Guidelines for Training in Cultural Psychiatry

Cultural safety in telehealth consultations with Indigenous people: A scoping review of global literature

IntroductionTelehealth has become increasingly routine within healthcare and has potential to reduce barriers to care, including for Indigenous populations. However, it is crucial for practitioners to first ensure that their telehealth practice is culturally safe. This review aims to describe the attributes of culturally safe telehealth consultations for Indigenous people as well as strategies that could promote cultural safety.MethodsA scoping review was conducted on key features of cultural safety in telehealth for Indigenous people using the Johanna Briggs Institute (JBI) guidelines and PRISMA-ScR checklist. Five electronic databases were searched, and additional literature was identified through handsearching.ResultsA total of 649 articles were screened resulting in 17 articles included in the review. The central themes related to the provision of culturally safe telehealth refer to attributes of the practitioner: cultural and community knowledge, communication skills and the building and maintenance of patient-provider relationships. These practitioner attributes are modified and shaped by external environmental factors: technology, the availability of support staff and the telehealth setting.DiscussionThis review identified practitioner-led features which enhance cultural safety but also recognised the structural factors that can contribute, both positively and negatively, to the cultural safety of a telehealth interaction. For some individuals, telehealth is not a comfortable or acceptable form of care. However, if strategies are undertaken to make telehealth more culturally safe, it has the potential to increase opportunities for access to care and thus contribute towards reducing health inequalities faced by Indigenous peoples.

[Strategies for organizing research and care in mental health for migrant populations]

The mental health challenges faced by the migrant population in Spain are analyzed, emphasizing the gaps of our healthcare system to addresses their specific needs. Among these challenges are a high prevalence of mental disorders, increased exposure to mental health determinants, differences in the expression of distress, and behaviors related to access and demand for services. Proposals are presented to improve healthcare at multiple levels: 1) fostering of high-impact research, 2) providing rigorous culturally humility training for healthcare professionals and for the integration of community mental health agents, and 3) establishing reference care units as an organizational shift to enhance care and promote public health policies. In conclusion, urgent action through public health policies is necessary to ensure the best care for all.

Lessons from a multicenter, international, large sample size analysis of patients with obsessive-compulsive disorders: an overview of the ICOCS Snapshot studies

Obsessive-compulsive disorder (OCD) is a prevalent and highly disabling condition, characterized by a range of phenotypic expressions, potentially associated with geo-cultural differences. This article aims to provide an overview of the published studies by the International College of Obsessive-Compulsive Spectrum Disorders, in relation to the Snapshot database which has, over the past 10 years, gathered clinical naturalistic data from over 500 patients with OCD attending various research centers/clinics worldwide. This collaborative effort has provided a multi-cultural worldwide perspective of different socio-demographic and clinical features of patients with OCD. Data on age, gender, smoking habits, age at onset, duration of illness, comorbidity, suicidal behaviors, and pharmacological treatment strategies are presented here, showing peculiar differences across countries.

Diversity Awareness in Medical Education: An Innovative Training with Visual Reflection Tools

Dealing with a diverse population is one of the most challenging topics in medicine, with consequences for health disparities as evidenced by poorer health of marginalised groups. An urgent need exists to build a diversity-responsive curriculum in medical education. At the core of such a curriculum are experiential learning and a focus on self-awareness and reflexivity via small group trainings. This Show and Tell paper describes the development and qualitative evaluation of such a training, that was implemented at the University of Antwerp in Belgium, presenting answers to some of the gaps and challenges described in the literature. This training is guided by three visual reflection tools - the kaleidoscope, the iceberg and the communication compass - to inspire learners on how to deal with the diversity of their future patients. The content, method, and educational aim of this hands-on training are described. We discuss some of the challenges the educational methods pose on reflexivity and awareness, looking at the lessons learned based on participants' feedback. While the visual reflection tools offer a dynamic space to broaden the way we look at patients, it remains imperative to create a safe environment for discussing tensions, sharing difficult topics and being aware of different voices. Taking time (space for discussion, small groups, training of faculty) and allowing for continuous reflection of the educators are key in the development of diversity-responsive education.

