religions and they were quite committed to their own religious traditions.

“Any prayers would help,” the patient importuned, undeterred by any religious differences. Those were desperate words, spoken when one senses that one’s time is coming to a close.

Even though the last appointment had not been confirmed, I phoned the patient just the same. When my patient’s phone did not answer at our usual time, I left a voice message, consoling myself that their voice message remained active, yet still wondering about the worst. Then I dialed the spouse’s phone number, knowing that it was time to reach out to the emergency contact whose name had been listed several years before. That phone answered immediately. I introduced myself, and the spouse acknowledged me just as immediately. They addressed me by name, as if they were expecting my call. Without delay, they delivered the worst news—news that I was expecting, yet dreading to hear.

After wiping my tears, stifling my spontaneous sobs, and hearing the unrestrained sobs of the spouse, we spoke for a while, using the time that I had set aside for my now deceased patient’s appointment and knowing that they and I would never have another appointment.

My initial inclination, after ending that call, was to say Kaddish, the Jewish prayer for the dead, but I stopped myself—but not because the patient was not Jewish. The patient had, after all, beseeched me to add a prayer for the sick at the Saturday morning Sabbath service at the synagogue, although they themselves followed a very different faith. It was not a matter of religion that stopped me. My second thought was about boundary-breaking, which itself is close to a cardinal sin in psychiatry.

It is always difficult to draw the fine line between compassion and caring and overreaching in clinical care—but exceptional circumstances permit more wiggle room than is ordinarily accorded. I considered consulting the American Psychiatric Association’s (APA’s) committee on Religion and Spirituality. It crossed my mind to call my rabbi to ask for advice—until I remembered that one says Kaddish for 7 people only: a spouse, a son or daughter, a sister or brother, or a mother or father. (Those gender-specific rules were devised long before nonbinary identities came into being.) Some people say Kaddish for those who perished in the Shoah/Holocaust without leaving survivors.

In orthodoxy, only men say Kaddish, and female mourners are expected to find a male to pray on their behalf. This tradition is so ingrained that some 19th-century Yiddish authors, writing in first person, refer to their son as “my Kaddish”—and do not allude to “my son, the doctor,” like the more Americanized stereotypes. For having a son—rather than a daughter—ensured that a parent’s memory would live on forever when the son recited this prayer for the dead.

Gender roles, sexism, and religious regulations aside, there were other valid reasons for my hesitation. If people said Kaddish for anyone and everyone who passed, the world would be in a constant state of mourning, and that is not the goal of most religions (except perhaps world-renouncing religions that aspire to such sad states). But there was another, equally important reason it was not appropriate to me to say Kaddish for this patient—or for any other patient. Even though this patient’s passing caused me such pain, my saying Kaddish would imply that I felt the same degree of grief as the bereaved spouse, and that presumption would disrespect the spouse’s distress. Having never been widowed, I could barely imagine how painful it must be to lose one’s spouse, especially one so young.

And so, I answered my own question without consulting a rabbi or a committee on religion: No, it is not appropriate for psychiatrists to say Kaddish for their patients. I cannot speak about mourning practices in different traditions—and I am well aware that there are many, many varieties of Jewish practice and belief as well—but I felt relieved to realize that the rules of my own religion provided useful boundaries that went beyond the clinical practice of psychiatry. To channel my distress, I drafted this article instead, expecting that other psychiatrists have encountered similar dilemmas themselves, and perhaps this piece will help them put their own situations in perspective.

is an assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mount Sinai in New York, New York.

Can religion provide boundaries that extend beyond those of clinical psychiatry? 

Should a Psychiatrist Say Kaddish for Her Patient?

Psychiatrists have been interested in the cross-cultural dimensions of psychosis ever since Emil Kraepelin (1856-1926) sailed to Java in 1904 and published his pivotal 

 [Comparative Psychiatry]. Kraepelin provided the first known comparison of psychotic symptoms across populations: “The early stages of a depression were rarely seen, and violent excitement was also uncommon, but at the same time the very severe forms of 

, so common in our own mental hospitals and found among the Europeans in Java as well, seem rarely to develop among the indigenous population.”

