goal i: cultural competence
DESCRIPTION
Goal I: Cultural Competence. AACAP Cultural Competency Curriculum Ayesha Mian & Gabrielle Cerda. Historical Perspective. Cultural psychiatry > 100 years (“unusual syndromes” by Western standards) Limited focus to “exotic” Not incorporate cultural eval into mainstream - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/1.jpg)
Goal I: Cultural Competence
AACAP Cultural Competency Curriculum
Ayesha Mian & Gabrielle Cerda
![Page 2: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/2.jpg)
Historical Perspective
• Cultural psychiatry > 100 years (“unusual syndromes” by Western standards)
• Limited focus to “exotic”• Not incorporate cultural eval into mainstream• 1994 DSM-IV Appendix I—”Cult Formulation”
– Framework to assess impact of culture on mental illness
![Page 3: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/3.jpg)
Relevance of Culture• Culture shapes
– which sx are expressed – how they are expressed
• Culture influences – meaning given to sx– what society deems appropriate or
inappropriate– conceptualization & rationale of psychiatric
diagnostic categories/ groupings– matrix for clinician-pt exchange
![Page 4: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/4.jpg)
Culture Defined Many Ways
• Set of shared norms, beliefs, meanings, values
• Dynamic, evolves over time with generations
• Terms usable & relevant to mental health• Cultural identity > ethnicity/ race
– Occupation --Age gender– Sexual orientation --Spirituality/ religion
![Page 5: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/5.jpg)
Essential Components of Culture
![Page 6: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/6.jpg)
Cultural Assessment: Advantages
• Clinician more informed on pt perspective • Assist rapport—care about whole person,
not just illness• Identify areas that impede/ strengthen tx• Potential cultural conflicts for pt
– Identity (parent v. child)– Traditional v. mainstream expectations
(parenting role)
![Page 7: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/7.jpg)
Outline For Cultural Formulation• Cultural identity of individual
– What does belonging in that group mean to pt• Cultural explanation of illness
– Often somatic—only Western separate mind-body• Psychosocial environment/ level of fn
– Intergenerational conflicts• Therapeutic relationship
– Clinician/ child/ parent• Overall cultural assessment for dx/ care
– Accepting/ dynamic attitude to new info/cont monitor
![Page 8: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/8.jpg)
Cultural Identity
• Ethnicity• Race• Country of origin• Language• Gender • Age • Marital status• Religious/ spiritual
beliefs
• SES• Education• Other identified
groups• Sexual orientation• Migration history• Level of acculturation
![Page 9: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/9.jpg)
Acculturation Process• Active v. passive• From external sources v. individual• Solitary endeavor or do others participate with pt• Process constant v. intermittent• Subtle v. dramatic or in-between• Attitude about acculturation: indiv v. others• Vision re: where new cult elements take him• Fully adopt new culture = assimilated/
integration
![Page 10: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/10.jpg)
Migration History
• Pre-migration history– Country of origin/Family/ education– SES/ community & family support/ political
• Experience of migration– Migrant v. refugee/ why left?/ who left behind?– Who paid for trip?/ means of escape/ trauma
• Degree of loss– Loss family members/material losses/
career/community & family support
![Page 11: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/11.jpg)
Migration History
• Traumatic experience– Physical: torture/ starvation/ imprisonment– Mental: rage/ depression/ guilt/ grief/ PTSD
• Work and financial history– Original work/ current work/ SES
• Support systems– Community/ religion/ family
![Page 12: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/12.jpg)
Migration History
• Medical history– Beliefs herbal medicine/ somatic complaints
• Family’s concept of illness– What do family members think is problem/
cause/cure? Expected result?• Level of acculturation
– Generation? Differences among family members?• Impact on development—level of adjustment
![Page 13: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/13.jpg)
Explanatory Models
• Moral– Moral defect: lazy, selfish, weak will– Try fix character flaw: “just have to work harder”
• Spiritual/ religious– Transgressions—”angered higher power”– Interventions—atonement/ religious leader
• Magical– Hex/ sorcery/ witchcraft– find person caused/ healer
![Page 14: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/14.jpg)
