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Chapter: Essentials of Psychiatry: The Cultural Context of Clinical Assessment

Cultural Competence

Recent years have seen the development of professional stand-ards for training and quality assurance in cultural compe-tence .

Cultural Competence


Recent years have seen the development of professional stand-ards for training and quality assurance in cultural compe-tence (Lopez, 1997; Sue, 1998). This term stands for a range of


Table 2.3         Strategies to Elicit Cultural Information

·            Present an open, friendly face of the institution (have the diversity of the community represented within the diversity of the institution, with attention to not simply reproducing the class structure of the society in the institutional hierarchy).

·            Make explicit the clinician’s position and identity, explain goals and methods, use self-disclosure appropriately.

·            Ask for clarification of unfamiliar terms or key terms that may be mistakenly assumed to be familiar.

·            Ask for detailed description of practices related to health, illness and coping.

·            Have the patient compare situation with previous events or experiences of others from similar background.

·            Interview other family members and patient’s entourage to obtain normative framework and identify consensus and conflicting perspectives.

·            Consult knowledgeable clinicians, culture-brokers, interpreters, anthropologists and ethnographic literature.


approaches aimed at improving the delivery of appropriate serv-ices to a culturally diverse population. Cultural competence may involve both culture-specific and generic strategies to address a range of practical issues in intercultural work (Okpaku, 1998). This includes the clinician’s ability to elicit cultural informa-tion during the clinical encounter (Table 2.3), to understand how different cultural worlds of patients and their families influence the course of the illness, and to develop a treatment plan that empowers the patient by acknowledging cultural knowledge and resources while allowing appropriate psychiatric intervention.



Specific cultural competence has to do with knowledge and skills pertaining to a single cultural group, which may in-clude history, language, etiquette, styles of child-rearing, emo-tional expression and interpersonal interaction as well as cultural explanations of illness and specific modalities of healing. Often, it is assumed that specific cultural competence is assured when there is an ethnic match between clinician and patient (e.g., aHispanic clinician treating a client from the same background). However, ethnic matching without explicit training in models of culture and intercultural interaction may not be sufficient to ensure that clinicians become aware of their tacit cultural knowl-edge or biases and apply their cultural skills in a clinically effec-tive manner.


Ethnic matching can occur at the level of the individual, the technique, the institution, or any combination of these levels (Weinfeld, 1999). At the level of the individual, it may be easier to establish rapport when clinician and patient share a common background. However, there is a risk that some issues may be left unexplored because they are taken for granted, or are taboo and awkward to approach. There is also difficulty when the pa-tient’s expectations of a fellow community member are not met because the clinician applies the rules and limits dictated by pro-fessional training. This may include expectations of receiving special treatment, of being cured quickly, of becoming friends, or intervening inappropriately on behalf of other family or com-munity members.


In many cases, however, ethnic matching is only crude or approximate. For example, the term Hispanic covers a broad ter-ritory with many cultural, educational and social class differences that transcend language. Indeed, there is enormous intracultural variation and no one person carries comprehensive knowledge of his or her own cultural background, so there is always the need to explore local meanings with patients.


In the course of professional training, clinicians may dis-tance themselves from their own culture of origin and become reluctant or unable to use (or understand the impact of) their tacit cultural knowledge in their clinical work. Clinicians from ethnic minority backgrounds may resent being pigeon-holed and expected to work predominately with a specific ethnocultural group. Patients may have complex reactions to meeting a clini-cian from the same background. These issues require attention and sensitive exploration just as much as the feelings evoked by meeting someone from a different background.


At the level of technique, the clinician familiar with a spe-cific ethnocultural group learns to modify his or her approach to take advantage of culturally supported coping strategies. For example, religious practices, family and community supports, and appeals to specific cultural values may all provide useful strategies for symptom management and improved functioning. Traditional diagnostic and treatment methods may be used in concert with conventional psychiatric treatments. The clinician may use his or her own person differently in recognition of cul-tural notions of healing relationships, adopting a more authorita-tive stance, making selective use self-disclosure, or participating in symbolic social exchanges with patients and their extended families to establish trust and credibility.


At the level of institutions, ethnic match is represented in the organization of the clinical service, which should reflect the composition of the communities it serves (Kareem and Littlewood, 1992). This is not merely a matter of hiring prac-tices but also involves creating structures that allow a measure of community feedback and control of the service institution. When people feel a sense of ownership in an institution, they will evince a higher level of trust and utilization. It is important, therefore, for clinicians to understand how the institutional set-ting in which they are working is seen by specific ethnocultural communities.


Increasingly, clinicians work in settings where there is great cultural diversity that precludes reaching a high level of specific competence for any one group. Changes in migration patterns and new waves of immigrants and refugees lead to cor-responding changes in patient populations. For all of these rea-sons, it is crucial to supplement specific cultural competence with more generic competence that is based on a broad theoreti-cal understanding of culture and ethnicity. Generic cultural com-petence abstracts general principles from specific examples of cultural differences. The core of generic competence resides in clinicians’ understanding of their own cultural background and assumptions, some of which are related to ethnicity and religion and many of which derive from professional training and the con-text of practice. Appreciating the wide range of cultural variation in gender roles, family structures, developmental trajectories, explanations of health and illness, and responses to adversity allows the clinician to ask appropriate questions about areas that would otherwise be taken for granted. The culturally competent clinician has a keen sense of what he or she does not know and a solid respect for difference. While empathy and respectful in-terest allow the clinician gradually to come to know another’s world, the clinician must tolerate the ambiguity and uncertainty that comes with not knowing. In the end, patients are the experts on their own experiential worlds and cultural context must be reconstructed simultaneously from the inside out (through the patient’s experience) and from the outside in (through an appre-ciation of the social matrix in which the patient is embedded).


The wide range of specific and generic skills needed for competent intercultural work means that most clinicians will find it helpful to work in multidisciplinary teams that contain cultural diversity that reflects the patient population. A variety of models for such teamwork have been developed (Kareem and Littlewood, 1992; Kirmayer et al., 2003).

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