The history and future of cross-cultural psychiatric services

Community Mental Health Journal, Vol. 32, No. 6, December 1996 The History and Future of CrossCultural P s y c h i a t r i c Services H. Steven Moffic, M.D. J. David Kinzie, M.D. A B S T R A C T : With c u l t u r a l i s s u e s p r o m i n e n t in t h e United S t a t e s today a n d w i t h ongoing r a p i d changes in h e a l t h care m a n a g e m e n t a n d delivery, this p a p e r discusses the shift from a generic-type p s y c h i a t r y (i.e., a s s u m i n g t h a t h u m a n s the world over a r e no different, a n d will r e a c t to given s t r e s s o r s in life in the s a m e m a n n e r ) to one recognizing t h a t c u l t u r a l beliefs, mores, peer p r e s s u r e , family expectations, a n d o t h e r ing r e d i e n t s operate in unique combinations in various cultures a n d ethnic groups. These social a n d c u l t u r a l factors can a n d will i m p a c t t r e a t m e n t modalities a n d outcomes. Lite r a t u r e reviewed h e r e i n i l l u s t r a t e s the progressive stages of a w a r e n e s s a n d incorpor a t i o n of cultural differences a n d the m a n y w a y s they i m p a c t t r e a t m e n t . Unfortunately, the rise in m a n a g e d , r a t i o n e d h e a l t h care t h r e a t e n s t h e f u t u r e of this progression: It is e s s e n t i a l t h a t c u l t u r a l l y - b a s e d m a n a g e d care p r o g r a m s be developed a n d funded to e n s u r e the a v a i l a b i l i t y of cost-effective t r e a t m e n t , t h r o u g h a n integ r a t e d s y s t e m of services, to p a t i e n t s of all c u l t u r a l and economic b a c k g r o u n d s . Appropriately incorporating patients' cultural background has rapidly become one of the most challenging tasks for psychiatry in the United States. Though the definition of "cultural psychiatry" is difficult to agree upon (Moffic, Kendrick, Lomax, and Reid, 1987), it might more accurately refer to the consideration of the individual's cultural background, as well as that of the clinician; just as there is no generic patient, there is no generic psychiatrist. This introduces two highly variable factors into psychiatric encounters. H. Steven Moffic, M.D., is Professor and Director of Development, Department of Psychiatry, Medical College of Wisconsin, Milwaukee, Wisconsin. J. David Kinzie, M.D., is Professor of Psychiatry and Director of Clinical Services, Oregon Health Sciences University, Portland, Oregon. Address correspondence to H. Steven Moffic, M.D., Medical College of Wisconsin, Mental Health Clinic at Curative, 1000 North 92nd Street, Milwaukee, Wisconsin 53226. 581 © 1996 Human Sciences Press, Inc. 582 C o m m u n i t y Mental Health J o u r n a l Culture here refers to shared group values developed and preserved over time, often over generations. Understanding the special needs and factors specific to a given culture will allow us one day soon to translate this to a wide variety of groups with factors in common, such as ethnic minorities, religions, gender, individuals in the public eye, women, the poor, the elderly, the deaf, people with specific disabilities, etc. (Moffic and Adams, 1983). Cultural variables play significant roles, whether patients and clinicians are from the same or similar backgrounds and belief systems, or when widely divergent both culturally and philosophically. HISTORICAL REVIEW In a simplified historical sense cultural factors in clinical services can be traced through several rough, overlapping phases. These phases do emphasize and enlarge upon a particular theme of increasing awareness of services to those of different cultures and ethnic groups. Phase One, Recognition of Differences The first phase involved treatment focused on "foreigners" and patients who clearly seemed "different" culturally. Observation of people whose lives have been touched or shattered by war has been of great interest to clinicians for decades and has brought major new understanding and advances to the field of psychiatry. Benton, in 1921, commented on World War I veterans, describing a particular "war neurosis" as follows: This particular condition occurs among foreigners, especially Italians, Greeks, Austrians, and Poles. One of the fundamentals of the condition seems to arise from a general belief that the United States is a wealthy country and that the government is due and destined to provide for them for the rest of their l i v e s . . . They do not show pathologies in the usual sense of the word, but their attitude is so persistent and usually so persistently free from somatic factors that I facetiously refer to these people as suffering "Italianitis." (Benton, 1921). Attempts thereafter became somewhat more objective in describing patients "different" from Caucasian patients. Negroes (as they were called in the early literature) were found to have a "higher hospital admission rate," although the author does not elaborate (Shermerhorn, 1956). Later studies of hospitalization rates showed that, although Japanese- and Chinese-Americans had lower admission rates, they H. Steven Moffic, M.D. a n d J. D a v i d Kinzie, M.D. 583 tended to remain inpatients longer. Awareness began that cultural diversity posed challenges in traditional outpatient psychoanalysis for Negroes (Kennedy, 1952), and that difficulties were encountered in cross-cultural psychotherapy in