Cognitive cultural competence

Cognitive cultural competence, otherwise known as “knowledge,” involves awareness of the various ways in which culture, immigration status, and processes of racialisation impact psychosocial development, psychopathology, phenomenology of illness, and therapeutic transactions. For instance, it has been shown that the experience of depression varies between cultures and can show itself as feelings of sadness, guilt, shame, or persecution, and that it can be somatised in different ways [Reference Radjack, Bossuroy, Camara, Touhami, Ogrizek and Rodriguez50]. Diverse experiences may not only be experienced but also expressed in different ways, for example, through different idioms of distress. Idioms of distress may include narrative, symbolic, and non-verbal ways of expressing ways of referring to a specific kind of psychological experience, like depression. Explanatory models may differ across cultural groups, for instance, in some cultural traditions, psychotic symptoms may be interpreted in relation to spirits or other seemingly supernatural forces [Reference Adeponle, Groleau and Kirmayer27].

It is not only symptom presentation that varies, but the way that patients can make themselves understood to clinicians also relies on their understanding and experiences of (mental) health terminology and willingness to talk about themselves in a language that can be interpreted as pathologising and stigmatising. A cultural perspective on medical knowledge involves an understanding that psychiatric conditions are sociocultural constructs as much as they are medical conditions. Diagnosing personality disorders in different cultures, for instance, requires an awareness of acculturative tensions and clashes which, depending on other personality traits, can affect different types of behaviours, which may seem unusual or excessive but are not necessarily indicative of psychopathology [Reference Williams, Rouleau, La Torre and Sharif8, Reference Jani and Johnson51]. The ICD-11 diagnostic requirements for personality disorders authoritatively underline these studies by stressing the requirement for “knowledge of normative personality function for the sociocultural context, variations in cultural concepts of the self, and evidence for consistent traits and behaviours across time and multiple social contexts” [52]. The ICD-11 gives an example that children in more collectivist cultures might be perceived to be dependent in their attachment styles in comparison to more individualistic cultures, whose cultural inclination towards self-involvement may, in turn, be read as narcissistic by collectivist cultures.

Cultural attitude

Cultural attitudes are unquestioned assumptions and beliefs that colour practitioners’ knowledge, views, and behaviour. Intercultural work requires psychiatrists to challenge their own perceptions of “reality,” explore their own cultural identity, conventional wisdom, prejudices, and biases, reflected in the way they look, their religion, life habits, title, or possible sociocultural message linked to their name. Cultural attitude can also be seen as a moral, social, and local reflection of one’s position and the ability not to assume that one’s position is “normal” [Reference Chiarenza, Horvat, Lanting, Ciannameo and Suurmond48]. One important aspect is that of cultural counterference, which can be described as the clinician’s thoughts, feelings, and attitudes that come up in relation to a patient’s perceived cultural “otherness.” Intercultural skills in this context can be understood as building a therapeutic relationship with a “culturally different” patient, and the ability to adapt diagnosis and treatment in response to cultural differences between the psychiatrist and the patient [Reference Bhugra53, Reference Bhugra54]. (Trans-)cultural competencies are important to ensure the transferability of psychiatric expertise between different cultures and national standards.

Cultural sensitivity

Cultural sensitivity implores clinicians to create an open and safe environment in which patients feel sufficiently comfortable to explore difficult and painful ideas and emotions [Reference Qureshi, Collazos, Ramos and Casas55]. Cultural sensitivity can go hand in hand with cultural empathy and insight, the ability to actively listen to a patient’s experiences of illness within the context of their culture and acculturation processes. As an example, cultural sensitivity might pay attention to how patients’ transnational and multi-generational migration experiences can lead to “cultural bereavement” [Reference Eisenbruch56] – a perceived loss of the familiar language (especially colloquial and dialect), attitudes, values, social structures, and support networks that occurs when moving from one cultural and social setting to another. Cultural sensitivity might then require an open narrative inquiry into roles of religious or natural symbols and images, functions of elders, and cultural rites and rituals [Reference Radjack, Bossuroy, Camara, Touhami, Ogrizek and Rodriguez50]. In consequence, on the patients’ side, cultural sensitivity can create cultural safety, the feeling that one’s culture is the experience of feeling that your cultural identity is recognised, respected, and nurtured.