Today’s psychiatrists in North America and Europe do not need to go abroad to encounter individuals from different races and ethnicities. Affordable travel and developments in information technology have led to large-scale population migrations such that more physicians and patients identify as Black, Indigenous, or People of Color (BIPOC).

 Recognizing the increased likelihood of cross-cultural patient-clinician interactions, all medical students, psychiatry residents, fellows, faculty at academic medical institutions, and even psychiatrists in independent practice from certain American states must now develop skills in cultural competence

 to avoid perpetuating disparities in health outcomes for BIPOC individuals with serious mental illnesses.

 This raises a fundamental question of how to understand terms like 

. DSM-5-TR defines culture in the following way

“Culture refers to systems of knowledge, concepts, values, norms, and practices that are learned and transmitted across generations. Culture includes language, religion and spirituality, family structures, life-cycle stages, ceremonial rituals, customs, and ways of understanding health and illness, as well as moral, political, economic, and legal systems. Cultures are open, dynamic systems that undergo continuous change over time; in the contemporary world, most individuals and groups are exposed to multiple cultural contexts, which they use to fashion their own identities and make sense of experience.”

The Centers for Medicare and Medicaid Services—the largest funder of mental health services in the United States—defines 

 as “the capacity to identify, respect, and understand differences in cultural beliefs, behaviors, and needs of consumers.”

 Decades before cultural competence became mandatory for clinicians, cultural psychiatrists pointed out that psychiatrists have their own professional cultures with biomedical knowledge, concepts, values, norms, and practices that introduce barriers to care.

 This article synthesizes research on how culture can impact 

 across the mental health services pathway. It offers suggestions for providing culturally competent care and ways to overcome potential challenges.

Cultural Considerations Affect the Entire Pathway of Mental Health Care

The health services pathway can be divided into 4 discrete phases: help-seeking through the first contact with a mental health clinician, receiving the diagnosis of a psychotic disorder, initiating treatment such as 

 or pharmacotherapy, and adhering to treatment.

 Cultural differences among patients and clinicians affect each of these steps.

. Compared with those who are from majority ethno-racial populations in high-income North American and European countries, BIPOC individuals may make sense of their initial psychotic symptoms through shame and stigma,

 and are more likely to distrust psychiatrists based on personal experiences of 

, which delays their initial contact with mental health clinicians.

: “Mrs Williams” is a Black American woman who contacts her son’s pediatrician out of concerns related to behavioral changes. Her son’s teachers report that he stopped participating in his classes. At first, Mrs Williams thought his behaviors were part of normal adolescent development, but when he started to say that the government wants to kill all Black people, she became concerned. Her pediatrician makes a referral to a child and adolescent psychiatrist who asks how long her son had been experiencing paranoid delusions, and she says, “about 9 months.” He asks why she did not seek care sooner, and she informs him that with so many instances in the news of Black males with mental illnesses experiencing violence from law enforcement officials, she did not want him to be labeled. He evaluates her son, counsels her about first-episode psychosis, and gains her trust by guiding her through the special educational services process with the Department of Education for him to receive medical accommodations.

. Psychiatrists are more likely to diagnose BIPOC individuals with a psychotic disorder rather than a 

 based on misinterpretations of symptoms.

 Studies across countries show that individuals from minoritized ethno-racial backgrounds have 1.35 higher odds compared to majority populations of reporting hallucinations or delusions that are clinically subthreshold and do not meet full criteria for a psychotic disorder, perhaps due to greater acculturative stresses.

 Psychiatrists who are unfamiliar with the cultural backgrounds of patients or exhibit biases are more likely to exacerbate misdiagnoses.