general (Abel, 1956). For the first time there was awareness that social issues could influence the apparent psychotic symptoms of Black Americans (Brady, 1961). Phase Two, Treatment Variations Phase two was characterized by a growing perception that Caucasians tended to access psychiatric services more frequently than those from other cultures, despite conveniently located community mental health centers t h a t began springing up in the 1960's and 1970's. Although their stated goal was to provide improved outreach services to minorities, a variety of studies exposed the fact that minority and refugee patients were actually accepted for treatment less frequently, received less psychotherapy, had a higher dropout rate, and had poorer outcomes than did Caucasians (Karno, 1966; Sue et al, 1974; Westermeyer et al, 1983). Later studies discerned a slight increase in clinic usage by members of minorities proportional to the increase in minorities employed by the facility (Wu and Windle, 1980). Phase Three, Treatment Changes Triggered by the evident disparities between services available to Caucasians and minorities, the third phase emphasized a change in psychiatrists' approach to meeting patients' needs to the degree that they were impacted by cultural factors. Apparently, the first mention of these changes was by Bolman (1968), in an examination of cross-cultural psychotherapy. A sophisticated model for delivery of services for Spanish-speaking minorities was reported by Abad, Ramos, and Boyce in 1974, who advocated use of bilingual staff, walk-in clinics, education and preventive programs, collaboration with faith healers, and seeking involvement of local political and religious leaders. During the 1970's and 1980's the Indian Mental Health Service first attempted to develop a policy integrating traditional and western healing (Meketon, 1983). When Indochinese refugees flocked to the United States after the fall of Saigon in 1975, a large proportion were found to have psychiatric disorders. This prompted the establishment of specialty clinics devoted to providing culturally sensitive treatment (Kinzie and Manson, 1983; Westermeyer, 1985; Mollica and Lavelle, 1988). 584 C o m m u n i t y Mental Health Journal Phase Four, Cultural Biology Previous efforts had focused on psychotherapy. Phase four saw psychiatry's recognition, at last, that in addition to having cultural and psychologic differences, patients also have different biological responses. Drug response varies between ethnic groups due to differing m e a n capacity in drug metabolism or different frequency of this capacity by the occurrence of genetic enzyme variants (Kalow, 1982). Differences in alcohol-metabolizing enzyme between ethnic groups have been documented recently, as have differences in the metabolism of tricyclic antidepressants, benzodiazepines, and haloperidol (Lin, Poland, and Kakasaki, 1993). Clinical application of this new information is not only heuristic but it is clear also that our clinical treatment must be very sensitive to these culturally diverse responses. Also complicating matters is the tendency of some cultural groups to express distress through physical symptoms; i.e., somatization. This characteristic may present an impediment to insight-oriented psychotherapy (Kirmayer, 1989). Noncompliance frequently frustrates clinicians but may be due to cultural stigmas about psychiatric treatment or may be due to denial, as well. Newer Directions New directions have been forged in recent years. Many community mental health clinics developed for refugees and other cultural groups have expanded their services and now also provide health maintenance and physical diagnosis. Victims of trauma and h u m a n rights violations now receive more attention (Motlica, Wyshak, and Lavelle, 1987). Ethical issues involving cro~s-transference when treating traumatized patients have come under scrutiny (Kinzie and Boehnlein, 1993). Social networking and rehabilitation services for minorities are much more available today (Kinzie et al., 1988); appropriate cultural diversity in clinic staff can aid patients with very fragmented families and a destroyed social network by providing a place that is less intimidating culturally due to its mix of individuals. Psychiatry has increasingly focused on culturally-related personal and family issues. These have demanded urgent consideration, since the longer refugees live in the United States the more pressing family and generational problems become, especially as the new culture is embraced by younger members of the family and conflict develops over this, with older family members clinging to the culture they left behind. Parental education is both supportive and effective, especially in H. S t e v e n Moffic, M.D. a n d J . David Kinzie, M.D. 585 encouraging acceptance of the new culture while maintaining their own values, and setting appropriate limits for their children. The very essence of cultural psychiatry is broadening so that now other groups besides ethnic minorities and refugees receive services specifically tailored to the needs of a group with similar characteristics, as mentioned previously in this paper. The Present Much progress since the beginning of this century can be seen in availability of cross-cultural clinical services. Several programs have achieved national recognition, including the Indochinese Psychiatric Program