World Psychiatric Association-Asian Journal of Psychiatry Commission on Psychiatric Education in the 21st century

Psychiatric practice faces many challenges in the first quarter of 21st century. Society has transformed, as have training requirements and patient expectations, underlining an urgent need to look at educational programmes. Meanwhile, awareness has grown around psychiatric disorders and there are evolving workforce trends, with more women going to medical school and specialising in psychiatry. Trainee psychiatrists carry different expectations for work-life balance and are increasingly becoming conscious of their own mental health. A tendency to see health as a commodity and the litigious nature of society has elicited additional pressures for healthcare professionals. Cartesian mind-body dualism has created further complexity and this can often be frustrating for patients and care-partners alike. In many cultures across Asia and beyond, patients can present with physical symptoms to express underlying psychological distress with increasing physical investigations. Simultaneously, in various countries, a shift from asylums to community-based interventions and then home treatments have changed psychiatric care in remarkable ways. These changes have added to pressures faced by mental healthcare professionals. However, trainees and other mental healthcare professionals continue to receive similar training as they did a generation ago. The tensions and differences in ideology/orientation between different branches of psychiatry have made responses to patient needs challenging. Recognising that it is difficult to predict the future, this World Psychiatric Association-Asian Journal of Psychiatry Commission makes recommendations that could help institutions and individuals enhance psychiatric education. This Commission draws from existing resources and recent developments to propose a training framework for future psychiatrists.

The World Psychiatry Exchange Program in Iran: a unique academic and personal experience

The World Psychiatry Exchange Program in Iran is an academic experience we are delighted to share. As two participating early career psychiatrists, a local psychiatry faculty member manager, and the lead founder and international coordinator of the programme, we focus in this article on the unfolding of this new learning experience, the difficulties we encountered and the main lessons learned by the participants: commonalities and differences in training and practice in general adult psychiatry and child psychiatry in Tunisia and Iran, as well as in idioms of distress between the Arab and Persian cultures.

Mental Health Literacy about Personality Disorders: A Multicultural Study

Mental health literacy (MHL) refers to lay people's knowledge and beliefs about the diagnosis and treatment of mental illness. The current study aimed at investigating MHL regarding personality disorders (PDs) multiculturally, comparing Turkish and Italian populations. In total, 262 participants responded to an online vignette identification task that required them to label the PDs of seven hypothetical subjects and rate various dimensions of their disorders. Narcissistic (25%), obsessive-compulsive (13%), and paranoid (12%) PDs were the most correctly labeled, while the average accuracy values for other PDs were below 0.04%. Compared to Turkish participants, Italian participants were more accurate in labeling narcissistic PD. Additionally, of the seven PDs, narcissistic PD was associated with the most happiness and success at work. Subjects with borderline and avoidant PDs were the most recognized as having psychological problems (>90%), yet their PDs were among the least correctly identified. Overall, participants from both cultures were generally successful at recognizing the presence of a mental illness, but they rarely labeled it correctly. Only limited cultural differences emerged. The present findings may inform the design of outreach programs to promote MHL regarding PDs, thereby facilitating early recognition of PDs and help-seeking behaviors for affected individuals.

Decision-making and best practice when nasogastric tube feeding under restraint: multi-informant qualitative study

BACKGROUND

Clinicians working in mental health in-patient settings may have to use nasogastric tube feeding under physical restraint to reverse the life-threatening consequences of malnutrition when this is driven by a psychiatric condition such as a restrictive eating disorder.

AIMS

To understand the decision-making process when nasogastric tube feeding under restraint is initiated in mental health in-patient settings.

METHOD

People with lived experience of nasogastric tube feeding under restraint and parents/carers were recruited via the website of the UK's eating disorder charity BEAT. Eating disorder clinicians were recruited via an online post by the British Eating Disorders Society. Semi-structured interviews were administered to all participants.

RESULTS

Themes overlapped between the participant groups and were integrated in the final analysis. Two main themes were generated: first, 'quick decisions', with the subthemes of 'medical risk', 'impact of not eating' and 'limited discussions'; second, 'slow decisions', with subthemes of 'threats', 'discussions with patient', 'not giving up' and 'advanced directives'. Benefits and harms of both quick and slow decisions were identified.

