CHAPTER 36

Treatment of Culturally Diverse Populations

Francis G. Lu, M.D.

Roberto Lewis-Fernandez, M.D.

Annelle B. Primm, M.D., M.P.FI.

Russell F. Lim, M.D., M.Ed.

Neil K. Aggarwal, M.D., M.B.A., M.A.

The concept of the "Treatment of Culturally Diverse Populations" has evolved over time in the field of psychiatry. Emil Kraepelin, well known as the principal designer of modern psychiatric nosology, is less well known for his pioneering work in comparative sociocultural psychiatry. Based on his trips to Asia and Africa, Kraepelin commented on certain differences in the incidence and presentation of psychopathological phenomena that he considered to be due to ethnic-cultural characteristics or social conditions (Jilek 1995). In DSM-5, "Culture refers to systems of knowledge, concepts, rules, and practices that are learned and transmitted across generations. Culture includes language, religion and spirituality, family structures, life-cycle stages, ceremonial rituals, and customs, as well as moral and legal systems" (American Psychiatric Association 2013, p. 749).

In the United States since the 1964 United States Civil Rights Law, the Federal Government has led a focus on ensuring nondiscrimination in the treatment of persons from four racial/ethnic minority groups: Black or African American, American Indian and Alaska Native, Asian and Pacific Islanders, and Hispanic or Latino. As will be discussed initially in the chapter, the concepts of cultural competence and linguistic competence arose to guide both individual clinicians and health care organizations in providing services that were adapted to the needs of these populations. However, we must prevent stereotyping by recognizing the heterogeneity of individuals from these four racial/ethnic groups based on cultural identity characteristics other than race/ethnicity: age, gender, gender identity, language, country of origin and acculturation, sexual orientation, socioeconomic status, religion/spirituality, geographic location, among others. Furthermore, in DSM-5, it is noted that "Cultures are open, dynamic systems that undergo continuous change over time; in the contemporary world, most individuals and groups are exposed to multiple cultures, which they use to fashion their own identities and make sense of experience. These features of culture make it crucial not to overgeneralize cultural information or stereotype groups in terms of fixed cultural traits" (American Psychiatric Association 2013, p. 749).

Since the 2001 Surgeon General's Report on Culture, Race, and Ethnicity, cultural and linguistic competence have been seen as essential to reducing and eliminating mental health disparities or achieving health equity. While the 2001 report focused on the four racial/ethnic minority groups, the field has begun to embrace cultural and linguistic competence to reduce mental health disparities for those populations defined by cultural characteristics other than those listed above.

Finally, the concept of "the Culturally Diverse" has evolved from the initial focus on the "exotic other." Sometimes, people with particular cultural characteristics were considered to have psychopathology; for example, until 1973, the American Psychiatric Association conceptualized homosexuality as a mental disorder in the DSM-II. Then being a member of one of the four racial/ethnic minority groups was regarded as "the culturally diverse." While the 1994 DSM-IV Outline for Cultural Formulation section on cultural identity mentioned explicitly only race/ethnicity, acculturation, and language, the DSM-5 Outline for Cultural Formulation section on cultural identity notes that "Other clinically relevant aspects of identity may include religious affiliation, socioeconomic background, personal and family places of birth and growing up, migrant status, and sexual orientation" (American Psychiatric Association 2013, p. 750). The DSM-5 Outline for Cultural Formulation and Cultural Formulation Interview are tools for every clinician to use with every patient.

Cultural Competence

Cultural competence was originally defined in 1989 as "a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situations" (Cross et al. 1989, p. iv). A culturally competent system, institution, or agency was characterized as "1) valuing diversity, 2) having the capacity for cultural self-assessment, 3) being conscious of the dynamics inherent when cultures interact, 4) having institutionalized cultural knowledge, and 5) having developed adaptations to diversity" (p. v). Although this 1989 monograph was focused on severely emotionally disturbed children from four sociocultural groups (African Americans, Asian Americans, Hispanic Americans, and Native Americans), the concept of cultural competence has evolved over time to encompass linguistic competence (because effective communication is vital to cultural competence) and to be applicable to individuals, families, and groups whose cultural diversities are not confined to race and ethnicity (Table 36-1).

Why is there a need for culturally competent mental health care? With the population surge in people from racially and ethnically diverse backgrounds and the resultant inevitable increase in cross-cultural interactions in the mental health care setting, culturally competent care can improve the quality of mental health services and outcomes (Cohen and Goode 1999). Cultural competence can also be seen as a moral, ethical, and civil rights measure to foster equality in mental health care in an effort to eliminate disparities in health status of people of diverse racial, ethnic, and cultural backgrounds. Furthermore, providing culturally competent care is increasingly necessary to meet legislative, regulatory, and accreditation mandates. For example, standard ED-21 of the Liaison Commission on Medical Education (2012) accreditation standards for medical schools states: "The faculty and medical students of a medical education program must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments" (p. 10). The annotation amplifying the standard states: "To demonstrate compliance with this standard, the medical education program should be able to document objectives relating to the development of skills in cultural competence." (Liaison Commission on Medical Education 2012, p. 10). A second prominent example of such a mandate is the Joint Commission's requirement that a health care organization, in order to receive accreditation, must ensure that all patients receive the same high-quality care by integrating cultural competence into the core activities of its system of care delivery (Joint Commission 2010). When psychiatrists and other mental health professionals incorporate the principles of cultural competence into their practices, they also may reap practical benefits, including gain of a competitive edge in the marketplace and reduction in the likelihood of malpractice claims (Cohen and Goode 1999).

Source. Office of Minority Health, U.S. Department of Health and Human Services: National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice (pp. 138-139; adapted from Cross et al. 1989). April 24, 2013. Available at: https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedCLASStandardsBlue-print.pdf. Accessed August 5, 2013.

The U.S. Department of Health and Human Services Office of Minority Health (2013) National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care consist of 15 standards that define culturally competent care that is consistent with cultural health beliefs (Table 36-2). The standards address incorporating language preferences in signage, literature, and interpretation; instituting various organizational supports for cultural competence; and ensuring that staff at all levels and across disciplines receive ongoing education and training in how to deliver care that is appropriate to the language and culture of the patients served by a given health care organization (Lim 2010).

At the individual practitioner level, cultural competence requires consciousness of one's own self-identity and introspection about one's personal views on racial and cultural issues, including countertransference. Recognition of the cross-racial power dynamics that may exist between psychiatrists/clinicians and people receiving mental health services is another important aspect of culturally competent care. Also, culturally competent service provision calls for the development of skills in being flexible in providing care that is acceptable to the patient and that takes into account patient preferences (Cross et al. 1989). In August 2012, the National Quality Forum (NQF) endorsed 12 quality measures focused on reducing health care disparities and promoting culturally competent care for racial and ethnic minority populations. These included measures for evaluating patient engagement and experience, which will equip clinicians with the information they need to support high-quality care for all patients (National Quality Forum 2012).

