Training the Next Generation in Culture and Mental Health

1. Training the Next GenerationinCulture and Mental Health APA/SAMHSA Minority Fellowship Group for Advancement of Psychiatry Nathan Kline Institute/NYS OMH Center of Excellence for Culturally Competent Mental Health Care Helena Hansen1, Terry Dugan1, Anne Becker2, Manuel Trujillo1 1 NYU Medical Center, 2 Massachussetts General

2. Goals • Generate hypotheses about solutions and barriers to training residents to treat diverse patients in informed, sensitive way • Identify cultural psychiatry curriculum best practices • Document evolution of residency programs in US toward training in culture

3. Methods • 20 Semi-structured interviews with psychiatry faculty who teach culture • Recruited through modified snowball sample with geographic distribution • Thematic and content analysis of interview transcripts and course syllabi (In Progress)

4. All Culture in Psychiatry Curriculum is Local Faculty: most cross-trained in social science or non-European Most see themselves as tokens on faculty Diverse faculty attract diverse residents Groups studied reflect local patient populations (eg Somali, Hmong refugees)

5. Natural History of Cultural Curriculum • Oldest Courses: over 30 years • Median: 12 years • Median # of course meetings: 6 • Fewest: 1 Most: 24 • Residency year: between PGY 2 and 3

6. A Typology Cultural Competence Model: Didactic, Evidence Based, Sx, Dx, Tx by Ethnic Group Led by MDs (clinical researchers, non-white faculty) Cultural Humility Model: Immersion/Site Visits, Alternative Healing, Clinical Ethnography Multiple Identities/Multidetermination, by MDs trained in Anthro Cultural Critique Model: Self-examination, Psychiatry as cultural system (History,Symbolism and Assumptions of American Psychiatry) Led by MDs cross-trained in Humanities

7. Successes • Programs initiated by faculty with interest, independent of mandated core competencies • Faculty with cultural perspective secure resources (NIMH, APA Fellowship) • Many established cultural faculty are now training directors • Many residents/junior faculty are initiating new cultural curricula

8. Culture and PsychiatrySpring, 2008, NYU PGYIII classManuel Trujillo, MD, Course DirectorHelena Hansen, MD, Ph.D., Associate Course DirectorKim Hopper, Ph.D., Associate Course Director 14 one hour seminar meetings 10 Lecturers (MDs, Ph.D.s in anthropology, cultural studies, one service user) One field trip to religious CBO (planned) Two interview workshops One review of resident cases with cultural supervision

9. Module One: Perceiving the Other Goals: Residents will encounter how socio-cultural processes relate to local knowledge and behavior of individual patients, and to patient care Objectives Residents will articulate strategies for distinguishing individual psychopathology from socio-cultural variation Residents will identify the impact of patients’ socioeconomic instability and related coping strategies on the doctor-patient relationship, and how to negotiate these factors to provide good quality of care 3. Residents will articulate at least one example demonstrating how axes of difference (e.g. ethnic, class, religious) affect the therapeutic alliance, diagnosis and treatment of patients

10. Module Two: Perceiving Self Goals: Residents will experience their own cultural backgrounds, and examine its influence on the doctor patient relationship as cultural transference and countertransference Residents will gain awareness of American psychiatry as a socio-cultural product Residents will experience themselves as patients see them: representatives of a powerful majority culture’s mental health system. Objectives: 1. Residents will demonstrate curiosity about the influence of their own acculturation, before and during residency, on their perception of patients 2. Residents will articulate strategies for responding empathetically to patients’ challenges to their professional power

11. Module Three: Working Through Cultural Transference/Countertransference Goals: Residents will practice conceptualizing culture in the doctor-patient encounter using a culturally interpretive clinical approach Residents will engage patients and establish rapport by assessing the role of culturally variable help seeking behaviors and beliefs in patients’ lives Objective: By the end of the module, residents will have completed at least one clinical patient assessment using a cultural interpretation of thoughts or behavior

12. The Four C’s of Culture Adapted from Kleinman, A 2006 by Dugan, T and Hansen, H • Call (What do you call your problem?) • Cause (What caused your problem?) • Course (How does it affect your body and mind with time?) • Consequence (How will it affect your life? What do you fear most about it?)

13. Age Disabilities Dominant Language Religion/Spirituality Ethnicity Socioeconomic Status Sexual Orientation Indigenous Heritage National Origin Gender The ADDRESSING FrameworkAdapted from Pamela Hayes, APA Press 2001

14. Course Evaluation Pre and Post Course Focus Groups (Needs->Effects) Pre and Post Course Knowledge, Attitudes, Beliefs Analysis of Residents’ Patient Case Presentations

15. Evaluation Results So Far Course ranked “one of the best in residency” Focus groups: Critical Thinking lectures most popular More site visits, case discussion, cultural faculty Ethnic data via case studies, not EBM didactics Recommended integration of topics over four years

16. Evaluation Results So Far Patient Case Presentations • Residents varied in ability to break out of DSM format • Cases ranged from white, middle class student to recent Kenyan refugee • Religion and sexuality, effects of background of resident (cultural transference/countertransference) explored • Faculty supervisors encouraged less “reading up” on ethnic groups/tribes and more curiosity about individual patient

17. Course Syllabus, Readings and Recorded Lectures Soon to be Available Online at http://cecc.rfmh.org NKI Center of Excellence in Culturally Competent Mental Health