Culture as a Multidimensional Construct

Despite years of training about how to care for others, many health care providers know little about themselves. This is nowhere more relevant than when caring for patients who come from cultures other than our own because in these clinical encounters, we may not recognize our own implicit biases. Our cultural identity as health care workers is multifaceted, including attitudes shaped by our life experience and those shaped by the culture of our health care system. This chapter discusses the concepts of culture and cultural self-awareness and introduces strategies that health care workers can use to understand their own cultural influences and consider how these may be impacting their clinical work. We present a case example that exemplifies the principles outlined in the chapter.

Global Psychiatric Epidemiology

This chapter offers an introduction to and discussion of the basic principles, concepts, and challenges of global psychiatric epidemiology, including the classification of mental illness, cultural concepts of distress, and the current understanding of global epidemiology and its limitations. The authors discuss how practitioners can use this information to improve their awareness of how their personal backgrounds and professional training impact their classification, understanding, and treatment of mental illness, and how they can take actions toward improving their cultural competence and ultimately improving patient relationships and care management. This discussion focuses primarily on the challenge of understanding global epidemiology through the lens of biomedical diagnostic classification systems, and on the importance of understanding how culture and society affect our knowledge of and approach to the diagnosis and treatment of illness.

Teaching Sociocultural Psychiatry Throughout the Lifespan

In response to persistent and growing health disparities among racial and ethnic minority groups in the United States, health care institutions have started to enhance cultural competency education and training in both health care organizations and medical education. This effort to integrate culture into professional guidelines and training curricula has been consistent among the psychiatric workforce over the last few decades. While these efforts to address mental health disparities among racial and ethnic minority groups are welcomed, much more work is needed to integrate sociocultural education into medical training. This chapter describes the evolution of sociocultural medical education from teaching cultural competence to cultural humility, with its opportunities and challenges. Using a case-based approach, the authors propose general principles from existing curricula that can help psychiatric faculty design and teach sociocultural curricula for psychiatry trainees in diverse settings.

Responding to Patients’ Provider Preferences

In today’s increasingly diverse world, patients will inevitably interact with physicians who are of very different racial, ethnic, religious, and/or geographical backgrounds from themselves. When a patient requests a physician of another race, religion, or gender, or one who speaks another language, the physician must take many factors into consideration when determining whether to accede to the request. These considerations include historical factors (e.g., bigotry vs. the potential benefits of race concordance), ethical considerations (e.g., autonomy, justice), patient factors (e.g., the patient’s decision-making capacity), and organizational factors (e.g., policies and procedures to respect both patients and providers). This chapter presents a general framework to help psychiatrists to make these sometimes difficult decisions. Case vignettes are provided and analyzed throughout the chapter.

Gender and Sexuality

The psychiatric encounter provides an opportunity to discuss sexuality and sexual behaviors with patients. Often patients are reluctant to discuss sexual matters with clinicians, as shame can often be associated with sexual behaviors and fantasies. Clinicians, therefore, need to be aware of both common and uncommon fantasies and behaviors and be willing to initiate conversations with patients in a safe and respectful manner. Sexual behaviors can be associated with some psychiatric disorders and can sometimes be a psychiatric disorder unto themselves. Therefore, a sexual history and assessment is often a required portion of a complete psychiatric evaluation. However, there is tremendous variability in what is considered normal and abnormal, posing challenges for clinicians. This chapter sets out to provide a framework for approaching some of these challenging situations.

Religion and Spirituality in Psychiatric Care

Religion and spirituality are important dimensions of human experience, dimensions that many patients would like to discuss with physicians in their medical and psychiatric care. Data support the benefits of such discussions, but few physicians routinely engage patients. Lack of time, experience, and training are cited as the main barriers. This chapter summarizes the rationale for including exploration of religious and spiritual issues in psychiatric care. Including the spiritual dimension of patients’ lives and understanding their religious beliefs and practices increases our potential to be of greater service to our patients, to grow ourselves, to provide better care, and to achieve better outcomes. In this chapter we address the barriers and describe an experiential training seminar for psychiatry residents as one of the solutions.

Psychiatry and Its Checkered Past

This chapter examines the history of critiques that have been made of psychiatric practice in specific times and specific places. Though psychiatry is well-established as part of the medical profession and requires completion of a medical education all doctors receive, psychiatrists are often viewed as distinct from other doctors, and psychiatry continues to be viewed negatively in the public eye. Psychiatrists themselves have been partly to blame for this; the profession originally spent decades attempting to differentiate itself from the other medical professions. Since it is not possible to cover every aspect of the history of critiques of psychiatry, the chapter focuses on two major problems that continue to influence how psychiatry is practiced and perceived today: the development of asylums as a form of confinement for those who are mentally ill, and the development of psychiatric nosology and diagnosis. By exploring the continuum of mental illness and the idea of “normal versus abnormal,” the chapter offers psychiatrists a framework for how they can think about their work going forward.

Social Determinants of Psychiatric Illness

The social determinants of health refer to the ways in which societal conditions impact the etiology, course, and treatment of health outcomes. This chapter summarizes four main topics related to the social determinants of mental health in order to provide a framework for clinicians to understand the major social determinants of mental illness and help them incorporate insights about the social determinants of health into their clinical practice. First, we demonstrate how social determinants are related to the field of public health and population health frameworks. Second, we describe how knowledge of social determinants can inform psychiatric clinical practice. Third, we summarize research on four major social determinants—gender, socioeconomic status, childhood adversity, and school and neighborhood environments—with respect to depression risk. Last, we show how information about social determinants can be integrated with more individual-level factors, including genetic variation.

Implicit Bias in Mental Health Care

Explicit attitudes are obviously predictive of behavior. However, two decades of research has shown that implicit attitudes have greater predictive validity than explicit attitudes in a particular set of situations. This chapter defines implicit and explicit attitudes and associations and reviews the scientific literature regarding implicit bias in the medical, psychology, and psychiatry literature. The authors pay specific attention to documented effects of implicit bias related to race and ethnicity, as well as to mental health diagnoses and body weight. The authors also outline interventions to decrease implicit bias in clinical care, as well as pitfalls to avoid when attempting to decrease implicit bias.

Culture in the DSM-5

This chapter focuses on the revision of the DSM-IV to DSM-5, including an increased emphasis on the role of culture in psychopathology. The DSM-5, published in 2013, includes a revision of DSM-IV’s Outline for Cultural Formulation and includes the newly added standardized and manualized Cultural Formulation Interview (CFI), the 12 supplementary modules to the CFI, and a Glossary of Cultural Concepts of Distress. With these changes, DSM-5 strives to provide clinicians with a practical interpretive framework to explore patients’ varied experiences and expression of mental distress, increasing the clinical significance of each patient’s ethnic and cultural context. This chapter explores these additions to and revision of the DSM-5, reviews some of its criticism, and offers best practices for using these tools in the evaluation and management of diverse patients.