Risk Management Group
AWAC Services Company, a member company of Allied World
According to the US Census Bureau analyses released in August 2021, the overall racial and ethnic diversity of the country has increased since 2010. The concept of “diversity” used for the US 2020 Census refers to the representation and relative size of different racial and ethnic groups within a population and is maximized when all groups are represented in an area and have equal shares of the population.1
The American Psychiatric Association vision statement speaks to the “provision of quality mental health to all persons regardless of race, ethnicity, age, gender identity, sexual orientation, national origin, religious orientation, and/or disability status.”2
This article will focus on elements of cultural competence for psychiatrists to best meet the mental health needs of different racial and ethnic groups.
How Does Culture Impact Mental Health?
Culture includes beliefs, values, norms, and behaviors, and affects how individuals experience and interpret the world, including cultural meanings of mental illness. Culture influences how people develop social support and how and whether a person:
- Seeks or avoids treatment
- Perceives and expresses symptoms
- Copes with stress
- Adheres to treatment plans
- Attaches stigma to mental illness3
Patients of different cultures have diverse ways of expressing symptoms of mental illness, thus making diagnosis difficult. An understanding of race, ethnicity, and culture is critical to both appreciate the diversity of human dynamics and to treat clients effectively.
What Is Cultural Competence?
Cultural competence is the ability to understand and interact effectively with people from other cultures. Cultural competency may be defined as a set of interpersonal skills that allow health professionals to understand and appreciate individuals of different backgrounds and provide culturally appropriate services to diverse populations.4
While researchers may disagree on the basic elements of cultural competence, mental health treatments that explicitly addressed the individual’s own cultural views of their illness had better outcomes than treatments that were not adapted to the specific culture.5
Of note, cultural competence is not a skill that can be “mastered,” but rather is an evolutionary process as new patients enter your practice, bringing with them new cultures, new family histories, and new opportunities to improve treatment and outcomes.
Why Is Cultural Competence Important for Psychiatrists?
Culturally competent psychiatrists are better able to connect with patients to alleviate mistrust and create shared understanding. That shared understanding is the first step toward successful diagnosis and treatment of mental illness.
What Are the Major Cultural Barriers for Individuals to Seek Mental Health Care?
Cultural barriers may prevent individuals from seeking appropriate mental health care, especially:
- Mistrust and fear of treatment, often related to the stigma of mental illness
- Alternative ideas about mental illness and health
- Language barriers resulting in ineffective communication
Inherent with these barriers are issues related to access to health insurance coverage and lack of diversity in the mental health workforce.
What Are the Key Cultural Differences for Psychiatrists to Consider with Care?
The following are key considerations for addressing culturally competent care and treatment of your patients:
It would be ideal to employ staff fluent in the languages of your patient population. In the absence of staff proficient in the language, you need to provide certified interpreters. Federal laws6 require health care providers to ensure that effective communication takes place between the provider and patients, including those who do not speak English. If using telehealth or if face-to-face interpreters are not available, then offer video or phone remote interpreting services.
You may think it is easier, more convenient, and less expensive to use family members or friends to translate for a patient. Friends and family members may not be impartial, do not know medical terminology, may not use the patient’s own words but supply their own responses to the questions asked, may not be comfortable asking sensitive or potentially embarrassing questions (consider a teenager asking her grandfather about his thoughts and/or plan to harm himself or others). Inappropriate/inaccurate translation increases the risk of medication errors, avoidable admissions and other adverse events. According to the Agency for Healthcare Research and Quality, nearly 9% of the U.S. population is at risk for an adverse event because of language barriers.7 If a patient suffers a negative outcome and sues on the allegation that it would not have occurred but for the psychiatrist’s failure to inform the patient appropriately, that psychiatrist may be held liable for the consequences.8
Paralanguage includes factors such as tone of voice, inflection, loudness, speed and pitch. Simply changing your tone of voice may change the meaning of a sentence. Depending on the culture, the patient may be loud with the use of hand gestures for emphasis or quiet and soft-spoken and even non-demonstrative. It is important to understand the cultural norms for communication to appreciate the style, tone, and type of verbal communication with your patients.
Be aware of differences with nonverbal communication. How one communicates depends on where you live, your culture, and how you communicate in general. Some cultures use many words. In other cultures, people speak very little but use many gestures.
- Eye Contact: While eye contact signals confidence in the West, it may be seen as rude or challenging in parts of Asia and the Middle East. There are gender rules around eye contact; for example, many Eastern cultures discourage women from making eye contact with men as it conveys authority or sexual interest.
- Touch: Touch is used frequently in communication with customs such as the handshake. But other cultures consider touching other people inappropriate. Some cultures tend to take a more conservative approach when it comes to touching, with a bow typically replacing a handshake.
- Hand Gestures: Psychiatrists need to be aware of the risks related to hand gestures. For example, pointing at someone else is an insult in most parts of the world, but in some places, it is often used simply as a reference. In the United States, the thumb and index finger in a circle means “Okay,” but is seen as vulgar in other cultures. In Japan, some take the thumbs up as a deference to money, whereas in France, it’s meaning is associated with worthlessness or zero. The most common gesture in the world is a nod, but even that can mean different things in different cultures.
- Facial Expressions: The good news is that facial expressions for happiness, sadness, anger, and fear are universal. The bad news is that not every culture is OK with using them in a clinical setting. Members of some cultures try to keep a neutral facial expression, believing that showing your emotions burdens the other person.
