Dr. Trujillo is professor of psychiatry and director of the Program for Public and Global Psychiatry at New York University School of Medicine in New York City.

Disclosures: Dr. Trujillo reports no affiliation with or financial interest in any organization that may pose a conflict of interest.
Please direct all correspondence to: Manuel Trujillo, MD, Professor of Psychiatry & Vice-Chair, Public & Global Psychiatry, Department of Psychiatry, NYU School of Medicine, 462 First Avenue, Room A648, New York, NY 10016; Tel: 212-263-6220; Fax: 212-263-8097; E-mail: manuel.trujillo@nyumc.org; Website: www.med.nyu.edu/people/M.Trujillo.html.

 


 

Focus Points

• The reduction of health disparities has become a national priority for health and mental health.
• A growing body of knowledge will help clinicians guide the treatment of minorities.
• This body of knowledge encompasses and can serve as a guide to assessment and diagnosis as well as medical, psychiatric, and psychosocial treatments.

 

Abstract

Health disparities, defined as population-specific differences in the prevalence, onset, severity of disease, and differential access to health care, is a rising issue in the mental healthcare debate. The populations most seriously affected by adverse health disparities include protected minorities who often seek and receive care through language and cultural barriers. This article discusses a body of knowledge, skills, and attitudes which can help clinicians bridge the care gaps created by such barriers. The article highlights means to overcome these barriers while performing diagnostic interviews, completing mental status examinations, and selecting and implementing pharmacologic and psychosocial treatments.

 

Introduction

Psychiatrists currently practicing in the United States and in many other countries around the world will undoubtedly have the opportunity to treat many patients belonging to ethnic and cultural groups different than their own. Such is the nature and magnitude of population changes since the end of World War II, which has accelerated through globalization in the last 2 decades. Though such changes will ultimately enrich the practice of psychiatry and its scientific knowledge base, it will, for many transitional years, present significant challenges to the practicing clinician, systems of care and training, and policy makers. Many such patients will have limited command of the English language and will probably hold beliefs about illness and health at some variance from the standard biomedical model that supported the psychiatrist’s training and that has evolved in the US and other Western countries over the last century. Fortunately for the practicing psychiatrist, patients in their care, and healthcare systems that support their work, the growing discipline of cultural psychiatry is developing a substantive and increasingly sophisticated body of knowledge that will enhance the psychiatrist’s capacity to provide quality care across language and cultural barriers. As this knowledge base is mastered, the contemporary psychiatrist will be equipped with the attitudes, basic knowledge, clinical skills, and professional attitude necessary. In confronting the clinical task of providing psychiatric treatment to patients from different cultural groups, psychiatrists have a decisive advantage; namely, their familiarity with Engel’s biopsychosocial model,1 which has long facilitated our understanding of the complex interactions that link our biologic systems to the contents of our minds and to the social environment in which we become unique individuals.

In the context of a well-constructed biopsychosocial formulation, it is relatively easy to understand cultural adscription and identity as a significant specifier of our social context. Enriched with the insights provided by cultural psychiatry, the biopsychosocial model can easily become a biopsycho-sociocultural model. The ultimate end of this process is the construction of a science of the person, culture being a very meaningful frame through which personhood emerges and expresses itself. The end result of acquiring relevant cultural knowledge will be, for the psychiatrist, an enhanced ability to provide culturally competent care, which is an increasingly common requirement of professional societies, regulatory agencies, and licensing and accrediting organizations.

 

Cultural Psychiatry

Before moving on to more clinical grounds, a few basic definitions are in order. Cultural psychiatry is defined as the discipline within psychiatry that studies the numerous interrelationships between culture and psychiatry. As such, it aims to understand variations of the incidence, prevalence, clinical expression, course, and/or outcome of common psychiatric disorders as they appear in different societies and ethnic or cultural groups. The value of such understanding includes the promotion of diagnostic and prognostic accuracy, the development of culturally syntonic interventions, and the achievement of a therapeutic partnership where the patient feels understood and supported. The American Psychiatric Association (APA) has recognized the importance of culture by addressing cultural variations in the text description of most of the major psychiatric disorders listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV),2 and by providing guidance to the development of cultural formulations.

A second aim of cultural psychiatry includes the careful description and tracking of patterns of symptoms and behaviors which, first, do not conform to the syndromes described so far in the DSM-IV-TR3 or the International Classification of Diseases, Tenth Edition (ICD-10),4 and second, are closely associated with certain cultural and/or ethnic groups including their belief systems and “idioms of distress.” These syndromes are commonly known as culture-specific or culture-bound syndromes and are recognized and listed in the DSM-IV.

A third aim of cultural psychiatry includes the elucidation and delineation of the pathways that transform culturally derived or mediated stresses into symptoms, syndromes, and adaptive or maladaptive behaviors. This is an area in need of much research if we are to understand basic clinical facts such as the gross variation in incidence and prevalence of major psychiatric disorders observed as a function of a given population ethnic origin, migratory status, and/or acculturation pressures.

 

Culture, Race, and Ethnicity

The diverse origin and confused utilization of these constructs have represented a significant obstacle to progress in the fields of cultural psychiatry and psychology.

Race typically denotes the description of individuals through compelling (but of questionable biologic significance) phenotypic features such as skin color, hair texture, and a few facial features. Some biomedical scientists have argued for the validity of such racial classifications to understand population’s variance in the prevalence of traits such as sickle cell anemia. However, even in such cases, the correlation between trait and race is far from perfect, since sickle cell anemia traits distribute not only among African blacks but also among other Mediterranean and Middle Eastern people. However limited the true biologic value of the construct of race, its social use has had (and unfortunately still has) devastating personal and group consequences through the attitudes and institutions of racism. The construct of ethnicity, a term much preferred by social scientists and anthropologists, may be of more value to psychiatrists since it denotes groups of individuals sharing a sense of common identity, a common ancestry, and shared beliefs and history. Thus, the construct ethnicity, a major contributor to the person’s cultural identity, is an internalized self-definition resulting for the person’s selective incorporation of values, beliefs, foundation myths, and customs from among those available in that person’s human ecology.

Such cultural identity holds great meaning to the person and needs to be ascertained in the clinical interview if the clinician is to develop a sound cultural formulation of their patient’s presenting complaints. Key dimensions of cultural identity include race, gender, language, sexual orientation, ethnic adscription, and religious and spiritual beliefs.

