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Sarah Hanafi: [00:00:08] Welcome to PsychEd, the psychiatry podcast for Medical Learners by Medical Learners. In this episode, we want to build off of some concepts that were touched on in a previous episode about newcomer mental health and explore more broadly the field of cultural psychiatry and the value this work can bring to communities that are increasingly diverse. I'm Sarah Hanafi, a PGY3 at McGill University, and I'm joined by Audrey Lee, a fourth year medical student at McGill.
Audrey Lee: [00:00:36] Hi, everyone. Thanks for having me here today.
Sarah Hanafi: [00:00:40] And we're really grateful to have our guest, Dr. Eric Jarvis, this week to share his expertise. Dr. Jarvis is an associate professor of psychiatry at McGill University, and he's the director of the Cultural Consultation Service at the first episode psychosis program at the Jewish General Hospital here in Montreal. Welcome, Dr. Jarvis, and thanks for joining us. I was hoping you can tell us a bit about your current clinical work and your research interests.
Dr. Eric Jarvis: [00:01:08] Yeah. I'd be happy to. Thank you for having me on this program. Right now, I am the director of the Cultural Consultation Service at the Jewish General Hospital. So that's a speciality team that evaluates newcomers, immigrants, and refugees, as well as other people where there may be questions of cultural understanding or religious issues or problems in their lives. And so we will do consultations to the community, to clinicians in the hospital or in the greater Montreal area, even sometimes other places, just to try to help people understand the diagnosis or the treatment planning better. And I also run a first episode psychosis program, which is really becoming more and more a culture and early psychosis program, as we have more projects that are kind of linking the cultural consultation service to what we do in first episode psychosis as well. So that's kind of what I do clinically. Research wise, I've been very interested in how culture and psychosis interact and how culture and psychosis influenced each other. And the most recent grant we have received from Health Canada is looking exactly at some of these problems. How do we adapt culturally some of the interventions that we do in the first episode psychosis program? So most specifically, how do we adapt culturally, family psychoeducation, for example, to the many diverse members of our community? So those are some of the things I'm doing.
Sarah Hanafi: [00:02:45] Excellent. Now I'm excited to hear more and I'm certain kind of later on in the episode you'll be able to draw from this clinical and academic work to illustrate some of the points in this episode. So in terms of today's episode, we're going to touch on several learning objectives. One, define culture. Two, describe how culture affects psychiatric care. Three, outline the goal in the structure of a cultural formulation interview. Four, evaluate clinical scenarios to determine whether to employ the cultural formulation interview or to seek a cultural consultation. Five, define the three types of cultural concepts of distress and compare these with DSM five and psychology. Six, discuss the concept of cultural competency. Seven, explore the role of advocacy in psychiatric practice. So for many of our listeners, this may be the first time they've heard of the concept of cultural psychiatry. Dr. Jarvis, I'm wondering, can you explain what this field entails and how does it differ from the field of social psychiatry?
Dr. Eric Jarvis: [00:04:00] Sure that's a good question. I think a lot of people lump together social and cultural or social and transcultural psychiatry, and in many ways they are the same and they do overlap, at least in many ways. But there are distinctions and I think if you're in the field of cultural psychiatry, it's important to maybe think about some of those differences. So social psychiatry has more to do with examining how the power structures are aligned in society and how they may give or deny resources or access to care, for example, to certain groups of people. And so social psychiatry is interested in determining the determinants of mental health and is closely aligned maybe with psychiatric epidemiology, say, whereas cultural psychiatry is a little bit different. It's not ignorant of those kinds of issues. I mean, certainly cultural psychiatrists know that that's very important. But cultural psychiatry borrows heavily from medical anthropology, and so it's interested really in how people construct their identity or their identities. It's interested maybe in other topics like how people believe that they become ill or how people understand the illness process or the illness experience. And then how do people react? Or how do communities organise to alleviate suffering and maybe even define suffering itself? So these are kinds of the questions, more of cultural psychiatry, and I think it's important to kind of take stock that there are some subtle variations or maybe not so subtle differences between the two fields.
Sarah Hanafi: [00:05:45] And how did you yourself come to be involved in work in cultural psychiatry?
Dr. Eric Jarvis: [00:05:52] Well, for me, it was a real choice. I mean, I did a non-science undergrad degree in history and I enjoyed the humanities immensely as well. And when I went to medical school, I was looking through all the different, different programs around the country. And I saw there was a transcultural psychiatry program at McGill, and I just was immediately taken with the idea of applying to McGill and going and doing a residency there and learning more about what that might be. And when I came to McGill, I immediately started to work in that field. I got to know Lawrence Kirmayer and others of his colleagues, and from there it was such a great natural fit. I've always been fascinated with the field ever since, and I've structured my clinical and research and writing interests around those kinds of topics. So it's been a really wonderful journey.
