Promoting Mental Health Care Engagement: A Family-Level Cultural Approach 

By Mandeep Kaur, M.D., F.A.P.A., D.F.A.A.C.A.P., General, Child & Adolescent Psychiatrist, Cape Fear Valley Medical Center

Megan Blanton, MS, Graduate Student, Clinical and Counseling Psychology Ph.D Program, University of South Alabama

Ana-Maria Balta, D.O., General Psychiatry Resident, Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School

Mental illness presentation and health-seeking behaviors are influenced by patient culture¹. Often, within an identified ethnic, racial, or geographic cohort there are established cultural norms that the individuals share. Because of this, attempting to understand an individual patient by applying broad generalized knowledge about different cohorts can be ineffective. Adopting a family-level cultural formulation approach is very useful in promoting mental healthcare engagement as exemplified by the following clinical vignette.

A 14-year-old boy, K, immigrated to the U.S. with his parents two years prior to presentation because of a political insurgence in their home country. During the year prior to presentation, K’s parents noticed that he became increasingly isolated, angry, and resistant to attending school. The school offered their usual supports, however, K’s school attendance remained inadequate. Thus, referrals to Child Protective Services and subsequently to an outpatient adolescent psychiatry clinic were made. On psychiatric evaluation, K’s symptoms included depressed mood, anhedonia, social withdrawal, irritability, anger outbursts, poor appetite, and poor sleep indicating diagnosis of Major Depressive Disorder. Post-traumatic stress from exposure to political instability and possibility of immigration trauma were ruled out. Marginalization, defined by low identification with the host culture along with one’s culture of origin, was also explored². However, based on K’s relative ease with English acquisition, acceptable academic performance during the initial semesters, and reported circle of friends, marginalization was ruled out.

Despite medication trials, individual and family therapy, minimal improvement was noted. His parents had difficulty in applying the recommended behavior management techniques, e.g., use of contingency management plans. Medication adherence was also poor. After several sessions, his parents disclosed that K’s mother had been diagnosed with cancer within the past year and was undergoing treatment. When asked about K’s response to his mother’s diagnosis, his parents revealed that they had not shared this with K. However, over the course of therapy, the clinician discerned that K had overheard his parents discussing this in their small apartment. The parents never discussed the mother’s diagnosis with K since discoursing personal health issues with children remained taboo due to embarrassment in the family’s culture.

After acquiring this information, clinicians concluded that the cultural norm of passive parenting, besides the additional stress of the mother’s cancer diagnosis and treatment, were crucial reasons for his lack of progress. K’s new treatment plan involved clinician facilitated intra-familial communication. K was enrolled in a day treatment program where he continued his education and received therapy. Gradually, improvement was noted in K’s psychosocial functioning, correlating with the increased communication within the household.

Understanding both patient and provider culture is vital for effective outcomes

The above vignette may be a familiar experience to clinicians who work with culturally diverse patients: assessment targeted at identifying symptom onset, intervention designed to alleviate identified symptoms, confusion when it does not work, and eventual discovery of important missed cultural factors.

One way to ensure that clinicians are not missing data during intake and then filling in the gaps with their own culturally based assumptions is to utilize person-centered assessment using a structured interview such as DSM-5 cultural formulation interview (CFI). Composed of 16 open-ended questions this assessment can be administered in about 20 minutes by a trained clinician³. The CFI includes questions such as, “What do you think are the causes of your [PROBLEM]?” and “Are there aspects of your background or identity that make a difference to your [PROBLEM]?” Such questions would have provided K with opportunities to disclose that he had overheard his parents discussing his mother’s diagnosis and revealed the communication dynamics in the family. Administering these questions to K’s parents would have given clues that contingency management plans were not a good fit for this family (e.g., K’s mother was exhausted from cancer treatment) or cultural practices (e.g., K’s parents traditionally did not assume an assertive parenting role).

In addition to considering the role that patient culture plays in mental health care engagement, it is equally important to consider the role that clinicians’ cultural beliefs play. This ability to critique one’s beliefs and examine one’s cultural identities is a practice referred to as “cultural humility” by the National Institutes of Health. Failure to practice cultural humility can cause clinicians to unconsciously treat patients differently based on race or other cultural factors in a phenomenon known as implicit bias⁴. A nationally representative study reported that Hispanics, Blacks, and Asians are significantly more likely than Whites to feel that their doctors look down on them and the way of their living⁵. Therefore, current cross-cultural education is moving beyond traditional cultural sensitivity and multiculturalism training and aims to build cultural humility among healthcare professionals.

Increasing healthcare system capacity for cultural humility

Cross-cultural education efforts such as training in assessment protocols such as the DSM-5 CFI³, the Cultural Formulation assignment model⁶, and curricula involving cultural humility-focused participatory learning activities⁷ are emerging strategies that promote effective cross-cultural care. Additionally, utilizing cultural humility focused participatory learning activities among medical residents (including home visits) has been found to increase attentiveness to their patients’ perspectives and social context⁸. Even an hour of training on the CFI has been shown to significantly improve psychiatric residents’ self-reported cultural competence³. Finally, studies have shown that providing spiritually integrated care is beneficial⁹. Therapists may suggest seeking out communication with patients’ religious leaders to promote communication and trust in the treatment process.

Broadly, tailored approaches to increasing healthcare engagement and promoting intra-familial communication is vital. Healthcare providers need to become informed of their patients’ family values, establish trust to promote open discourse, and provide educational material in their native language. With these approaches, healthcare professionals can increase patient engagement and lessen the cultural and ethnic disparities in health-seeking.

Reference List

1. Gopalkrishnan N. Cultural Diversity and Mental Health: Considerations for Policy and Practice. Front Public Health. 2018;6:179. Published 2018 Jun 19.

2. Fox M, Thayer Z, Wadhwa PD. Assessment of acculturation in minority health research. Soc Sci Med. 2017;176:123-132.

3. Jarvis GE, Kirmayer LJ, Gómez-Carrillo A, Aggarwal NK, Lewis-Fernández R. Update on the Cultural Formulation Interview. Focus (Am Psychiatr Publ). 2020;18(1):40-46.

 4. FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare professionals: a systematic review. BMC medical ethics, 18(1), 19.

5. Johnson, R.L., Saha, S., Arbalaez, J.J., Beach, M.C., Cooper, L.A. (2004). Racial and Ethnic Differences in Patient Perceptions and Cultural Competence in Health Care, 19, 101-110.

6. Tormala, T. T., Patel, S. G., Soukup, E. E., & Clarke, A. V. (2018). Developing measurable cultural competence and cultural humility: An application of the cultural formulation. Training and Education in Professional Psychology, 12(1), 54.

7. Juarez, J. A., Marvel, K., Brezinski, K. L., Glazner, C., Towbin, M. M., & Lawton, S. (2006). Bridging the gap: A curriculum to teach residents cultural humility. Family Medicine-Kansas City, 38(2), 97.

8. Williams, R. (1999). Cultural safety—what does it mean for our work practice? Australian and New Zealand journal of public health, 23(2), 213-214.

9. Pargament, K. I. (2011). Spiritually integrated psychotherapy: Understanding and addressing the sacred. Guilford Press.