“Is this culture, personality, or pathology?” Georgina, a bright, ambitious and curious clinician started with this question, as we met together. “Is this culture, personality, or pathology,” I repeated, allowing her enough time to collect her thoughts. “I already know her constant somatic complaints are related to her culturally acceptable way of expressing her emotional pain. I know it can also be part of her personality, her character structure, or her temperament. I also know that her somatic complaints may be part of a whole separate pathology, possibly Somatization Disorder, bordering on overvalued ideas, or obsession/compulsion and even psychosis. But which is it? And given the strong cultural component, how do I tease out the difference?” Georgina added this in a serious tone.
In three previous articles in this series, I described the following seven factors that illustrate the lies about cultural competency:
It misses the point
It leads to paradoxical effects
It leaves out the real why
It is far from real
We can do better
I also stated that in subsequent articles that I will describe what is missing about cultural competency, and this current article addresses it.
Here are three components that are missing in cultural competency, as it is being taught and practiced today:
1. Cultural competency fails to do justice to culture:
Culture is not about “minority” or “majority.” Culture is about culture, which includes subcultures, and it should lead to curiosity to a sense of wanting to understand, to appreciate, and to join in, in order to serve better, instead of unintentionally leading to stigma, fear of making mistakes, and fear of being misperceived. Cultural competency also fails to do justice to culture because there is the danger of putting everyone in one box, which in turn leads to more stigmatizing, more assumptions, more mistakes, leading to more frustrations, fear, resentment, and the cycle goes on. (Please note definitions on culture in the first article, entitled: The Lies About Cultural Competency: 2 Main Reasons)
2. Cultural competency fails to appreciate subcultures:
Cultural competency, not only fails to do justice to culture, it also fails to appreciate or take into account subcultures. My father is Jamaican, my mother is Columbian and I was adopted by a Jewish mom,” explained Mike, a patient and client at the Hope Clinic. Subcultures also go beyond ethnicity. They include all the family nuances, the different types of religious backgrounds, the socio-economic influences, and the types of neighborhoods, to name a few. Subcultures are as important as cultures, and an important component in cultural competency.
3. Cultural competency leaves out several populations:
“Now that I no longer use drugs or hang out with my friends, I don’t know who I am anymore. All my life I knew myself as an addict. Who am I now?” asked Mike. “I just got released from prison, 3 weeks ago after serving a 25-year bid. I don’t know how to take the subway, or the bus, or go anywhere anymore. All I know is the prison culture,” said Jahid, who spent both his 20s and his 30s in prison, both of his two most important developmental stages, according to Erickson. “All I know is how to survive. I only know the street. I saw my mom being raped in front of me before being killed. I received the news that my father was jumped and killed in prison before completing his 15-year bid. My only brother, who was there to protect me, got killed in a bad drug deal. I have had to protect myself, I had to join a gang, I had to survive, and all I know is the street,” explained Sonia during an initial psychiatric assessment.
“Is this culture, personality, or pathology?” Georgina, a bright, ambitious and curious clinician started with this question, as we met together.
In summary: Paying attention to culture is essential, but we need to understand that cultural competency, as it stands today, has major issues and needs to be rectified. Three of the missing components of cultural competency are as follows: (1.) It fails to do justice to culture; (2.) It fails to appreciate subcultures; and (3.) It leaves out several populations.
For more in this series of articles, check below!
Dr. Sidor is quadruple board certified in psychiatry, with vast clinical, teaching, supervision, mentorship, and management experience. He also has extensive experience in public speaking, leadership, business, and research, in addition to a passion for program development and project management. His overall goal is to empower all health care professionals throughout the United States and globally, towards ensuring the continuity of excellent patient care, while balancing the need to take care of themselves. Dr. Sidor is the main instructor for the SWEET Institute, and he is currently an Assistant Professor of Psychiatry at Columbia University. He is also the past Medical Director and Chief Medical Officer for CASES (Center for Alternative Sentencing and employment Services), where he continues to see patients and consult on challenging cases. He speaks and writes fluently in six (6) languages—French, English, Spanish, Portuguese, Creole and Italian.
Fassin, Didier; Rechtman, Richard (2009). The Empire of Trauma: An Inquiry into the Condition of Victimhood. Princeton.
Alarcón AD, Becker AB, Lewis-Fernandez R. Issues for DSM-V: the role of culture in psychiatric diagnosis. J Nerv Ment Dis. 2009; 197:559–560.
Patel V, Saraceno B, Kleinman A. Beyond evidence: The moral case for international mental health. Am J Psychiatry. 2006; 163:1312–1315.
Alarcón RD. Bio-cultural connections in psychopathology. Presented at the First World Congress of Cultural Psychiatry, Beijing. 2007.
Alarcón, R. , Westermeyer, J. , Foulks, E. , et al. (1999) Clinical relevance of contemporary cultural psychiatry. Journal of Nervous and Mental Disease, 187(8), 465–471.
Bebbington, P. , Feeney, S. , Flannigan, C. , et al. (1994) Inner London collaborative audit of admissions in two districts. II: Ethnicity and the use of the Mental Health Act . British Journal of Psychiatry, 165, 743–749.
Benedict, R. (1934) Patterns of Culture (Boston: Houghton Mifflin).
Kirmayer IJ. Cultural evaluations in the response to psychiatric disorders and emo-tional distress. Soc Sci Med. 1989;29:327–339.