The term “culture” is as key a concept for psychiatry and psychology as it is difficult to define. As defined by the noted British anthropologist Sir Edward Tylor in 1871,5 culture is “the complex whole which includes knowledge, beliefs and morals and other capabilities and habits acquired by man as a member of society.”

For clinical purposes, the definition provided by the National Institute of Mental Health’s Culture and Diagnosis Group may be the most comprehensive and descriptive:

 

Culture refers to meanings, values and behavioral norms that are learned and transmitted in the dominant society and within its social groups. Culture powerfully influences cognition, feelings, and self-concept as well as the diagnostic process and treatment decisions.6

Culture is thus best conceptualized as a totality, composed of a complex system of symbols possessing subjective dimensions represented by values, feelings, and ideals, as well as objective dimensions expressed in the form of beliefs, traditions, and behavioral prescriptions, some of which may be articulated into rituals and codified as laws. This unique capacity of culture to bind the objective world of perceived reality to the subjective world of the personal and intimate lends it its powerful role as expressor, mediator, and moderator of psychological processes and, ultimately, emotional well being or disorder.

 

Through little known mechanisms, culture influences cognitions, feelings, emotional conflicts, self-concept, and the underlying brain functions that control mood and behavior. Culture also represents a normative framework that defines normality and deviance, thus promoting certain behaviors while suppressing others. This process may set the stage for psychological stress and intrapsychic conflict.

It is important to emphasize the great diversity and heterogeneity of each ethnic group. The labels African American, Asian, Hispanic, and Native American, among others, are super-ordinate constructs that hide more than reveal a tremendous diversity of racial features, historic legacies, belief systems, behavioral traits, and the like. As such, clinicians should use these generalized labels as a step in the road to understanding the unique individual that becomes their client. Beyond such provisional labels one must inquire the specific parameters of racial background, native language, religious coordinates, and socioeconomic conditions that define the specific and unique person.

 

Culture and Clinical Psychiatry

The relationship between culture and clinical psychiatry can certainly be studied through three vantage points. First, the presence of health disparities. Second, the clinical encounter across the language and cultural barrier. Last, the presence of culture-bound syndromes.

 

Health Disparities

Health disparities represent a clearly visible effect of cultural and linguistic minority status and are generally defined as population specific differences in domains of health such as incidence of illness, access to care, or outcomes of care.

In the US, health disparities are well documented in minority populations such as African Americans, Asians Americans, Native Americans, and Hispanics. Though much additional research is needed, health disparities can be causally related to barriers to prompt access to care of adequate quality; problems in providing such care across the language, culture, and health beliefs divide; and the compounding health effect of poverty and its attendant adverse environmental conditions.

The most common barriers to care affecting the presence of health disparities include lack of health insurance (or underinsurance), stigma, consumer’s unawareness of the availability or underappreciation of the efficacy of treatment, and health providers’ lack of awareness of the availability of culturally syntonic treatments.

The impact of the linguistic barriers in the clinical encounter needs to be highlighted. In so far as oral communication is the main vehicle for the transmission of mental health information, clinicians need to make significant efforts to compensate for its relative absence when examining and treating monolingual patients (or limited bilinguals) who speak a language different than their own. Language is the key for the patient’s symbolic universe; it determines which words access what emotions and, in bilinguals, which language serves to enhance communication and emotional contact with the therapist and which language can be used as a defense.

When compensating for a linguistic barrier through translation and interpretations, the clinician is best served by some skepticism. A clinician should ask a question several times and from different angles so that the composite picture has additional chances to approximate the clinical reality.

The Surgeon General Culture Race and Ethnicity supplement to the Mental Health Report7 highlights recognized minority health disparities. Tables 1–4 aggregate and summarize minorities’ clinical and health behavior observations for underrepresented groups in the US who experience documented health disparities.

 

 

 

 

 

 

 

Culture and Psychiatric Diagnosis

Cumulative cross-cultural research can help the clinician arrive at a comprehensive diagnosis of patients evaluated across the language and cultural barriers. Such patients could in theory present three different diagnostic pictures. First, the patient may suffer an episode of illness easily clarifiable as a typical DSM-IV-TR syndrome. Alternatively, the patient may present with a syndrome with specific cultural features which warrant special evaluative care. In this regard, the DSM-IV-TR  discusses cultural features for most major diagnoses. Last, the patient meets the description of one (or more) of the culture-bound syndromes reported in the literature, congruent with the patients’ culturally mediated idioms of distress.

 

Cultural Features of Major Psychiatric Diagnosis

Schizophrenia
The diagnosis of schizophrenia depends on the significant presence over a 1-month period of two out of five of the following symptoms: delusions, hallucinations, disorganized speech, disorganized behavior and negative symptoms, and social dysfunction. Social dysfunction is further defined as a significant erosion of work, interpersonal roles or self-care below the level of achievement prior to the onset of illness. All these criteria are subject to attained distortion through the cultural lens. In some cultures (eg, Mediterranean and Hispanic) visual or auditory hallucinations of religious objects, persons, or theme, may be a component of certain religious experiences or may appear as part of other disorders such as dissociative phenomena or psychomotor epilepsy. Some care should be exercised while diagnosing delusional ideas. The boundaries between ideas, overvalued ideas, beliefs, and delusions are also heavily mediated by culture, especially around issues such as demonic possession and paranormal influences (hexing, sorcery, witchcraft) in general.

The criterion “disorganized speech” is extremely difficult to assess in a monolingual patient by a clinician who is unfamiliar with the patient’s language. The articulation of language, sentence structure, and the logical order and focus of speech are also mediated by culture, educational level, and by perceived power differential between speakers.

The evaluation of affect (another key criterion for a schizophrenia diagnosis) is also complex, especially as it pertains to evaluating its congruence with mental content that is produced in a language that the clinician may not understand. Intensity and range of affect are also heavily mediated by culture and by the authority differentials in the therapeutic relationship. Finally, the evaluation of dysfunction has to be adjusted to the norm which constitutes the patient’s adaptive ecology, since “functioning” is heavily shaped by expectations derived from culture and dependent on socioeconomic status.

