I'm Dr. Amy Cohen, Program Director for SMI Advisor and a clinical psychologist. I'm pleased that you're joining us for today's SMI Advisor webinar, DSM-5 Outline for Cultural Formulation and Cultural Formulation Interview, Tools for Culturally Competent Care. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. And now I'd like to introduce you to the faculty for today's webinar, Dr. Francis Liu. Dr. Liu is the Luke and Grace Kim Professor in Cultural Psychiatry Emeritus at the University of California, Davis. As a Distinguished Life Fellow of the American Psychiatric Association, Dr. Liu has contributed to the areas of cultural psychiatry, including the interface with religion and spirituality, psychiatric education, diversity and inclusion, mental health equity, and psychiatry in film. He has presented at every APA annual meeting since 1984, and from 2002 to 2019, he served on the APA Council on Minority Mental Health and Health Disparities. He was awarded the APA Special Presidential Commendation in 2002 and 2016 for his contributions to cultural psychiatry, and in 2020, he received the APA Distinguished Service Award. In 2008, the American Psychiatric Foundation awarded him an Advancing Minority Mental Health Award, and the Association for Academic Psychiatry awarded him its Lifetime Achievement in Education Award. In 2020, the Society for Study of Psychiatry and Culture awarded him the Lifetime Achievement Award. Dr. Liu, thank you for leading today's webinar. Well, thank you very much for that kind introduction. And I have no disclosures or conflicts of interest in this presentation today. Here are the learning objectives to define the five parts of the DSM-5 outline for cultural formulation and to apply it in the clinical assessment of patients with severely mental illness. Cite the 16 questions of the DSM-5 cultural formulation interview and also apply it. And then list the 12 supplementary modules of the cultural formulation interview and be able to apply them. So we're going to focus on two clinical tools in the DSM-5 that you can immediately use with all of your patients to optimize your diagnosis and your treatment plan by bringing cultural issues into the process. So this is something with all patients, not just racial, ethnic, minority patients, for an example. So I'm going to start just to lay the groundwork so we're all on the same page as to what is cultural competence and why should we care about it. Then I'm going to go over the cultural issues in DSM-5 with a little roadmap about where you will find it. And we'll focus on our two clinical tools and highlighting changes from DSM-4 in 1994 to DSM-5 because there were some very important changes that were made. Just to give you the historical background, the outline for cultural formulation did appear in DSM-4, but it appeared in Appendix I, the ninth appendix. So hardly anybody knew about it. And one of my purposes in life since that time has been to tell people that it exists and that it can be useful. And it was retained in the DSM-5 and revised. So I like this one-sentence definition of cultural competence from the Joint Commission, the ability of health care providers, clinicians, and health care organizations, systems. So you have clinical cultural competence, systems cultural competence to understand and respond. And that's very important. There's the understanding, but then there's the responding effectively. What are you going to do differently here? To the cultural and language needs, and language is explicitly mentioned here to highlight the importance of it for obvious reasons, brought by the patient to the health care encounter. So this is a day in and day out event. And so we need to really bring cultural competence into every aspect of our care. And this is my one slide, deeper dive into cultural competence. I see these as essential elements of the journey, meaning that these are all parts of the elephant. They're all important. And this is a journey. It's an ongoing, continuous learning process, CQI process. And we have an opportunity every day to deepen our experience here. So it has to start with yourself in terms of reflecting on your own cultural identity, values, prejudices, and biases. And we all have these things. And secondly, the attitude of humility, very important here, knowing the limits of your assessment and treatment knowledge and skills in this area. And this can all boil down to the motto that I'll mention throughout this presentation of ask, don't assume. Ask, don't assume. It's always good to ask the questions rather than jumping to conclusions. Next is the attitude of valuing diversity to acknowledge that it makes a difference in our clinical care and our assessment process, as opposed to saying that, well, diversity doesn't matter very much because I treat all my patients the same. And I provide equally quality care to everybody. And I treat everybody the same. That's just a shortcut response that cuts off really paying attention to this area. Next is ensuring safety about the power dynamics that result from cultural differences, meaning that we know in the patient-clinician relationship there is a power difference and that cultural differences can make this even more problematic. And I will illustrate that later in the talk. And then last is this vital element of responding to the cultural differences through adapting our assessment and treatment. So now I'm going to very, very quickly go through some landmark reports that are about 20 years old, but really provide the basis for the rationale for all of this. And so this first report came out looking at our health care system, saying that we need improvement. And they talked about six quality outcomes as goals. And