A culturally-humble C-L psychiatrist accepts that there may be a limit to their understanding
A culturally-competent C-L psychiatrist seeks to fully understand a patient’s cultural background. A culturally-humble C-L psychiatrist accepts that there may be a limit to their understanding and instead focuses on relationship-building and self-reflection, believing that a lack of knowledge is not inherently harmful to their work.
Those are the conclusions of Nhi-Ha Trinh, MD, MPH, at the Massachusetts General Hospital, and colleagues, who reviewed trends in psychiatrist diversity, education, and training on cultural humility.
Background
Cultural competency has long been the gold standard for clinicians who treat patients of different races and/or cultural backgrounds other than their own. However, in recent years, there has been increasing criticism of the cultural competency framework because of its reliance on stereotypes and an overemphasis on knowledge acquisition.
The topic has grown in importance because of rapid demographic changes. Although the US population already has extensive racial and ethnic diversity, this pattern is expected to be magnified in the coming decades. The US will become a “majority-minority” country by 2044, according to census projections—no racial nor ethnic group will represent more than 50% share of the nation’s total population. By 2060, nearly one in five is projected to be foreign-born.
“Ongoing efforts are needed to increase both the diversity of the physician workforce and the capacity and skill of health care providers to deliver quality health care for diverse patient populations,” say the authors, who call for “training focused on fostering an attitude of cultural respect.”
In their paper, Cultural Humility and the Practice of Consultation-Liaison Psychiatry, published in the July/August edition of Psychosomatics, the researchers focus on how C-L psychiatrists can incorporate updates in the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) regarding the role of culture in clinical diagnosis, treatment, and management.
Not only is greater cultural humility relevant to patient outcomes, increasingly C-L psychiatrists will work with a rapidly changing demographic profile of psychiatry colleagues.
A 2018 resident/fellow census, by the American Psychiatric Association, found that 52.1% of surveyed postgraduate year one residents identified as white and 24% identified as Asian. Only 8.1% and 8.9% identified as Black/African American or Hispanic/Latinx, respectively, although these categories have experienced slight growth since 2012.
Cultural competency
“Research has demonstrated that understanding a patient’s culture increases a clinician’s ability to deliver high-quality care; this is particularly important given that cultural beliefs shape definitions of normality and pathology, duration of symptoms, the presentation of psychiatric disorders, and treatment responses,” say the researchers. “Minority patients treated by clinicians of another race often report lower treatment satisfaction, more communication challenges, and less decision-making power than white patients.
”Because of this, ‘cultural competency’—congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professions to work effectively in cross-cultural situations—became au courant as a clinical solution.”
Cultural competency has often focused on a categorical approach that involves ascribing attitudes, values, beliefs, and behaviors to broad cultural groups, which may lead to stereotyping, say the researchers.
The cultural competency framework has been challenged on both conceptual and semantic grounds. It has been criticized not just for increasing stereotyping, but also for ignoring power dynamics, and exacerbating the “othering” of patients with marginalized identities.
Cultural competence, some have argued, has not done enough to change the white, middle-class standards of behavior that drive patient evaluations, contributing to a continuing lack of understanding between patients and clinicians, despite good intentions on the part of clinicians.
“Research has been limited on how such interventions improve patient outcomes in racial and ethnic minority groups,” say the researchers. “In one review article, which aimed to evaluate the effect of cultural competence trainings on patient, professional, and organizational factors, researchers found no evidence of improved treatment outcomes based on cultural competence interventions.
“In addition, none of the studies evaluated potential adverse events of such interventions. Therefore, while there have been educational initiatives to address issues of clinician bias and discriminatory behavior within the health care system, it is not currently known based on available data whether these interventions are effective.”
To address the shortcomings of cultural competence models that focus primarily on knowledge acquisition, rather than examining attitudes or developing skills, some have sought an approach that is more deeply based in self-reflection and relationship-building, and one that is less likely to lead to overgeneralization.
Cultural humility
Cultural humility expands on cultural competence and is defined as the ability to maintain an interpersonal stance that is open in relation to aspects of cultural identity that are most important to patients.
The culturally-humble C-L psychiatrist is able to express respect and a lack of superiority regarding the patient’s culture and does not assume competence in terms of working with a particular patient simply based on prior experience with other patients from similar backgrounds.
“While the culturally-competent C-L psychiatrist may view culture as something to be mastered, the culturally-humble C-L psychiatrist normalizes the process of not knowing and emphasizes this as a strength rather than a failure. In addition, utilization of a culturally-humble framework minimizes power imbalances between C-L psychiatrists and patients, thereby reducing the opportunity for a C-L psychiatrist to assert themselves as correct and a patient as misguided. This approach involves patient-focused interviewing and care, rather than having the C-L psychiatrist dominate the conversation.”
C-L psychiatrists are urged to use open-ended, non-focused questions that integrate empathy and to include psychosocial topics in their questioning rather than focusing entirely on biomedical aspects of care.
In addition, culturally-humble C-L psychiatrists accept that there are limits to understanding a culture to which one does not belong and that they should attempt to accommodate aspects of culture that are most important to the patient.
DSM-5 recommendations
DSM-5 proposes significant changes to the way culture is conceived and used by mental health clinicians—and the authors’ paper helpfully provides tables and glossaries to enhance training and self-awareness. Discussion of mental health disorders in the paper contains multicultural explanations for similar symptoms—for example, ‘panic disorder’ contains a discussion of ataque de nervios, a condition similar to panic attacks, although with some notable differences, that is seen primarily in Hispanic communities.
“A culturally-humble framework minimizes power imbalances between C-L psychiatrists and patients, thereby reducing the opportunity for C-L psychiatrists to assert themselves as correct and patients as misguided.”
Section III of DSM-5 contains updated tools for clinicians, including an interview based on 16 stem questions and probes, which was tested for feasibility, acceptability, and clinical utility in a field trial. Areas addressed in the tools include:
Cultural Humility and the Practice of Consultation-Liaison Psychiatry by Nhi-Ha Trinh, MD, MPH; Sylvie Tuchman, BA; Justin Chen, MD, MPH; Trina Chang, MD, MPH; and Albert Yeung, MD, ScD, is here.