Depression
In the case of depression, culture can influence the prevalence rates, subjective experience of depression, and preferred channel for the expression of emotions. In some cultures (and socioeconomic conditions) depression may be communicated to the clinician in somatic terms such as fatigue, anergia, headaches, and malaise (“malestar” for some Hispanic populations). Symptoms such as sadness, guilt, and other psychological representations of the depressive experience may not be reported spontaneously during the clinical interview, and its elicitation may need a more active inquiry from the clinician than is the norm when interviewing patients from their own ethnic group.

Anxiety
The experience of anxiety may also be culturally mediated. As in the case of depression, the somatic expression (palpitations, tachycardia, fainting sensations) is emphasized in many cultures over the psychic content. The situational triggers for some episodes of anxiety, including panic, are also often culturally mediated. The fear of being “hexed” or subjected to witchcraft or other forces with malevolent intent may reach to panic proportions.

 

Culture-Bound Syndromes

In evaluating a patient to establish a differential diagnosis for a possible culture-bound syndrome, the clinician should consider the following. First, reflect on the cultural assumptions under which the Western biomedical model of diagnosis and treatment operates. After all, the constructs of illness defined in the DSM-IV-TR and ICD-10 classifications systems represent a uniquely western amalgam of objective knowledge and culturally mediated ideas, as derived from repeated medical observations on patients acculturated to the “Western” medical and social explanatory framework. A dose of cultural humility is the optimum result of such reflection.

Second, as psychiatric disorders, whatever their biologic determinants, usually find expressions through ideas, beliefs, and behavior, all societies have found ways to separate the normal from the abnormal. They all devise rules to attribute causality and motivation to such behaviors. Each culture (and person for that matter) creates an “explanatory framework” for such behaviors which must be teased out during the clinical encounter since it represents a rich lode for therapeutic intervention.

Third, be alert to the presence of symptoms such as unusual forms of anxiety, apathy, and significant withdrawal; sudden outbursts of angry and difficult to explain aggressive behavior; bizarre and unconventional motor behaviors (such as trance-like taking off of clothes, thrashing about, shouting swearing); prominent dissociation; sleep problems with parasomnias; and many others.

Last, ask patients (and their families and other culturally aware informants) about their own and their cultural group’s explanations for those symptoms and behaviors, and assess their “fit” with known culture-bound syndromes.

The APA’s glossary lists3 and describes succinctly some of the best studied culture-bound syndromes and idioms of distress that may be encountered in clinical practice in North America.

Amok
A dissociative episode characterized by a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at people and objects. The episode tends to be precipitated by a perceived slight or insult and seems to be prevalent among men. The episode is often accompanied by persecutory ideas, automatism, amnesia, exhaustion, and return to a premorbid state after the episode. Some instances of amok may occur during a brief psychotic episode or constitute the onset or exacerbation of a chronic psychotic process. Severe bereavement and serious interpersonal results have been noted as precipitants.

Ataque de Nervios
Ataque de nervios is an idiom of distress that is principally reported among Latinos from the Caribbean but recognized among many Latin American and Latin Mediterranean groups. Commonly reported symptoms include uncontrollable shouting, attacks of crying, trembling, heat in the chest rising into the head, and verbal or physical aggression. Dissociative experiences, seizure-like or fainting episodes, and suicidal gestures are prominent in some attacks but absent in others. A general feature of an ataque de nervios is a sense of being out of control. Ataques de nervios frequently occur as a direct result of a stressful event relating to the family (eg, news of the death of a close relative, a separation or divorce from a spouse, conflicts with a spouse or children, witnessing an accident).

Boufée Délirante
Boufée Délirante is a syndrome observed in West Africa and Haiti. This French term refers to a sudden outburst of agitated and aggressive behavior, marked confusion, and psychomotor excitement. It may sometimes be accompanied by visual and auditory hallucinations or paranoid ideation. These episodes may resemble an episode of brief psychotic disorder and need careful differential diagnosis.

Brain Fag
Brain fag is a term initially used in West Africa to refer to a condition experienced by high school or university students in response to the challenges of schooling. Symptoms include difficulties in concentrating, remembering, and thinking. Students often state that their brains are fatigued. Additional somatic symptoms are usually centered around the head and neck and include pain, pressure or tightness, blurring of vision, heat, or burning. Brain tiredness or fatigue from too much thinking is an idiom of distress in many cultures and resulting syndromes can resemble certain anxiety, depression, and somatoform disorders.

Dhat
Dhat is a folk diagnostic term used in India to refer to severe anxiety and hypochrondriacal concerns associated with the discharge of semen, whitish discoloration of the urine, and feelings of weakness and exhaustion. It is similar to jiryan (India), sukra prameha (Sri Lanka) and shen-k’uei (China).

Falling Out or Blacking Out
Episodes of falling out or blacking out occur primarily in the southern US and in Caribbean groups. They are characterized by a sudden collapse, which sometimes occurs without warning but sometimes is preceded by feelings of dizziness. The individual’s eyes are usually open, but the person may claim an inability to see. The person usually hears and understands what is occurring around him or her but feels powerless to move. This may correspond to a diagnosis of conversion disorder or a dissociative disorder.

Ghost Sickness
A preoccupation with death and the deceased (sometimes associated with witchcraft) frequently observed among members of many American Indian tribes. Various symptoms can be attributed to ghost sickness, including bad dreams, weakness, feelings of danger, loss of appetite, fainting, dizziness, fear, anxiety, hallucinations, loss of consciousness, confusion, feelings of futility, and a sense of suffocation.

Hwa-Byung
Hwa-byung (also known as Wool-Hwa-Byung) is a Korean folk syndrome that is literally translated into English as anger syndrome and is attributed to the suppression of anger. The symptoms include insomnia, fatigue, panic, fear of impending death, dysphoric affect, indigestion, anorexia, dyspnea, palpitations, generalized aches and pains, and a feeling of a mass in the epigastrium.

Koro
Koro is a term, probably of Malaysian origin, that refers to an episode of sudden and intense anxiety that the penis (or, in women, the vulva and nipples) will recede into the body and possibly cause death. The syndrome is reported in south and East Asia, where it is known by a variety of local terms such as shook yong and suo yang (Chinese), jinjinia bemar (Assam), or rok-joo (Thailand). It is occasionally found in the West. Koro at times occurs in localized epidemic form in east Asian areas. This diagnosis is included in the Chinese Classification of Mental Disorders, Third Edition (CCMD-3).8 Subjective ideas of genital change may be more common in the general population and among other psychiatric disorders than generally realized.