I've just given you two of the six here that are relevant to my talk here today. One is, and again, I'm sure all in the audience here are fully aware of this, but just to reiterate patient-centered care, providing care that is respectful of and responsive to. So you see that, again, respectful of, understanding, and responsive to individual patients' preferences, needs, and values. And this is linked to culturally and linguistically competent care. And then equitable care, providing care that does not vary in quality because of social, cultural identity variables. And so this touches into health equity, of course, or reducing or eliminating disparities in care. These are very interrelated. The next report came out just a year later from the Institute of Medicine, now the National Academy of Medicine, which for the very first time documented racial and ethnic disparities in health care. So ethnic minorities receiving lower quality of care despite controlling for a number of variables. And they looked at why this might be the case. And there were system issues or systems cultural competence issues. But they also discovered clinical encounter factors involving clinicians that contribute to disparities. And so you see biases and prejudices can play a role in this. So this comes back to us, the clinicians, understanding our own biases. And so when we look at a deeper dive at this concept of biases, yes, there are intended, conscious, and explicit ones. And we need to recognize the unintended, the unconscious, and the implicit biases. So I'm sure many of you are familiar with the Harvard Implicit Bias Test, which you can access by just Googling that and learning more about this concept of implicit bias. And bias can be involving individuals based on a number of cultural identity variables that are listed here. That can be due to our own personal experience or even our professional training and disciplines. So for example, homosexuality, as we know, was classified as a mental disorder in the DSM-II until 1973. And the bias against religion and spirituality as a form of psychopathology pervaded most of last century. A third report, which documented for the first time mental health disparities for racial ethnic minorities. This is the famous report from the Surgeon General David Satcher on mental health, culture, race, and ethnicity. And again, documenting for the very first time these disparities. And the follow-up report to that was this book edited by Pedro Ruiz, the past president of APA, and Enel Prim, deputy medical director at APA at that time, which explored disparities in psychiatric care not only for racial ethnic minorities, but related to the other cultural identity variables and diagnoses and care settings that you see listed here. There are chapters on each of these areas. Now moving on to the roadmap here, cultural issues appears in section one, which is the introduction to DSM-V. And there's a cultural issues and a gender differences section there. And secondly, in section two, which is the bulk of DSM-V, in the narrative sections of some diagnoses, there are specific culture-related diagnostic issues and gender-related diagnostic issues sections. And the page number here refers to DSM-V. And so in the back, there's an index where it lists all of the diagnoses where there are these sections. I should also mention here that there is going to be coming out a DSM-V-TR, or text revision, I think most likely in 2021, in which the text, not the diagnostic criteria, but the texts are going to be updated, including these sections. So that would be important to look for. And then some of the diagnostic criteria for panic disorder, for example, changed as a result of the studies in cultural psychiatry. And then I do want to mention the other conditions that may be a focus of clinical attention or the V codes. Then in section three, there's a section of emerging measures, and there's a whole section on cultural formulation. And here's where we find our two clinical tools described. And then in the appendix, there is a glossary of cultural concepts of distress, which replaces the glossary of culture-bound syndromes that was in DSM-IV, and that term does not exist now in DSM-V. So here is an example of culture-related diagnostic issues for schizophrenia. This existed in DSM-IV, that we need to understand cultural factors, particularly when there are differences between the clinician and the individual. As an example, ideas that appear to be delusional in one culture, such as witchcraft, may be commonly held in another, and that in some cultures, visual or auditory hallucinations with a religious content, such as hearing God's voice, are a normal part of religious experiences. And then this last sentence here was added in DSM-V to give more description of what this is about. So this section, as you can see, is just a little stop sign, if you will, to ask, don't assume, you see. So when you say, well, do you hear voices, or the patient says, yes, I hear God's voice, before you say, that means auditory hallucination, that means a psychotic symptom, that means a psychotic disorder diagnosis, or a mood disorder with psychotic features, or substance abuse with psychotic features, before you go down that track, which we're all trained to do, quite understandably, is to ask, don't assume that, just check in, just ask, well, can you tell me more about God's voice? And the patient may say, well, I go to church every week, and during that religious ceremony, we hear God's voice, and so that sounds like that might be more related to the person's cultural background. I mean, of course, we need more information, but if the patient says, oh, yes, I do hear God's voice telling me to jump off the