: “Mr Delgado” is an agricultural worker in his 40s who comes to the United States on a seasonal H-2 visa every year to harvest oranges. His mother passed away 5 months ago. He presents for an initial evaluation at an outpatient clinic run by residents and fellows. Although he is sad and tearful, he describes himself as interacting more with colleagues at work and better able to focus than right after his mother died. “Dr Xi,” a Chinese-American physician, asks him if he can hear or see things other people cannot. Mr Delgado replies that he sometimes hears his mother’s voice and sees her image in the form of a guardian angel. Because of his interests in cross-cultural care, Dr Xi asks if these experiences are common in Mr Delgado’s community. Mr Delgado says yes. Dr Xi asks if Mr Delgado wants to try a medication to help treat the visions or only to treat his poor mood, anhedonia, and poor motivation. Mr Delgado says he finds the visions comforting. Both agree to initial treatment with an 

. Mr Delgado comes back 3 months later, before he is to return to Mexico, and thanks Dr Xi for acknowledging his treatment preferences. He no longer describes extrasensory hallucinations.

. Psychiatrists are less likely to offer BIPOC individuals with psychosis a second-generation oral antipsychotic and are more likely to offer long-acting injectable agents.

 BIPOC individuals are also less likely to receive clozapine

. Although patients from all ethno-racial groups exhibit negative attitudes toward pharmacotherapy to treat psychotic disorders, BIPOC individuals are more likely to discontinue these medications due to concerns about adverse effects.

 Due to implicit biases, psychiatrists are less likely to monitor metabolic parameters for BIPOC patients with psychotic disorders who take antipsychotics.

Fortunately, clinical research is increasingly showing how psychiatrists can develop cultural competence skills to improve patient care.

The Cultural Formulation Approach May Improve Clinician Cultural Competence

Studies show that the cultural formulation approach can elicit the knowledge, concepts, values, norms, and practices that individuals with psychosis employ to make sense of their experiences. Researchers on McGill University’s Cultural Consultation Service have used an expanded version of the DSM-IV-TR Outline for Cultural Formulation to assess for cultural issues related to diagnosis, treatment planning, and treatment adherence. Clinicians collaborating with cultural and linguistic brokers and presenting cases in a multidisciplinary conference were able to rediagnose 34 out of 70 cases (49%) from a referral diagnosis of a psychotic disorder to a nonpsychotic disorder, and rediagnose 12 out of 253 (5%) cases from a referral diagnosis of a nonpsychotic disorder to a psychotic disorder.

 Although changes in diagnoses occurred across all ethno-racial groups, immigrants and refugees were misdiagnosed more with an initial psychotic disorder, showing that cultural information related to how individuals make sense of their experiences can impact diagnostic assessment and treatment selection.

Many psychiatrists may not have access to a cultural consultation service or find that cultural issues exist even with patients who share their ethnic, racial, and religious backgrounds. DSM-5 and DSM-5-TR include a series of semi-structured interviews known collectively as the Cultural Formulation Interview, which the American Psychiatric Association (APA) has disseminated free of cost. The 16-question version for use with patients can be found 

. A 17-item for use with informants can be found 

Clinical studies show mixed results in individuals with psychosis. The interview can require more reflection on personal identity and treatment planning than can be tolerated in patients with florid hallucinations or paranoid delusions.

 However, stable outpatients with chronic illnesses felt that clinicians using the CFI validated their experiences and presented new avenues for recovery.

 Practicing clinicians may find the CFI helpful upon resolution of acute symptoms. Cultural competence is a lifelong pursuit, and tools like the CFI can help clinicians take that first step.

is an assistant professor of clinical psychiatry at Columbia University, and a research psychiatrist at New York State Psychiatric Institute in New York, New York.

Cultural psychiatry in a creolizing world: questions for a new research agenda.

3. Aggarwal NK, Like R, Kopelowicz A, et al. 

Has the time come for a cultural psychiatry fellowship in the USA?

Cultural competence in mental health care: a review of model evaluations.

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)

. American Psychiatric Association; 2022. Accessed June 24, 2022. 

https://doi-org.ezproxy.cul.columbia.edu/10.1176/appi.books.9780890425787

6. Centers for Medicare and Medicaid Services. 

Cultural Competence and Language Assistance

https://marketplace.cms.gov/technical-assistance-resources/training-materials/cultural-competence-language-assistance.pdf

Patients and Healers in the Context of Culture: An Exploration of the Borderland between Anthropology, Medicine, and Psychiatry

Measuring pathways to care in first-episode psychosis: a systematic review.