- Posture: With posture, the traditional route is the best route. It is important not to slouch when sitting or to sit with legs crossed. Face people as they speak to you and nod enough to show you are paying attention to what they say.9
Depending on the culture, the patient may be trusting of physicians, believing they are the experts. From what has been taught and instilled into them from their culture of origin, doctors and other healthcare providers are to be respected due to their high levels of education and as such, questions are rarely asked. However, as with each instance of consent to treat and/or when prescribing high risk medications, it is important to discuss the proposed treatment and the need for consent.
Is the patient a member of a cultural group that involves people who may not traditionally be involved in the decision-making process, such as the male leader of the family (father, eldest son/brother)? Do you need to take into consideration who the major authority in the family is for decision making?
Having consistent consent forms, such as consent to treat and consent for antipsychotic medications, with English on one side and the specific language translation on the other side would help both provide interpretation for the patients and ensure the patient understands what is being signed.
It is best practice to tailor education for all patients based on their needs but also their culture. One example is when prescribing patients who may be skeptical of taking “western” medications and may try holistic approaches rather than take their prescribed medications. It is critical for psychiatrists to ask the patient about their willingness to take the prescribed medications and to anticipate the need for more in-depth discussions on the purpose and benefits of any prescription compared to an alternative holistic treatment.
Education on mental health and treatment options can increase interest in treatment. Research shows that providing culturally tailored follow-up for patients in the patient’s primary language, including medication and diagnosis-related guides in their language, increases health literacy compared with regular informative texts or no follow-up at all.10
Risk Management Tips
- Learn and understand the different cultures in your practice and in your community.
- Ask non-judgmentally about the individual’s beliefs and understanding of their illness.
- Avoid stereotyping a person from a specific culture into thinking they have the same beliefs as someone else from that same culture. Learning whether a patient considers himself typical or different from others in their cultural group is important as there are many factors which influence how an individual views their own culture/beliefs.
- Don’t push individuals to accept a psychiatric diagnosis – build trust over time and use terms that are acceptable to them, including: “stress,” “nerves,” “sadness,” “worries,” etc.
- Consider describing mental illness as a biological disorder rather than a psychological problem or weakness.11
- Ask if the patient observes any religious or traditional customs or practices that you should know about. Also ask about religion and spirituality in general, which can be a helpful source of support for those with mental health problems.
- If you or a staff member are not proficient in the patient’s language, be sure a professional interpreter is used when there is a language barrier. Do not rely on family members to interpret.
- Provide easy-to-read forms, including informed consent and educational materials, especially medication and diagnosis-related guides, in the patient’s primary language.
Be sure to check your state requirements regarding whether healthcare professionals must undergo cultural competence training to be compliant with the state’s mandatory CME education.
By understanding the role that cultural differences play in patient evaluation, assessment, diagnosis and treatment, and by providing culturally competent care tailored to the individual’s identity, culture and experience, psychiatrists can strengthen the provider-patient relationship and ensure that the patient is treated with respect and their mental health outcomes improve.
Diversity and Health Equity. American Psychiatric Association. Diversity & Health Equity (psychiatry.org)
6 Culturally Sensitive Ways to Approach Mental Health. Quality Interactions. 6 Culturally Sensitive Ways to Approach Mental Health (qualityinteractions.com)
Agency for Research and Quality Health Literacy Toolkit: http://www.improvingchroniccare.org/downloads/health_literacy_universal_precautions_toolkit.pdf
Agency for Healthcare Research and Quality (AHRQ). Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals (ahrq.gov) 2012.
Cultural Competence in Mental Health. Community Integration Tools. Temple University. Microsoft Word – CULT COMP_FS_ on Template-12 5 07.doc (tucollaborative.org)
Health Literacy: Why This Matters to Psychiatrists. In Session with Allied World. Spring 2017.
Identity and Cultural Dimensions. National Alliance on Mental Illness. Identity and Cultural Dimensions | NAMI: National Alliance on Mental Illness
Improving Cultural Competence: A Treatment Improvement Protocol. SAMHSA. First Printed 2014. TIP 59: Improving Cultural Competence (samhsa.gov)
National Culturally and Linguistically Appropriate Services Standards. U. S Department of Health and Human Services. CLAS Standards – Think Cultural Health (hhs.gov)
Rice, Alana, Harris, Suzanne. Issues of cultural competence in mental health care – Journal of the American Pharmacists Association (japha.org) Volume 61, Issue 1, January-February 2021, Pages e65-e68.
1 United States Census. 2020 US Population More Racially and Ethnically Diverse Than Measured in 2010. 2020 U.S. Population More Racially and Ethnically Diverse Than Measured in 2010 (census.gov)
2 Diversity and Health Equity. American Psychiatric Association. Diversity & Health Equity (psychiatry.org)
3 6 Culturally Sensitive Ways to Approach Mental Health (qualityinteractions.com)
4 Rice, Alana, Harris, Suzanne. Issues of Cultural Competence in Mental Health Care. Journal of the American Pharmacists Association. Volume 61, Issue 1, January-February 2021, Pages e65-e68.
6 I Title VI of the Civil Rights Act of 1964; Section 1557 of the Affordable Care Act (ACA)
7 Agency for Healthcare Research and Quality (AHRQ). Improving Patient Safety Systems for Patients with Limited English Proficiency. 2012. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals (ahrq.gov)
8 Health Literacy: Why This Matters to Psychiatrists. In Session with Allied World. Spring 2017.
9 Top 8 Differences in Nonverbal Communication Across Cultures – Silver Sage Magazine August 16, 2021.