Cultural humility

Another concept that has grown in prominence over the last ten years is that of cultural humility, which can be understood as the de-centring of the health care professional as the only or “real” expert in the room. As such, it is an integral part of patient-centred cultural competence training [Reference Carballeira Carrera, Levesque-Daniel, Radjack, Moro and Lachal29, Reference Kirmayer, Fung, Rousseau, Lo, Menzies and Guzder39]. Various aspects are involved in showing cultural humility: (i) a continuous commitment to self-reflection and self-critique, (ii) a conscious addressing of power imbalances between patient and clinicians as well as different occupational groups within the wider care sector, (iii) the effort to meaningfully engage in non-paternalistic partnerships [Reference How, Kho, Rodríguez and Shim17]. On the side of the supervisor, this might require deferring to a trainee’s specific skills, knowledge, and immigration experiences as long as that is not done in a tokenistic way [Reference Kirmayer, Fung, Rousseau, Lo, Menzies and Guzder39].

Asking questions with a curious mind, seeking to engage with doubt and uncertainty, and not settling for simple explanations are other hallmarks of cultural humility. This decentring must go hand in hand with a critical reflection of “Western” medicine and an openness to value the wisdom presented in communities and ancient traditions, including religion and spirituality [Reference Bell, Sandage, Morgan and Hauge57, Reference Kirmayer, Andermann, Fung, Guzder and Jarvis58].

Structural competence

Another addition to the understanding of cultural competences is that of structural competences. Some commentators go as far as suggesting a complete shift from culture to structure in competence frameworks [Reference Hansen, Braslow and Rohrbaugh41, Reference Ortega and Müller59, Reference Martinez-Hernaez, Bekele, Sabariego, Rodriguez-Laso, Vorstenbosch and Rico-Uribe60]. Structural competences require a political commitment to working towards human rights, social justice, and health equity by tackling the root causes of poor mental health and wellbeing. Most importantly, they require clinicians to develop an understanding of the social determinants of health, for instance, immigration status and housing.

Theoretical understanding

A final element of cultural competence training is grappling with theories and concepts that have largely evolved in the Social Sciences and Humanities but also in health-related disciplines such as Medical Anthropology, Public Health, or Social Epidemiology [Reference Aggarwal61]. These include theoretical understandings of racism and intersectionality, both laid out in section Critical engagement: cultural competencies in dialogue of this guidance.

Cultural competences in the curriculum: a collaborative process

In a scoping review on the topic of cultural competences in medical education, Gruner, Feinberg [Reference Gruner, Feinberg, Venables, Shanza Hashmi, Saad and Archibald64] identified that the most common learning objectives included access to care barriers, social determinants of health for refugees, cross-cultural communication skills, global health epidemiology, challenges and pitfalls of providing care, and mental health; each of which requires a systems approach to teaching and thinking.

In another systematic review of cultural competency training for psychiatry residents and mental health professionals [Reference Venkataramu, Vajawat, Raghuraman and Chaturvedi7], the authors draw out, compare, and analyse various training models in cultural competency training across their 14 included studies, grouping them as: active/passive/mixed; group training/individual training. They find that in general active methods of training, including for instance documentary film, video demonstrations, case vignette discussions, and various case and group formats, as well as mixed training, showed better outcomes than more passive learning methods, such as reading or lectures.

Chu and colleagues [Reference Chu, Wippold and Becker3] found in their systematic review that the most common types of instructional categories in training are lectures (89.2%), discussions (86.5%), or assignments and exercises (e.g. presentations or privilege walk, 59.5%). More hands-on, practical instructional tools were much less common, though (e.g. clinical experience: 16.2%; modelling: 13.5%).

In terms of designing the cultural competence curricula, Kirmayer et al. [Reference Kirmayer, Fung, Rousseau, Lo, Menzies and Guzder39] stress that cultural competence training needs to be ongoing and recommend a combination of theory lectures and rotation (of 3–12 months) in three major domains: direct patient contact, consultation with referring clinicians, and outreach to community referral sources, including a mix of cultural consultation, community consultation, short-term treatment of refugees and survivors of torture, child and family assessment and interventions, as well as cultural psychiatric research.

The Canadian Psychiatric Association shows useful core competencies and didactic principles in their updated guideline for cultural psychiatry. In comparison to an older version, where Kirmayer, Fung [Reference Kirmayer, Fung, Rousseau, Lo, Menzies and Guzder40] identified the following as core themes in a cultural psychiatry curriculum: culture and health, culture, illness and psychopathology, culture in clinical practice, and culture and health care policy, services and systems; now it is stressed that cultural competences cannot be readily taught in a classroom but are rather experiential learning and a process of reflection, often in a group setting [Reference Kirmayer, Fung, Rousseau, Lo, Menzies and Guzder39] and for all career stages, not only residents [Reference Corral, Johnson, Shelton and Glass34].