Differences in duration of untreated psychosis for racial and ethnic minority groups with first-episode psychosis: an updated systematic review and meta-analysis.

10. Misra S, Etkins OS, Yang LH, Williams DR. 

Structural racism and inequities in incidence, course of illness, and treatment of psychotic disorders among Black Americans.

11. Halvorsrud K, Nazroo J, Otis M, et al. 

Ethnic inequalities in the incidence of diagnosis of severe mental illness in England: a systematic review and new meta-analyses for non-affective and affective psychoses.

An updated and conservative systematic review and meta-analysis of epidemiological evidence on psychotic experiences in children and adults: on the pathway from proneness to persistence to dimensional expression across mental disorders.

13. Lawson W, Johnston S, Karson C, et al. 

Racial differences in antipsychotic use: claims database analysis of Medicaid-insured patients with schizophrenia.

14. Williams JC, Harowitz J, Glover J, et al. 

Systematic review of racial disparities in clozapine prescribing.

Trends in outpatient psychotherapy provision by U.S. psychiatrists: 1996-2016

16. Levin JB, Seifi N, Cassidy KA, et al. 

Comparing medication attitudes and reasons for medication nonadherence among three disparate groups of individuals with serious mental illness.

17. Phillips KL, Copeland LA, Zeber JE, et al. 

Racial/ethnic disparities in monitoring metabolic parameters for patients with schizophrenia receiving antipsychotic medications.

18. Adeponle AB, Thombs BD, Groleau D, et al. 

Using the cultural formulation to resolve uncertainty in diagnoses of psychosis among ethnoculturally diverse patients.

Clinician perceptions of implementing the Cultural Formulation Interview on a mixed forensic unit.

20. Muralidharan A, Schaffner RM, Hack S, et al. 

“I got to voice what’s in my heart”: participation in the Cultural Formulation Interview—perspectives of consumers with psychotic disorders.

All mental health clinicians must now develop skills in cultural competence to avoid perpetuating disparities in health outcomes for BIPOC individuals with serious mental illnesses.

Cultural Issues in Diagnosing and Treating Psychotic Disorders

The lifetime prevalence of schizophrenia and related psychotic disorders is approximately 1% of the population.

 These disorders have clear genetic and biological underpinnings

 and generally respond favorably to antipsychotic medication, particularly in reducing the hallmark positive symptoms (eg, delusions, hallucinations).

 However, even with medication, some positive symptoms persist. Furthermore, negative symptoms (eg, asociality, amotivation), which have an even greater detrimental impact on quality of life, are less impacted by medication,

 underscoring a need for additional therapeutic interventions for individuals with 

. Sociocultural factors have been shown to impact both the presentation and course of schizophrenia/psychosis. In this article, we use 3 case vignettes to illustrate how cultural factors can be considered in treatment planning and for a more holistic understanding of how to improve outcomes for individuals with schizophrenia/psychosis (

“Mr Williams” is a 40-year-old single Black man with a history of schizophrenia, although he notes, “I have been told I have everything: schizophrenia, 

, paranoia, you name it.” Mr Williams states he came in at his sister’s request because she noted he was sleeping less and talking to himself more than usual. Mr Williams explains he has been more anxious about the police in his neighborhood. This coincided with a shooting approximately 1 month ago, when a close acquaintance was shot and killed by police about 3 blocks from his home. Mr Williams says he believes the police have bugged his house and he feels energized to solve the issue. “I have been installing a new security system and filling in all the gaps in my house so no radio waves can get through.” He has also been talking more to his grandmother, who died a decade prior. He hears her voice more frequently when he is distressed, and he likes hearing from her.

Mr Williams’ statement about his many diagnoses reflects an unfortunate reality for Black men with experiences of psychosis. It has been shown that Black men tend to to be overdiagnosed with schizophrenia and underdiagnosed with bipolar disorder.

 Notably, schizophrenia tends to be more stigmatized than 

. This discrepancy in diagnosis has contributed to poorer quality of care, because these 2 diagnoses have key differences in first-line treatment.