CONCLUSIONS

This research offers a new perspective regarding how clinical teams can make best practice decisions regarding initiating nasogastric feeding under restraint. In-patient mental health teams facilitating this clinical intervention should consider discussing it with the patient at the beginning of their admission in anticipation of the need for emergency intervention and in full collaboration with the multidisciplinary team.

Transcultural skills for early childhood professionals

Context

Transcultural skills are especially useful for those involved in the perinatal period, when parents and babies must adapt to one another in a setting of migration a long a focus of transcultural clinical practice.

Objective

The aim of this article is to provide useful transcultural skills for any health care worker (e.g., psychologists, child psychiatrists, midwives, family doctors, pediatricians, specialized child-care attendants, and social workers) who provide care or support to families during the perinatal period. It highlights the cultural aspects requiring attention in relation to representations of pregnancy, children's needs, obstetric complications, and postnatal problems. Taking into account the impact of culture on clinical evaluation and treatment can enable professionals to distinguish what involves cultural representations of pregnancy, babies, and sometimes of disease from what is associated with interaction disorders or maternal psychopathology.

Methods

After explaining the relevance of transcultural clinical practices to provide migrant mothers with better support, we describe 9 themes useful to explore from a transcultural perspective. This choice is based on the transcultural clinical practice in our specialized department.

Results

The description of these 9 themes is intended to aid in their pragmatic application and is illustrated with short clinical vignettes for specific concepts. We describe situations that are extreme but often encountered in liaison transcultural clinical practice for maternity wards: perinatal mourning with cultural coding, mediation in refusal of care, cultural misunderstandings, situations of complex trauma and of multiple contextual vulnerabilities, and difficulties associated with acculturation.

Discussion

The transcultural levers described here make it possible to limit cultural misunderstandings and to promote the therapeutic alliance. It presupposes the professionals will concomitantly analyze their cultural countertransference and acquire both the knowledge and know-how needed to understand the elements of cultural, political, and social issues needed to develop clinical finesse.

Conclusion

This combined theoretical-clinical article is intended to be pedagogical. It provides guidelines for conducting transcultural child psychiatry/psychological interviews in the perinatal period aimed at both assessment and therapy.

Articulating biological and social approaches in child and adolescent psychiatry

Child and adolescent psychiatry has been based on numerous fields of research and theories, including neuroscience, physiology, psychology (developmental, psychodynamic, systemic, cognitive-behavioral, etc.), anthropology, sociology, and education sciences. Integrating transdisciplinary knowledge in multi-level models is an ongoing challenge for the future that is not immediately applicable in clinical practice and research. Articulating, i.e., to connect, to be jointed, (psycho)biological and (psycho)social approaches in child and adolescent psychiatry is a daily challenge for clinicians and researchers. Research is often limited to specific fields whereas real-life clinical practice needs a pluralistic approach. Research designs, tools, and clinical training need to provide knowledge applicable to the necessarily pluralistic daily clinical practice. This article provides some perspectives on how to articulate biological and social approaches, from research to clinical practice, and discusses the concept of pluralistic approaches, multimodal interventions, and how to provide articulated mental health care and training. Suggestions to better articulate biological and social approaches are provided: (I) State that the research object can be approached from different theoretical, research and clinical angles and explain the one chosen; (II) Propose synthesis articles that articulate biological and social knowledge; (III) Design biological studies that take into account social factors, and design social studies that take into account biological factors; (IV) Design transcultural tools; (V) Build pluralistic interventions, i.e., therapeutic modalities and mental health care settings that articulate biological and social approaches; (VII) Develop training in pluralistic articulated care.