The fact that genital retraction symptomatology has been reported in association with stimulant abuse (amphetamines) and heroin withdrawal, as well as in the context of epileptic confusional states, cerebral syphilis, brain tumors, and other alterations of brain physiology, should prompt physicians confronted with a complaint of genital retraction to carefully rule out the presence of organic pathology.

Latah
Latah is hypersensitivity to sudden fright, often with echopraxia, echolalia, command obedience, and dissociative or trance-like behavior. The term latah is of Malaysian or Indonesian origin, but the syndrome has been found in many parts of the world. Other terms for this condition are amurakh, irkunii, ikota, olan, myriachit, and menkeiti (Siberian groups); bah tschi, bahtsi, and baah-fi (Thailand); imu (Ainu, Sakhalin, Japan); and mali-mali and silok (Philippines). In Malaysia, it is more frequent in middle-aged women.

Locura
Locura is a term used by Latinos in the US and Latin America to refer to a severe form of chronic psychosis. The condition is attributed to an inherited vulnerability, the effect of multiple life difficulties, or a combination of both factors. Symptoms exhibited by people with locura include incoherence, agitation, auditory and visual hallucinations, inability to follow rules of social interaction, unpredictability, and possible violence.

Mal de Ojo
Mal de ojo is a concept widely found in Mediterranean cultures and elsewhere in the world. Mal de ojo is a Spanish phrase translated into English as evil eye. Children are especially at risk. Symptoms include fitful sleep, crying without apparent cause, diarrhea, vomiting, and fever in a child or infant. Sometimes adults (especially women) have the condition.

Nervios
Nervios if a common idiom of distress among Latinos in the US and Latin America. A number of other ethnic groups have related, although often somewhat distinctive, ideas of nerves (such as nervra among Greeks in North America). Nervios refers to a general state of vulnerability to stressful life experiences and to a syndrome brought on by difficult life circumstances. The term nervios includes a wide range of symptoms of emotional distress, somatic disturbance, and inability to function. Common symptoms include headaches and brain aches, irritability, stomach disturbances, sleep difficulties, nervousness, easy tearfulness, inability to concentrate, trembling, tingling sensations, and mareos (dizziness with occasional vertigo-like exacerbation). Nervios tends to be an ongoing problem, although variable in the degree of disability manifested. Nervios is a broad syndrome that spans the range from cases free of a mental disorder to presentations resembling adjustment, anxiety, depressive, dissociative, somatoform, or psychotic disorders. Differential diagnosis depends on the constellation of symptoms experienced, the kind of social events that are associated with the onset and progress of nervios, and the level of disability experienced.

Pibloktoq
Pibloktoq is an abrupt dissociative episode accompanied by extreme excitement of as long as 30 minutes’ duration and frequently followed by convulsive seizures and coma lasting as long as 12 hours. This is observed primarily in arctic and subarctic Eskimo communities, although regional variations in name exist. The individual may be withdrawn or mildly irritable for a period of hours or days before the attack and typically reports complete amnesia for the attack. During the attack, the individual may tear off his or her clothing, break furniture, shout obscenities, eat feces, flee from protective shelters, or perform other irrational or dangerous acts.

Qi-Gong Psychotic Reaction
Qi-Gong is a term describing an acute, time-limited episode characterized by dissociative, paranoid, or other psychotic or nonpsychotic symptoms that may occur after participation in the Chinese folk health-enhancing practice of qi-gong (meaning exercise of vital energy).

Rootwork
Rootwork is a set of cultural interpretations that ascribe illness to hexing, witchcraft, sorcery, or the evil influence of another person. Symptoms may include generalized anxiety and gastrointestinal complaints (eg, nausea, vomiting, diarrhea), weakness, dizziness, the fear of being poisoned, and, sometimes, the fear of being killed (voodoo death). Roots, spells, or hexes can be put or placed on other people, causing a variety of emotional and psychological problems. The hexed person may even fear death until the root has been taken off (eliminated), usually through the work of a root doctor (a healer in this tradition), who can be called on to bewitch an enemy. Rootwork is found in the southern US among African American and European American populations and in Caribbean societies. It is also known as mal puesto or brujeria in Latino societies.

Sangue Dormido (Sleeping Blood)
Sangue dormido is found among Portuguese Cape Verde Islanders (and immigrants from there to the US) and includes pain, numbness, tremor, paralysis, convulsions, stroke, blindness, heart attack, infection, and miscarriage.

Shenjing Shuairuo (Neurasthenia)
In China, shenjing shuairuo is a condition characterized by physical and mental fatigue, dizziness, headaches, other pains, concentration difficulties, sleep disturbance, and memory loss. Other symptoms include gastrointestinal problems, sexual dysfunction, irritability, excitability, and various signs suggesting disturbance of the autonomic nervous system. In many cases, the symptoms would meet the criteria for a DSM-IV-TR mood or anxiety disorder. This diagnosis is included in the CCMD-3.

Shen-K’uei (Taiwan); Shenkiu (China)
Shen-k’uei or shenkui is a Chinese folk label describing marked anxiety or panic symptoms with accompanying complaints for which no physical cause can be demonstrated. Symptoms include dizziness, backache, fatigability, general weakness, insomnia, frequent dreams, and complaints of sexual dysfunction (such as premature ejaculation and impotence). Symptoms are attributed to excessive, or passing of white, turbid urine believed to contain semen. Excessive semen loss is feared because of the belief that it represents the loss of one’s vital essence and can thereby be life threatening.

Shin-Byung
Shin-byung is a Korean folk label for a syndrome in which initial phrases are characterized by anxiety and somatic complaints (general weakness, dizziness, fear, anorexia, insomnia, and gastrointestinal problems), with subsequent dissociation and possession by ancestral spirits.

Spell
A spell is a trance state in which individuals communicate with deceased relatives or with spirits. At times, this state is associated with brief periods of personality change. This culture-specific syndrome is seen among African Americans and European Americans from the southern US. Spells are considered to be medical events in the folk tradition but may be misconstrued as psychotic episodes in clinical settings.

