Introduction: Reflections on the Crossing of Cultures in Psychiatry

Special Reports have long been a mainstay feature of the monthly Psychiatric Times issues, but this two-part report on cultural competence and diversity is unique in both style and content.

Culture is the widening of the mind and of the spirit.
-Jawaharlal Nehru

It is not a tautology to write that this is a very special Special Report. Special Reports have long been a mainstay feature of the monthly Psychiatric Times issues, but this two-part report on cultural competence and diversity is unique in both style and content. The authors, while citing evidence-based literature and referring to salient scholarly work on the respective topics, have written articles more in the genre of a reflective essay. They think critically about a wide variety of issues, several of which would not immediately be associated with a narrow formulation of the theme of cultural diversity, yet all the authors mirror a broad and humanistic perspective on culture.

Looking from within that wider lens, each of these authors is able to make visible two often hidden aspects of the cultural landscape that illuminate the world within which psychiatrists, our patients, and colleagues dwell. First, culture is not, as sometimes simplistically described, a static singularity. Rather, all of us belong to a multitude of cultures dynamically crossing through our biology and beliefs, our ethnicity and ethos. When all is well, those cultures bring to the individual and the institution openness and resilience; when all is not well, they may tragically bring defensiveness and inflexibility. And second, psychiatry, as Luhrmann’s1 fieldwork found, is itself a set of cultures that interact and at times conflict.

[[{"type":"media","view_mode":"media_crop","fid":"38649","attributes":{"alt":"Cultures in Psychiatry. © Leonard Zhukovsky/Shutterstock.com","class":"media-image media-image-right","id":"media_crop_2624692316149","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3859","media_crop_rotate":"0","media_crop_scale_h":"200","media_crop_scale_w":"125","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"© Leonard Zhukovsky/Shutterstock.com","typeof":"foaf:Image"}}]]In all the negative commentary about DSM-5, the general consensus is that positive progress has been made in cultural assessment. In Part 1 of this Special Report, Ravi DeSilva, MD, MA, Neil Krishan Aggarwal, MD, MBA, MA, and Roberto Lewis-Fernández, MD, MTS, take psychiatric practitioners on a clinically oriented tour through the components and domains of the Cultural Formation Interview-an evidence-based set of questionnaires developed by the Cross-Cultural Issues Subgroup to individualize cultural assessment.2

Religion is one of the most universal and ancient cultural expressions. In their article “Religious Understanding as Cultural Competence: Issues for Clinicians,” Rob Whitley, PhD, and G. Eric Jarvis, MD, through a series of cases and activities, provide recommendations for developing religious competence in a private mental health practice as well as in the organizational setting of the clinic. This competence can help psychiatrists of any or no belief to heal the historic rift between psychiatry and religion for the benefit of the often-religious patient.3

Jay H. Shore, MD, MPH, W. J. Richardson Jr, BA, AAS, Byron Bair, MD, and Spero Manson, PhD, foster a similar effort of spiritual rapprochement in “Traditional Healing Concepts and Psychiatry: Collaboration and Integration in Psychiatric Practice.” These authors compare and contrast Western and traditional systems of healing practice and practitioners and suggest ways to eschew culturally impeding psychiatric approaches in favor of those that facilitate a harmony of treatments.

The impressive distance the culture of psychiatry has traveled in moving from the stigmatization of homosexuality as a disorder to inchoate recognition of the unique gifts and needs of the LGBT community. In the July issue, Part 2 brings the article “Cultural Competence and LGBT Issues in Psychiatry” by Vernon A. Rosario, MD, PhD. However, the author is quick, and right, to point out that psychiatry still has a way to go to deliver the open and affirming care the author embraces to these too often socially marginalized individuals.

In the article “Pediatric ADHD and the Cultural Psychotherapeutic Model,” Martin J. La Roche, PhD, Olivia Carrick, MD, and Paul Hammerness, MD, show us how important such a tailored cultural assessment can be to the diagnosis and treatment of one of the most common disorders in child psychiatry-ADHD. The authors underscore that while there are currently no practice guidelines, there is practical guidance. They offer ways that explanatory models and cultural values of the Latino community and family can be incorporated into the care of patients with ADHD.

The article “Cultural Issues in Treating Geriatric Patients With Mental Illness,” by Kenneth Sakauye, MD, exemplifies this concept of multicultural membership in that this cohort of patients belongs to the subculture of older adults with mental illness, as well as in the context of their own ethnic group, all of these subcultures influencing the expression of even very neurobiologically based psychiatric conditions-dementia and geriatric depression.

The June CME activity synergizes with these cultural reflections as Greg Sazima, MD, bravely and insightfully deconstructs our difficult patient interactions using transactional analysis in “The ‘Hateful Patient’ Revisited: A Transactional View of Difficult Physician-Patient Relationships.” We will have truly arrived at cultural competence when we can reconstruct our relationships with these challenging patients on the empathic model the author illustrates.

This Special Report is unique in a very special way. The Editors of Psychiatric Times are asking readers to extend this journey of reflection on culture outside the bounds of the Special Report and thoughtful essays in this issue. Please join us on the Internet (www.psychiatrictimes.com), where I will be reviewing (and, in some cases, responding to) reader comments. I urge you to share your reflections on the crossing of cultures in psychiatry.

Disclosures:

Dr Geppert is Chief of Consultation Psychiatry and Ethics at the New Mexico Veterans Affairs Health Care System in Albuquerque. She is also Professor in the department of psychiatry and Director of Ethics Education at the New Mexico School of Medicine.

References:

1. Luhrmann TM. Of Two Minds: The Growing Disorder in American Psychiatry. New York: Alfred A. Knopf; 2000.

2. Narrow WE, Clarke DE, Kuramoto SJ, et al. DSM-5 field trials in the United States and Canada, Part III: development and reliability testing of a cross-cutting symptom assessment for DSM-5. Am J Psychiatry. 2013;170:71-82.

3. Koenig HG. Religion and medicine I: historical background and reasons for separation. Int J Psychiatry Med. 2000;30:385-398.