Teaching competence among educational leaders and peers is a key prerequisite for the effective delivery of cultural competence training. For instance, culturally competent didactics should include elements of peer learning and take into account different learning styles, some of which may be due to different cultures of learning and education, as well as approaches in different disciplines [Reference Kirmayer, Sockalingam, Fung, Fleisher, Adeponle and Bhat65]. One such training modality may be the interdisciplinary case discussions as outlined by Rousseau, Johnson-Lafleur [Reference Rousseau, Johnson-Lafleur, Papazian-Zohrabian and Measham66], here the authors explain how they critically implemented the CFI into their everyday practice. Culturally competent clinical supervision needs to integrate and continuously reflect upon learnings in everyday clinical practice on a regular and routine basis [Reference How, Kho, Rodríguez and Shim17, Reference von Lersner, Baschin, Wormeck and Mosko38]. Training in cultural competences must be seen as a continuous and never-ending process.

Recent publications have underlined the importance of pairing training in cultural competences with awareness and anti-racism training built into an ethics of accountability and continuous reflection on power differences between different social and cultural groups [Reference Kirmayer and Jarvis14]. Cultural competences may also be implemented in a larger advocacy framework, whereby “doctors can and must speak on behalf of all those who may not be able to speak for themselves” [Reference Bhugra67], again highlighting the ethical importance of using one’s privilege for good.

Cultural formulation interview

The CFI of the DSM-5, originally developed in 2013 by the American Psychiatric Association (APA), offers a basic approach of understanding the cultural context of a patient’s experience of illness, this being essential for effective diagnostic assessment and clinical management, and has been reviewed and tested widely [Reference Jones-Lavallée, Bernard, Taing and Leanza68]. Since then, it has been translated and implemented in a variety of cultural settings [Reference Jones-Lavallée, Bernard, Taing and Leanza68, Reference Jarvis, Kirmayer, Gomez-Carrillo, Aggarwal and Lewis-Fernandez69]. Research indicates that the CFI’s open-ended questions can establish a patient-centred approach, centring patients’ opinions, perceptions, and experience, thereby allowing them to better build their own models of illness [Reference Aggarwal, Jarvis, Gomez-Carrillo, Kirmayer and Lewis-Fernandez70]. It is a vital element to decrease or avoid mistrust and build a strong therapeutic alliance [Reference Aggarwal, Jarvis, Gomez-Carrillo, Kirmayer and Lewis-Fernandez70]

The CFI consists of an interview protocol with 16 semi-structured questions, taking around 20 minutes, with a training time of around one hour [Reference Jarvis, Kirmayer, Gomez-Carrillo, Aggarwal and Lewis-Fernandez69]; the questions refer to four domains of assessment: Cultural Definition of the Problem, Perceptions of Cause, Context and Support, Cultural Factors Affecting Self-Coping and Past Help Seeking, and Cultural Factors Affecting Current Help Seeking [71].

Since the publication of the original guidance document in 2015, the CFI has been implemented and tested globally [Reference Aggarwal, Jarvis, Gomez-Carrillo, Kirmayer and Lewis-Fernandez70] and has proven itself as a useful framework for culturally sensitive psychiatric care in various settings [Reference Jarvis, Kirmayer, Gomez-Carrillo, Aggarwal and Lewis-Fernandez69, Reference Aggarwal, Jarvis, Gomez-Carrillo, Kirmayer and Lewis-Fernandez70, Reference Aggarwal, Lam, Castillo, Weiss, Diaz and Alarcon72]. Using the CFI, psychiatrists may obtain information during the mental health assessment about the impact of culture on key aspects of the patient’s clinical presentation and care, making it a critical tool to master the cultural formulation of clinical cases [Reference Corral, Johnson, Shelton and Glass34]. The CFI has also been found to facilitate the identification of depression diagnoses amongst migrants [Reference Wallin, Galanti, Nevonen, Lewis-Fernández and Bäärnhielm73].