Audrey Lee: [00:06:54] Thank you for sharing with the listeners the journey that you took into getting involved within this field. Dr. Jarvis. So we've talked a little bit already about what cultural psychiatry is, and evidently culture is an important and central concept in this field. In the DSM-5, culture is defined as systems of knowledge, concepts and rules and practices that are learned and transmitted across generations. Could you elaborate more on what we really mean when we're talking about culture? And furthermore, how does culture differ from race and ethnicity?
Dr. Eric Jarvis: [00:07:30] Yeah, I mean, the definitions of culture abound. There are so many different definitions. Every book that you read on the topic will have a slightly different take on what it means. A few ideas that I always think about culture is it's kind of a legacy that we receive from those who came before us. So many of the things that we take for granted in our lives, the patterns that we follow throughout our lifetimes, maybe the beliefs that we think are spontaneously coming up from our own psyches are actually bequeathed to us by the people that we've known in our lives, people that are parents or our families and people in our communities all around us. And so for me, this culture is not something that necessarily just comes into being through our own wills and our own ways of living that we choose. It's something that comes to us from long ago, and I think we can remember that and recognise that we'll see why it's so critical to take account of the cultures of the peoples around us, professional cultures as well as ethnic and religious cultures that we might participate in. So important to remember that culture is a legacy, but it's also something that is often taken for granted. It may be things we're dimly aware of, practices and beliefs that we're dimly aware of until we encounter somebody that's different from ourselves.
Dr. Eric Jarvis: [00:09:01] And that's an important opportunity and important moment when we encounter somebody who believes or behaves very differently from how we think is what we would consider to be normal or acceptable. We have to step back, descend ourselves, and begin to ask some very important soul searching questions and try to reach out to people and form commonalities or bridges that can help us to not just communicate, but to maybe be helpful if they're in distress. So final point on culture I wanted to mention has to do with the fact that we often put culture into other people. We might say that patients or families or other people from other places have culture. But to remember that we as observers in medicine and psychiatry, we also have a culture of our profession. We have cultures that we've grown up learning and understanding and believing. And part of cultural psychiatry is to seriously consider what those core beliefs are that we have that may or may not be shared by other people. What are the things? What are the ideas and the values that we might put out there that other people may not understand or may not accept, but that we think are maybe right or valuable just in and of themselves. So this is something that I think cultural psychiatry can really bring to medicine in general, in psychiatry more particularly.
Sarah Hanafi: [00:10:39] I really appreciate that. Dr. Jarvis, that reminder that we, you know, take a step back and consider the culture that we bring, whether as an individual clinician or as a professional body. I wonder, you know, with these differences culturally or these different legacies, how do you find that this impacts care in psychiatry?
Dr. Eric Jarvis: [00:11:05] Well, for me, as I've kind of come along over the years, I've come to realise that culture is at the root of what makes meaning and value to people. So if I'm going to try to understand other people and try to offer some help to them, then I think for me, I need to take account of this aspect of their lives. To pretend that people are all the same, or to pretend that culture isn't really present or maybe isn't that important if it is, I think, is really missing a lot of what we need to take account of as clinicians. I think ignoring culture means we may be misled in our diagnostic practices or what disorders we think are present in people. We may completely miss the boat on proper and acceptable treatments for our patients. And if we don't take account of people's cultural backgrounds and what's at stake for them in the clinical encounter, we may not ever see them again after the first visit. I mean, they may not want to come see us again. They may not adhere to the kinds of medications or other interventions we think may be important to alleviate their distress. So to me, a cultural evaluation is just part of a routine and comprehensive psychiatric or mental health evaluation.
Sarah Hanafi: [00:12:39] I mean, it sounds like culture or taking culture into account can affect all facets of psychiatric care. I wonder going further with that: Do you find that certain cultural communities experience disparities in our mental health system in terms of their outcomes?
Dr. Eric Jarvis: [00:13:00] Yeah, definitely. I think that that's part of the interest, but also the challenge of cultural psychiatry, is to try to find ways to reach out to people who may, because of various problems, it may not be anything to do with them, it may be the way that society is structured, because of social structures and structural issues, maybe systemic racism or other problems. But certain people from different communities, different backgrounds, may find they can't or aren't willing to access care or may feel very mistrustful of what we think are such basic notions like psychotherapy or maybe taking medications. So yeah, I think that some communities are more adversely affected than others by this. I hesitate to make stereotypes sort of by drawing attention to particular issues. I know in the news right now, a lot of people are very upset, rightly so, about mistreatment of African Americans, African Canadians, black Britons, people of African origin in different countries and societies who have very difficult and historical legacies of oppression through the police, for example. But some of those kinds of problems exist in psychiatry as well, and Summer Knight, she's a student with us on our team, has recently done her master's thesis on this very topic and finds that people of African origin here in Montreal suffer a greater degree, greater amounts of coercive treatment measures, for example, than members of other communities. So what does that mean in psychiatry? It might mean outcomes like forced treatment orders, it might be being forced or compulsorily admitted. It might be having police contact prior to presentation at the emergency department. These kinds of outcomes she found in her master's thesis to be present. So I think these kinds of things are very real and they negatively impact the way that we can help other people. So cultural psychiatry is trying to take stock of these issues and trying to modify the way we approach members of indigenous or African communities who may feel very deeply wounded and have been deeply wounded for decades or even centuries.