bridge, well, you see, that does move us more in the direction of psychopathology, and sometimes we have a situation where it is a combination of both. We may have a patient who does hear God's voice in a religious ceremony every week, and that is part of the person's culture, but is also hearing God's voice to telling him to jump off the bridge. So that's both, and that is a situation that does certainly happen, and it is our job as clinicians to do that assessment and differential diagnosis of the specific phenomenon in front of us. Now in terms of the other conditions that may be a focus of clinical attention, this is described in DSM-5. It's on page 715, and there's a little very brief header that describes this section, and I've quoted it here. This discussion covers other conditions and problems that may be a focus of clinical attention or might otherwise affect the diagnosis, course prognosis, or treatment of a patient's mental disorder. A condition or problem in this chapter may be coded if it's a reason for the current visit or explains the need for a test procedure or treatment. Thank you. Most important, the conditions or problems listed are not mental disorders, but they are here to provide a systematic way of documenting these issues. And I dare say that, you know, I believe that the V codes are really off the radar screen because they are not mental disorders, they're not billable, so, you know, why, like, pay attention to this section? And yet, I do think, I really do think that these V codes are distressing experiences that patients bring to us. Now these are the categories of the V codes, and under each of these categories, there are a number of different codes, specific codes, and, again, I dare say that many of our patients come in with multiple experiences like this, you know, we call this the social history, if you will, but there is a way of actually diagnosing these distressing experiences so that we bookmark it for the treatment plan, you see? This is a way of translating that information into the treatment plan. This is a possibility that I would like to suggest for all of you to consider. And so I do think that these V codes are like the tips of the iceberg above the waterline that are visible, but underneath the waterline are the social determinants of mental health, that those categories that we just saw there map well to a number of the social determinants of mental health. Now, this is a table or a figure from the work of Michael Compton and Ruth Shim. They wrote a book in 2015 published by Appy Press called The Social Determinants of Mental Health, and in that book, they had nine chapters on each on a social determinant of mental health. Now, in this latest rendition, they have 16, and they've added, for example, in the upper right exposure to the impacts of global climate change. You see that? I think that that's really very interesting. Now, if you look down at the bottom middle block, there's one called discrimination and social exclusion slash social isolation. So for that social determinant of mental health, which Compton and Shim wrote about in 2015, there is a V code that corresponds to that, and I don't have a slide for it, but I'll read it to you. This is on page 724 of the DSM-5. It's entitled Target of Perceived Adverse Discrimination or Persecution. This category should be used when there is perceived or experienced discrimination against or persecution of the individual based on his or her membership in specific categories, and it goes on to list a number of different cultural identity categories, and again, we may have patients coming in that are expressing feelings of hatred or discrimination. Certainly in the Asian American community, we're seeing that now, and obviously in the Black community, and so this is something that may be distressing for the patients. This is a way of actually coding that. Now here's another example of a V code, religious or spiritual problem, which I helped to actually get into the DSM-4 25 years ago to provide a differential diagnosis for distressing experiences that are not mental disorders. So for somebody who has lost his faith in God or feels God is punishing me for my sins or having a mystical experience or near-death experience that's become very distressing to them, these are ways that clinicians can be respectful of these experiences and not label them as psychopathological, as mental disorders, you see, but to address them, understand them differently so that we can work with them differently. Now moving on to our two clinical tools, the DSM-5 outline has five sections. The first four are four interrelated fields of information that we are asking the clinician to gather, and these are the cultural identity of the individual, the cultural concepts of distress, and what's in the parenthesis was the wording in DSM-4. Cultural concepts of distress is broader than cultural explanations of illness. And the third are the cultural stressors and supports in the person's life. The fourth field are the cultural features of the relationship between the individual and the clinician. And then the fifth section is the overall cultural assessment, meaning how do you put all of this information that you've gathered and how does that then impact your differential diagnosis and your treatment plan? That's the responsiveness, you see. That's where we're, this is not just a political correctness exercise. It is meant to be useful in your clinical work, and this is a tool to help guide you as to what are the areas to look at. Now the workgroup on cultural issues for DSM-5 that Roberto Luis Fernandez at Columbia University chaired, and I was part of that 30-person workgroup, felt it was important to help the