Health and Mental Health Disparities as a Rationale for Advancement of Cultural Competence

According to U.S. Census Bureau estimates released on June 27, 2013 (http://quickfacts.census.gov/qfd/states/00000.html), 37% of Americans self-identify as nonwhite (including Black or African American, American Indian and Alaska Native, Native Hawaiian and Other Pacific Islander, Asian, Hispanic or Latino) or of two or more races. Taken together, these groups represent an emerging majority—by 2050, nonwhites are expected to account for more than half of the U.S. population (Passel et al. 2012). Although health and mental health disparities are associated with a variety of population characteristics, such as socioeconomic status, age, education, sexual orientation, and rural location, among others, our focus in this chapter is health disparities related to culture, race, and ethnicity. We believe that a thorough understanding of the types of barriers faced by ethnic and racial minority populations will serve to make evident the importance of cultural competence in the provision of health and mental health care.

Increased cross-cultural contact requires psychiatrists to seek a broader understanding of the mental health status and needs of racially and ethnically diverse population groups and to gain an awareness of the mental health disparities affecting these groups. Psychiatrists also need to recognize the unequal social and economic conditions faced by ethnic and racial minorities in the United States, characterized by greater exposure to racism, discrimination, violence, and poverty, which—taken together—have a significant negative impact on mental health. Finally, psychiatrists must develop relevant skills and commit themselves to the challenge of delivering equitable mental health care to all patients.

Source. Office of Minority Health, U.S. Department of Health and Human Services: National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice (p. 13). April 24, 2013. Available at: https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedCLASStandardsBlueprint.pdf. Accessed August 5, 2013.

Defining Health Disparities

Health disparities are inequalities in health outcome between population groups based on differences in social, demographic, environmental, and geographic characteristics (Centers for Disease Control and Prevention 2011). The term health disparity is also used to describe certain population groups. A health disparity population is one in which there exists "significant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality or survival" compared with the general population (U.S. Public Law 106-525, Minority Health and Health Disparities Research and Education Act of 2000).

Numerous reports have explored the full range of disparities in health status and health care. One major report, the Institute of Medicine's "Unequal Treatment: Confronting Racial and Ethnic Health Care Disparities," was a landmark document that provided an extensive literature review confirming the existence and toll of health care disparities in non-majority populations (Smedley et al. 2002). In that report, the Institute of Medicine defined health disparities as differences in health care quality that are not the result of differences in clinical needs or preferences and that cannot be explained by differences in socioeconomic status or health insurance coverage (Smedley et al. 2002).

Mental health disparities among racial and ethnic minority groups were the focus of Dr. David Satcher's groundbreaking supplement to Mental Health: A Report of the Surgeon General (U.S. Department of Health and Human Services 2001). Titled Mental Health: Culture, Race and Ethnicity, this supplement presented research evidence that people of African, American Indian and Alaska Native, Asian, and Hispanic or Latino descent receive fewer mental health services and a lower quality of mental health care compared with white Americans (U.S. Department of Health and Human Services 2001). Subsequent reports, such as the National Healthcare Disparities Reports prepared annually by the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ), continue to document mental health disparities in access, quality of care, and outcomes among racial and ethnic minority groups. Underservice and substandard care create a heavy disability burden on these population groups.

Many reasons have been put forward to explain the existence of mental health disparities. Racism, discrimination, and economic impoverishment are common experiences among racially, ethnically, culturally, and linguistically diverse population groups. Unfortunate historical realities undergird the mistrust that some members of non-majority population groups hold toward systems and institutions in the United States: slavery among the ancestors of African Americans; forced dislocation and seizure of land among American Indian groups; harsh immigration policies applied to people of Hispanic descent; and internment of Asian Americans in the 1940s and 1950s (Western Interstate Commission for Higher Education 1998). This socio-historical context contributes to a wariness of people in authority, including psychiatrists and other mental health professionals, among these populations.

Other elements that influence disparities in mental health care include communication styles, both verbal and nonverbal; the extent of family and community support; health-seeking behaviors; support systems and protective factors; how people perceive and cope with mental illness; and how clinicians interact with people with mental illness (U.S. Department of Health and Human Services 2001).

Disparities in Mental Illness Burden

It is important to understand the epidemiological differences that exist in diverse racial and ethnic groups compared with whites. In American Indian tribes, the lifetime prevalence of any psychiatric disorder (50%-54% in men, 41%-46% in women) has been found to exceed that of the U.S. population (44% in men, 38% in women) (Beals et al. .2005). Past-year prevalence of any psychiatric disorder is lower among African Americans (15%), Asian Americans (9%), and Hispanics (16%) than among non-Hispanic whites (21%) (Alegria et al. 2010). However, the authors pointed out that "in the aggregate, the U.S.-born are at higher risk for disorders than immigrants" (Alegria et al. 2010, p. 314), which highlights the need to attend to variables beyond race in order to prevent stereotyping.

Whereas prevalence rates of specific mental disorders are mostly similar across population groups, some differences are worthy of note. African Americans have been found to be overrepresented among patients with dysthymic disorder, isolated sleep paralysis, or cognitive disorders (Primm 2006). Suicide rates among Asian American women older than 65 years as well as those in the 15- to 24-year age group are significantly higher than rates among all women in the United States (Centers for Disease Control and Prevention 2006, 2009).

Disparities in Help Seeking for, Access to, and Utilization of Mental Health Services

A study of the use of mental health services in the United States concluded that "unmet need for treatment is greatest in traditionally underserved groups, including elderly persons, racial/ethnic minorities, those with low incomes, those without insurance, and residents of rural areas" (Wang et al. 2005, p. 629). Lack of medical insurance is a major barrier to receipt of psychiatric care. In 2010-2011, the rate of uninsurance was 20% for African Americans, 30% for Hispanics, 27% for American Indians/Alaska Natives, 19% for Native Hawaiians/Pacific Islanders, and 18% for Asian Americans, compared with 11% for whites (non-Hispanic) (De-Navas-Walt et al. 2012). Immigrants are nearly three times more likely to be uninsured than are people born in the United States (Singh and Hiatt 2006).

Limited English proficiency is a major obstacle to receipt of care among non-majority population groups. For example, in one study, the likelihood of receiving needed mental health care was significantly lower among non-English-speaking Asian Americans than among Asian Americans who spoke only English (Sentell et al. 2007). In the same study, fewer than 10% of non-English-speaking Hispanics with a mental health care problem received needed services (Sentell et al. 2007).

There are also disparities in help seeking among racial and ethnic minorities that revolve around the use of alternative sources of care outside conventional Western medicine. For example, American Indian adults with a diagnosis of depression, anxiety, or substance use disorder are significantly less likely to seek help from specialty mental or behavioral health or other medical sources than from a traditional or spiritual healer (Beals et al. 2005; Walls et al. 2006).