Audrey Lee: [00:15:44] I really appreciate your perspective on the impact that culture can have on the psychiatric care of certain marginalised populations within society. And I think that this is an extremely important topic to address within the current social climate that we're living in. Now that you've provided some insight into why culture is important and into its relevance in psychiatry, I think that listeners would benefit from learning about some tools that they can use to tackle cultural issues within their clinical work. So I understand that the cultural formulation interview or the CFI is one such tool that exists and that it's a framework. Can you perhaps elaborate a little bit more about the CFI and its goal?
Dr. Eric Jarvis: [00:16:28] Yeah, for sure. So in the DSM-IV, there was something called the outline for cultural formulation and it was really a broad general framework trying to help people who are interested in in considering culture in the clinical encounter. It gave five kind of general categories of topics to cover that a clinician could use. The cultural formulation interview arose because people found the outline for cultural formulation a little bit too vague and maybe not very specific in its direction as to how to inquire about these basic ideas. So the outline for the culture formulation interview is comprised of 16 questions, and the questions come out of the basic categories of the outline for cultural formulation, like cultural identity, for example, or examining explanatory models. These are sort of general categories from the outline of culture formulation. The culture formulation interview takes these basic building blocks and then makes concrete questions that fit into each of these larger categories. And so a clinician can use these really in any clinical setting, usually at the beginning of the interview, to make sure that at least some facets of culture are covered in the evaluation or clinical interview.
Dr. Eric Jarvis: [00:18:04] It takes about 20 minutes to do a cultural formulation interview. And, I mean, these 16 questions really are quite basic. They're certainly not a comprehensive cultural evaluation or psychiatric or mental health evaluation. If people discover that there's more to discover or more to uncover, I guess, in the evaluation, there are 12 supplementary modules as well that a person can turn to, a clinician can turn to, and find much more guidance on how to pursue, say, issues of religion and spirituality, or if they want to go deeper into immigration or migration. They could find a supplementary module to complement what they've already tried to do in the interview. There's also a version of the CFI for families or for third parties. It's called the informant version of the interview. So it could be for family members, it could be for community members or other people who are participating in the interview. And the informant version of the CFI has one more question than the usual 16, and it just asks the person at the beginning what their relationship is to the patient that you're interviewing. So that's kind of a general overview of the CFI.
Audrey Lee: [00:19:32] So now that the listeners have a bit of a better idea of what the cultural formulation interview consists of. When exactly do you decide to introduce the CFI when you're evaluating a patient, and what are the indications that you look for that warrant, this kind of assessment?
Dr. Eric Jarvis: [00:19:48] Yeah, that's a good question. People wonder maybe when should I introduce it or when should I do it really? The CFI was made for everyone, every clinician to use and the idea is for people to use it all the time. When you wouldn't use it? Maybe if you're already kind of doing a more in-depth cultural assessment of a person, you may kind of surpass what the cultural formulation interview is able to give you. If you already know a person well or if you're doing a more in-depth cultural evaluation at the beginning, you may not do the CFI for various reasons, which I'll talk about. But for most clinicians, the CFI is really made for you to use. And so I would encourage the listeners to check out the CFI and the DSMV and look it over. It's not too intimidating. I hope the 16 questions are fairly simple and easy to use, I think, and you can look it over and begin to consider how they could use it in their practice. So that's what I would recommend and hope. I mean, the CFI is studied fairly widely around the world in different settings, mostly academic settings, but it's been shown to be feasible, it's been shown to be useful, and it's been shown to be pretty well tolerated by clinicians and patients alike from a wide variety of backgrounds. So I think it's something really to consider using more routinely in our clinical work.
Sarah Hanafi: [00:21:27] So you kind of touched on something. I was hoping, you know, we would get to the the evidence around the CFI. So it sounds like it's something that's been demonstrated as as valid and feasible. I guess, just for clarification, has this been solely in Canada or the States or has this also been looked at in other practice populations?
Dr. Eric Jarvis: [00:21:54] Yeah, the CFI, it was initially pilot tested in various centres around the world, not just in mostly the US and Canada I guess, but it was pilot tested in other settings as well. Since that time there have been a number of studies from different places that have used the CFI in the work that they're doing. One of the problems is most of these settings are academic settings, so it hasn't really been culturally validated, so to speak. It's been shown more to be feasible and useful in clinical settings. So cultural validation would be a much longer, more complicated issue. So that's something that hasn't yet been achieved. The CFI hasn't been shown to be culturally valid necessarily. It also is kind of lacking in effectiveness studies. So does use of the CFI really improve clinical outcomes? This is a question that remains still. It's something that can be, as I say, that's useful and that can be implemented well in clinical settings. And we feel like it's helpful and it brings a lot of good things into the clinical evaluation. But effectiveness studies need to still be done. It's really kind of a work in progress. The CFI, it's still the subject of a lot of ongoing investigations and it appears in the DSMV, but it'll keep growing as the research database grows. And I think you'll get more and more attention as it does so.