Forcibly displaced persons and mental health: A survey of the experiences of Europe-wide psychiatry trainees during their training

Many European countries have seen increasing refugee populations and asylum applications over the past decade. Forcibly displaced persons (FDPs) are known to be at higher risk of developing mental disorders and are in need of specific care. Thus, specific training for mental health professionals is recommended by international health organizations. The aim of this exploratory study was to assess the experience of clinical work with FDPs among psychiatric trainees in Europe and Central Asia as well as their interest and specific training received on this topic. An online questionnaire was designed by the Psychiatry Across Borders working group of the European Federation of Psychiatric Trainees (EFPT) and was distributed via email through local networks among European trainees from 47 countries between March 2017 and April 2019. Answers of 342 psychiatric trainees from 15 countries were included in the survey analysis. A majority of trainees (71%) had had contact with FDPs in the last year of their clinical work. Although three-quarters expressed a strong interest in the mental health of FDPs, only 35% felt confident in assessing and treating them. Specific training was provided to 25% of trainees; of this subset, only a quarter felt this training prepared them adequately. Skills training on transcultural competencies, post-traumatic stress disorder, and trauma management was regarded as essential to caring for refugees with confidence. Although psychiatric trainees are motivated to improve their skills in treating FDPs, a lack of adequate specific training has been identified. The development of practical skills training is essential. International online training courses could help meet this pressing need.

How Do We Address and Treat the Trauma of a 16-Year-Old Girl, Unaccompanied Minor, and Her Rape-Born Son? A Case Report

BACKGROUND

The child psychiatry unit of the Cochin Hospital in Paris is specialized in a transcultural clinical approach and treatment of psychotraumatism. The clinical demands addressed to the service often combine several levels of vulnerability: recent migration, repeated and intentional traumas, isolation and breach in family bonds sometimes precarious living conditions. Mastering how to approach trauma content adapting to the person's temporality while taking into account the individual, family and collective dimensions, is a key driver to the clinical intervention (of our approach).

OBJECTIVE AND METHOD

We describe a paradigmatic clinical situation articulating its multidimensional complexity: the case of Céline, a 16-year-old Mozambique teenager, unaccompanied minor (UM), who arrived in France three years ago with her 4-year-old child born out of rape. They are both cared for by Paris Child Welfare Bureau. The authors used the CARE guidelines for a rigorous approach to clinical case writing.

RESULTS AND DISCUSSION

In the clinical discussion, we highlight the pertinence of transcultural abilities for the treatment of a complex PTSD (post-traumatic stress disorder). We describe the measures taken to adapt the clinical interview framework to the mother's psychic temporality, while negotiating what can be said in attendance of the child. The idea of tranquility is primordial-whether she decides to tell or not tell the child. Removing the pressure to have to tell is an element of treatment.

CONCLUSION

Working through a progressive narrative construction, the therapeutical process allowed for the restoration of multiple levels of continuity between times prior to the trauma and following it, as well as prior to migration and following it, to create a continuum from adolescence to adulthood. Restoring narrativity favors the process of becoming a mother and the one of negotiating this new identity. The therapeutic axes also focused on improving the well-being of the UM-mother and preventing the impacts of transgenerational trauma transmission to the child. For women with similar experiences, sharing their emotions and their stories with us makes their choice about telling their child legitimate and comfortable, regardless of the decision they make.

Exploring Mechanisms of Mental Illness Stigma Reduction in Asian Canadian Men

OBJECTIVE

Although there is evidence of effective stigma reduction by various psychological and educational interventions, the mechanisms of change remain unclear. In this article, we examine hypothesized processes that might have mediated reductions in stigma observed among Asian men who had received in mental health promotion interventions in Greater Toronto Area, Canada.

METHOD

Our sample consisted of 495 Asian men, who received either acceptance and commitment therapy (ACT; n = 133), contact-based empowerment education (CEE; n = 149), combination of ACT and CEE (n = 152), or psychoeducation (n = 61). Group differences on intervention outcomes, including stigmatizing attitudes (Community Attitudes toward the Mentally Ill), internalized stigma (Internalized Stigma of Mental Illness), valued living (Valued Living Questionnaire), and attitudes to engage in social change (Social Justice Scale) were hypothesized to be due to the impact of the different interventions and mediated by changes in specific underlying psychological processes. These process-related changes were modelled using measures of mindfulness (Freiburg Mindfulness Inventory), psychological flexibility (Acceptance and Action Questionnaire version II), and empowerment (Empowerment Scale [ES]). Their pre- and post changes were analyzed with repeated measures analysis of variance, and mediational analyses were performed.