Mental health service utilization varies greatly among racial and ethnic minority groups. Among people with depression in the past year, 69% of Asians, 64% of Latinos, and 59% of African Americans sought no mental health care, compared with 40% of non-Latino whites (Alegria et al. 2008). In one study of adolescents' use of public sector mental health services in San Diego, Latinos with psychiatric disorders were significantly underserved compared with whites. In multivariate analyses, Latino youths were significantly less likely than white youths to use specialty mental health services independent of diagnosis, gender, age, and the service sector from which they were selected (Hough et al. 2002).

In a study of Medicaid beneficiaries with mental illness, non-majority patients were more likely than whites to receive mental health care in inpatient and emergency room hospital settings and less likely to receive such care in outpatient community settings (Samnaliev et al. 2009). An analysis of availability, use, and quality of depression care in the United States based on data from the Collaborative Psychiatric Epidemiology Surveys found that whereas few Americans with recent major depression received any form of depression care, and even fewer received guideline-concordant care, the lowest rates of care receipt were among Mexican Americans and African Americans. These ethnic/racial differences were found despite comparable depression care need (Gonzalez et al. 2010).

Disparities Related to Diagnosis, Treatment, and Quality of Care

Although elimination of disparities in access to and utilization of mental health care among diverse racial and ethnic groups is crucial, appropriate diagnosis and equitable care that meets guidelines are other important goals. Members of these population groups are more likely than whites to experience misdiagnosis of mental disorders and to receive mental health care in inpatient and emergency room hospital settings. In addition, underuse of community outpatient care, less receipt of evidence-based care, and less follow-up after inpatient treatment are common among ethnically and racially diverse population groups (López et al. 2013).

Older African Americans have been found to have a lower depression prevalence rate than their white counterparts and to present with different symptoms (less low mood and less loss of pleasure in activities). In addition, older African Americans with depression are less often prescribed antidepressants than are their white counterparts (Harralson et al. 2002). However, prevalence rates of depression were found to be similar to those of whites when structured interviews are used, which suggests that greater awareness among clinicians of this difference in presentation in African American older adults may improve detection of depression and delivery of appropriate treatment in this population group.

Due to culturally based shame associated with mental illness in Asian American communities, Asian Americans are much less likely than whites to mention mental health concerns to friends or relatives, psychiatrists or other mental health professionals, or other physicians (Sribney et al. 2010). This finding suggests that clinicians should recognize the stigma attached to mental illness and learn how to ask the kinds of questions that elicit the most valid responses, such as through use of the DSM-5 Cultural Formulation Interview.

Compared with whites with similar symptom presentations, African Americans are more likely to receive a diagnosis of schizophrenia and less likely to receive a diagnosis of a mood disorder (A.B. Primm and Lawson 2010). A lack of awareness on the part of white clinicians of how African American cultural factors shape the expression of emotional distress may play a role in misdiagnosis (Breshnahan et al. 2007; Gara et al. 2012). In regard to appropriate care, Alegria et al. (2008) found disparities in the adequacy of treatment for depression wherein the percentage of whites receiving adequate treatment (33%) was much higher than that of African Americans (12%), Asians (13%), and Latinos (22%). Treatment adequacy was defined as "four or more specialty or general health provider visits in the past year plus antidepressant use for 30 days or more or eight or more specialty mental health provider visits lasting at least 30 minutes, with no antidepressant use" (Alegria et al. 2008, p. 1264).

Ethnic and racial disparities have also been found in the treatment both of substance use disorders and of co-occurring mental health and substance use disorders. Whites are three times more likely than African Americans to receive substance abuse treatment services. African Americans with co-occurring substance use disorders and mental illness are less likely to receive treatment for mood and anxiety disorders (B.J. Primm et al. 2010). Also, culturally diverse populations with access to care experience disparities in quality of care, less specialty care, and less recurring care (B.J. Primm et al. 2010).

Clinicians' possible lack of understanding of cultural concepts of distress—which include cultural syndromes, cultural idioms of distress, and cultural explanations, as defined in DSM-5 (American Psychiatric Association 2013, p. 758)—may lead to underdiagnosis or misdiagnosis of mental illness. Other factors that play a role in underservice to and under-treatment of racially and ethnically diverse populations include health literacy barriers, stigma attached to mental illness, language and communication barriers, and mistrust of the mental health system and professionals.

Remedies for Mental Health Disparities

The key messages of Mental Health: Culture, Race and Ethnicity, the supplement to the Surgeon General's Report on Mental Health (U.S. Department of Health and Human Services 2001), can be summarized in two brief statements:

1. Mental health disparities are real and cause a significant disability burden in diverse communities.
2. Culture counts.

To improve mental health services for racially, ethnically, and culturally diverse population groups, barriers affecting access to and quality of mental health care must be surmounted. Critical areas of focus toward this goal include the following: 1) increasing mental health workforce diversity, a public health issue directly tied to eliminating health care disparities; 2) increasing cultural competence among psychiatrists and other mental health clinicians; 3) expanding insurance coverage for minority populations, and 4) addressing the culturally mediated stigma associated with mental illness.

Clinical Cultural Competence in Mental Health: Cultural Psychiatry

Clinicians seeking to provide culturally appropriate mental health services to racially and ethnically diverse populations need training that encompasses culturally relevant knowledge, attitudes, and skills. Information about a patient's culture can be obtained from clinicians and other helpers knowledgeable about the appropriate cultural group (i.e., "cultural brokers"), as well as from books such as Ethnicity and Family Therapy (McGoldrick et al. 2005). "Suggested Readings" are provided at the end of this chapter. It is our hope that these readings may give both a good starting place for clinicians and trainees to learn what is normative among various cultural groups and some clues about how to ask more culturally pertinent questions to obtain an individualized, nonstereotyped understanding of each patient.

In addition to building culturally specific knowledge, clinicians and trainees would benefit from diversity training. Such training can help clinicians to understand both their own cultural identity and the identities of others as well as to develop essential attitudes of cultural competence (Table 36-3). Training in use of the DSM-IV/DSM-IV-TR/DSM-5 (American Psychiatric Association 1994, 2000, 2013) Outline for Cultural Formulation and the DSM-5 (American Psychiatric Association 2013) Cultural Formulation Interview is discussed in the next few sections.