clinicians gather the information for the outline for cultural formulation by providing them questions that they can actually ask the patients or the informants to gather this information. It was felt that the outline for cultural formulation by itself was hard to operationalize without giving the clinicians some help in terms of gathering the information. So hence, we have the cultural formulation interview, which is brand new in DSM-5. As you can see, there's a patient version and an informant version. And then there are 12 supplementary modules, which you can access by Googling this term, supplementary modules DSM-5. You'll come to a PDF that the APA puts out where we have 12 lists of questions concerning deeper dives along all of these areas that we see here related to the outline for cultural formulation. And in these last four modules involving specific patient groups that you may be working with, and here are more questions that you can ask to gather more specific cultural information for these patients. So I really recommend especially those last four supplementary modules to you. Now, this is what it looks like, the core CFI of the 16 questions in the DSM-5. This is what it looks like. And as you can see, it's not simply a list of the 16 questions, but rather, as you can see, there are two columns, a guide to the interviewer and the specific instructions. And it's like to help you here. And as you can see, the first question there is what brings you here today? So again, hopefully you're asking that question already. So you're already doing one of the 16. So now I'm going to go through the 16 questions chronologically and relate them back to the outline for cultural formulation because they're not in the same order. And the reason for that is we felt that it's better to start with a question like, what brings you here today, rather than a question like, tell me, can you tell me what's most important about your background or cultural identity? We felt that that would be kind of difficult to start there. So we first really start with the cultural definition of the problem. And what brings you here today, the patient may say wind illness. So then you would say, well, sometimes people describe to their social network their problem. How would you describe your wind illness to them? And what troubles you most about your wind illness? So problem is in brackets and caps because we want you to use the patient's words. And then we go into causes. Why do you think this is happening to you? What do you think are the causes of your wind illness? And what about your social network? What do they say are the causes? So these first five questions relate to part B of the outline for cultural formulation, the cultural concepts of distress. And in section three, this is all described. These are quotes from section three where this is all described. There are three subtypes. There are cultural syndromes, idioms of distress, and explanatory models. The idioms of distress are like the building blocks. Cultural syndromes is a clustering of the building blocks. And as you can see, we ask that we compare the severity and meaning of these distressing experiences in relation to the norms of the individual's cultural reference groups. So that's why we have those questions about the social network, to get a sense of context. And then finally, this section asks us to assess the coping and help-seeking patterns of professional as well as traditional alternative or complementary sources of care. Now, the CFI questions that pertain to this aspect of cultural concepts of distress are questions 11 to 15. So we'll see that a little bit later. And the other thing is that, as you can see, it's not just professional care, but also the religious or spiritual healer or the herbal medicine or the acupuncture. We want to hear all of the kinds of care that the patients maybe have used. Now, as I mentioned, in the appendix, there is this glossary of cultural concepts of distress that give you nine examples. So there are more than these. But these are just nine examples to just give you a sense about this idea. So here's a little table that describes this. In the first column to the left is the actual name that the patients may use. What brings you here today? Well, nervious, you see. And then in the middle, is it a cultural syndrome? Is it an explanation of illness? Or is it an idiom of distress? And some of these are related. So nervious is an idiom of distress. And that's a building block for a taqe de nervios. And in the far right column are regions in the world where we see these phenomenon. And of course, we are interested in this because people come from all over the world to the United States. Now, the next two questions in the CFI relate to the stressors and supports. Are there any kinds of support that make your wind illness better? And are there any kind of stresses that make your wind illness worse? So these two questions relate to part C. The stressors and supports. And this is a quote right from that section. And identify the key stressors and supports in the individual social environment, which may include both local and distant events. And the role of religion, family, and other social networks in providing support. Now, the key words here are the key stressors and supports, local and distant, and then religion, family, and other social networks. Now, what was in DSM-IV was religion and family. Other social networks was added. Now, this is a continuation that describes this further. Now, how do we look at this? Well, there are certainly interpersonal relationships involving religion, family, and social networks. That's one local, see, local sorts of thing. But the more distant ones, I would say, are