The need for greater cultural competence in psychiatry is one of the key issues confronting the field today, according to panelists at a presidential symposium held October 30 at APA’s 1999 Institute on Psychiatric Services in New Orleans.

"This is one of the most important, underaddressed issues in psychiatry," said APA President Allan Tasman, M.D., who served as a discussant along with former APA President Harold Eist, M.D. Although the profession acknowledges the importance of cultural and ethnic differences in psychiatry, "we rarely directly address the issue," said Tasman.

Culturally competent psychiatry "is not a subspecialty" and is critical to understanding any patient, not just members of racial and ethnic minorities, observed panelist Renato Alarçon, M.D., M.P.H., a professor and vice chair of the department of psychiatry at Emory University School of Medicine.

"Culture plays an interpretive and explanatory role" in understanding psychopathology, he noted. A sound understanding of cultural variables can be "a tool" for effective diagnosis, while failure to understand the role of culture can obfuscate diagnosis. Cultural bias may result in misdiagnosis. For example, there is evidence that clinicians disproportionately characterize African Americans as "paranoid" and Hispanics as "histrionic," Alarçon observed.

Although the "biopsychosocial" model of psychiatry is helpful, a more comprehensive model would be "biopsychosocial-cultural-spiritual," he asserted.

Psychiatry must be "concerned with the person as a whole," said panelist Francis Lu, M.D., a clinical professor of psychiatry at the University of California at San Francisco. The profession must "guard against the temptation to reduce human experience to the lowest common denominator."

But it is not enough for psychiatry to acknowledge the importance of culture or to address cultural differences ad hoc; rather, said Lu, the field must develop systematic approaches to cultural competence.

There have been laudable efforts to address systematically the issue of cultural competence, observed Lu. Most recently, the AMA published the "Cultural Competence Compendium," which functions as a "Yellow Pages" of resources for culturally competent care. The compendium is far ranging and includes a heading on "complementary and spiritual practices," Lu noted.

Other efforts have come from the federal Center for Mental Health Services, the Department of Health and Human Services’ Office of Minority Health, and the state mental health departments of New York and California, according to Lu.

The World Health Organization’s concept of health is "a state of complete physical, mental, and social well-being and not merely the absence of disease," observed panelist Juan Mezzich, M.D., Ph.D. Mezzich is secretary-general of the World Psychiatric Association and a professor of psychiatry at Mt. Sinai School of Medicine. Mental health must be placed within a multidimensional context that includes illness, functioning, social interaction, ethical issues, and overall quality of life. Seen in this broader context, the field of psychiatry must take care not to pathologize culture-bound behaviors that deviate from the dominant cultural norms, unless they appear to impact healthy social functioning, Mezzich asserted.

The goal of attaining cultural competence in psychiatry is made harder by the absence of an inclusive, cross-cultural perspective, observed panelist Edward Foulks, M.D., Ph.D., the Sellars-Polchow Professor of Psychiatry and associate dean for graduate medical education at Tulane University School of Medicine in New Orleans. Values, often taken for granted, can be a significant obstacle to cross-cultural understanding and culturally competent care. The clash of cultures becomes apparent when a behavior that is accepted in one culture or subculture is seen with disapproval by the dominant culture, Foulks noted. In the context of the patient-therapist relationship, such cultural discord will undermine if not destroy the patient-therapist relationship.

Cultural descriptions of psychiatric disorders may employ idioms and norms unfamiliar to the Western-trained clinician, said Foulks. A non-Western culture may see a disorder as caused by "spirit loss" or a case of amnesia as reflecting the absence of a specific spirit, he noted.

Cultural norms surrounding the concept of family and living space often differ from those accepted by Western clinicians. When Foulks spent time in an Inuit village in Alaska, he observed that it was common for parents, grandparents, and children to live together in a one-room house. This situation would be viewed as undesirable by most Westerners, but among the Inuit, any protracted separation from the nuclear family is experienced as traumatic, even if it involves a positive situation such as seeking education away from home.

It is easier to be aware of profound cultural differences when facing only one defined culture—the situation Foulks faced in the Inuit village. But it is easy to ignore or minimize the impact of culture in the day-to-day clinical setting.

"We are all faced in our daily lives and our clinics not with one culture but myriad cultures," said Foulks, and the challenge is to integrate an understanding of diverse cultures into the patient-therapist equation.

Underserved racial and ethnic minorities make up more than a fifth of the U.S. population, observed Foulks. Thus, the provision of culturally competent care has the potential to impact millions of Americans.

A valuable tool for culturally competent care is the cultural section in the back of the DSM-IV, according to Foulks. Among the dimensions addressed are the meaning of cultural or ethnic reference groups, cultural explanations of illness, the impact of culture on psychosocial environment and functioning, cultural elements impacting the patient-therapist relationship, and ways in which an overall cultural assessment may affect diagnosis and care.

Discussant Harold Eist, M.D., commented that "cultural competence must be addressed as a two-way street. It’s not something we do to people; it’s something we engage with people around and about."

The capacity for "empathy can help us bridge gaps," said Eist. "It is something we bring to the table," and it should be fostered in training. Cultural competence depends also on the therapist’s being open and nonjudgmental, he continued. Given the growing proportion of the U.S. population made up of people who are minority group members, the need for culturally competent care is an issue of mounting significance.