Cultural Competence in Clinical Psychiatry

Increasingly, clinicians are working in multiethnic, multicultural settings, providing care for patients of diverse backgrounds. As Dr. Tseng and Dr. Streltzer point out in this book, clinicians need to be culturally competent to be clinically competent. The editors’ primary intention is to foster cultural competence by addressing theoretical and conceptual issues but with an emphasis on clinical applications. The unique aspect of this book is the examination of cultural issues as applied to the practice of subfields of psychiatry rather than an analysis organized by different ethnic groups. The result is an insightful, scholarly work written by academic psychiatrists with a wealth of clinical experience in treating patients from different ethnic groups.

An introductory chapter presents general issues associated with cultural competence in assessing and treating patients. Subsequent chapters address how cultural factors may be considered when providing culturally competent psychiatric care in different clinical settings (inpatient, outpatient, emergency, and consultation-liaison), across subspecialties (child/adolescent, geriatric, addiction, and forensic), and using different modes of psychiatric care (pharmacotherapy and psychotherapy). This approach lends itself to use by busy psychiatric practitioners by allowing them to focus on their areas of greatest interest. Moreover, the authors’ clarity and minimal technical language invite allied mental health professionals as an additional audience.

The book’s conceptual framework is anchored to the cultural formulation provided in DSM-IV-TR, which, in turn, borrows heavily from anthropology. A unifying theme throughout the book is the authors’ contention that in the medical setting three cultures are present: the culture of the patient, the culture of the physician, and the culture of the medical setting itself. The dynamic interplay of these cultural perspectives is discussed in each chapter, with relevant case vignettes provided to illustrate the main points and suggestions for clinical practice listed at the end of each chapter. Two contributions that stand out as excellent reviews of their respective topics are Joseph Westermeyer’s chapter on culture and addiction psychiatry and Keh-Ming Lin’s chapter on culture and drug therapy.

Although this book is both practical and innovative, a few limitations should be noted. For instance, despite its stated aim not to examine different ethnic groups, the preponderance of case vignettes are drawn from the Asian population (probably because all but two of the 13 contributors are based at the University of Hawaii School of Medicine or are of Asian heritage), leaving the reader uncertain as to whether the principles and issues discussed really do generalize across groups. In addition, a general definition of culture is used by the authors as a framework within which to assess the different ethnic-racial cultural groups. This might not be sufficient for practitioners working in urban areas who are treating members of diverse ethnic groups exhibiting different stages of acculturation and assimilation, often occurring within one couple or family. In some cases, culture may mask an underlying pathology, and, conversely, psychopathology at times may mask cultural issues. In still other cases, such as a depressed-appearing man who is actually suffering from tuberculosis, the cultural and psychopathological issues may not play a central role.

Finally, in the authors’ discussion of the three cultures that should be incorporated into the case formulation, the authors omitted a key cultural component; namely, DSM-IV-TR. In the continued absence of vastly underrepresented members of ethnic-racial groups in evaluations of assessment instruments, diagnostic tools, and clinical trials, great caution needs to be exercised in applying DSM-IV-TR criteria to the diverse patient populations addressed in this book.