In contrast to previous versions, the CFI in the DSM-5 includes more sociologically minded and structurally thinking question prompts like “Has anything prevented you from getting the help you need – for example, cost or lack of insurance coverage, getting time off work or family responsibilities, concern about stigma or discrimination, or lack of services that understand your language or culture? What got in the way?” In successful implementations, specifically trained staff, like social workers, assess these more structural stressors and, if desired, refer patients to transportation vouchers, housing, food stamps, or vocational training [Reference Aggarwal, Chen and Lewis-Fernández74]. Assessment by parties other than the clinician can be a useful way to make the implementation and training of the CFI feasible.

However, the CFI has not gone uncriticised: a qualitative study in Denmark [Reference Lindberg, Carlsson, Kristiansen, Skammeritz and Johansen75], for instance, found that mental health professionals experienced distance, “othering,” and discomfort in the encounter with patients, critically highlighting a potential risk of stereotyping. Other critical reviews [Reference Jarvis, Kirmayer, Gomez-Carrillo, Aggarwal and Lewis-Fernandez69, Reference Lewis-Fernandez, Aggarwal and Kirmayer76] suggest that the CFI may be more difficult to conduct with patients who have severe symptoms and that, worse, it may also lead to racist stereotyping [Reference Jarvis, Andermann, Ayonrinde, Beder, Cenat and Ben-Cheikh12]. Understanding psychopathology and formulating psychiatric diagnosis as part of the CFI could be facilitated by a multi-dimensional approach, more than by a categorical approach [Reference Adeponle, Groleau and Kirmayer27, Reference Oher, Demjaha, Jackson, Morgan, Dazzan and Morgan77, Reference Braca, Berardi, Mencacci, Murri, Mimmi and Allegri78].

Practices and tools for cultural competences, such as the DSM-5 CFI or case-based learning, have been deemed problematic in that they may lead to stereotyping, meaning that if a specific experience was found to be true for one patient of a specific culture, that truth is then applied to other patients believed to belong to the same culture [Reference Jarvis, Andermann, Ayonrinde, Beder, Cenat and Ben-Cheikh12, Reference Carballeira Carrera, Levesque-Daniel, Radjack, Moro and Lachal29, Reference Radjack, Bossuroy, Camara, Touhami, Ogrizek and Rodriguez50, Reference Jarvis, Kirmayer, Gomez-Carrillo, Aggarwal and Lewis-Fernandez69]. In their study on implementing the CFI in Canada, Rousseau and colleagues [Reference Rousseau, Johnson-Lafleur, Papazian-Zohrabian and Measham66] posit that interdisciplinary case discussion seminars are a useful technique to avoid stereotyping and sensitise CFI-interviewers towards in-group differences and multiple levels of diversity (individual, disciplinary, and interinstitutional), underlining that cultural formulation is always relational and possibly just a snapshot taken in a moment in time.

Use of interpreters and cultural brokers

Collaboration with trained interpreters, cultural brokers, or transcultural mediators [Reference Ogrizek, Moro, Bouznah and Lachal79] is an integral part of cultural competences. Clinicians should be trained in cross-language interviews and when interacting with the interpreters and be aware that there is no guarantee for complete understanding. Patients need to be empowered when they do not have proficiency in the languages spoken by the clinicians [Reference Skammeritz, Sari, Jimenez-Solomon and Carlsson80]; doctors need to act as advocates helping patients enforce their legal rights to interpretation services.

Linguistic abilities are a massive barrier to accessing care; for instance, the communication of distress in the face of language barriers can be a significant reason for non-engagement, increased levels of dissatisfaction, and drop-out. The idiom of distress in which patients communicate with psychiatrists can vary considerably across cultures and languages. We know that many languages do not have equivalent words to describe various mental disorders. For example, the word and notion of “depression” do not exist in all cultures, even though sadness, unhappiness, and other symptoms can be described and verified. Presenting with somatic symptoms, like sleep disturbances – a common symptom for depression in the Black community [Reference Perez, Melkus, Wright, Yu, Vorderstrasse and Sun81] – may delay diagnosis and treatment and can carry with it the risk of unnecessary clinical investigations.

Another challenge in successfully working with interpreters is the lack of common criteria and standards across and within Europe, and the fact that hiring agencies have no incentives to enforce those requirements that exist [Reference Frankova, Scheeres, Menculini, Cikrikcili, Matei and Fellinger15]. And although service providers are required by law to provide sufficient interpretation services, interpreters of more unique languages or dialects are often hard to get by and require longer waiting periods. Too often, their cost is not reimbursed, even though they are very cost-effective in the long run [Reference Brandl, Schreiter and Schouler-Ocak82]. Moreover, in out-patient care, the extra time required for interactions with qualified interpreters is not compensated, and interpreters, especially those for less common languages, are often booked out, requiring long waiting.