Susto (Fright or Soul Loss)
Susto is a folk illness prevalent among some Latinos in the US and among people in Mexico, Central America, and South America. Susto is also referred to as espanto, pasmo, tripo ida, perdida del alma, or chibih. Susto is an illness attributed to the experience of a frightening event that causes the soul to leave the body and results in unhappiness and sickness. Individuals with susto also experience significant strains in key social roles. Symptoms may appear any time from days to years after the fright is experienced. It is believed that, in extreme cases, susto may result in death. Typical symptoms include appetite disturbances, inadequate or excessive sleep, troubled sleep or dreams, a feeling of sadness, lack of motivation to do anything, and feelings of low self-worth or dirtiness. Somatic symptoms accompanying susto include muscle aches and pains, headache, stomachache, and diarrhea. Ritual healings are focused on calling the soul back to the body and cleansing the person to restore bodily and spiritual balance. Different experiences of susto may be related to major depressive disorder, posttraumatic stress disorder, and somatoform disorders. Similar etiologic beliefs and symptom configurations are found in many parts of the world.

Taijin Kyofusho
Taijin Kyofusho is a culturally distinctive phobia in Japan, in some ways resembling social phobia in the DSM-IV-TR. This syndrome refers to an individual’s intense fear that his or her body, its parts, or its functions displease, embarrass, or are offensive to other people in appearance, odor, facial expressions, or movements. This syndrome is included in the official Japanese diagnostic system for mental disorders.

Zar
Zar is a general term applied in Ethiopia, Somalia, Egypt, Sudan, Iran, and other North African and Middle Eastern societies to the experience of spirits possessing an individual. People possessed by a spirit may experience dissociative episodes that may include shouting, laughing, hitting the head against a wall, singing, or weeping. Individuals may show apathy and withdrawal, refusing to eat or to carry out daily tasks, or may develop a long-term relationship with the possessing spirit. Such behavior is not considered pathological locally.

 

The Clinical Encounter Across the Language and Cultural Barrier

Key tasks of the psychiatric clinical encounter, such as an accurate diagnostic assessment and the mobilization of rapport along the axis of understanding (for the clinician) and feeling understood (for the patient), may be seriously compromised when the clinical encounter occurs across the language and cultural barriers. The following case vignette illustrates some of these difficulties:

Several years ago I was called to provide a cultural consultation on a patient (Helen) recently admitted to an inner-city inpatient hospital unit with the diagnosis of schizophrenia. The physician in charge of Helen’s care, a non-Hispanic psychiatrist, requested a cultural consultation to facilitate making a decision on a discharge disposition for Helen. He asked me whether this patient should be transferred for long-term care to a state-supported psychiatric hospital, or else discharged to a community based intensive rehabilitation facility. His working diagnosis for Helen was schizophrenia, chronic undifferentiated type, and his prognosis for a socially functional recovery was, at best, guarded.

My first impression as the patient walked into the consultation room supported the physician’s diagnosis. The patient displayed many of the stigmata seen in the later phases of illness in patients suffering from chronic schizophrenia, including a somewhat disheveled appearance, expressionless facial features, a slow somewhat shifting gait, and a relative indifference to her surroundings. As the interview proceeded in perfectly coherent Spanish, the patient gave the following account of her problems. With no prior psychiatric history, she started to develop symptoms shortly after the death of her only son, a 21-year-old substance abuser fatally shot in the aftermath in a narcotic dealer’s power and turf struggle. The patient reacted to her son’s death with intense and prolonged grief which lasted many months. At times, during that grief process, she heard the voice of her son beckoning her to join him in the afterlife. Additionally, having lost her son—her only close bridge to the English-speaking community—Helen became increasingly isolated, prompting the concern of some of her few relatives and friends. One of her nieces finally took Helen to the emergency room for evaluation as she was worried about Helen’s increasing isolation and a potential for suicide should Helen act out her expressed wish to join her son and obtain some “rest.”

Upon arrival to the emergency room, the report of the clinician in charge of her care highlighted in his notes the presence of “auditory hallucinations, possibly delusional, exhibits flat affect.”

Since the patient’s command of English was extremely limited, the physician focused his intake efforts on eliciting the basic set of signs and symptoms which would allow him to establish a working diagnosis and to evaluate clinical risks. While the patient was held in the emergency room, the patient’s increasing desperation was interpreted as “agitation” and the patient received several doses of haloperidol. Upon admission to the ward, the patient—partly in fear of a process that she could not understand, and partly due to the extrapyramidal side effect of the haloperidol—exhibited extremely passive and avoidant behavior, comparable to the stance often seen in cases of severe chronic mental illness.

The case of Helen illuminates some of the difficulties of arriving at an accurate diagnosis when evaluating and treating a patient across the language and cultural barrier. The psychiatric consultant, who first evaluated the patient upon arrival to the emergency room, evidently interpreted her anguished, anxious pacing and rapid “unintelligible” speech in a language which he could not understand, as a sign of psychiatric agitation. The history of “withdrawal” from social interaction supplied by the ambulance attendant was assessed as evidence of schizoid/schizophrenic isolation. The presence of “auditory hallucinations,” the content/type of which could not be fully ascertained because of the clinician’s lack of knowledge of the patient’s Spanish language, added a key step toward a possible diagnosis of schizophrenia.  The patient received several doses of haloperidol a few hours after presenting to the emergency room. In a brief mental status examination shortly afterward, her affect was described as flat, thus locking in the admission diagnosis of schizophrenia. As will be discussed later, the evaluation of key mental health status items, such as affect, thought process, speech, and hallucinations and delusions, are especially sensitive to culture and learning, and thus very vulnerable to distortions when evaluating a patient through the language and cultural barrier.

 

The Diagnostic Assessment Examination

The diagnostic assessment of patients across the language barrier is full of opportunities for misunderstanding, over- and underestimation of psychopathology, and consequent misdiagnosis. Marcos and colleagues9 found that schizophrenic patients of Hispanic origin exhibited higher rates of psychopathology in interviews conducted in English than in interviews held in their native Spanish.