Skills Training: DSM-IV/DSM-IV-TR/DSM-5 Outline for Cultural Formulation

DSM-IV and DSM-IV-TR contained an Outline for Cultural Formulation and a Glossary of Culture-Bound Syndromes in Appendix I. DSM-5 provides an updated version of this Outline in the Cultural Formulation chapter of Section III (pp. 749-750). For simplicity, we will refer to DSM-5 (rather than DSM-IV/DSM-IV-TR/DSM-5) in the remainder of this chapter. The Outline for Cultural Formulation (OCF) provides a useful framework for culturally competent assessment that is both sensitive and responsive to the person's cultural background. Its main goal is to help clinicians identify cultural contextual factors affecting the patient that are relevant to diagnosis and treatment (Mezzich et al. 2009). The OCF organizes assessment of the relevance of culture within the patient-clinician encounter around five dimensions (Lewis-Fernandez 1996; Lu et al. 1995; Table 36-4). Another explicit function of the OCF is to assist clinicians in diagnosis of patients whose presentations do not correspond to DSM diagnoses (Lewis-Fernandez and Diaz 2002).

The OCF has been called the most important contribution of anthropology to psychiatry (Good 1996). Journals such as Culture, Medicine, and Psychiatry and Transcultural Psychiatry have published many case reports illustrating the benefits of its use. The OCF has also been widely used within psychiatric education to promote cultural competence among trainees (Aggarwal and Rohrbaugh 2011).

Source. American Psychiatric Association 2013.

Applications of Culturally Effective Treatment

In this section, we will discuss how the key to engaging members of racial/eth-nic minority groups in mental health services is to begin with an understanding and acceptance of their cultural beliefs about illness and to apply the principles of adapting services and systems to population needs. Examples of adaptations to existing treatments will be described (Lim 2012).

Southeast Asian Communities

In his article "Psychotherapy for Massively Traumatized Refugees: The Therapist Variable," David Kinzie described the types of trauma experienced by Southeast Asian refugees and summarized four primary needs of these patients: 1) safety (both physical and emotional), 2) predictable and stable relationships, 3) reduction of symptoms, and 4) reestablishment of social relationships (Kinzie 2001). According to Kinzie, the therapist must be able both to listen to a person's trauma without interruption and to be present in a dependable and stable relationship. In addition, because gifts of modest value represent culturally appropriate ways for a person to honor the therapist-patient relationship, it would be culturally appropriate for the therapist to receive them from traumatized Southeast Asians refugees (despite professional training to not accept gifts of any kind).

Hinton and Otto (2006) described a modification of cognitive-behavioral therapy (CBT) for use in the treatment of post-traumatic stress disorder (PTSD) in Cambodian patients, who attributed their illness to "bad wind" caused by forced labor, chronic starvation, and sleep deprivation experienced in the killing fields. The catastrophic cognition would be that this "bad wind" could cause a heart attack, cessation of breathing, or rupture of the blood vessels in the neck or the head, leading to fainting, blindness, or death. An indigenous treatment for "bad wind" would be to release it either by "cupping" (which consists of causing redness on the skin by applying negative pressure through a heated glass bulb applied to the skin) or by "coining" (which consists of using coins to rub the skin, causing a round red mark on the skin). In the modified CBT protocol (Otto and Hinton 2006), the therapist introduces the "Limbic Kid" to explain the automatic responses and thoughts associated with the catastrophic cognitions. The therapist then induces dizziness in the group participants by having the patient play a childhood game called "hung," wherein the player holds his or her breath while running to retrieve a stick, experiencing dizziness, but no other ill effects, allowing a disconnection of the physical sensation from catastrophic cognitions. Finally, the therapist incorporates a Buddhist ritual, the three bows, with three statements. The first bow acknowledges the pain that the patient has suffered. The second denotes the patient's acceptance that the trauma has caused lingering effects, and the third represents a return to focusing on the present and planning to have a good life.

Hispanic Communities

An example of group treatment adapted/modified for use in specific ethnic populations or to treat survivors of specific events is CBT for depression adapted for use in Spanish-speaking patients (Miranda et al. 2006). Miranda and colleagues reported that in an ethnically diverse sample of patients with a diagnosis of major depressive disorder, patients randomly assigned to culturally adapted CBT or medication management did better than those simply referred to community mental health care in Washington, D.C., and surrounding counties. The authors noted that community outreach was vital to educate patients about their illness and the types of treatment available.

Ruiz and Langrod (1976) identified the importance of spiritual beliefs among Hispanic groups living in the Bronx in New York City and described efforts by a local community health center to increase its engagement with the community through collaboration with traditional healers. These activities included recruiting mediums, accepting referrals from and referring cases to mediums, engaging in active outreach to the community by visiting spiritualist centers, conducting ethnographic observations, and exchanging views on treatment and explanatory models with espiritistas and other spiritual authorities (Ruiz and Langrod 1976). Barrio (2000) similarly described the importance of outreach to and engagement of the family and community through community support centers, which can bridge gaps between the community mental health center and the ethnically diverse populations they serve.

Using Systems to Support Culturally Competent Services

Another strategy, similar to Barrio's (2000) description of creating systems linkages, is using access services, usually provided by community agencies that can supply language translation services. For example, Asian Pacific Community Counseling in Sacramento, California, not only provides language and culturally appropriate psychotherapy through the Transcultural Wellness Center (Asian Pacific Community Counseling 2011) but also serves as an access point for people to enter the county mental health system (Sacramento County Specialty Mental Health Services 2011). Finally, another approach that has been helpful in linking ethnic minority patients from the community to mental health services is the Bridges Program at the Charles B. Wang Community Health Center, which integrates physical health and mental health services. Chinese patients seen in primary care are referred to mental health professionals practicing in the same building as the primary care physician, thus reducing the stigma patients might experience if they were to be referred to a freestanding mental health clinic (Chen et al. 2003).

Ethnopsychopharmacology

Ethnopsychopharmacology is the study of how race and ethnicity (among other factors) affect the bioactivity of psychotropic drugs. In a recent book, Ethno-Psycho-pharmacology: Advances in Current Practice, Ng et al. (2008) explain that there are many biological, environmental, and psychological reasons for the broad range of response to psychiatric drugs seen among different racial and ethnic groups. For example, the hepatic cytochrome P450 (CYP) enzyme system—in particular, isozymes 2D6, 3A4,1A2, 2C19, and B6—is responsible for the metabolism of many psychotropic medications. Depending on the number of copies of genes coding for these enzymes that a person has, that person may be a slow metabolizer, in whom lower-than-usual medication dosages can result in a therapeutic effect while usual dosages may lead to intolerable side effects. Conversely, a person may be an ultra-fast metabolizer, in whom higher-than-usual dosages are needed for a therapeutic effect. Diet and smoking also affect drug metabolism, sometimes inhibiting or accelerating its rate.

Finally, the patient's expectations regarding how the drug will work may influence his or her perceptions of the actual effect, or such expectations may cause an effect of their own. On a clinical level, psychiatrists and primary care practitioners are well advised to consider starting medications at a low dosage and advancing titration slowly in case the patient is a slow metabolizer. Genetic screening tests are now available that provide CYP genotyping from a cheek swab sample, making it possible to assess the activity of a particular enzyme and adjust dosages accordingly (AssureRx 2012).