Although ad hoc solutions like non-professional translators (such as family members, hospital staff members) or the use of open access translation tools, like Google Translate, can be very helpful in urgent situations, relying on such informal sources can have a negative impact on medical treatment due to erroneous translation in the form of omissions, additions, or indeed changes to the initial message, not to speak of the emotional strain on those involved. Working with language interpreters and cultural brokers, if available, seems to come with clear advantages and improved treatment outcome in terms of quality and patients’ satisfaction [Reference Bauer and Alegría83].

In practice, however, Frankova and colleagues [Reference Frankova, Scheeres, Menculini, Cikrikcili, Matei and Fellinger15] challenge that working with interpreters is universally good. In their survey of clinicians working with forcibly displaced patients (FDPs), they found that although half of the respondents felt confident working with an interpreter, paradoxically, those who felt most confident working with FDPs felt less confident working with interpreters, although reasons for this and its effects on quality of care remain unclear. Another notion is added by Kirmayer et al. [Reference Kirmayer, Fung, Rousseau, Lo, Menzies and Guzder39] who argue in their guidelines on cultural competences, working with professional interpreters and cultural brokers may also require tolerance for ambiguity and uncertainty, where professionals have to unlearn a vocabulary of mastery, precision, and efficiency in favour of listening [Reference von Lersner, Baschin, Wormeck and Mosko38].

The role of (digital) simulations, technologies, and artificial intelligence

In psychiatric training, simulations with actors in real-life or virtual classroom settings may play an important role in becoming culturally competent with patients from diverse cultures. In a review about simulation training in psychiatry, Piot et al. [Reference Piot, Attoe, Billon, Cross, Rethans and Falissard84] highlight that simulation may help trainees to grapple with the cultural-historical meaning-making processes in how mental disorder is displayed in various person-centred care settings. Virtual patients and other interactive computer simulations may also offer innovative training opportunities in significantly improving confidence in cultural competencies [Reference Pantziaras, Fors and Ekblad85, Reference Pantziaras, Fors and Ekblad86]. Telehealth consultations may also help to improve cultural safety in that they facilitate access to skilled interpreters and culture brokers; in the context of Indigenous care, though, Terrill and colleagues [Reference Terrill, Woodall, Evans, Sen Gupta, Ward and Brumpton87] argue in a scoping review that face-to-face communication remains irreplaceable.

Other innovative tools

More innovative models could include cultural exposure through resident and faculty international medical graduates, rotations across different European and non-European countries, and cultural exchange of professional staff with other international medical schools [Reference Jani and Johnson51]. Although it might appear common sense to foster a culture of innovation in cultural competence training, the literature currently lacks a more thorough engagement in pedagogies and creative approaches to innovation in cultural competence training and development.

Health as culture

Importantly, all reviews underline that culture should not be read synonymously with “ethnically different”; in fact, everybody has a culture, and developing an awareness of one’s own beliefs, values, assumptions, and taken-for-granted practices and rituals is core in practicing cultural humility. But it is not only individuals who have different cultures; the institutions in which they work are also deeply cultural.

Culture needs to be understood as a dynamic, relational, fluid, and constantly contested process, where one’s culture is dependent on context, time, and place [Reference Hansen, Braslow and Rohrbaugh41]. Acculturation processes have been identified as one way of addressing the complex interplay between different cultural dimensions and processes of adapting others’ cultural norms, values, and practices over time. A criticism of acculturation theory, however, is that it does not factor in the dimension of power.

The UEMS’ understanding of culture, for instance, also emphasises the difference between different therapeutic cultures and their understanding of health, illness, and recovery [88]. Different health beliefs are tied to different values, traditions, and also reflect in the ways that patients understand and communicate their symptoms, and psychiatric services are shaped and delivered in various European countries [89]. It is therefore important to consider cultural practices within dominant groups and consider health professions within psychiatry as their own unique culture, built on a set of assumptions, values, and beliefs about who can be deemed “healthy,” “ill” and in need of help. Following the recommendation by the UEMS, a way forward for psychiatric care in Europe must be “recovery-focused and trauma-informed with a culture of respect for human rights” [89] (Box 1).