Explanatory Models
• Medical—biological model– Western– non-Western
• Homeopathic, traditional Chinese,• Herbal medicine, osteopathic
• Psychosocial stress– Illness due to overwhelming stress– Treatment targets stressors
![Page 15: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/15.jpg)
Conflicting Explanatory Models
• Patient- provider– Decr rapport/tx non-adherence/ tx dropout
• Patient- family– Lack support/shame/ family discord
• Patient- community– Social isolation/ stigmatization
![Page 16: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/16.jpg)
Cultural Explanations of Illness
– Symptoms– Severity– Course of presentation– Precipitants & explanations– Treatment – Experiences with help seeking– Type of treatment pt/ family wants now
![Page 17: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/17.jpg)
Psychosocial Environment
• Cultural factors related to psychosocial environment & levels of functioning– Stressors & supports
• Individual• Family/ community• Environment
![Page 18: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/18.jpg)
Psychosocial Environment
– Assessing psychosocial enviroment & functioning
• Partner/ parent support• Partner/ parent stressors• Family support• Family stressors• Community support• Community stressors• Religion/spirituality• Functioning
![Page 19: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/19.jpg)
Therapeutic Relationship• Cultural elements of relationship between
individual & clinician– Own cultural background– Patient’s cultural identity– Parent’s cultural identity– Move from categorical approach– Ongoing assessment– Transference/ counter-transference– Consider cultural consult– Patient’s motivation for treatment
![Page 20: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/20.jpg)
Therapeutic Relationship• Provider’s cultural identity & culture of mental
health tx can significantly impact patient care• Influence many aspects of delivery of care
– Diagnosis/Treatment– Organization/ reimbursement
• Issues that arise from cultural conflicts• Pitfalls of assessment tools• Appropriate use interpreters/ cultural
consultant
![Page 21: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/21.jpg)
Interpreters
• Verbal/ non-verbal communication• Types interpretation
– Verbatim– Summary– Cultural
• 3 phases interpreted interview– Pre-interview– Interview– Post-interview
![Page 22: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/22.jpg)
Assessment Tools
• Normed on ethnic minorities?• Translation not sufficient
– Languages have different• Meanings• Connotations• Idioms of expression
• Rating scales may be used if– Translated/ back-translated/ validated
![Page 23: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/23.jpg)
Clinician’s Role
• Clinicians who have clarity about their own– Cultural identity– Role in mental health treatment
• Better position to anticipate problematic cultural dynamics of clinical exchange– Decrease negative outcomes– Enhance positive outcomes
![Page 24: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/24.jpg)
Therapeutic Relationship
• Interethnic Transference– Patient’s response to an ethno-culturally
different clinician• Interethnic Counter-transference
– Ethno-culturally different clinician may respond in non-therapeutic manner
– Denial of cultural influence on clinical encounter
![Page 25: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/25.jpg)
Cultural Influences On Transference
Interethnic effects• Overcompliance• Deny ethnocultural
factors• Mistrust • Hostility• ambivalence
Intraethnic effects• Omniscient-omnipotent
therapist• The traitor• Autoracism• ambivalence
![Page 26: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/26.jpg)
Cultural Influences On Counter-transference
Interethnic effects• Deny ethnocultural
factors• Clinical anthropologist
syndrome• Guilt or pity• Aggression• Ambivalence
Intra-ethnic effects
• Over-identification• Distancing• Cultural myopia• Ambivalence• Anger• Survivor’s guilt
![Page 27: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/27.jpg)
Overall Assessment
• Overall cultural assessment for dx & care– Make differential diagnosis– Formulate case narrative including cult factors– How will cultural formulation affect managmnt
• Language• Patient/Parents/ Family• Treatment approach
» Engagement» Adherence
![Page 28: Goal I: Cultural Competence](https://reader036.vdocuments.us/reader036/viewer/2022070500/5681683f550346895dde0f6d/html5/thumbnails/28.jpg)
Case: Cultural Formulation• Cultural identity of individual• Cultural explanation of illness• Psychosocial environment• Therapeutic relationship• Overall cultural assessment for dx/care