Summary

Thus, clinical applications of cultural psychiatry include training in culturally specific knowledge as well as culturally generic attitudes and skills that encourage culturally appropriate assessment and treatment planning. Use of the DSM-5 Outline for Cultural Formulation and the DSM-5 Cultural Formulation Interview can help clinicians to establish rapport with their culturally diverse patients as well as to obtain clinical information for making a culturally appropriate diagnosis and negotiating a culturally acceptable treatment plan.

Cultural Psychiatry in DSM-5

The various revisions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) have been important documents for cultural psychiatry. The specified descriptions of mental disorders in these manuals establish their accepted phenomenological boundaries of disorders. However, an unintended consequence of this specification has been to exclude alternative symptom variants based on cultural differences that exist worldwide (Klein-man 1988). In addition, the shift in emphasis after DSM-III (American Psychiatric Association 1980) to descriptively based assessment has meant that clinicians pay less attention to contextual information when making a diagnosis. Such contextual information includes the person's interpretation of the condition or distress; whether the condition is considered pathological by others in the person's cultural setting, and if so, what the perceived level of severity is; whether the symptoms depend on particular situations or precipitants; and what relationship exists between persistence of the disturbance and availability or nonavailability of supports and interventions (Kleinman and Benson 2006). For example, in the diagnostic criteria, the circumstances that precipitate what appears to be major depressive disorder have become less important over time. From a partial exclusion of 2 months for acute bereavement in DSM-IV/DSM-IV-TR, there is no exclusion for acute bereavement in DSM-5; instead, clinicians are urged to "carefully consider" whether a major depressive episode is present in the midst of acute grief (Zisook et al. 2007). This strong reliance on clinical symptoms as the primary definition of the disorders argues for continuing to press for the inclusion of information on cultural and contextual factors in DSM.

In fact, progressive DSM revisions have paid more attention to cultural factors affecting diagnosis. In both DSM-IV and DSM-IV-TR, the importance of cultural factors was noted in the Introduction, and a subsection titled "Specific Culture, Age, and Gender Features" was included in each disorder chapter (Mez-zich et al. 1999). These DSM editions also provided an Outline for Cultural Formulation and a Glossary of Culture-Bound Syndromes in Appendix I. DSM-5 has pushed forward the initial steps of DSM-IV/DSM-IV-TR in each of these areas. In this section of the chapter we describe each of these developments in detail. We review the following changes in DSM-5:

1. Section I: the Introduction (pp. 14-15)
2. Section II: the descriptive text for each disorder
3. Section III: the Cultural Formulation chapter, including Outline for Cultural Formulation, Cultural Formulation Interview, and Cultural Concepts of Distress (pp. 749-759)
4. Appendix: the Glossary of Cultural Concepts of Distress (pp. 833-837)

These changes have been the work of international experts in cultural mental health who are members or advisors of the DSM-5 work groups and of the DSM-wide Cross-Cultural Issues subgroup of the Study Group on Gender and Cross-Cultural Issues. Led by Drs. Roberto Lewis-Fernandez and Kimberly Yonkers, the Cross-Cultural Issues subgroup organized literature reviews of relevant topics as well as a field trial of the DSM-5 Cultural Formulation Interview with additional cultural experts in five continents. Several of these literature reviews and field trial reports have been published or are under review, and others are forthcoming (e.g., Brown and Lewis-Fernandez 2011; Hinton and Lewis-Fernandez 2011; Lewis-Fernandez et al. 2010; Spiegel et al. 2011). We summarize the work of these experts below.

The Introduction to DSM-5

The "Cultural Issues" section of the Introduction to the overall DSM-5 succinctly acknowledges the crucial contribution of culture in providing "interpretive frameworks that shape the experience and expression of the symptoms, signs, and behaviors that are criteria for diagnosis" (American Psychiatric Association 2013, p. 14). In other words, culture plays a key role in determining the level at which an experience becomes problematic or pathological. Cultural factors can have the result of normalizing behaviors that may seem pathological in other contexts (e.g., intensely shy, socially reticent behavior in certain cultural settings may be experienced by the person and seen by others as respectful, rather than as a sign of social anxiety disorder; Heinrichs et al. 2006). On the other hand, culture may also contribute to vulnerability and suffering, such as by amplifying fears that maintain panic disorder or health anxiety (Hinton et al. 2009).

The "Cultural Issues" section of the DSM-5 Introduction clarifies that culture is the province of everyone, not only of racial and ethnic minority groups. All individuals and groups are cultural beings, and even scientific endeavors such as the DSM are based on cultural premises and have culturally relevant effects. This section of the DSM-5 Introduction outlines the multiple ways in which culture influences the diagnostic and treatment process, including with respect to symptom expression (e.g., alternative symptom variants), clinician assessment (e.g., diagnostic accuracy, evaluation of severity), and patients' responses (e.g., coping strategies, help-seeking choices, treatment adherence). The DSM-5 Introduction also explains why the older term culture-bound syndrome has been replaced by three concepts that offer greater cultural utility: cultural syndromes, idioms of distress, and explanations. These concepts are described in greater detail later in this chapter (see subsection titled "Cultural Concepts of Distress").

Inclusion of Culture-Relevant Material in Descriptive Text for Each Disorder

Whereas DSM-IV/DSM-IV-TR limited the explicitly culture-related material in each disorder chapter to a single section on Specific Culture, Age, and Gender Features, DSM-5 separated this section into three independent subsections on Development, Culture, and Gender. Some work groups took this opportunity to pursue a comprehensive revision of cultural factors relevant to each disorder. In the interest of space, we illustrate this approach with examples from the Work Group on Anxiety, Obsessive-Compulsive Spectrum, Post-traumatic, and Dissociative Disorders.

The first step in this more comprehensive revision process was to review the quality of the existing data on cultural variation for each DSM disorder. This review involved answering the following questions for each disorder:

• What level of integration is needed for cultural information within DSM-5?
• Is the evidence strong enough to warrant changes to disorder criteria?
• Or, instead, should cultural data go only in the descriptive text to help the clinician apply existing criteria across cultural presentations?
• Alternatively, should nothing be changed from DSM-IV-TR?

The basis for this comprehensive review was the assumption that every disorder description is incomplete until it encompasses the fullest possible range of cultural variation of the syndrome worldwide. Clearly, an institutionalized process with multiple stakeholders, such as that followed for DSM revisions, is inherently resistant to change, sometimes appropriately so. It can be destabilizing, for example, to make too many changes at once in a nosology that has clinical, social, forensic, and fiscal uses. Not only these sociopolitical processes but also the shortcomings of the existing data sets limited the extent of cultural variation that could be proposed. But within these constraints, the Work Group marshaled the evidence for change.

