Transcultural Psychiatry 50(6) 765–768 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1363461513513415 tps.sagepub.com

Editorial

Reflections on current research and future challenges in cultural psychiatry Ronald Wintrob Brown University

This special issue of Transcultural Psychiatry evolved from a series of symposia organized by the Transcultural Psychiatry Section of the World Psychiatric Association (WPA-TPS) for the XV World Congress of Psychiatry, held in Buenos Aires in September 2011. WPA-TPS sponsored 10 symposia on the theme “current research in transcultural psychiatry in countries and regions around the world”, as well as an over-arching symposium on “culture and person-centered medical and psychiatric care” at the congress in Buenos Aires. The symposia on current research in transcultural psychiatry around the world, comprising more than 40 individual presentations, focused on developments in Britain, The Netherlands, German-speaking countries, Scandinavian countries, France, Russia, Spanish-speaking countries, Canada, USA, Caribbean countries and Asian-Pacific countries. Presentations at these symposia led to the series of six articles that comprise this special issue, concerning transcultural psychiatry research in Britain, The Netherlands, Germany, Scandinavia, the Caribbean and Australia. The articles include an assessment of the historical context of the development of cultural psychiatry research in each of the countries, current research themes, their scope and limitations, future directions of research, as well as issues and challenges confronting the future of cultural psychiatry. The history of transcultural psychiatry research has been characterized by efforts to establish the cross-cultural applicability and validity of psychiatric diagnostic categories. These efforts began by using standard “western” descriptive categories and diagnoses, then progressively recognizing the need to take account of the great variation in cultural conceptions of misfortune, illness, symptom expression, acceptance of the sick role, and both functional and social impairment. There is still lively debate in the field about “western diagnostic bias” and its universal, cross-cultural application on one hand, and cultural relativism, the long-term psychopathological effects of colonial exploitation, and the psychological effects of

Corresponding author: Ronald Wintrob, Clinical Professor of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, RI, USA. Email: [email protected]

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rapid culture change on the other. Each of the articles in this special issue addresses these issues. A major focus of transcultural psychiatry research has been the ongoing effort to establish incidence and prevalence rates of major psychiatric disorders in countries around the world, and that is especially true for psychotic disorders. This effort has been closely related to another major focus of transcultural psychiatry research: the delineation of psychiatric illness among immigrants, and more recently also among refugees and asylum seekers. Several articles in this special issue address the important topic of the reported high incidence of the diagnosis of schizophrenia among immigrants; generally people who have migrated from “low-income countries” and countries affected by war and natural disaster, to “high-income countries” of North America, Europe and Australasia. The articles raise the level of debate about the putative causal factors in the reported higher rates of psychosis among migrants, emphasizing the cumulative effects of both pre- and postmigration traumatic experience among migrants, combined with the social disadvantage and discrimination they experience in the host countries with respect to economic and educational opportunity, housing, social integration and political representation. All of these features of social disadvantage are exacerbated among migrants whose official designation in the host countries as refugees or asylum seekers makes their sociopolitical acceptance much more tenuous and stressful. Several authors of this series of articles directly address the national policy issues inherent in the acceptance of immigrants, refugees and asylum seekers and their integration in the national life of the host countries. In these times of economic recession and austerity in many host countries, with resulting political backlash against liberal immigration policies, there is increasing risk that overt discrimination toward migrants will intensify, decreasing the numbers of immigrants and the resources, support and goodwill devoted to their successful integration in national life. A substantial fund of support and goodwill helped immigrants integrate into the social fabric of many host countries during the last three decades of the 20th century. The result was that the immigrant proportion of many host countries increased from less than 5% to more than 15% of the national population during those decades. However, anti-immigrant bias has become much more manifest in the past decade, actively encouraged in some countries by xenophobic political movements that have gained substantial power in the wake of the rapid increase in immigrant numbers in response to what seemed to be a rising tide of international turmoil. Anti-immigrant bias has increased the acculturative stress of immigrants and diminished the chances of their cultural integration. As these authors have rightly emphasized, national immigration policies have a direct and profound impact on the mental health of the foreign-born population of their host countries. During the three decades of surging immigration at the end of the 20th century, host countries that maintained open immigration policies became aware of the need for health services and institutions that were more sensitive and responsive to the