RESULTS

Findings from mediational analyses suggest that empowerment (ES) mediated a significant portion of the effects observed in reduction in stigmatizing attitudes and internalized stigma across intervention groups (t = 3.67 to 3.78 for CEE groups, and t = 4.32 to 4.56 for ACT groups). For the ACT groups, reduction in internalized stigma might also have been partly mediated by psychological flexibility, an intervention-specific psychological process.

CONCLUSIONS

Results from the current study suggest that different stigma reduction interventions may be mediated by increased empowerment as a common mechanism of change, while intervention-specific mechanism of change, improved psychological flexibility through ACT, may also contribute to improvement in internalized stigma.

Training in cultural psychiatry: Translating research into improvements in mental health care for migrants

This special issue of Transcultural Psychiatry on training in cultural psychiatry discusses translating research into improvements in mental health care for refugees and migrants. This topic is timely because, in addition to a global increase in migration, the number of forcibly displaced people is growing rapidly due to war and conflicts. We know that migrants, particularly refugees, are at increased risk of psychiatric disorders, including psychotic disorders and post-traumatic stress. Despite this, there is evidence of major disparities in care for minorities, migrants, and refugees. The gap between needs related to mental health care for migrants, refugees, and minority groups and available services points to the need to improve accessibility and adapt systems, services, and interventions. Health professionals have a key role in ensuring the quality of care. Their capacity to cope with new challenges depends on their competence, knowledge, skills, and attitudes toward their patients' needs. Mental health professionals need training in working with cultural diversity and structural competence to understand, treat, and support migrant and refugee patients-and to respond to racial discrimination. Mental health care services need to reduce barriers to providing adequate resources, including supporting skills training for mental health professionals. Hopefully, this thematic special issue will motivate further research, discussion, and sharing of local experience and pedagogical methods in this vital field.

Prevalence and correlates of depression among Black individuals in Canada: The major role of everyday racial discrimination

BACKGROUND

Depression is a common mental health problem causing significant disability globally, including in Canada. Prevalence estimates for depression within Black communities in Canada are unknown. This study determined the prevalence of depression in a sample of Black Canadians and the association between everyday racial discrimination experiences and depression.

METHODS

We analyzed data collected from the Black Community Mental Health project in Canada. Participants provided sociodemographic information and completed measures assessing depressive symptomology, everyday racial discrimination, and social support. The prevalence of depressive symptomatology was computed across sociodemographic variables and categories of everyday racial discrimination. Different regression models were conducted to examine the relationship between depressive symptoms and everyday racism controlling for sociodemographic factors.

RESULTS

In total, 65.87% of participants reported severe depressive symptoms, with higher rates among women, those who are employed, and those born in Canada. The linear regression models showed that everyday racial discrimination is the best predictor of depressive symptoms, with a final model explaining 25% of the variance. A logistic regression model demonstrated that those experiencing a high level of racial discrimination are 36.4 more likely to present severe depressive symptoms when compared to those reporting a low level of discrimination.

CONCLUSIONS

Rates of depressive symptoms among Black individuals are nearly six times the 12-month prevalence reported for the general population in Canada. Racial discrimination, which significantly predicts greater depressive symptomatology, is consistent with earlier studies in the United States and suggests that Canadian colorblind policies may inadvertently reinforce racial discrimination with detrimental effects on mental health.

Health Professionals' Experiences with Treatment Engagement Among Immigrants with Co-occurring Substance Use- and Mental Health Disorders in Norway

Immigrants face barriers in seeking and accessing mental health and addiction services. Health professionals are crucial in providing and promoting healthcare and it is important to understand their experiences in order to enhance the access of mental healthcare. The aim of this paper is to explore and describe health professionals' experiences with treatment engagement among immigrants with co-occurring substance use disorders (SUD) and mental health disorders (MHD) in Norwegian mental health and addiction services. Within a collaborative approach, 3 focus group interviews were conducted with health professionals, who had provided various mental health and addiction care services to immigrants with co-occurring SUD and MHD. The focus group interviews were transcribed verbatim and analyzed using systematic text condensation. The analysis resulted in 5 main categories: (1) difficulties due to language barriers, (2) difficulties due to lack of culturally competent services, (3) difficulties due to social factors, (4) being curious and flexible improves the user-provider relationship, and (5) increasing access to mental health and addiction services. This study provides an enhanced understanding of how health professionals' experienced treatment engagement among immigrants with co-occurring SUD and MHD in the Norwegian context. Implications of the findings for clinical practice and future research are discussed.