Audrey Lee: [00:23:39] I think that it could also be helpful for our listeners to get a sense of how to use the cultural formulation interview through examples. So would you be able to share with us perhaps a typical case that you might see in either the Cultural Consultation Service or the first episode psychosis program and how you go about implementing the CFI.
Dr. Eric Jarvis: [00:24:04] Well, the CFI is something, as I mentioned, that really depends on the individual clinician. Do they want to make its implementation a priority or not in their clinical practice? So it's really an open tool that we can use. It doesn't have to be used in just speciality or subspecialty services, like in a general psychiatric practice. I would really encourage its use there. For example, I think that it's best to use the CFI at the beginning of the evaluation because it, as I mentioned, after practice, takes maybe about 20 minutes to use the CFI, but it really opens up some general information about the client or the patient, their identity, what they feel is important about themselves and their presenting problem. So it's kind of a new way to introduce the patient to the mental health evaluation. You know, there are some limitations of the CFI, though it's not been very well studied in patients that need a linguistic interpreter or culture broker. Also, if you're doing evaluations with family members present, it might be a little complicated to use the CFI if there's referring clinicians as well present or members of the cultural community.
Dr. Eric Jarvis: [00:25:30] For this reason, in the Cultural Consultation Service at McGill, we don't use the CFI very often because most of our evaluations are with other people present. So it's not sort of a one-on-one kind of an interaction. Also, if people are acutely ill with psychosis, maybe, or acutely suicidal, if they're aggressive or if they have cognitive problems, cognitive neurocognitive disorder, for example, and they may not be able to actually finish a questionnaire like the CFI, you may have to radically adapt your interview to suit their needs. So those are some of the thoughts I have on the CFI. Personally, I think the CFI there's one question in the CFI that has to do with the clinician patient relationship, which I don't think is enough. I think the clinician patient relationship is so important. As I as I was mentioning before, psychiatry itself is a culture and all psychiatrists, all mental health professionals come to clinical encounters with their own cultural backgrounds. So I think the CFI needs to pay more attention to that, to the culture of the observer.
Sarah Hanafi: [00:26:47] I think those are really thoughtful points and ones that maybe we don't often consider. Kind of coming from that, you've talked a little bit about the Cultural Consultation Service. Can you share with us, you know, maybe a typical case you might see on the on the CCS? And how do you approach that, especially if the team maybe isn't necessarily using the CFI?
Dr. Eric Jarvis: [00:27:14] Yeah, well, most of the people referred to the culture consultation service are either immigrants or refugees. I guess refugees are a kind of immigrant. So it's more than 90% of the people referred come from those two kinds of groups. We've had a few indigenous patients referred over the years, about 30 total maybe, and they might make up the bulk of the non-immigrant, non-refugee referrals to the service. So what we do is we work with the referring team and we invite the referring team to come to the consultation. And we also spend quite a bit of time before the consultation learning about the client and his or her family. So we'll ask if they need an interpreter and we ask if a culture broker would be beneficial, we try to determine if that would be the case. How do we know if an interpreter is necessary, if somebody has a mother language other than French or English? In Montreal, we would at least offer an interpreter. Some people might take that to be a little bit offensive, maybe like if they've been to school in France, in French, in another country or English, another country, and they feel they're very proficient in that language, they might feel a little bit miffed.
Dr. Eric Jarvis: [00:28:39] But we take the risk because so many people are never offered an interpreter during the time of their psychiatry evaluation or the time of their psychiatric treatment. So we take that risk. And many, many people are extremely grateful to have an interpreter present. When do we need a culture broker? We would try to have a culture broker present for every client, but sometimes we don't have a person we've identified as a culture broker. We have a network of culture brokers that we work with fairly regularly. But sometimes we don't have a person that we could pair up with a client from a particular background. So in those cases, it's up to me and the resident or the interpreter and other people who are present in the evaluation to do the best that we can. And we have to use our cultural competency skills to the best of our abilities. You know, they're strained sometimes, but it's it's always a very challenging a kind of a career, a challenging kind of an interaction. You're trying to really reach out to people. You're trying to help people feel comfortable, people who have been horribly traumatised or may have a terrible mistrust of anything official, especially anything official in Canada.
Dr. Eric Jarvis: [00:30:04] I mean, especially if they've been brutalised by police in the past or they're seeking refugee status, they may worry that anything they say could and will be used against them. So much of the cultural consultation at the beginning stages anyway is trying to help people feel culturally safe and comfortable in the evaluation at least enough that they can have a meaningful interaction. So the culture of consultation is usually maybe one or two evaluative sessions. And then from there we try to gain a decent sort of overview of the person's life, and we then meet with the clinicians in a separate meeting. We call it a clinical case conference, and there we present the case to the referring clinician and we have the culture broker present, if there has been one, and we present the report and we try to definitively - well, I won't say definitively - but we'll try to settle on a most appropriate diagnosis, and then we'll try also to work out some helpful recommendations. Some of them are biologic, meaning using medication or other interventions, but a lot of what we try to do is modify the social world or recruit resources from the social world, maybe from religious communities or other other community organisations to try to help individuals.