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increasingly multicultural character of their communities. Medical and social service agencies, including hospitals and medical schools, recognized the need to increase “cultural sensitivity”, “cultural safety” and “cultural competence” in the professional staff of their facilities that served the more culturally diverse populations they encountered daily in their institutions. The cultural psychiatry perspective flourished in this environment, encouraging the acceptance of the biopsychosocial model of medicine, an “explanatory model” of illness that is explicitly respectful of cultural differences among people and among patients, and encouraging its application by means of “culturally sensitive clinical interviewing”. Over the past decade this has led to the development and refinement of “cultural case formulation”, first in psychiatric assessment and treatment responsive to diverse patient populations, and more recently applied to clinical interviewing and treatment approaches in medicine and public health more broadly. One of the current challenges in the field of cultural psychiatry, to which much effort is being directed, is the development and refining of the conceptual and operational details of the “culturally sensitive clinical interview” that can be widely used in psychiatric assessment and treatment, and can be a model for clinical interviewing, assessment and treatment in medicine generally. Another challenge of the application of the concept of multiculturalism to the everyday reality of clinical medicine in general, and culturally sensitive clinical care in particular, is the need to have cultural diversity at all levels of the administrative and the clinical staff of health care facilities—diversity that more closely mirrors the population being served in the community of each health care facility. There is also a greater recognition of the need to establish “cultural competence” in the clinical staff of each facility, through education, training and supervised staff experience. Because it is both a medical and a clinical discipline, psychiatry has been fundamentally concerned with pathology, its diagnosis and treatment. There has been much less focus on those factors of individual perseverance in the face of adversity and illness, of spiritual strength and purpose, of family support, of community belonging, that contribute to coping ability, recovery and an overall sense of wellbeing. Cultural psychiatry does recognize the importance of each of these factors in coping with the stress of rapid culture change, migration, acculturative stress, the social burden of discrimination and unequal access. For this reason, cultural psychiatry has the potential to stimulate research on human resilience in coping with stress. This includes resilience at the level of the individual, the family and the affiliative cultural groups with which individuals and families identify themselves. Culturally, psychiatry needs to expand research into “cultural resilience” as it applies to individuals, families and communities across generations. This research would delineate the impact of all aspects of acculturative stress, and its complex outcomes related to cultural integration, assimilation, separation and marginalization. Such research would recognize that intra-cultural and inter-generational differences in each of these outcomes of acculturative stress can and will vary

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considerably, thereby helping to avoid cultural stereotyping and clarifying the nature of human resilience. Finally, I would like to emphasize the value of another current perspective in medicine that fits closely with the values of cultural psychiatry. The rapidly developing perspective of “person-centered care” contrasts with the longestablished tradition of medical treatment being determined mainly by physicians, who deliver their diagnoses and their treatments to patients in hospitals and medical clinics where the patients tend to feel powerless and do as they are told, in institutions that feel more like “medical fortresses” than care facilities designed for the comfort and wellbeing of people who come to them for care. Reformulating health care interactions not as doctors giving medically necessary treatment to patients, but as person-centered care determined by discussion and agreement with persons who are viewed as partners in care, fits easily with cultural psychiatry’s multicultural perspective. It fits cultural psychiatry’s emphasis on cultural explanations of illness, the cultural meaning of psychosocial context and functioning, cultural case formulation, and culturally sensitive clinical interviewing. Person-centered care within the conceptual framework of cultural psychiatry would emphasize the personal and cultural identity of each individual, their conceptions of illness and its appropriate treatment, personal resilience and family support, religious and spiritual orientation, and capacity for long-term restoration and maintenance of individual and family wellbeing. Integral to this approach to care is the recognition that reaching accord between the persons receiving care and the providers of care will enhance the acceptance of such care and thereby increase both adherence and satisfaction with care by everyone involved in the process. With a range of challenges this broad and complex, there should be great opportunities ahead for the next generation of researchers in cultural psychiatry to prepare a follow-up special issue of Transcultural Psychiatry on current research directions in cultural psychiatry. Until then, I would like to express my great thanks to the authors of the articles comprising this special issue of Transcultural Psychiatry sponsored by WPA-TPS, and to the presenters at all the symposia on this theme organized by WPA-TPS. I very much appreciate the significance of the formal agreement with WPA-TPS by which Transcultural Psychiatry has become the official journal of WPA-TPS, and that has made it possible for this to be the second special issue of the journal sponsored by WPA-TPS.

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Reflections on current research and future challenges in cultural psychiatry.

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