in Portland, the Indian Health Service, the Ethnic-Minority Psychiatry Inpatient Program in San Francisco, and the Indochinese Psychiatric Program in Boston. Many books have explored this subject, and cultural diagnostic delineations have been added to DSM-IV. Research, in part stimulated by the Society for the Study of Psychiatry and Culture, has expanded from the study of cultures outside of the U.S.A. to also include those within the U.S.A. There are now also model programs for the education of psychiatrists and other future clinicians, which emphasize a broad view of culture and the cultural identity of the clinician (Moffic et al, 1987). As breakthroughs in knowledge and understanding of cultural variations have been made and applied to clinical treatment, the key elements in treatment of the culturally different have been established (Kinzie, 1989). Especially important are the following: 1. Programs need to address the major psychiatric disorders: schizophrenia, substance abuse, depression (often severe and recurrent), PTSD, etc. 2. A well-trained, bilingual mental health staff is essential. Difficulties in communication will sabotage all efforts at treatment; encourages a high treatment dropout rate; and obviously increases stressors such as frustration, feeling isolated and alone, not- or misunderstood, and lost in an unfamiliar and intimidating culture; yet frequently this key element is sadly deficient or lacking at many clinics serving minorities. 3. The program must focus its services on patients' needs rather than on the special interests of providers. Areas to address include the patient's expectations of treatment, symptom reduction, cultural implications of being treated for a "mental" condition, etc. 586 C o m m u n i t y Mental Health Journal 4. The program must identify and possibly treat both physical and mental ills. Many patients have a tendency to express social and intrapsychic stress through body language (somatization). By having a single clinic, patients with somatic symptoms are not forced to be referred elsewhere to a "mental health" clinic, and thus stigmatization can be reduced and genuine physical disorders can be recognized. 5. The program or clinic must be physically accessible to the largest possible number of the minority patients, and they must feel comfortable and accepted--not singled out as special or different. 6. The most successful programs have excellent reputations among their patients' social networks, and this method of reference and referral encourages more individuals to enter treatment. 7. Outpatient, inpatient, emergency, rehabilitation, and social services must interact "seamlessly," if at all possible, so that all services required for a particular patient are easily accessed. 8. Feedback from the population served is critical to targeting additional needs and measuring patients' and their families' perceptions of the program's usefulness. A patient advisory board can be very effective. Major obstacles to effective application of what we have learned remain (Gong-Guy, Cravens, and Patterson, 1991). Impediments to smooth delivery of services include fragmentation, frequent changes in staff, language barriers, inappropriate use of interpreters and paraprofessionals, and culturally inappropriate treatment measures. Unfortunately, there are too many examples of this. Rating scales supposedly culturally tailored can be overused or used without input from trained clinicians. Many programs select psychiatrists and clinicians who "look like" they're from the same culture or who actually are from the same ethnic group as the major criteria, erroneously assuming that cultural differences are insurmountable and that patients will not feel confident with a psychiatrist from a different background. A psychiatrist from the refugees' "new" culture may provide the first real connection to anyone--or anything--in the new culture, and become the bridge that eases their transition. Matching culture of physician and patient can be overemphasized, and mistakenly confused with diagnosis and treatment (i.e., "they're alike; therefore they will bond and treatment will be successful"). Without a psychiatric evaluation even the most bizarre behavior can be dismissed as a cultural difference, such as a Vietnamese patient urinating on the floor of a hospital, or a H. Steven Moffic, M.D. and J. D a v i d Kinzie, M.D. 587 Cambodian patient acting rather strangely and given family therapy instead of being diagnosed as schizophrenic and given medication. Emphasis on cultural diversity and sensitivity in the United States has provided many economic opportunities for indigenous healing and paraprofessional services and yet, sadly, may not necessarily help those in need. Accrediting bodies are sorely needed to evaluate organizations serving minority groups. THE FUTURE Certainly, the aforementioned incentives to provide more culturally appropriate services will continue. Two trends have emerged that are certain to affect the future delivery of these services. The first trend involves the cultural diversity occurring within the United States. The second trend pertains to health care specifically. Cultural Diversity Exploding cultural diversity in the United States makes it imperative that we provide culturally appropriate services to groups traumatized severely in their native countries and thrust into a foreign culture