What's race got to do with it? A proposed framework to address racism's impacts on child and adolescent mental health in Canada

This commentary responds to current events that have highlighted the ways that systemic racism affects a wide variety of health outcomes. We specifically discuss how systemic racism adversely affects the mental health of children and adolescents in a Canadian context and use a structural framework to demonstrate how race is embedded in various Canadian systems and thus affects child and adolescent mental health in both conscious and unconscious ways throughout the lifespan. Experiences of systemic racism affect the mental health of Canadian young people in multiple complex and intersecting ways including access to care, experience of mental health services, and outcomes of care. We currently lack a national best practice framework for mental health professionals that unifies approaches to research, education, and clinical care for young racialized Canadians; in addition, concerted efforts to collect race-based data are lacking. We suggest that a blueprint for improved services for racialized young people in Canada would include: Development of a funded and sustainable research agenda responsive to community expertise, development and implementation of a Canadian Child and Adolescent task force focused on educational strategies on racism and service provision at both the postgraduate and continuing professional development (CPD) levels, and consideration of clinical parameters that improve access to, and experience of, care for Canadian racialized youth.

The Cultural Formulation Interview: Progress to date and future directions

The Cultural Formulation Interview (CFI) developed for DSM-5 provides a way to collect information on patients' illness experience, social and cultural context, help-seeking, and treatment expectations relevant to psychiatric diagnosis and assessment. This thematic issue of Transcultural Psychiatry brings together articles examining the implementation and impact of the CFI in diverse settings. In this editorial introduction we discuss key areas raised by these and other studies, including: (1) the potential of the CFI for transforming current psychiatric assessment models; (2) training and implementation strategies for wider application and scale-up; and (3) refining the CFI by developing new modules and alternative protocols based on further research and clinical experience.

Cultural Competence of Professionals Working With Unaccompanied Minors: Addressing Empathy by a Shared Narrative

BACKGROUND

The number of migrant youth traveling without parents continues to rise in Europe and North America. Some of t hem leave their home countries on their own and find themselves in a new country, separated from their family and cut off from their cultural roots. Besides those who leave to study, work, and pursue a better life, others are escaping war-torn countries. They need adequate social, educational, and therapeutic spaces, where they can feel entitled to speak. Social workers often ask about how they can understand these young people better so that they can provide them with better care (cope with their trauma and suspicion, deal with the cultural distance between the adolescents and their social workers, etc).

AIM

At Cochin Hospital in Paris, we led a participative action-research program to transmit cultural competence to social workers who provide care for these youth. The aim was to develop an approach to help these young migrants to share their representations about themselves and to train these social workers to encourage this sharing in a culturally sensitive manner.

METHODS

This study used a qualitative method that mixed narrative and transcultural approaches. Two researchers met each youth and social worker with an interpreter-cultural mediator three times (once a month) to assess changes in their relationships during the study. The youth were asked to bring three items of their choice, representing their past, present, and future. They could use their imagination and creativity. We also used the circle test described by Cottle for this purpose. We used a phenomenological approach to analyze the interviews.

RESULTS AND DISCUSSION

This study included 29 young people from 13 different countries and 29 social workers. A transcultural approach appears to be a useful framework for reactivating their identity construction process. It promotes the emergence of cultural representations and takes their experiences before, during, and after migration into account. We assisted them in developing their ability to produce a thorough narrative of their bicultural adolescences and simultaneously helped their social workers to develop their cultural competence.

CONCLUSION

Together, a transcultural approach and methods stimulating the production of narrative are relevant ways to help children to describe their representations of themselves, especially those who have learned to protect themselves by remaining silent. This protocol could be useful for both preventive action and therapy for psychotrauma.