Beyond the language barrier, specific group stressors suffered by certain minority groups may add additional confusion. For example, cross-cultural clinicians working with refugees warn the culturally naïve evaluator not to mislabel as Axis I psychopathology the sometimes vivid and highly emotional narratives of Southeast Asian and other refugees describing having witnessed or suffered terrible atrocities in their countries of origin or in the process of immigration. Fortunately, clinicians practicing today across language and cultural barriers have access to the findings of numerous studies that provide guidance for accurate evaluation and diagnosis and will allow them to correct many distortions and provide culturally syntonic care.10

 

Mental Status Examination

The mental status examination, the key component of a psychiatric diagnostic interview, is subject to many distortions when conducted across a language and cultural barrier. The central process of the mental status examination requires observation and interpretation of the patient’s appearance, behavior, language, and mental activity, both spontaneous and as elicited by the clinician’s questions. In interpreting the patient’s appearance, behavior, language, and thought content, the clinician must guard against what has been called “the category fallacy,” which is the effort to fit all conditions, whatever their cultural context, into the Western diagnostic framework, without regard to validating that diagnostic framework in the local culture. Patient responses to specific mental status items are affected by the patient’s culture of origin, educational level, literacy, language proficiency, and level of acculturation. Investigators consider the following items of the mental status examination to be more sensitive to cross-cultural misinterpretation.

Appearance and Behavior
The mental status sections of psychiatric case reports when describing patient’s appearance and behavior are often replete with such expressions as “normal,” “attractive,” and “appropriate” and other terms subject to significant cultural variation. Appearance and behavior must be carefully evaluated by the clinician, with the patient’s own development and culturally determined normative framework as a referent.

Relationship to the Evaluator
The assessment of a patient’s attitude and relationship to the clinician, who is performing a psychiatric evaluation, is affected by many psychosocial variables, including whether the interview is voluntary and the relative emergency of the clinical situation. Key factors of such as assessment (eg, maintenance or avoidance of eye contact, personal deference, reserve, physical proximity, physical contact) are subject to cultural prescriptions that the clinician should strive to decode.

Motor Behavior
The assessment of motor activity is considered a fundamental part of the mental status assessment. Motor activity while producing speech is an activity which is also culturally mediated. In a prior publication, Marcos and Trujillo11 noted that patients who communicate in a nondominant language may use extra nonverbal activity to facilitate verbalization across the language barrier. This extra activity needs to be carefully evaluated, lest those which are used to facilitate verbalizations be attributed to tension, hyperactivity, or other forms of motor psychopathology.


Speech and Thought

Patients communicating in a language over which they have a poor command often exhibit a high frequency of speech disturbances such as omissions, sentence incompleteness, and long pauses. These must be carefully distinguished from the impact of anxiety, depression, or emotional withdrawal.

Affect
In evaluating the range, responsiveness, and quality of a patient’s affect, clinicians working across the language barrier must recognize that both the spontaneous and the elicited expressions of affect are deeply patterned by cultural norms and expectations. Culturally sanctioned impassiveness should not be misinterpreted as poverty of affect any more than the ebullience often attributed to people of Mediterranean origin should be evaluated as excessively intense affect. Clinicians need to be equally sensitive to the significance of linguistic factors that may cloud the interpretation of affect.

When a mental status evaluation is performed across language and cultural barriers, certain linguistic problems may be misinterpreted as surplus psychopathology, and clinicians should guard against this error by repeating key questions, introducing redundancies to facilitate communication, and identifying paralinguistic cues that may cloud their evaluation of mood and expression. When in doubt they should use trained translators, cultural consultants, or structured, validated interviews as aids in the diagnostic process.

 

Cultural Formulation

The incorporation of cultural content into the DSM-IV represents a major achievement as it may encourage clinical practices that will result in improving the diagnosis and treatment of minority patients. Additionally the clinical cultural knowledge accrued may increase our knowledge of models of psychopathology. Clinicians using the framework proposed in the DSM-IV have three options to improve the diagnostic process when working with patients belonging to a culture different than their own. First, the clinician is invited to consider cultural variations and specifiers as they apply to almost 100 diagnostic categories. Second, the clinician is presented with a guideline to the completion of a cultural formulation which encourages the systematic exploration of the patient’s cultural identity, the perceived causes or explanatory models used by the patient and his or her reference group, and the cultural factors that shape the therapeutic relationship. Third, clinicians are offered a glossary of culture-bound syndromes which may be used to perform a differential diagnosis or to complement, in some cases, the diagnoses made possible by the DSM-IV.

The development of a cultural formulation is probably the jewel in the crown of cultural offerings of the DSM-IV. Just like the psychodynamic formulation is central to the therapeutic process of psychodynamic psychotherapy, the cultural formulation can inform and enrich the clinician’s view of the patient’s problems and guide their treatment.

As described in the DSM-IV-TR, the suggested outline for a cultural formulation contains elements  found in Table 5.

 

 

 

Cultural Identity

The DSM-IV recommends that in assessing an individual’s cultural identity, the clinician should “note the individual’s ethnic or cultural reference group. For immigrants and ethnic minorities, they should assess the degree of involvement with both culture of origin and host culture.”12

To these factors one must add migration history, which is commonly left out of the clinical evaluation of cross-cultural patients. Culturally uninformed clinicians often treat their immigrant patients as if their lives began when they arrived in the US, and their clinical narratives often lack key data from the patients’ preimmigration experience. Careful attention must be paid to the traumas and losses encountered by refugees in their country of origin, often including exposure (as witness or victims) to physical or emotional torture, or both. The process of acculturation is once again key to understanding the psychological distress and psychopathology of immigrants. Rogler13 has identified three major sources of stress in the migration experience. First, insertion into the host society, frequently at lower occupational and social levels. Second, disruption of primary interpersonal networks. Last,  the stress-inducing acculturation process. The clinician can assess the degree of acculturation and the nature of the acculturation process through many indirect means. Age at immigration, number of years in the US, occupational status, language proficiency, and participation in the host culture social networks, give the clinician some idea of the rate and ease of acculturation for a given patient.

Families can also be classified by degree of acculturation. From this perspective immigrant families may be described along a continuum of acculturation as traditional, transitional bicultural, and Americanized. Each of these family structures presents different assets and vulnerabilities in relation to the immigrant experience.

Clinicians need to understand that cultural identity is a very fluid and dynamic construct. Each person develops their own sense of identity by selecting from a rich tapestry of belief systems and behavioral models available in the context of their native and adoptive cultures. As such, any label including Hispanic, African American, and the like, should only support additional lines of inquiry to understand the nuances of the cultural identity of their patients. Beyond these differences, additional refinements and complexities are added as generations of immigrants develop. The loyalties and cultural conflicts of the original immigrant are not the same as those of the first or second generations of their successors.