Sometimes the data were robust enough to warrant proposed revisions at the level of criteria sets. This was the case for social anxiety disorder, agoraphobia, specific phobia, posttraumatic stress disorder, and dissociative identity disorder, among others. Social anxiety disorder may serve as an example (Lewis-Fernandez et al. 2010). Decades of cross-cultural research have noted that the fear of negative evaluation by others (i.e., the hallmark of social anxiety disorder) can take the form of fear that the individual will cause offense to others, in addition to or instead of the fear that the person will feel embarrassed or humiliated as a result of engaging in the social behavior (Choy et al. 2008; Kirmayer 1991). Labeled "other-directed" or "allocentric" fear, this type of fear is a characteristic symptom of certain forms of culturally described distress in East Asia, such as taijin kyofusho in Japan and taein kong po in Korea. However, fear of offending others is also observed among individuals with social anxiety disorder in many cultural settings, such as Australia and the United States (Choy et al. 2008; Kim et al. 2008). In fact, in most cases of social anxiety disorder cross-culturally, the fear of offending others and the fear of suffering embarrassment or humiliation oneself occur together, rather than being mutually exclusive, indicating that they are related presentations (Lewis-Fernandez et al. 2010). The Work Group felt that the cross-cultural evidence was sufficiently robust to warrant revision of the social anxiety disorder criteria to indicate this relationship, in order to help reduce the potential for misdiagnosis in settings where "other-directed" fear is the primary or initial presentation. The revised social anxiety disorder Criterion B now reads: "The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (e.g., will be humiliating or embarrassing; will lead to rejection or offend others)" (American Psychiatric Association 2013, p. 202).

At other times, evidence on the impact of cultural factors in diagnosis was not felt to warrant a revision of diagnostic criteria but was considered a useful addition to the textual description of the disorder (e.g., its diagnostic features, associated features, and prevalence). The intent was to help clinicians and researchers identify individuals suffering from the disorder and facilitate assessment of severity, comorbidity, and prognosis as well as selection among treatment options. Cultural informational contributions to the text took several forms:

• In light of the growing international use of DSM revisions, an effort was made throughout the text to limit eth-nocentrism. Given that an important DSM goal is to advance toward a truly international nosology that can be integrated with the International Classification of Diseases, 11th Revision (ICD-11; scheduled for release in 2015), an essential first step was to clarify the limitations of the existing data. Thus, if information about a disorder's development and course was available only from studies conducted in certain regions of the world (e.g., the United States and Europe), that circumstance was noted in the text. By clearly stating such limitations, the text both guards against overgeneralization and identifies logical next areas for research.
• Two subsections of the text—"Diagnostic Features" and "Prevalence"—include culture-relevant information directly. The "Diagnostic Features" subsection describes any symptom variation in disorder presentation that led to a revision of disorder criteria (e.g., the revision of Criterion B for social anxiety disorder mentioned earlier). The "Prevalence" subsection provides data on variation in prevalence by race/ethnicity in the United States and the range of prevalence internationally. For example, most of the anxiety disorders have been examined in many countries with the same instrument, the World Health Organization's Composite International Diagnostic Interview (Kessler and Ustün 2004), yielding comparable values for 12-month prevalence. The values from countries with the highest and lowest prevalence estimates are reported as the endpoints of a range for each disorder.
• As previously described, the DSM-IV/DSM-IV-TR subsection "Specific Culture, Age, and Gender Features" was disaggregated into separate subsections in DSM-5. For each DSM-5 disorder, the new subsection "Culture-Related Diagnostic Issues" contains most of the data on explicitly cultural features of the disorder (e.g., cultural variation in disorder symptoms that did not warrant criteria revision), as well as culture-related information on development and course, risk and prognostic factors, interpretation of stressors, impairment, and severity. More fine-grained information on cultural, racial, and/or ethnic variations in disorder prevalence (e.g., by nativity status, by subethnicity) is also included in this subsection. Finally, cultural labels, explanatory models, and/or cultural syndromes associated with the disorder are listed in this subsection and cross-referenced with individual entries in the Glossary of Cultural Concepts of Distress in the DSM-5 Appendix. For example, a complex association exists between ataques de nervios (attacks of nerves), a cultural syndrome common among Latinos, and several DSM-5 disorders (Guarnaccia et al. 1996; Lewis-Fernandez et al. 2002). Individual presentations of ataque can be variously diagnosed as panic disorder, other specified dissociative disorder, and conversion disorder (functional neurological symptom disorder), among others. That is, the cultural label unifies presentations that are considered psychiatrically diverse.

As an example of the kind of material included in the explicit "culture-related" section of the text, we can consider PTSD. This section includes information on variation in the risk of onset and severity of PTSD as a result of various cultural-contextual factors (e.g., the impact on disorder severity of the meaning attributed to the traumatic event), the level of cultural variation in clinical expression of individual symptoms and symptom clusters of PTSD, and the role that cultural syndromes and idioms of distress play in the expression of PTSD and the range of comorbid disorders (Hinton and Lewis-Fernandez 2011).

DSM-5 Outline for Cultural Formulation

An updated version of the DSM-IV/DSM-IV-TR Outline for Cultural Formulation is provided in DSM-5. Revisions to the OCF were made in response to criticisms on several fronts: busy clinicians may not use the OCF if it takes too much time (Lewis-Fernandez 2009); the OCF dimensions may be too indistinct and overlapping (Ton and Lim 2006); and use of the OCF may repeat information from the standard clinical assessment (Caballero and Martinez 2009). The Cross-Cultural Issues subgroup found at least four different versions of the OCF in use, preventing standardization of training and research (Alarcon 2009). Nonetheless, researchers at McGill University in Montreal, Quebec, demonstrated the Outline's utility in identifying misdiagnosis of psychotic disorders among ethnic minority and immigrant patients referred to a cultural consultation service (Adeponle et al. 2012). In this study, use of the DSM-IV/DSM-IV-TR OCF for case reassessment of 323 patients referred over a 10-year period resulted in 34 (49%) of 70 cases with a referral diagnosis of a psychotic disorder being rediagnosed as having a nonpsychotic disorder, and 12 (5%) of 253 cases with a referral diagnosis of a nonpsychotic disorder being rediagnosed as having a psychotic disorder. The cultural consultation service utilized 60 cultural and linguistic brokers, 1.5-hour clinical assessments, and a 2-hour case conference in addition to the OCF (Kirmayer et al. 2003).