Although Mr Williams seems to relay his experiences of disparate diagnoses to his provider as humorous, it should act as a clue to the provider that his existing diagnosis may not be accurate and that Mr Williams may not completely trust the insights of his providers. Potential follow-up questions may be: “What do you think about your diagnosis? Is there a label you prefer that reflects your difficulties with mental health?” Direct questioning about symptomology would also be needed to clarify diagnosis, but these initial questions can help create a shared language between provider and client that prioritizes the client’s understanding of the symptoms. Providers may also reflect this experience back to the client: “That might be frustrating—to be told all these different diagnoses over the years.” Acknowledgements like this can help establish a sense of trust, letting your patients know it is appropriate to acknowledge their challenges with the health care system to their providers.

Mr Williams endorses a belief that the police are recording him inside his house and has acted in response to this delusion. Providers are often told not to reinforce delusions or give them too much airtime beyond what it takes for diagnosis and assessment of severity. Unfortunately, this guidance may be overused such that providers avoid better understanding or seeing the greater context of delusions/hallucinatory symptoms. The presentation and expression of symptoms differs across ethnic groups, often due to differential experiences and environments.

In the case of Mr Williams, although the police may not be explicitly recording him in his home (although further questioning is warranted), his delusion seems triggered by real-life experiences. Black Americans are proportionally more impacted by police brutality and 

 and consequently demonstrate greater levels of suspiciousness in general.

 With this cultural consideration in mind, providers need to be especially cautious of rating something as abnormal or delusional when it is a reality for Black individuals (eg, being followed/watched in stores, being targeted for harassment at work, feeling unsafe at home, being wary of police intentions).

In addition, increased experiences of discrimination are linked to increased 

 and psychotic experiences in ethnic minorities.

 For Mr Williams, it would be helpful to acknowledge and reinforce the realities of his experience (“I am so sorry to hear about your friend. I understand why this would make you fearful of the police.”) while guiding him toward relevant solutions (“Have you talked to anyone, like your sister, about what happened? How are the other individuals in your neighborhood coping with this?”). Further conversation may help Mr Williams consider how to get familial/community support and assist him in finding spaces that feel welcoming and safe (eg, support groups, volunteering, reaching out to friends). For some patients in which the delusion is seemingly unconnected to the environment, clinicians may reinforce the patient’s experience (“What I am hearing is that you have been feeling fearful lately.”) and point to emotion-focused coping strategies instead.

In a similar vein, Mr Williams also acknowledged hearing the voice of his late grandmother, but notes that he likes hearing from her. Although hallucinations/voices can be extremely distressing, they are not always so, with some cultures or groups having higher rates of positive or benign experiences.

 In fact, there is a growing movement among those with experiences of hallucinatory voices to integrate them into daily life rather than trying to avoid them completely (ie, Hearing Voices Network), with some evidence of success.

 Providing quality care therefore involves balancing many considerations (eg, existing symptoms, adverse effects, barriers to adherence), and the distress of current symptoms should not be assumed. Follow-up questions should aim to be neutral (“What is it like to hear your grandmother’s voice? How often does this happen? Are you able to shift your focus when other things need to be done?”) to get a better sense of how it impacts Mr Williams.

“Ms Khan” is a 55-year-old divorced Sunni Muslim Pakistani woman on disability, diagnosed with 

. Outside of 3 relapses triggered by big life changes, Ms Khan mostly struggles with negative symptoms (eg, asociality, low motivation). Ms Khan scheduled a mental health appointment because she has been struggling to get out of bed. She explains, “What is keeping me in bed is a jinn holding me down. It stops me from doing my prayers and makes me lazy. I should do my wudhu and pray, but once I get out of practice, I feel guilty and avoid it.”