Sarah Hanafi: [00:31:34] I think one thing I wanted to almost circle back to that you mentioned was this idea of the families involvement in the process of evaluation. I know often when we think of child and adolescent psychiatry, when we're talking about family systems and including that in the clinical evaluation, particularly in the work of cultural psychiatry. Can you elaborate a bit more on the role of the family system and how it might differ from what we typically see in psychiatric clinical interviewing?
Dr. Eric Jarvis: [00:32:13] Absolutely. I mean, in cultural consultation and cultural psychiatry, I should broaden out a little bit. I mean, family and family interviewing and family interventions are key, very, very critical because you're trying to establish the context of a person's behaviours. So we do see people who are individualised, I mean people that come without their families, they're maybe in Canada alone or something, or in rare cases they might refuse to have family involvement. But the majority of cases we see with family members, I'd say, and that's because I guess like in child and adolescent psychiatry, we realise so, so much the role of the family not only in supporting, helping or sometimes harming individuals even, but also in structuring what the distress is really all about and the form the distress takes. So we want to see that interaction. So we do see people without their family members. We might if we come into an interview, we begin to suspect a problem of abuse or other issues. We will ask the family members to leave for a time and interview the individual alone, especially if it's a woman or a younger person. But oftentimes, we almost always start off the evaluation with the family together in the consultation. And that may be a little bit different than most psychiatric evaluations, because, like I say, we really are searching and seeking for the context. And we look at the interactions, we see who speaks the most often, what languages are used. Sometimes people might speak English to the interpreter and then maybe French to some people in the family, and then maybe another third language to the grandparents. And so this is all of great importance to us as we're doing our evaluation, trying to see how the system, the family system was set up and how it may or may not be a microcosm of something larger, a larger cultural construct.
Audrey Lee: [00:34:23] Thank you for that detailed explanation of the CFI and its usage. Dr. Jarvis. In the DSMV, there's also this mention of cultural concepts of distress. Could you describe what these are in further detail?
Dr. Eric Jarvis: [00:34:38] Yeah. So cultural concepts of distress are ways that people from different backgrounds might describe their suffering. So we have our own cultural concepts of distress in North America. So some of them are lay, some of them are professional. So we have a whole DSM full of diagnoses that you could argue to some degree are cultural concepts of distress that have kind of emerged over the last century or so of psychiatric practice and wisdom, you know. So it's kind of a new way of understanding. DSMV, the diagnoses, the nosology that we all take for granted. But I think it's good to step back and look and see how these kinds of concepts affect psychiatry and medicine as well as other people and other peoples. I don't know. There's three different kinds of cultural concepts of distress that people talk about. So I don't know if that's of interest to you guys, but I could talk about a little bit here maybe. So there are cultural syndromes that have been identified, in DSM IV, there was a glossary of these culture bound syndromes which has been abandoned. And the reason that it was abandoned is that cultural behaviours and forms of cultural distress aren't usually limited to one group. People from all different backgrounds can experience anxiety, depression, anger, irritability and psychosis, for example. So these syndromes aren't really culture bound. They're more emphasised maybe in one place, more than another. So one place may emphasise sad feelings or sorrow as part of depression.
Dr. Eric Jarvis: [00:36:34] Another place may emphasise maybe backache or headache when they're feeling discouraged. So they may nonetheless experience the full gamut of depression symptoms at different times, and maybe they just won't focus on the same degree. So the new term is cultural syndromes, and these are really like clusters of symptoms that may be specific to certain cultural groups and that form a pattern of recognisable symptoms of distress. So there are some examples listed in DSMV and there's many we could talk about. One of them is an entity called taijin kyofusho, which may be related to a form of social anxiety disorder, say, in Japanese people, where people from that particular background might feel that their body odour is offensive to other people, or maybe they have offensive breath to sort of an extreme degree. But this problem of being sensitive to how your body odour is affecting other people might be relatively present in Japanese society. It might be more of an issue for Japanese people in general. It's always hard to stereotype. Individual people, of course, have great variation in every context, every society. But so this this kind of cultural syndrome taijin kyofusho might be a representation of an extreme form of this concern about offending other people. So that's sort of an example of a cultural syndrome, and how it might overlap in some ways with an entity or a diagnostic category from the DSM. But these overlaps aren't perfect. And so it's rare that you can have a 1 to 1 equation between what would be called a culture bound syndrome and something from the DSM. There's also some other ideas about cultural concepts of distress.