Intersectionality: Culture as Identity

Cultural competence is often cited in the context of providing mental health care for migrants. In this context, “culture” is sometimes used synonymously with “race,” ethnicity, nationality, or language, often different from that of the majority culture [Reference Ortega and Müller59, Reference López, Ribas, Sheinbaum, Santos, Benalcázar and Garro90, Reference Beagan, Frisby and O’Donohue94]. Not only is this problematic, but it also essentialises and therefore stigmatises a highly diverse set of patients as “migrants” [Reference Jarvis, Andermann, Ayonrinde, Beder, Cenat and Ben-Cheikh12]. It is also problematic in that it neglects other dimensions of culture, such as age, gender, family values, regionality, and religion – all of which are an integral part of understanding culture as dynamic [95].

The Accreditation Council for Graduate Medical Education (ACGME) (see table 1 in [Reference Corrales, Paba, Poole and Malfatti96]), for instance, moves away from seeing migrants as the only relevant patient group with a “culture” or as beneficiaries of cultural competence training. Instead, their framework differentiates between different age groups as well as other identity markers such as socioeconomic status, gender, LGBT issues, religion, and disability. To understand how culture is political, reviews have highlighted the importance of the concept of “intersectionality,” specifically given that current training tools in cultural competences are largely void of these intersectional dimensions [Reference Corral, Johnson, Shelton and Glass34].

An intersectional approach to cultural competence training would, for instance, take into account how migration status or processes of racialisation connect to gender, sexual orientation, income, education level, or age [Reference Pezzella, Pistella, Baiocco, Kouta, Rocamora-Perez and Nielsen97, 98].

Racism: cultural competences cannot be apolitical

A key criticism towards cultural competences has been that an over-emphasis on “cultural differences” in approaching patients with complex health needs possibly over-simplifies or neglects other complex bio-social, political, economic, and environmental factors to good mental health [Reference Ortega and Müller59]. Reducing these holistic factors to cultural affiliation alone might mean missing other important areas of intervention and might leave deeper-seated power imbalances or inequalities unaddressed [Reference Beagan, Frisby and O’Donohue94].

A central power dimension often met with defence is racism. As Jarvis et al. [Reference Jarvis, Andermann, Ayonrinde, Beder, Cenat and Ben-Cheikh12] argue, many psychiatrists have not been trained to see structural violence as part of their clinical landscape, and thus fail to recognise racism as a force that shapes diagnostic outcomes, access to care, and therapeutic relationships. When racism is framed as systemic rather than interpersonal, it demands not just awareness but accountability and change [Reference Jarvis, Andermann, Ayonrinde, Beder, Cenat and Ben-Cheikh12, Reference Corral, Johnson, Shelton and Glass34, Reference Lazaridou and Fernando91].

Racism has received increasing attention by the psychiatric community, stressing here that it is no longer enough to not be racist, psychiatrists must be actively anti-racist. This may be achieved by considering processes of identity formation, including Othering, more research on anti-Blackness, as well as critically interrogating Whiteness within mental health care. In general, recent publications have highlighted that theorisation and conceptualisation of racism in Europe are still in its infancy [Reference Cénat99, Reference Moffitt, Lukate and Dv100] (Box 2).

In the context of central Europe, anti-racism in psychiatric care might include not only a deep engagement with non-White communities, such as the African Diaspora, but also with the mental health experiences of racialised communities that may, judging from their complexion or skin tone, for instance, be present as White. Examples include Roma and Sinti communities, Jewish communities, or Eastern Europeans (or “Slavic” communities).

Integration into structural competences and structural change

In the UEMS’ European framework for competencies in psychiatry, the authors underline the importance of “respecting all other barriers, such as the cultural differences between the countries with regard to how mental health care is considered and funded, neglected role of psychotherapy, culture and family context” [Reference Štrkalj Ivezić, Marčinko, Bajs Janović, Bilić and Casanova Dias102]; here the psychiatrist can take the role of a collaborator with other social and cultural networks (p.356). The adjoining document “Training requirements for the specialty of psychiatry” by the UEMS specifies this advice with reference to knowledge tests, clinical examinations, and in-training assessment. Importantly, cultural differences are not only to be found between different countries but also, of course, within individual countries, (federal) states, or regions.