Ms Khan endorses a belief that the reason she is struggling to leave bed is the influence of a jinn (ie, a supernatural spirit/demon). A provider unfamiliar with Islam may automatically view this as a sign of pathology. To assess this, however, a clinician should attempt to clarify how common this type of belief is to those who are part of the community. Clinicians may do this by asking questions directly (“I am unfamiliar with jinn. Is this a common experience for other individuals you know?”) but may also need to seek consultation from the patient’s community. In this case, research suggests that many Muslims do indeed believe that physical and mental ailments (eg, sleep paralysis, depression, fever) are caused by jinn

 and subsequently endorse religious-based solutions such as wudhu (ie, ablution), prayer, and consulting an imam. However, Muslims and other religious groups tend to endorse multiple models of mental illness, often endorsing biological factors in addition to others (eg, jinn, engaging in sin, God’s will, environmental factors).

In developing suggestions, clinicians may gain more traction by acknowledging the patient’s perspective. Clinicians should still provide recommendations within their purview (eg, medication changes, therapy recommendations), while also supporting cultural practice and assisting in problem- solving (“Are there other Muslims you know to whom you can reach out for support?”).

In addition, Ms Khan would likely benefit from greater religious coping, because she indicates that being less engaged with her religious practice leads to more distress. In fact, in the United States, the majority of the general public and individuals with schizophrenia in particular endorse engaging in religious and spiritual practices and report finding these practices highly important to them.

 Religious practice is also broadly associated with better mental health.

 In the case of Ms Khan, if clinicians consider behavioral activation—for example, an emphasis on increased religious practice (eg, prayer and wudhu) and engagement with religious community (eg, going to mosque, finding Quran study groups)—this may be especially beneficial, because it already aligns with the patient’s belief system and desires.

Clinicians should be wary of 2 potential issues. First, not all religious coping is created equal, with some strategies consistently leading to less distress (eg, prayer, belief that God is supportive) and others leading to more distress (eg, believing one’s difficulties are a punishment from God, using religion to avoid problems).

 Second, emphasis on religion may not be useful if the patient endorses significant religious delusions. In these cases, focusing on other strategies (eg, light exercise, relaxation techniques) and support networks (eg, family, book club) tends to be more beneficial.

“Mr Baker” is a 60-year-old White retired male veteran who received a diagnosis of schizophrenia and lives with his long-term girlfriend. Over the past year, he has struggled to keep up with chores and relies on his girlfriend to make most of his meals. This has led to fights that escalate into his girlfriend threatening to leave him due to his “laziness, lack of caring, and craziness.” Mr Baker feels like a burden on his girlfriend and is also afraid to tell others how much he struggles with his mental health. “I always prided myself, especially with my veterans group, that I was dependable and logical. If I admit to them that I have heard voices and had to go to the hospital, I will have to admit I am a screwed-up person.”

Mr Baker has internalized the idea that mental illness is shameful, which is more common among men.

 Unfortunately, self-stigma is linked to marked increases in distress and to greater risk of suicide.

 His noted feelings of burdensomeness, therefore, could warrant a suicide risk assessment. Although psychoeducation can reduce 

, engaging with individuals openly about their experience with mental illness tends to be most effective.

 Mr Baker would likely benefit from a referral to support groups of other veterans with serious mental illness. Providers may begin suggesting these referrals by highlighting the effectiveness of therapy for others, because focusing directly on Mr Baker’s need for support may lead to defensiveness or denial: “I find a lot of veterans in your situation have really enjoyed this outpatient group we have.” Keeping it low stakes may also prove helpful: “Hey, this is a good way to get out of the house and meet some new individuals.”

There is also a high level of criticism and hostility (ie, expressed emotion) in Mr Baker’s household, which research indicates is related to higher rates of relapse for individuals with serious mental illness.

 Hostility and criticism occur in some ethnic groups at higher rates (eg, White families) than others (eg, Latinos).

 Mr Baker and his girlfriend may benefit from psychoeducation such that they can recognize that many of Mr Baker’s symptoms are related to a mental illness. This could help reduce some of the girlfriend’s frustration by shifting the blame away from her partner. This couple might also benefit from developing strategies to meet their household needs and demands in tandem with each other. Culturally informed therapy for schizophrenia (CIT-S) is a family intervention that emphasizes the family unit’s shared values, engages in psychoeducation with culture in mind, reinforces positive religious coping, and guides the family unit through communication and problem-solving techniques.

 Rather than solely focusing on Mr Baker, it equally acknowledges the needs of his girlfriend and guides both individuals through their shared difficulties.