Dr. Eric Jarvis: [00:38:40] One of them is a cultural idiom of distress. And this is not quite a cultural syndrome, it's a manner of expressing distress that is recognisable in a group of people but it's not on the way to becoming syndromic. It's something that's more kind of colloquial or in the common language of things. So a person might say, for example, focus on, as I mentioned earlier, pain or discomfort in their body as opposed to feeling sad or melancholic about a life situation. And we have it in North America as well. People might get backaches or frequent headaches or stomach upset in distressing situations. So if more people, more and more people take these kinds of use these ways to express their distress, that it might become an idiom of distress. A cultural explanation is a third kind of concept, a cultural concept of distress. And it's kind of a cultural explanation or perceived cause that has more to do with how somebody explains what's happening to them as part of their explanatory model. So somebody might say, you might ask them what their problem is and they might say, my problem is jinn possession. Say they might say spirit possession. It's not in any part of a syndrome. It's not necessarily an idiom of distress. It might be something, an explanation of what they're going through. So these are some of the ways that people might might categorise cultural concepts of distress. They differ by degree of organisation into discrete illness or syndromic categories.
Audrey Lee: [00:40:45] You know, I think that the topics that we've touched on throughout this episode, such as the CFI and these cultural concepts of distress, just speak to this growing need for cultural competency, humility and safety and and that these calls are growing within medicine and certainly within psychiatry. However, I can understand and see that there are many variations and nuances to these different concepts. So I was hoping that you could explain the role of cultural competency within mental health care and how it differs from cultural safety.
Dr. Eric Jarvis: [00:41:20] Okay. No problem. Cultural competency refers to the idea of skills that clinicians can acquire, that can help them to work with diverse clientele or diverse populations of patients and their clinics. So one of the problems of the cultural competency idea is it may foster a false sense of security. I mean, if you sort of pass a certain level of competency, if you're checked off as being competent culturally in a certain situation or with a certain group of people, you might kind of think, oh, now I know it all kind of. But really part of cultural competency is a concept called cultural humility, where clinicians recognise the tremendous diversity of beliefs and of health beliefs, I guess, and of values among their clients. And so we recognise and we strive to recognise that we don't have all the answers, even if we have mastered some aspects of cultural competency and we sort of recognise as kind of a lifelong process of learning more and more about the people that we're trying to help and allowing them to speak up and and teach us about what is helpful to them. And for me in my practice, and I learn a tremendous amount from my patients, about what can be helpful and what may not be. So this is just a caveat when it comes to ideas of cultural competency.
Dr. Eric Jarvis: [00:43:02] There's also the issue of cultural safety, which I think I touched on before. Cultural safety is another component of cultural competency. And what that means is that as clinicians we recognise that people from various backgrounds, various cultural communities may have important histories of oppression where they don't feel safe coming to meet professionals like us and to them we represent the oppressor of the past. We might represent power or authority or various problems, and that to them, coming to see a psychiatrist or any kind of mental health practitioner might be a very daunting task. So for us, it's incumbent upon us as the people with the power to recognise that. And then we try, as I mentioned before, in cultural consultations, we spend time to help all of our clients feel comfortable to the degree that we can. I mean, nobody's perfect to the degree that we can. We may help people to feel comfortable and give them some space and time and then acknowledge these differences and these historical legacies that can many, many times be very harmful. So if we can do that, I think we are able to reach a lot more people and people will be more likely to come to us and take note of what we're trying to tell them, because we do have important treatments and important ideas to share with people about their health and their mental health.
Dr. Eric Jarvis: [00:44:38] So we don't want to kind of squelch it off at the beginning by being a little too, I guess I'll say, arrogant about what we've come to understand or I mean, this is part of the problem. So cultural competency includes these kinds of ideas. Culture competency also includes a number of other skills. Some of them are more generic, some of them are more specific that clinicians can try to - I shouldn't say try to learn - every clinician can improve, I think, some of the general skills have to do with active listening skills in a non-judgmental manner and a patient manner. Even when people are not behaving the way you anticipated, they might behave in a clinical context. There's an idea called scientific mindedness. Stanley Sue and his group in California came up with some of these ideas about some elements of cultural competency. Scientific mindedness has to do with keeping an open mind and not forming a hard and fast conclusion about the people that you're meeting too quickly, letting people have some room to move around in the evaluation or maybe in a few evaluations or in a few meetings and not locking in, say, a diagnosis or a treatment plan too quickly. There's another kind of a concept called dynamic sizing, which means that we can kind of modulate the interventions and the perspective that we're taking ourselves.
Dr. Eric Jarvis: [00:46:15] Sometimes we might pull back and adopt a psychiatric perspective with the people that were interacting with. Other times you might want to take a little more of a on the ground level view of what's going on. We might try to enter the worldview of our clients and see if we can. Maybe they need that to establish a relationship of trust with us, for example, and so we can work on these kinds of skills preventing premature closure, trying to adapt the perspective that we come into the evaluation with. There are specific skills for cultural competency as well. We might become very knowledgeable about one or two communities over the time of our professional lives, and maybe because of our birth or where we come from, we might know third or fourth languages, and this can be very helpful. It just takes a long time to acquire the in-depth knowledge of some of these specific cultural skills. And we have to be, again, humble. And if we recognise we're a little bit outside of our comfort zone, we can reach out to linguistic interpreters and culture brokers who can come to help us to give extra input so that we can understand the patient and his or her context better. So those are some ideas of cultural competency.