DSM-5 Cultural Formulation Interview

On the strength of these findings and the international field trials for the Cultural Formulation Interview, the Cross-Cultural Issues subgroup developed the Cultural Formulation Interview (CFI; Table 36-5), a standardized 16-item questionnaire that operationalizes the OCF. The questions are intended for use at the very beginning of the initial assessment of patients and cover the same topical areas as the OCF. The CFI includes instructions that precede the questions and a guide to the interviewer on the type of content that can be generated by each question. The CFI is organized into four sections: 1) cultural definition of the problem (questions 1-3); 2) cultural perceptions of cause, context, and support (questions 4-10); 3) cultural factors affecting self-coping and past help seeking (questions 11-13); and 4) cultural factors affecting current help seeking (questions 14-16).

To avoid stereotyping, the CFI uses a person-centered approach that focuses on the views of the individual patient, rather than inquiring generically about the views of the group (s) the person self-identifies with or is assigned to by the clinician (Kleinman and Benson 2006). This approach allows intracultural heterogeneity of views to emerge. It also accounts for hybrid identities in the person, because individuals typically hold views that stem from a diversity of cultural influences in their lives, which can best be assessed on an individual basis (Aggarwal 2012). To facilitate this use of the Interview, a variegated concept of culture informs the CFI, composed of three elements (American Psychiatric Association 2013, p. 750):

• The values, orientations, knowledge, and practices that individuals derive from membership in diverse social groups (e.g., ethnic groups, faith communities, occupational groups, veterans groups).
• Aspects of a person's background, developmental experiences, and current social contexts that may affect his or her perspective, such as geographical origin, migration, language, religion, sexual orientation, or race/ethnicity.
• The influence of family, friends, and other community members (the individual's social network) on the individual's illness experience.

Note. Supplementary modules (available online at www.psychiatry.org/dsm5) have been developed that expand on each domain of the CFI and guide clinicians who wish to explore these domains in greater depth.

Source. Reproduced (excluding referencing of supplementary modules) from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Washington, DC, American Psychiatric Association, 2013, pp. 752-754. Copyright 2013, American Psychiatric Association. Used with permission. Please refer to DSM-5 for the full CFI including referencing of supplementary modules under pertinent subheadings.

Cultural factors are subordinated to the information that can be elicited from the individual patients, including their perspectives on the views of their social group.

Another aspect of the CFI that bears noting is that it is not intended exclusively for the evaluation of members of nondominant cultural groups, such as racial/ethnic minorities. Instead, it is intended for use by any clinician with any patient, regardless of cultural background. Even patients and clinicians who appear to share the same cultural background may differ in ways that are relevant to care. Although its use is appropriate in any clinical setting, the CFI may be most helpful in the context of the following (American Psychiatric Association 2013, p. 751):

• Difficulty in diagnostic assessment owing to significant differences in the cultural, religious, or socioeconomic backgrounds of clinician and the individual.
• Uncertainty about the fit between culturally distinctive symptoms and diagnostic criteria.
• Difficulty in judging illness severity or impairment.
• Disagreement between the individual and clinician on the course of care.
• Limited engagement in and adherence to treatment by the individual.

The main goals of the CFI are to enhance the cultural validity of diagnostic assessment, facilitate treatment planning, and promote patient engagement. In particular, clinicians are encouraged to look for discrepancies between a patient's symptom presentation and DSM diagnostic criteria, uncertainties related to illness severity or impairment, differences of opinion about the course of care, and ways in which clinician identities may interact with patient identities throughout the evaluation. Acquisition of cultural-contextual information is an essential part of the diagnostic process, and the CFI provides an evidence-based method of obtaining this information. The CFI does not by itself yield a diagnosis; rather, the information elicited must be integrated with all other available clinical material into a comprehensive clinical and contextual evaluation. The process of conducting the Interview may be as helpful as the information obtained. For example, when patients feel respected and understood through use of the CFI, patients are more likely to be engaged in treatment.

As part of the development of the CFI for DSM-5, an American Psychiatric Association-supported field trial is being conducted. With a targeted enrollment of 330 patients in six countries across five continents, the goal of the field trial is to test the feasibility (Can it be done?), acceptability (Do people like it?), and perceived clinical utility (Is it helpful?) of the CFI among patients and clinicians. Data on approximately 200 patients were used to revise the initial version of the CFI into the final version included in DSM-5. Final field data results will be available in late 2013.

In addition, supplementary modules have been developed for use in conjunction with the CFI to help clinicians conduct a more comprehensive cultural assessment for patients who require it; these modules are available online (www.psychiatry.org/dsm5). Topical modules cover the explanatory model; level of functioning; social network; psychosocial stressors; spirituality, religion, and moral traditions; cultural identity; coping and help seeking; and the patient-clinician relationship. Population-specific modules address the special needs of school-age children and adolescents, older adults, immigrants and refugees, and caregivers. Clinicians may choose either to utilize all modules for a full assessment or to apply selected modules if they wish to expand a particular component of the CFI.

Cultural Concepts of Distress

As noted earlier in this chapter (see "The Introduction to DSM-5"), DSM-5 has thoroughly revised the DSM-IV/DSM-IV-TR Glossary of Culture-Bound Syndromes, producing two new sections: Cultural Concepts of Distress in the Cultural Formulation chapter in Section III and a Glossary of these concepts in the Appendix. The text in the Cultural Formulation chapter in Section III replaces the older conceptual description of culture-bound syndromes with three concepts having greater clinical utility (American Psychiatric Association 2013): Cultural syndromes are clusters of symptoms and attributions that tend to co-occur among individuals in specific cultural groups, communities, or contexts and that are recognized locally as coherent patterns of experience. Cultural idioms of distress are ways of expressing distress that may not involve specific symptoms or syndromes, but that provide shared ways of experiencing and talking about personal or social concerns (e.g., everyday talk about "nerves" or "depression"). Cultural explanations or perceived causes are labels, attributions, or features of an explanatory model that indicate culturally recognized meanings or etiologies for symptoms, illness, or distress (Groleau et al. 2006; Hinton and Lewis-Fernandez 2010; Nichter 1981).

Although the differences between syndromes, idioms of distress, and explanations are worth distinguishing conceptually, in common practice the same cultural term frequently denotes more than one kind of cultural concept. A familiar example of this usage may be the term depression:, which can describe a syndrome (e.g., major depressive disorder), an idiom of distress (e.g., as in the common expression "I feel depressed"), or a perceived cause (similar to "stress"). Despite this overlap, the distinctions between syndromes, idioms of distress, and explanations can help clinicians recognize how cultural concepts are deployed by patients, thereby facilitating diagnosis and treatment negotiation (American Psychiatric Association 2013). The Glossary contains nine examples of cultural concepts of distress from around the world that typify syndromes, idioms, and explanations and their interrelationships: ataque de nervios, dhat syndrome, khyâl cap, kufungisisa, maladi moun, nervios, shenjing shuairuo, susto, and taijin kyofusho. Only high-prevalence concepts that have received considerable research attention are included, and for each concept, the Glossary lists related conditions both in other cultural contexts and in DSM-5. These examples are intended to assist clinicians in the evaluation and treatment of individuals who present for care reporting one of these nine specific cultural concepts, but they are also meant to illustrate the process by which clinicians can translate from local expressions to DSM diagnoses.