 

Overall Cultural Assessment

The cultural formulation must be focused on providing a culturally informed explanation for the patient’s actual symptoms and dysfunctions. By thus anchoring the formulation on clinical facts, the clinician ensures its relevance to the patient’s presenting problems and to the process of care. Here, experience will teach the clinician to select succinct and potent explanations while separating what is clinically meaningful from the many interesting but not clinically relevant cultural facts which could easily be collected in any clinical encounter. The place for such synthesis is the last item of the cultural formulation guide, ie, overall cultural diagnosis.

 

Therapies

Much knowledge has accrued about the applications of standard, psychoanalytically based, psychotherapy to populations and ethnic backgrounds other than Caucasians of Western origin. To the repeated observation that ethnic communities are accepted for psychotherapy treatment at lower rates and drop out earlier than their mainstream counterparts, researchers and clinicians have provided a bounty of adaptations ranging from preparations for psychotherapy to substantive framework modifications. The most daring step in this continuum is the development of culture-specific therapies empirically derived from culture-specific behavioral features. Szapocznick and colleagues,14 for example, developed and proposed a model of family therapy for Miami, Florida’s Cuban families guided by empirically derived values prevalent in that population, such as strong familial affliction and preference for hierarchical family structures.

Other therapies such as cognitive and cognitive-behavioral therapies may achieve some modicum of freedom from cultural bias, to the degree that cognitive therapists work with the specific pathogenic beliefs of the patient, whatever the cultural origin of such beliefs. Its application to minority populations suffering from anxiety and depressive disorders may be an area of promising cross-cultural research.

Just like in the practice of psychiatry with any population, the optimum approach to treatment includes the selection of interventions based on evidence. Tables 6 and 715 illustrate how the evidence (still scarce but growing) accumulated regarding the mental health of minorities can be used productively by clinicians, and systems of care, to craft relevant interventions.

 

 

 

All these therapeutic strategies need to be mediated by the ongoing assessment of the patient’s language competence, acculturation status, and voiced personal preference.

 

Ethnic Psychopharmacology

The treatment of psychiatric disorders with psychotropic medications has been one of the great success stories of biomedicine particularly in the second part of the 20th century. However, since most currently used psychotropic agents were developed and tested in Western populations, there is little knowledge of the effects of psychotropics across different ethnic groups to guide clinical practice. Thus, cross-cultural psychopharmacology is a relatively young field. Clinicians prescribing medications to patients belonging to different ethnic groups need to consider the following factors when deciding to prescribe psychotropics to their patients.

First, cultural factors include mediating beliefs and expectations about both the therapeutic and adverse effects of medications. Included here are religious beliefs and taboos that may affect parameters such as the timing of medication intake, acceptability of utilizing certain medications, duration of the episode of treatment, and other factors. In many cultures, the patient’s family may play a role in making medical decisions for the patient and should be involved in psychoeducation efforts.

Second, certain environmental factors that, when maintained over long periods, may lead to adaptations of metabolism and promote a differential response to treatment. Factors such as the use of tobacco, caffeine, preferred foods and food additives, over-the-counter medications, and herbal medicines are ethnically mediated and may affect the effectiveness and safety of psychotropic medications. For example, by promoting the induction of key hepatic enzymes, alcohol may lower the effective level of medications.

Third, biologic factors should be considered. Ethnicity is known to affect the bioavailability and effect of medications through three broad biologic mechanism; namely, pharmacokinetics, pharmacodynamics, and pharmacogenetics.

Potential ethnically mediated cytochrome P450 (CYP) variability should be specially noted. Pharmacokinetics studies the absorption, distribution, metabolism, and excretion of drugs in the human body. CYP plays a key role in the metabolism of psychotropics (and many other endogenous and exogenous chemical compounds) and is subject to genetically mediated variation in activity. Such genetic variation in activity permits the allocation of individuals to any of three groups; these include poor metabolizers, who have reduced (or non-existent) enzyme activity and metabolize certain drugs slowly achieving higher blood levels with equal doses; extensive metabolizers, who have normal amounts and normal enzymatic activity; and intermediate metabolizers, who have intermediate enzymatic activity. The percentages of poor and extensive metabolizers vary in different ethnic populations as reflected in Table 8.16

 

 

 
A fourth category, ultra-rapid metabolizers, have enhanced enzymatic activity and metabolize the drug rapidly, requiring higher dose to sustain therapeutic efficacy. Certain populations (Arabs and Ethiopians) have high prevalence of CYP 2D6 ultra-rapid metabolizers (20% to 30% versus 1% to 5% among Caucasians).

In addition to these activity differences, clinicians need to take into account the fact that many psychotropics act themselves as inhibitors (or inducers) of the isoenzymes. The selective serotonin reuptake inhibitors (SSRIs), for example, inhibit the activity of CYP 2D6 and CYP 2C19, which may affect the therapeutic availability of the SSRI itself and/or co-administered medications. Inducers increase the synthesis of CYP enzymes and reduce the serum level of affected medications. The most common psychotropics which act as inducers are carbamazepine and other anticonvulsants, which increase the synthesis of CYP 3A4 and may reduce the bioavailability of other CYP 3A4 substrates such as benzodiazepines.

The same is true of herbs and dietary products. Chinese herbs such as ginseng and glycyrrhiza promote induction of CYP enzymes. Table 9 summarizes observed clinical effects in the administration of medications that maybe related to differences in CYP enzymatic activity. Table 10 summarizes existing knowledge regarding the effect, in different ethnic populations, of widely used psychotropics.

 

 

As ethnic psychopharmacology continues to make advances in the understanding of pharmacogenetics, pharmacodynamics, and pharmacokinetics, clinicians working with ethnically diverse populations should review the following factors while considering prescribing psychotropics.

Cultural Factors
First, clinicians should review patient (and family) history of use of psychotropic and other medications. Second, one should inquire about expectations of clinical effect and rate of recovery and about tolerance to known side effects. Third, the clinician should assess readiness for maintenance treatment when indicated. Fourth, the clinician should inquire about cultural or religious restrictions or the use of certain medications.

Environmental Factors
Clinicians should review the use of tobacco, alcohol, caffeine, over-the-counter medications, folk herbs, and other remedies.