On the other hand, institutional cultural competence requires not only the recognition of the barriers that exist to quality care at a systemic, organisational, and institutional level but also the elimination of these [Reference Fung, Lo, Srivastava and Andermann103–Reference Betancourt, Green, Carrillo and Park105]. The demand to remove barriers to access have more recently been linked to discourses on health equity in psychiatric care [Reference Kirmayer and Jarvis14, Reference Moreno and Chhatwal106]. Some of these barriers are relatively straightforward, such as having insufficient professionals who speak the same language as the patient, a lack of access to services via public transportation, restricted opening hours of a centre, and so forth.

Integration into trauma-sensitive care

There seems to be a strong case for the usefulness of cultural competences when working with care of FDPs, that is, people who have fled war or torture and are seeking refuge in one of the European countries [Reference Frankova, Scheeres, Menculini, Cikrikcili, Matei and Fellinger15, Reference Morina, Akhtar, Barth and Schnyder107]. This population often presents with complex migration histories alongside psychological trauma, which is itself deeply cultural and sometimes trans-generational; this trauma may be pre- or post-migration [Reference Silver, Williams and Forty47].

The role of culture in the experience and reporting of trauma needs to be anchored in cultural competence curricula [Reference Im and Swan108] and trauma care alongside a profound socio-political understanding of war and immigration as a social determinant for mental health [Reference How, Kho, Rodríguez and Shim17, Reference Morina, Akhtar, Barth and Schnyder107, Reference Griffith, Kohrt, Dyer, Polatin, Morse and Jabr109]. For instance, a study for culturally sensitive perinatal psychiatric care in a hospital in France [Reference Radjack, Bossuroy, Camara, Touhami, Ogrizek and Rodriguez50] highlight that culturally sensitive clinicians might consider traumatic dimensions in countertransference in order to gauge the impact of war and terror on individual patients. Working with this group of traumatised patients, psychiatrists need to take into account the risk of vicarious trauma, such as a “blank mind” or seemingly false representation of facts, places, and times. Cultural competences then need to be embedded into an agenda of global public mental health and a general understanding of historical and geopolitical processes that inform how trauma may present itself within specific migration trajectories and cultural settings [Reference Griffith, Kohrt, Dyer, Polatin, Morse and Jabr109].

Integration into community-centred care and family structures

Key publications recommend seeing the patient within the context of their communities and family, and considering the patient’s family’s history of (ongoing) trauma [Reference Brittlebank, Hermans, Bhugra, Pinto da Costa, Rojnic-Kuzman and Fiorillo30]. These developments highlight the link between cultural competence training and training in (complex) trauma and community care [Reference Griffith, Kohrt, Dyer, Polatin, Morse and Jabr109, Reference Im and Swan110]. Actively involving family members in psychiatric care can be helpful to understand the acculturation process and to interpret subtle cultural differences within groups. Incorporating community elders can also help establish contacts with community associations, the voluntary sector and other actors relevant to delivering psycho-social support to at-risk groups [Reference Pejic, Alvarado, Hess and Groark111, Reference Pejic, Thant, Hess, Cornell, DeJesus and Yager112].

Integration into advocacy and political action

Cultural competence is just one type of competence that is required, next to a host of others cited in the literature on refugee and asylum seekers’ mental health care; for instance, in a scoping review focusing on displaced children and young people’s health needs [Reference Due and Currie6], the authors identify five other key competencies next to cultural competence: (1) knowledge of the complexity of the needs of refugees; (2) use of holistic approaches; (3) ability to work in coordination with others in a child’s network; (4) ability to build therapeutic relationships; (5) seeking feedback. Their findings support other guidelines and statements, such as those of the UEMS [89] and Kirmayer et al. [Reference Kirmayer, Sockalingam, Fung, Fleisher, Adeponle and Bhat65] that advocate for a networking perspective and collaboration with civic society organisations, such as housing and employment agencies. Advocacy also entails an active feedback culture that meaningfully involves communities in shared decision making, seeing patients as the actual experts [Reference Pejic, Thant, Hess, Cornell, DeJesus and Yager112]. Involving beneficiaries, such as forcibly displaced people, in co-creation and other patient-centred initiatives is identified as a key pillar for equitable service delivery [Reference Silver, Williams and Forty47, Reference Im and Swan108, Reference Im and Swan110].