difficult to comprehend and converse in. Similarly, groups with special needs mentioned previously (i.e., disabled, elderly, women, etc.) must be able to receive sensitive, and not generic, psychiatric and support services. Despite gains made in civil rights in the last 25 years the United States clearly is a country with a significant degree of cultural conflict remaining. A less privileged class, characterized by poverty, drugs, violence, crime, and single parent families, is growing in size at an alarming rate; this is especially true among black Americans. Each year over 1 million immigrants, both legally and illegally, cross our borders to live, in a wave not seen since the early 1900's. Economic stability of border states, in particular, is being strained severely, and increasing demand for publicly-funded social and health services exceeds what we are able to provide. The higher birth rate in immigrant and minority families is triggering even greater diversity. The influx of women in the work force and in politics has brought about great change, as have accommodations for the disabled (due in part to growing public awareness s well as being legislated by the Americans with Disabilities Act), and recognition of the growing elderly population's special needs. 588 C o m m u n i t y Mental Health Journal Managed Care Managed and rationed health care is the second trend that will affect the future of clinical services. Administrative decisions determine who will receive treatment, how much they may receive and how often, and accomplish this by internal review of medical records without ever seeing the patient. In this way they attempt to objectively determine the most cost-effective and "medically necessary" treatment required while keeping costs to a minimum. Unfortunately, many people slip through this impersonal sieve and receive far less, or none, of the health care services they desperately need. Managed care's effects on cultural psychiatry are just beginning to be felt, but the glimpse of the future this provides us is grim. Who is receiving treatment is an important question. Though managed care initially involved only the private sector it now is applied to the public sector where most ethnic minorities and the poor are served. Instead of the community mental health centers of the 1970's and 1980's whose target was culturally-based populations we now see the major share of health care dollars funneled to populations covered by insurance groups and capitated contracts. What is being provided is also undergoing change. Managed care in effect dictates--and authorizes payment for---only what is "medically necessary" (i.e., the minimum standard treatment for covered DSM-IV psychiatric disorder). The former two-tiered system of psychiatric care is being leveled. Although the poor and minorities are starting to receive care previously reserved for the middle class, the quality and level of care that many receive is actually little better than before. One positive aspect of managed care involves a peculiar synergy with cultural psychiatry in targeting prevention. Community mental health centers over several decades had emphasized prevention but as financial constraints restricted their efforts more and more this was virtually eliminated. Today's capitated managed care now rewards systems--and sometimes physicians--for keeping patients healthy (Freeman, 1994). Many cultural problems in the United States, including immigrant culture shock, inner city violence, drug abuse, and the roles of women and the aged in society, have mental health and financial ramifications that leave us little alternative but to attempt prevention. Using violence as an example, traditional public health principles of surveillance, intervention, and evaluation may be effective (Moran, 1994). Interventions could include culturally-based educational efforts aimed at conflict resolution, mentoring programs for H. Steven Moffic, M.D. and J. David Kinzie, M.D. 589 children and adults at risk, addressing child abuse in the home, and limiting access to firearms. Another example of early intervention involves assisting homosexual men to develop self-esteem. Paternal involvement and support has resulted in men more capable of having healthy relationships (Geoffrey, 1994). Partly through input from the Task Force Advisors on Cross-Cultural Issues, DSM-IV now emphasizes the cultural component in psychiatric diagnosis for the first time. Each diagnostic category has a section titled "Specific Culture, Age, and Gender Features," and there is an appendix that presents an "Outline for Cultural Formulation" and a "Glossary of Culture-Bound Syndromes." If these features are used there may be less under-diagnosis of depression in certain minority groups, less over-diagnosis of paranoid schizophrenia in certain groups, and better familiarity with normal cross-cultural personality characteristics. It seems likely that the American Psychiatric Association's guidelines will follow DSM-IV's example in the future and incorporate cultural variables in treatment, especially in the areas of psychopharmacology and psychotherapy. Many questions still remain about ethnic variances in drug response (Lin, 1993), along with how to apply this clinically. In the near future psychotherapy will probably follow an integrative mode and address the everyday realities of these groups, including