the social determinants of mental health that we talked about before, and maybe related to those V codes that the patients are experiencing. Now, Pamela Hayes, in her book, Addressing Cultural Complexities in Practice, third edition now, has a chapter on culturally related strengths and supports. And again, the idea here is we're all interested in understanding, you know, what could be supportive of the patient. We're always looking for that in terms of ways of helping the patient. And by putting on the control lens, perhaps it enlarges the radar screen. We can see more. And these are just examples of things that we otherwise may not realize are important. So for some patients, extended families or religious communities, traditional celebrations and rituals are important. And we know how important involvement in political or social action groups are for some of our patients. And here, caring for animals, we know, is very important. For some people, it may be a place to pray and so on. So these are just ways of looking at that. Now, right, so here are the key books in this area. Again, the Compton and Shim book, The Social Determinants of Mental Health, the Pamela Hayes book, and I especially recommend the Monica McGoldrick book, that has 50 chapters, not only on Japanese families and Vietnamese families, but also Irish families, Italian families, and Russian families, and Irish families. So everybody, you know, everybody has some cultural aspects to think about. Now, the next three questions involve cultural identity. Cultural identity. So here is where we say, for you, what do you, is most important aspect of your background or identity? And how is this related to your problem? And are there any other aspects of your identity that you'd like to discuss? So this ties in with part A, the cultural identity of the individual. This is what we see in DSM-IV. So there's mention of race, ethnicity, and the issue of biculturality. You know, how much am I Chinese? How much am I American? And language. Now, very important, added in DSM-V is this sentence, which explicitly expands the list of cultural identity variables that we need to think about here. So, and this is not, this does not have everything. For example, gender is not here, or age is not here. But the idea is expanding the list. And so in Monica McGoldrick's book, Addressing Cultural Complexities in Practice, she uses that word addressing as an acronym for all of these cultural identity variables. Similar to the list we just saw there. But off to the right there is language in brackets, because there's just no L in addressing, you see. And so, and that's obviously an important one. And so, again, it's not, it doesn't cover everything, but it's a way of helping you recognize all of this. So that ultimately, cultural identity is not one of these cultural identity variables. And you can't tell someone's cultural identity just by looking at the person, because you have to ask them. You see, that's ask, don't assume. Because something else might be very important to them. And then is the concept of intersectionality. This is so important. So it's not just one of these, but it's the intersection of all of these. And here is a diagram from thinkculturalhealth.org. I'll give you the website later where you can find this diagram. This, again, you see the intersectionality of all of these variables. And how does that intersect with the environment and the health beliefs and practices that the person has? So you can see that intersectionality. That's the important thing to understand this person's cultural identity. Right. So ask, don't assume. As you can see, there are many different Asian subgroups and national origin doesn't define a homogeneous ethnic group. There are 54 distinct ethnic groups in Vietnam. Again, ultimately you need to ask because how the person sees their cultural identity is very important. Now the next questions, 11 to 15, deal with self-coping and past help-seeking, barriers to care. And here is where the rubber meets the road. What kinds of help do you think would be most useful to you at this time for your wind illness? And are there any other kinds of help that your social networks have suggested for you? Okay. So we ask this because this is most relevant now as we're thinking about the treatment plan is how are we going to, we need the input from the patients so that we can work with the patients here. So this gets back to part B where we had that section on coping and help seeking. I said we would come back to that in questions 11 to 15. Now we come to the last question of the CFI, which is this one about possible misunderstandings because of different backgrounds. And so have you been concerned about this and is there anything we can do to provide the care that you need? So this relates to part D. What's in bold was added in DSM-5. Language was added there for obvious reasons because communication is an important part of treatment. And this one, this sentence, which again I think relates very much to our current social scenario, that experiences of racism and discrimination in the larger society may impede trust and safety in the clinical diagnostic encounter. So we need to keep that in mind as a possibility. And that if you don't pay attention to this area, we could have problems in eliciting symptoms or misunderstanding things, and ultimately difficulty in establishing or maintaining rapport in the clinical alliance. This was added in DSM-5. So how do we operationalize this? So there's a three-step method and there's a one-step method that they complement each other, actually. So the three-step method is, one, understanding your own cultural identity. You've got to start with yourself. That's really