Integration into organisational settings

But cultural competences must not only happen on the level of the individual but also on the level of the organisation, especially on the management level, who need to take an active stance against discrimination [Reference Schenk, Sonntag, Beck, Khan, Peppler and Schouler-Ocak32]. Anti-racism and anti-discrimination policies and infrastructures must be installed and integrated into cultural competence training. For instance, trainees must be aware of where and how to report suspected instances of discrimination in their specific clinic, organisation, or association. Additional support must be made available for those affected by or witnessing discrimination, all while making their safety and (if desired) anonymity the highest priority.

Awareness should also be central in the way that service facilities and service delivery are designed. The culturally sensitive hospital for instance is dedicated to ensuring culturally sensitive food options (e.g. marking halal meat options), culturally sensitive reading materials in waiting rooms (e.g. avoiding stereotyping children’s books or offering magazines in different languages), access to safe sanitary facilities (e.g. indicating if male cleaning staff is likely to be present in female bathrooms), and a warm and inviting atmosphere (e.g. warm lighting, comfortable seating and culturally sensitive wall art, like abstract paintings rather than people and places). For facilities in countries where English is not the first language, it may be helpful to install bilingual signage and way-markers, all while carefully observing the language barriers and language needs of international as well as domestic patients, some of whose second language may be French. Signage or translations based on images, icons, and simple language may also be helpful. Initiatives like the culturally sensitive hospital [Reference Droste, Gün, Kiefer, Koch, Naimi and Reinecke113] are good practice examples for linking cultural competences with diversity and integration officers in the hospital and other (public) health settings [Reference Akbulut and Razum114].

Integration into personnel measures

Hiring processes, faculty development, and human resource departments also play a key role in the culturally sensitive clinic. A more diverse staff can aid innovation and is vital for practices of continuous peer learning [Reference Kirmayer, Fung, Rousseau, Lo, Menzies and Guzder39]. Training the trainer initiatives (a core element in structural competence training, for instance) and further learning and teaching opportunities need to be actively supported from a management level. Involving “experts by experience” in community-focussed psychiatric care and linking with voluntary sector organisations are ways to improve the “image of psychiatry” [Reference Möller-Leimkühler, Möller, Maier, Gaebel and Falkai92], both as a service provider and a possible employer. Building peer-led infrastructures where people usually labelled “patients” can become “providers” (in a wide or narrow sense) can be a crucial step towards inclusion and justice in the clinic. One best practice is the Weddinger Modell, a participatory model originally developed in Berlin, Germany, that aims to reduce coercion and improve safety for patients and staff on the ward by, for instance, employing former patients as peers [Reference Gooding115].

Evaluation, monitoring, and incentive structures

It is also necessary to build local infrastructure to implement cultural competency training. Organisational change might be achieved through more comprehensive monitoring and evaluation of diversity-related health outcomes [Reference Aggarwal61, Reference Aggarwal, Chen, Lam and Lewis-Fernández116]. Evaluations are an important component in assuring accountability on an organisational level.

The word “competence” in cultural competence may suggest that deep-seated inequalities can be bridged through simply learning a new skill, implying here that once enough knowledge and tools are acquired, the clinician becomes an “expert” in understanding the complex experiences of others [Reference How, Kho, Rodríguez and Shim17]. In clinical studies, competence is often measured in terms of confidence or comfort, which may be unrelated to how respectful, collaborative, and effective psychiatric care across differences actually is. Measuring cultural competence might need to take into account a clinician’s in-session behaviour [Reference López, Ribas, Sheinbaum, Santos, Benalcázar and Garro90], their self-reflective practices, for instance, during supervision, and their diversity-oriented commitment in social and community life outside the clinic. Recent literature focuses more on the importance of grappling with in-competence, in the sense that tolerance of ambiguity, the willingness to listen, and adopting a learner’s mindset, which need to be at the heart of interacting with groups that we perceive to be different from ourselves [Reference Kirmayer, Fung, Rousseau, Lo, Menzies and Guzder39].

Therefore, performance indicators need to be carefully reviewed and checked against established frameworks, such as diversity, equity, inclusion, and belonging frameworks and initiatives [Reference Akbulut and Razum114]. It may be helpful to include more qualitative evaluation measures, such as multi-stakeholder focus groups [Reference Silver, Williams and Forty47, Reference Im and Swan108]. Accreditations and other methods of local monitoring can support and enhance the status of the ongoing process of the training [Reference Kirmayer, Fung, Rousseau, Lo, Menzies and Guzder40]. Evaluation practices can be combined with economic and other incentives, although critical concern around tokenism needs to be taken into account. Community-focused and equity-driven incentive structures might include fundraising and donations to local charity organisations.