In fact, the Cultural Concepts of Distress section in the Cultural Formulation chapter of Section III devotes considerable attention to explaining the relationship of cultural concepts to the conventional diagnoses in DSM-5 Section II. One way to understand the cultural concepts presented in the Glossary is that many DSM disorders started out as local expressions and over time became operationalized prototypes of disorder, based on a process of abstraction and generalization. Yet these prototypes do not exhaust cultural diversity in presentation, not only for cultural expressions that are closely related to DSM diagnoses (e.g., alternate versions of panic attacks), but especially for entirely different ways of organizing the classification of psychopathology (e.g., alternate types of disorder, such as anger-related conditions). As a result, clinicians may be exposed to local phenomena of distress that do not easily conform to conventional diagnoses. In fact, most of the cultural concepts included in the Glossary cut across DSM diagnoses, so that the relationship between concepts and disorders is not one-to-one, but instead one-to-many in either direction (Kleinman 1996). Symptoms or behaviors that might be sorted by DSM-5 into several disorders may be included in a single folk concept, and diverse presentations that might be classified by DSM-5 as variants of a single disorder may be sorted into several distinct concepts by an indigenous diagnostic system (American Psychiatric Association 2013). In effect, the existence of these alternative presentations suggests that all forms of distress are locally shaped (Kleinman 1996).

To deliver culturally appropriate care, it can be very useful to understand the association between locally patterned differences in symptoms, ways of talking about distress, and locally perceived causes, on the one hand, and coping strategies and patterns of help seeking, on the other. Toward this end, the Cultural Concepts of Distress section in the Cultural Formulation (DSM-5 Section III) explains in some detail the various ways in which knowledge of the cultural grounding of cultural concepts of distress can be important to diagnostic practice and clinical care generally.

Reasons for the importance of cultural concepts include to avoid misdiagnosis, to obtain clinically useful information, to improve rapport and engagement, to improve therapeutic efficacy, to guide clinical research, and to clarify the cultural epidemiology (American Psychiatric Association 2013, pp. 758-759). Each of these uses of cultural material is clarified, and particular illustrations are provided by the nine examples.

Conclusion

This chapter has provided a brief introduction to the assessment and treatment of culturally diverse populations. While the initial focus in mental health and psychiatry has been on the four largest racial and ethnic minority groups in the United States, treatment of culturally diverse populations today encompasses working with individuals whose cultural identities are defined by additional characteristics, such as age, gender, gender identity, sexual orientation, language, socioeconomic status, religion/spirituality, abilities/disabilities, and geographic location. Every clinical encounter can be seen as a cultural encounter in that the cultural identity of the clinician and that of the patient will be different when these characteristics are taken into account. To help clinicians understand and manage all cultural encounters, the authors have provided an introduction to the clinical tools of DSM-5: the Outline for Cultural Formulation and the Cultural Formulation Interview.

Key Clinical Points

• Cultural competence is an essential aspect of professionalism that includes respect for and responsiveness to cultural differences related to race/ethnicity, age, gender, gender identity, language, socioeconomic status, sexual orientation, country of origin and acculturation, religion/spirituality, abilities/disabilities, and geographic location, among other factors.
• Cultural competence is essential for competent clinical care of all patients because cultural differences always exist between the clinician and the patient that may affect assessment, diagnosis, and treatment planning.
• Cultural competence includes knowledge, attitudes, and skills that are essential for competent care that is both respectful of and responsive to the patient's cultural identity, values, and preferences.
• Cultural competence requires attitudes of respect for differences; humility in understanding the limits of one's knowledge and skills; self-reflectiveness in understanding one's cultural identity and cultural biases that may affect clinical care; vigilance toward the power dynamics resulting from cultural differences; and responsiveness to cultural differences via adaptation of assessment and treatment.
• Cultural competence includes skills in the use of the DSM-5 Outline for Cultural Formulation and the DSM-5 Cultural Formulation Interview.
• Cultural competence, at both the clinical and the systems level, is essential to reducing and eliminating mental health care disparities while increasing health equity, a key indicator of quality in health care.

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Otto MW, Hinton DE: Modifying exposure-based CBT for Cambodian refugees with posttraumatic stress disorder. Cogn Behav Pract 13:261-270, 2006

Passel J, Livingston G, Cohn D: Explaining why minority births now outnumber white births. Pew Social and Demographic Trends. Pew Research Center. Released May 17, 2012. Available at: http://www.pewsocialtrends.org/2012/05/17/explaining-why-minority-births-now-outnumber-white-births. Accessed October 22, 2012.

Primm AB: Cultural issues in assessment and treatment: African American patients, in Clinical Manual of Cultural Psychiatry. Edited by Lim RF. Washington, DC, American Psychiatric Publishing, 2006, pp 35-68

Primm AB, Lawson WB: Disparities among ethnic groups: African Americans, in Disparities in Psychiatric Care: Clinical and Cross-Cultural Perspectives. Edited by Ruiz P, Primm AB. Baltimore, MD, Lippincott Williams & Wilkins, 2010, pp 19-29

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Suggested Readings

Bhugra D, Bhui K (eds): Textbook of Cultural Psychiatry. Cambridge, UK, Cambridge University Press, 2007

Burt VK, Hendrick VC: Clinical Manual of Women's Mental Health, 2nd Edition. Washington, DC, American Psychiatric Publishing, 2005

Cabaj RP, Stein TS (eds): Homosexuality and Mental Health. Washington, DC, American Psychiatric Publishing, 1996

Josephson A, Peteet J (eds): Handbook of Spirituality and Worldview in Clinical Practice. Washington, DC, American Psychiatric Publishing, 2004

Lee E: Working With Asian Americans: A Guide for Clinicians. New York, Guilford, 1997

Lim RF (ed): Clinical Manual of Cultural Psychiatry. Washington, DC, American Psychiatric Publishing, 2006

López A, Carillo E: The Latino Psychiatric Patient: Assessment and Treatment. Washington, DC, American Psychiatric Publishing, 2001

McGoldrick M, Giordano J, Garcia-Preto N (eds): Ethnicity and Family Therapy, 3rd Edition. New York, Guilford, 2005

Ruiz P, Primm A (eds): Disparities in Psychiatric Care: Clinical and Cross-Cultural Perspectives. Baltimore, MD, Lippincott Williams & Wilkins, 2010

Sanchez-Hucles J: The First Session With African-Americans: A Step-By-Step Guide. San Francisco, CA, Jossey-Bass, 2000

Tseng W-S: Clinician's Guide to Cultural Psychiatry. New York, Academic Press, 2003