important. This is not a spectator sport where we're just kind of observing the other person over there and we're not involved. No, we're very much involved. So we need to understand ourselves. And then compare the cultural identity of the patient to that of the clinician. So the way to do this, to just start to get the ball rolling, is left column are the cultural identity variables, age, race, ethnicity, gender, sexual orientation, religious or spiritual beliefs, socioeconomic class, and so on. The next column are the patient cultural identity variables. And then the far right column would be the clinician's cultural identity variables. So we start there to begin with as a way of looking at the similarities and differences. And then the third step here is assess how these cultural features can impact these different aspects of the therapeutic relationship. Now, we're always concerned about the therapeutic relationship and these aspects of the therapeutic relationship. Again, the idea is to put on the cultural lens to see if there are, to what extent, cultural elements of the relationship is affecting our ability to work together. So I'm going to give you four very concrete, very simple examples, just to make this clear. I am Chinese, I only speak English. A Chinese patient comes up to me and starts speaking in Cantonese, and obviously there's a language difference. That's the cultural identity variable. There's a problem in communication, and I need to respond to that by either getting a trained interpreter or referring the patient to a Cantonese-speaking psychiatrist. Second example, I'm a man, patient's a woman. First interview, patient seems very reluctant to give any information, and then at the end says I much prefer speaking to a woman psychiatrist. What do I do with that? Do I say patient is treatment resistant, passive, blah, blah, or do I say, well, can you tell me more? Ask, don't assume. And she says, finally, you know, well, I've had a really hard time with my husband, I don't really want to go into it, and I'd really rather see a woman. As it turns out, the patient has a very long history of sexual abuse and has trust problems talking to a man. Third example, I'm a liberal Democrat, I voted for Clinton, and in walks a man with a red cap on that says make America great again, and he looks at me and says, well, what country are you from? So here we have a difference in political orientation. And this is obviously causing problems in our relationship right off the bat. So biases can perhaps come from patients and not just clinicians. Last example, I'm an atheist. Well, what brings you here today? Oh, I've lost my faith in God, God is punishing me for my sins. Well, there we have a difference in, and I asked more you know well tell me about this and oh I've been going to church for 30 years and I read the Bible every day and you know I'm a real Roman Catholic, blah, blah, blah. So here's our difference in in religious commitment. How am I going to respond to this, you know, I obviously need to understand this difference and I need to be careful about counter transference, I, you know, as an atheist I could inadvertently be disrespectful of this patient which could then cause problems in the relationship, or I could just stay silent about this like, well, you know, God is not important to me so you know why ask the patient about it you know God and this is, you know, outside the realm of my work, and so I'm just going to ignore it. Well, the patient may still feel very disrespected. So that's why, you know, the entity of the V code of religious or spiritual problem believe is helpful because you could actually diagnose that. If you don't feel comfortable in doing the assessment, you can ask a get a consultation ask a chaplain or pastoral counselor to help with that assessment and and address that aspect of the patient's distress, so that the patient might participate in other forms of treatment here. I mentioned there are two methods, the three step method which I just went over the one step method is just to ask this question, what would help the clinician to provide optimal care. And so sometimes there are cultural identity matches that are very important. So language or gender the first two examples I gave, it might be very important that we have actual matches there. Other times it's less important, and that means increasing our knowledge and skills involving these areas that may that may be a way of improving our care. The last part of the outline for cultural formulation. As you can see, is it two issues one of differential diagnosis. We all want to make a accurate and complete diagnosis which starts with a complete differential diagnosis. And so we want to avoid misdiagnosis which can lead to mistreatment and things like not understanding the cultural concepts of distress inadequate relationship to gather history, and our own bias and so on that can affect our care. So, the ways to do this is is to review the culture related gender related diagnostic issues sections to help us with with this differential diagnosis. This can be descriptions of how prevalence or course or outcome can vary by culture or gender, and then also to review and add the codes that map to the social determinants of mental health, so that they can be addressed in the treatment plan. You see, And this is a comment from a APA resource document that we need to take into consideration patients culture religious spiritual personal ideals. In terms of treatment planning there's the process that the process of negotiating and managing treatment plan to maximize adherence and compliance. This is something we're concerned about every day with every patient, again put on the cultural lens, you