Sarah Hanafi: [00:47:53] Thank you. I think that's very helpful. I really like the way that that you explain those different concepts and compare them to one another. Building a little bit off of that, we've talked a lot about how this practice of cultural psychiatry is also related to social context and how it can be very much rooted in social systems. And therefore, social inequities can impact on what patients are experiencing in terms of health disparities. I'm wondering in your practice, how do you view the role of advocacy as a psychiatrist?
Dr. Eric Jarvis: [00:48:36] The advocacy is, I think in cultural psychiatry, especially cultural consultation, also in culture and early psychosis. I mean, I think we are advocates most of the time for our clients because many of the people that we see are truly on the margins of society. Some of them come to us from very difficult backgrounds. They may be new to Canada as well because they have a mental disorder often, or at least they're suffering mental distress. There's a heavy stigma from families, from cultures of origins. So we as mental health professionals are poised and should be ready to advocate for people in these circumstances. I think that's a core aspect of our role as mental health professionals. When you're working with refugees in particular, I mean, as refugees are in a terribly precarious state. So they're waiting on other people to make decisions about their future lives. They're leaving very difficult circumstances. They're having a very hard time often understanding Canadian society and how to negotiate it. So as a mental health practitioner, we can help that quite a bit. We can guide them in the proper path to take. We can write letters for them. We can volunteer to speak to their lawyers, to their referring clinicians, and we can try to smooth over misunderstandings and the letters that we can write. Placing the person's individual's behaviour in a cultural context can be very, very eye opening to the judges on the immigration board and the lawyers as well who are helping to represent the clients. And so these are just some of the things we can do. I mean, we can also, in some cases, we might recognise that a refugee applicant may not be able to effectively represent him or herself for whatever reason. And so we can advocate for a designated representative that can accompany them to court and can serve some of the functions that a person regularly would do for him or herself. So, I can't stress enough the importance of the advocacy role for psychiatrists and mental health professionals, especially working with these populations.
Sarah Hanafi: [00:51:08] You know, it seems like I mean, there's so many ways in which a psychiatrist can impact on a patient's well-being and advocate for them beyond the clinical encounter. We're starting to near the end of our episode, so I'm hoping we could end more on the topic of training in cultural psychiatry. And one thing certainly that strikes me in this clinical work is that it seems more process oriented. I'm wondering, how do you approach educating trainees about this field?
Dr. Eric Jarvis: [00:51:40] Yeah, the training in cultural psychiatry is very experiential and there's a tremendous amount of literature as well on the topic. And in fact, it can be a little bit daunting to beginners in the field of cultural psychiatry. It's so multidisciplinary that people sometimes don't know where to begin. I mean, do you start with the social science literature, with the psychiatric literature, the anthropology, literature, history of peoples current events? They all are really important in cultural psychiatry and they help the culture, cultural psychiatrists and make or build a cultural formulation. So when you're building a cultural formulation, you're drawing in from these different, different perspectives that come to bear on the individuals and the families that you're seeing. So I tell beginners I meet with not to give up. Don't be discouraged, follow your interests. So if you have an interest in helping people in these kinds of situations as a clinician, or if you have research questions that you want to answer, follow through on those, and gradually you'll enter into this world, this larger world of cultural psychiatry and with all of its many bridges to different fields. There are some things you can do to help with this. You can watch for certain kinds of events that are going on during your training. Some people in residency training programs, for example, may not have a lot of access to cultural psychiatry training.
Dr. Eric Jarvis: [00:53:11] Some places have more in Canada or in the United States. But if if you're a resident, for example, you can watch for something called Cultural Psychiatry Day, which is put on annually, usually in April of every year, and it's open to all residency training programs across Canada. There's also cultural psychiatry events at the CPA. Usually there are some there you can attend. You can watch for some international conferences. There's one called the Society for the Study of Psychiatry and Culture, which takes place usually in the spring as well. In April or May this year, it's because of COVID. It was moved to October. Well, I think it's September 25th and October 9th and 10th of this year. It's entirely virtual this year. There's still time for people to join that conference that they want to. There's other opportunities that come up for training for people. There is a McGill Summer program in Social and Transcultural Psychiatry, which takes place every year around May. And there's an event study institute usually in June that people can attend. This is where you network. If you come to some of these events, you'll meet a lot of the cultural psychiatry people from around the world. And before you know it, you'll be part of the group and you'll have really a great experience and some of that confusion will disappear a little bit as you realise everybody is doing different things and it's okay.
