The Challenges and Rewards of Working With Culturally Different Patients


Cultural differences between patients and physician are hard to avoid. How can you best work with diverse patients?




As Larry Merkel, MD, PhD, professor of psychiatry and neurobehavioral sciences and Director of Outreach at the University of Virginia, told 2021 Annual Psychiatric TimesTM World CME Conference attendees, working with culturally different patients can be challenging and rewarding, but rarely avoided in current day psychiatry.

“Everyone’s backgrounds are very complicated, multi-layered, and dynamic,” said Merkel. “No person has influences these days from just 1 culture—we live in multiple cultures.”

Cultural distance is essentially qualitatively thinking about the difference between doctor and patient—how many things in your background are similar to their background, or not?

“There’s been research showing that the greater the cultural difference between the psychiatrist and the patient, the more likely there are to be mistakes of all sorts,” Merkel said.

Merkel also covered models for managing cultural differences, including the Cultural Formulation Interview (CFI) from DSM-5, which patients seem to value over traditional interactions.1 Field trials in a variety of locations (ie, United States, Canada, Netherlands, India, Kenya, and Peru) showed CFI is feasible, acceptable, useful, and sensitizes clinicians to cultural issues.2 An implementation study in an outpatient psychiatric clinic demonstrated CFI is an integral part of cultural competence training; there was a 50% reduction in discontinuation rate vs treatment as usual after one training session.3

CFI does have some potential problems, Merkel noted. CFI can help with direction of therapy, but not diagnosis. Additionally, it is not able to be used with cognitive disability or with severe symptoms such as acute psychosis, suicidal behavior, or aggression.

We're fathers, mothers, children, physicians, barbers, Protestants, Catholics, Jews—all sorts of identities.

Further, the concept of identity may be difficult to translate work with, according to Merkel. “We all have multiple identities. We’re fathers, mothers, children, physicians, barbers, Protestants, Catholics, Jews—all sorts of identities. We use those identities in different ways at different times. Sometimes, if you ask a person what their identity is, they may have no idea what you’re talking about.”

Merkel has a few recommendations for physicians working with culturally different patients:

-Know something about the main populations with whom you are likely to work.

-Adapt to include more culturally relevant data.

-Take time and effort to work with interpreters.

-Be brief and succinct in your questions if you are using an interpreter.

-Understand that it may be difficult, and be patient.


1. Paralikar VP, Deshmukh A, Weiss MG. Qualitative analysis of Cultural Formulation Interview: findings and complications for revising the outline for cultural formulation. Transcult Psychiatry. 2020;57(4):525-541.

2. Jarvis GE, Kirmayer LJ, Gómez-Carillo A, et al. Update on the Cultural Formulation Interview. Focus (Am Psychiatr Publ). 2020;18(1):40-46.

3. Lewis-Fernández R, Aggarwal NK, Kirmayer LJ. The Cultural Formulation Interview: progress to date and future directions. Transcult Psychiatry. 2020;57(4):487-496.

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