know you may see cultural issues that may be important. And then the content. And so just to give you a quick examples here in terms of medications we know that genetics related to race and ethnicity can affect the pharmacokinetics, but also environmental issues, also age and gender can affect pharmacokinetics. So how do we put that into our thinking when we prescribe our medications, and also how do we combine medications with biological approaches like acupuncture terms of psychotherapy my deceased colleague and Asian mental health and Evelyn Lee used to say when treating traditionally the tiger bomb oil at the first interview, meaning those patients expect some kind of relief after the first interview. It's unspoken, but if you don't understand that expectation you don't meet it, the patients may drop out of treatment. And then we have the usual questions around what kind of therapy some patients may benefit from family assessment brief family therapy, because they're more family oriented in the way they see themselves. Also, how do we modify our therapy methods so for example their books now on culturally responsive CBT, and their books on analytic approaches, now that are incorporating cultural identity variables, and that question of what therapist characteristics would facilitate or hinder treatment. And then finally the social cultural approaches keep in mind family, religion, spirituality, other social networks, and how do we address the social determinants of mental health and this whole concept of structural competency to complement cultural competency structural competency to address the social determinants of mental health. So books to help you. You're learning here, the clinical manual of cultural psychiatry now in its second edition edited by Russell limb, which is all about the outline, and the CFI handbook edited by Roberto Lewis Fernandez. There's a wonderful online training module on the CFI at these at this website. This is at the Columbia University Center for excellence culture, cultural competence the state of New York funds to cultural competence centers and ones that Columbia here the others that Nathan Klein. Also, I really recommend this e learning program for health professionals and a specific one for behavioral health professionals came online in May of 2019, and I was part of that behavioral health module advisory panel. If you go to this website. You can access that has five CE credits for free for many disciplines. And this is sponsored by the Office of Minority Health, based on the class standards that came out in 2001 originally and has been enhanced in 2013. So thank you very much. Thank you, Dr Lou for that very interesting and thorough presentation. Dr Lou it looks like Amy's having some issues right now. This is Sydney I work at the American Psychiatric Association as well and partner with the SMI advisor team. And, and that is that when a client wants a therapist more like them, but one is not currently available should we go deeper and see if we can be of help. We just try the best we can I think you explained the situation and, and, and, and certainly just work with the patient as best you can. I mean, we're always dealing with, you know, contingencies and all of that but I think the important thing is just to be aware of these issues and sometimes when the patients request, you know, like the woman patient requesting a woman psychiatrist, we, you know, we need to, we need to try to understand that more and not just take a doctrinaire stance that. No, we don't change therapists and all of that. I think that that allow for some flexibility when indicated. Yes. Next question. Wonderful. The next question that has come in is, do you have any tips for working with language interpreters. Oh yes I mean that's a whole subject unto itself. In terms of training, working with interpreters, I know there are. There. Yeah, I think it's very important it's very very important especially, especially when if your clinic has a large number of patients with limited English proficiency I think it's very important that the clinic schedules trainings to help clinicians actually do that. It's. I mean some very quick tips are for example and make sure you know who the interpreter is in terms of their training level, not only in health but but specifically mental health, and also in terms of, you know, the background experience of the interpreter. Secondly, it's always helpful to have a pre meeting with the interpreter to kind of outline what you're trying to find out about and a post meeting to rehash what what what the session was like, of course, we're always so pressed for time that those things The thirdly is to avoid at all costs using family members, especially children or adolescents because of family dynamics, but again, you know, we can't take a doctrinaire stance when there's nobody else available but we, that should be a very last resort kind of a desperation move rather than the first thing you think about. And then in terms of translation itself you know sometimes a word for word translation is vitally important. At other times a summary translation may be sufficient, but you can't have the. You can't have the patient be talking for two minutes and then the interpreter turns to you and gives you a one sentence summary. You know, maybe there was some very important things said in the two minutes and, you know, so you have to be mindful of that. Next question. Thank you, Dr. Lou. We're going to wrap up now.

Dr. Amy Cohen

DSM-5 Outline for Cultural Formulation

Cultural Formulation Interview

SMI Advisor program

Dr. Francis Liu

Cultural competence

Cultural concepts of distress

Social determinants of mental health

Language interpreters