Dr. Eric Jarvis: [00:54:43] Part of the great thing about cultural psychiatry is diversity and so people in the profession also appreciate diversity and the people that come to participate and they like to see diverse interests as well. You can do a rotation at McGill and the Cultural Consultation Service, if you like, to get kind of practical on the ground feeling about what cultural assessments might mean during all this process. It's important to choose a mentor. You might hear of somebody or hear someone speak, or you might read an article or paper, or you might see a podcast or hear a podcast or see some other thing where somebody really speaks to you, you know? And then you can choose to write or contact that person, write them and see what they have to offer. And they'll usually be very happy to talk to you and start to guide you in ways you can foster your own interests in the field. So this is kind of the informal way I think the training takes place. I think it's very important because I think it's really the way that I learned cultural psychiatry and the readings that I do and did are part of it, but it's a vast kind of pool.
Dr. Eric Jarvis: [00:55:59] And you need to have some personal, I think, one-on-one help in doing that, more formal ways to to engage in training and cultural psychiatry. I mentioned some things like cultural consultation, service or formal teaching structures that you can attend. A summer school, for example, can give a very good kind of overview of the field. And then gradually you begin to learn how to use interpreters and culture brokers in clinical work. And I think that when you learn those kinds of things, when you start to have an appreciation for that, I think that it really takes off. You can learn how to use the CFI, the cultural formulation interview. And to structure your thinking along the outline for cultural formulation to really make it maybe not too lengthy, hopefully, but helpful cultural formulations that can benefit the people that you're seeing. So these are some of the training problems and some of the benefits. To me, it's very wide open and cultural psychiatry, very exciting, a little daunting for the diversity and sometimes lack of structure. But if you enter in and start to look around, you'll impose your own structure and you'll start to make a unique contribution, which is, I think, what all of us want in cultural psychiatry.
Audrey Lee: [00:57:16] I had one last question for you, Dr. Jarvis, which is a bit of a follow up to what you just talked about. So along the same lines of tips and advice that you might have for trainees, what additional insight might you offer to trainees who are interested in cultural psychiatry but can feel overwhelmed by all the cultures that they might encounter or need to navigate?
Dr. Eric Jarvis: [00:57:39] Well, nobody is an expert in all the cultures. So I mean, I certainly am not. And when I was a new staff at the Jewish General Hospital in Montreal, I was the director of the Cultural Consultation Service. And people would come up to me and ask me what to do for this person from this country or that person from here or there. And I didn't know, I had to say, I'm so sorry. I know I'm the director of the service, but I'm going to have to get back to you on that one. So that's okay. It's okay to feel that way. And over time, what I found is if I kind of stuck to it and persisted and I found that there are some general kind of trends you can follow with people in general kind of approaches you can follow that I mentioned already some of those kind of general cultural competency skills that you can learn and you can. Those are helpful not just with our clients, with our colleagues as well, because our colleagues are also people coming with their own agendas, their own interests and their own needs. And when they ask you questions, when they submit a consultation. So this is the way that I've kind of negotiated that problem. And I think some patience is with yourself as it is a major step. You can't be expected to learn it all right away, and you can't be expected to know everything about every culture, every group. You're kind of forced into a culturally humble position. I think when you're working with a big group, with greatly diverse groups, you have to sort of be humble that way. And then gradually over time you'll learn about how you can reach out to people to help you.
Audrey Lee: [00:59:25] Thank you so much, Dr. Jarvis, for joining us today. I think we can speak on behalf of all of our listeners that we're very grateful to have had the opportunity to learn about this fascinating and important approach to mental health care. Do you have any closing remarks for the listeners today?
Dr. Eric Jarvis: [00:59:42] Yeah, I mean, to me, a lot of people look at cultural psychiatry and they just give up a little bit. They think, Well, I'm not going to get into all that stuff. It's just a little bit too much, you know? And I'm going to just stick to what I know and I'm going to try to do the work I do the best I can. And I think that's understandable. I think, though, that as psychiatrists, psychologists, mental health professionals, we have a responsibility to to watch out for ways we can improve ourselves. And I think that we need to watch out for the well being, too, of everybody that we see. So I would try to be a little daring. I would crack open the DSMV and go to the cultural formulation interview as a starting point, look through the questions and ask yourself, you know, how can I implement this in the evaluations that I'm doing? Is there a way I could put this in at the beginning of what I do, try it for two or three clients and see if it isn't something that opens up some new angles you hadn't seen before and if it doesn't create a better treatment alliance with your patients. So I guess I'm asking people to be a little bit daring and try something a little bit new and see if this can really make a difference or not for themselves.
Sarah Hanafi: [01:01:11] Well, thank you once again, Dr. Jarvis, for sharing your expertise and your time with us today. PsychEd is a resident driven initiative led by the residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Drs. Sarah Hanafi and Audrey Lee. Audio Editing and Show Notes by Dr. Sarah Hanafi. Our theme song is "Working Solutions" by All of Music, a special thanks to the incredible guest, Dr. Eric Jarvis, for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thank you so much for listening and take care.