Biologic Factors
If clinically possible, the clinician should start low and go slow. The clinician should assess family history (if available) of response and side-effects development. In the presence of non-response, psychotropic blood level should be evaluated and other CYP interactions should be considered. The clinician should evaluate for metabolic efficiency status (poor metabolizers, ultra-rapid metabolizers).

 

Cultural Competence

Though there are many definitions of cultural competence, the transformative work of Cross and colleagues17 offered an initial proposal-defining cultural competence as a set of behaviors, attitudes, and policies that come together in a system of care and among their clinicians as well as enable them to work efficiently in cross-cultural situations.

For the Office of Minority Health of the US Department of Health and Human Services, cultural competence involves having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.

Cultural competence cannot be thought of as binary present or absent condition. It is best conceptualized as a continuum of beliefs, attitudes, skills and practices that start (at the low point) at a culturally blind position and end (at the high point) in a position that holds the belief that culture makes a difference, cultivates an open attitude to incorporate cultural knowledge, and develops skills in culturally syntonic diagnosis and treatment (Table 11).18

 

 

 

Cultural Consultation

Many approaches have been used to enhance the cultural responsiveness of psychiatric services working with multicultural populations. The scarcity of clinicians and researchers from minority populations limits the development of ethnographic mental health services or clinics in sufficient volume to reach large numbers of minority patients. The services of trained mental health interpreters and translators are very valuable but their engagement in the ongoing process of care is, by necessity, limited. To deal with these limitations Kirmayer and colleagues19 have proposed and evaluated a model of cultural consultation based on the principles and processes utilized in general psychiatry by the sub-specialty of consultation liaison. The cases seen by Kirmayer and colleagues19 broadly demonstrated the impact of cultural misunderstanding in the process of care. Issues such as incomplete assessments, incorrect diagnosis and treatments, and undeveloped treatment alliances were identified and, when possible, corrected by the team carrying through the consultation.

 

Conclusion

As ongoing migrations enhanced by the forces of globalization continues, clinicians practicing psychiatry in most areas of the US and especially in urban centers can expect rising numbers of minority patients seeking their help. Additionally, policy makers and regulators are responding to the Surgeon General’s call to address the health and mental health adverse disparities found among minority populations by developing requirements for the assessment of non-English-speaking patients and standards for cultural competence. On the bright side, much clinical and health services research has accumulated evidence to support the provision of culturally competent mental health services.

Such research has illuminated differences in onset, prevalence, course, and outcome among different ethnic groups, and has alerted clinicians to the presence of systematic diagnostic distortions that may occur when evaluating patients belonging to different ethnicities.

Fortunately, these findings also teach clinicians methods to be alert to, and to compensate for, such possible distortions. Paying special attention to certain elements of the mental status examination can enhance the diagnostic accuracy by correcting potential distortions in evaluating items such as appearance and behavior, speech and language, and affect and mood. Knowledge of the patient’s original ethnic group’s normal “idioms of distress” can also help the clinician to accurately evaluate the patient’s culturally expressed presenting complaint.

When it comes to treatment, an emerging body of knowledge will also help the clinician establish a therapeutic alliance inclusive of the patient’s culturally mediated explanations of their own illness, and will facilitate an accurate assessment of the meaning and severity of symptoms in relation to the patient’s cultural norms. Finally, the clinical evidence accumulated by the discipline of ethnopharmacology can also guide the clinician’s interventions when they decide to provide psychotropics to treat their patient’s disorders. PP

 

References

1.    Engel GL. The clinical application of the bio-psychosocial model. Am J Psych. 1980;137(5):535-544.
2.    Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.   
3.    Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.
4.    International Statistical Classification of Diseases and Health Related Problems, (The) ICD-10. Second Edition. Geneva, Switzerland: World Health Organization; 2004.
5.    Tylor E. Primitive Culture. London, United Kingdom: Murray Publishers; 1871.
6.    Mezzich JE, Kleinman A, Fabrega H, Parron DL. Introduction. Mezzich JE, Kleinman A, Fabrega H, Parron DL, eds. Culture and Psychiatric Diagnosis: A DSM-IV Perspective. American Psychiatric Press, Inc.  Washington DC, 1996:xvii – xxiii.
7.    Mental Health: Culture Race and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Washington, DC: Substance Abuse and Mental Health Administration; 1999.
8.    Chinese Classification of Mental Disorders. 3rd rev. Beijing, China: Chinese Psychiatric Society; 2001.
9.    Marcos LR, Alpert M, Urcuyo L.  The effect of interview language on the evaluation of psychopathology in Spanish-Americans schizophrenic patients. Am J of Psychiatry. 1973;130(5)549-553.
10.    Trujillo M. Cultural psychiatry. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. Vol I, ed. 7. Baltimore, MD: Lippincott Williams & Wilkins; 2000:492-499.
11.    Marcos LR, Trujillo M. The psychiatric examination of Spanish Americans. In: Duran RP, ed. Latino Language and Communicative Behavior. Norwood, NJ: Ablex Publishing; 1981:141-148.
12.    Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994:843.
13. Rogler LH. The meaning of culturally sensitive research in mental health. Am J Psychiatry. 1989;146(3)296-303.
14.    Szapocznik J, Scopetta MA, King OE. Theory and practice in matching treatments to the special characteristics and problems of Cuban immigrants. J Community Psychol. 1978;6(2):112-122.
15.    Trujillo M. Culture and the organization of psychiatric care. In: Mezzich JE, Fabrega Jr H, eds. The Psychiatric Clinics of North America: Cultural Psychiatry: International Perspectives. Philadelphia, PA: W.B. Saunders Company; 2001:539-552.
16.    Cross T, Bazron B, Dennis K, Isaacs M. Towards a Culturally Competent System of Care. Vol I. Washington DC: Georgetown University Child Development Center, CASSP Technical Assistance Center; 1989.
17.    Trujillo M. Towards a culturally competent system of psychiatric care. Abstract presented at: the 149th Annual Meeting of the American Psychiatric Association; New York, NY; May 4-9, 1996.
18.    Gaw AC. Concise Guide to Cross-Cultural Psychiatry. Washington, DC: American Psychiatric Press; 2001.
19.    Kirmayer JL, Gutder J, Blake C, Jarius E. Cultural consultation: a model of mental health services for multicultural societies. Can J Psychiatry. 2003;48(3):145-153.