racism, oppression, sexual harassment, aging, and identity conflicts (Comas-Diaz, 1992). This integrative model will include culturally-specific techniques adapted in part from those used internationally and fitting current financial constraints. Past emphasis has been on individual, long-term psychotherapy and has virtually ignored the balance between relationships, spirituality, and transition phases in an individual's life, and has not considered non-verbal and physical components. Ironically, the integrative model would benefit the patient greatly and also cut the cost of treatment dramatically since only brief or intermittent therapy would likely be required through the course of a patient's life. That is, by addressing all aspects of the patient's life, key factors and issues in all probability would be dealt with rather than leaving major unresolved issues to compound the presenting problem. A creative form of group therapy might involve the participation of parents, siblings, children, or grandparents who can then provide additional insights, observations, and support. Family structure and dynamics would be observable to the psychiatrist, allowing more rapid discovery and resolution of underlying issues. In effect, this allows the 590 C o m m u n i t y Mental Health Journal psychiatrist to see the patient in three dimensions, rather than only the one or two dimensions seen with traditional psychotherapy. The more information available, the more accurate the diagnosis and the more effective the treatment. The integrative model also provides a unique educational opportunity for clinicians to learn about cultural identities, beliefs, and backgrounds. Managed care is also influencing the whom; clinicians and providers. Some community cultural healers may still be used and emphasized, both for their effectiveness with certain problems as well as their low cost to the managed care company. The future of professional providers is unclear. On the one hand, minority clinicians are feeling more and more excluded and discriminated against by managed care (Price, 1994). On the other hand, some companies are looking for minority experts well-qualified to empathize and treat ethnic minorities and other special groups such as fundamentalist Christians, homosexuals etc. (Markowitz, 1994). Where treatment will be provided is also headed for change, and perhaps will benefit cross-cultural psychiatry. With continuous efforts to reduce treatment costs and hospitalizations, in-home crisis care is increasing. Other "community" (more available) sites include the family practitioner's office, schools, the criminal justice system, and the workplace. Community screening and awareness days for various maladies will in all probability continue to increase as focus shifts even more to prevention and early diagnosis. The culturally competent clinician must possess finely-honed skills and attitudes in order to incorporate the changes managed care will continue to produce. The cross-cultural clinician needs to: 1. Examine the variety and complexity of his or her own cultural identity in order to understand how this affects his or her reactions to patients. 2. Be aware that in every patient there is some sort of cultural identity. This should be evaluated as part of the initial assessment of the patient. 3. Be a participant-observer in helping the patient ascertain his or her cultural identity and the meaning this holds to him or her. Perception of what is normal for that particular culture should be considered, and family input should be sought. 4. Assess the "cultural fit" of patient and clinician including language and prejudice and referral made, where necessary, for a better fit. H. S t e v e n Moffic, M.D. a n d J. David Kinzie, M.D. 591 5. Consider the cumulative effects on the patient's psychological processes of such cultural components as ethnicity, gender, age, and sexual orientation. 6. Adapt treatment techniques to the specific cultural values held by the patient. 7. Understand the broader societal, socioeconomic, and political factors impacting the status and development of culturally diverse groups. 8. Actively advocate for institutional policies and practices designed to make patients from diverse cultural groups feel comfortable. Some of these skills and attitudes could be monitored by managed care in QA and QI processes. For example, evaluations of every patient could be monitored to be sure that the cultural identity of the patient was delineated and discussed. CONCLUSIONS Review of culturally-sensitive psychiatric services indicates that the pendulum has swung from virtual neglect of patients from different cultures and their special needs to the point we are at today, with some model clinical programs targeting specific populations being designed and implemented. An encouraging sign is that the impact culture has on patients has permeated the consciousness of most clinicians, especially as medical schools place greater emphasis on producing physicians with strong humanistic qualities. However, continued movement in the current direction is sorely needed. As cultural diversity continues to increase in the United States, unique opportunities and dangers present themselves as psychiatry strives to incorporate culturally sensitive and specific treatment into managed care systems' awareness and policies. 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