Practices like CIT-S also highlight an important message across all 3 cases. Clinicians often see the individual (identified patient) arriving at a session as the sole therapy target. However, there is an untapped but extremely important social support network integral to the lives and well-being of individuals with schizophrenia/psychosis. It may be a family member who suggested they visit a doctor (case 1), a larger religious community that provides meaning (case 2), or a partner who provides resources (case 3). In addition to employing the aforementioned strategies and being mindful of cultural distinctions, providers benefit from relying on these social structures (eg, consultation) and encouraging their patients to be more engaged in these social supports, which ultimately could be an invaluable resource in improving the lives of patients with schizophrenia/psychosis.

is a predoctoral psychology trainee at the University of Miami in Florida.

is a professor of psychology at the University of Miami.

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Religious coping and psychological adjustment to stress: a meta‐analysis.

The stigma of psychiatric disorders and the gender, ethnicity, and education of the perceiver.

20. Oexle N, Rüsch N, Viering S, et al. 

Self-stigma and suicidality: a longitudinal study.

21. Mittal D, Corrigan P, Drummond KL, et al. 

Provider opinions regarding the development of a stigma-reduction intervention tailored for providers.

Expressed emotion and relapse of psychopathology.

23. Kymalainen JA, Weisman de Mamani AG. 

Expressed emotion, communication deviance, and culture in families of patients with schizophrenia: a review of the literature.

24. Weisman de Mamani A, McLaughlin M, Altamirano O, et al. 

Culturally Informed Therapy for Schizophrenia: A Family-Focused Cognitive Behavioral Approach, Clinician Guide

Sociocultural factors have been shown to impact both the presentation and course of schizophrenia/psychosis. Learn more here. 

Cultural Issues in Caring for Patients With Psychosis

As a psychotherapist and mental health practitioner in Washington, DC and Maryland, I have spent the past 2 decades working closely with dozens of high-profile clients, including politicians, foreign diplomats, lobbyists, CEOs, 

, and reality TV stars. Along the way, I have learned that high-profile clients face many of the same challenges that we face in our day-to-day lives—however, because of their power and influence, they often require an extra degree of accommodation that few therapists are prepared for.

To help give therapists a better understanding about what it is like to work with high-profile clients, I put together a list of some of the unique challenges I face and strategies to overcome them.

Before you begin working with a high-profile client, it is important to recognize that you will be working with a unique population of individuals who are often extremely wealthy, hold influential jobs or positions, and are constantly in the public’s eye. As a result, it is important to understand that their lifestyle is very different from your average Joe and will therefore require an extra degree of accommodation to protect their privacy and their busy schedule.

For example, many of the patients I work with do not work regular hours from Monday to Friday and often spend half of the year traveling for business. This can have a major impact on their family life and put pressure on their professional life. Other clients I work with have close 

 with some of Washington’s most powerful political families. This can impact who they invite into their social circle and limit what they can talk about. This can be a very isolating experience for many families, particularly if the family or individual they have a relationship with was only recently elected.

Before you begin working with a high-profile client, make sure you actually know the person you are working with. It is easy to believe you know the issues your client faces by reading about them in the news; however, it is important to remember that most news stories are designed for entertainment purposes only. Knowing how to discern fact from fiction is critical to building trust between you and your client, and it will demonstrate that you care about who they are as a person, rather than who they are reported to be.

A look at the unique challenges of working with powerful and influential clients and strategies for success.

Cultural Psychiatry

From the CDC to a Family: Organizational Culture Change is Hard, But Often Necessary

Should a Psychiatrist Say Kaddish for Her Patient?

Cultural Issues in Diagnosing and Treating Psychotic Disorders

Cultural Issues in Caring for Patients With Psychosis

Working With High-Profile Clients

If Looks Could Kill

In Case You Missed It: January 2022

Musicians’ Mental Health in the Empire City During COVID-19

Non-Sensuous Similarities: Language, Poetics, and Psychiatry

The Lehman Trilogy, Paper & Glue, and the Clinical Question: Does It Take One to Know One?