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S72 S. Bäärnhielm et al. / European Psychiatry 27 (2012) / supplement n°2 / S70-S75
The concept of cultural competence has been criticised.
Kleinman and Benson, e.g. [24] point out that it is not defi ned
and operationalized for clinical training and best practice.
Further, that a major problem with the idea of cultural
competence is that it suggests that culture can be reduced to
a technical skill. The popularity of the cultural competence
concept in the USA might be related to the fact that American
literature and research often refer to broad historically established
ethnic groups such as Afro- Americans, Latinos, etc. In
Europe, globalisation is patterned by a great diversity according
to culture, ethnicity, religious affi liation, language, and social
situation. Accordingly, culture needs to be approached in an
individualised way not stereotyping or falsely ascribing certain
characteristics due to the patients assumed belonging to a
group.
Cultural humility has been proposed as an alternative
concept as it includes self- evaluation [45]. From the colonial
context, with poor health status for the Maori population in New
Zealand, the concept of cultural safety has been developed and
this includes analysing power imbalance [38]. Another suggested
concept is cultural responsiveness.
3.2. Research and Evaluation results
of cross- cultural training
In contrast to the large amount of existing cross- cultural
training programmes and cross- cultural training providers,
there is a shortage of transparent documented and published
studies of such training, especially for mental health professionals.
Most published studies focus on somatic care and are
anchored in the framework of cross- cultural competence. The
existing three reviews on cross- cultural competence training are
based on a total of 69 analysed programmes between 1980 and
2010 written in English. There is evidence that cross- cultural
competence training for health care providers is a strategy to
improve knowledge, attitudes, and skills [36,7,28]. There is
excellent evidence that the cross- cultural competence training
improves the knowledge of health professionals and improves
attitudes and skills [7]. There is good evidence for a positive
impact on patients’ satisfaction but poor evidence for patients’
adherence. The evidence for improving patient outcome is not
very compelling. The overall quality of competency training with
regard to patient outcome was low to moderate [28]. Evidence
is poor as research is lacking.
A randomized control study of training effects on how
Swedish primary care child nurses evaluated their own cultural
competence indicated that training improved the participants’
cultural competence and had a positive impact on their ability
to cope with the demands of the work activities [8]. To maintain
the positive effects of training Berlin et al. [8] stressed the
importance of additional supervision.
There is a shortage of research evaluating cross- cultural
competence training for mental health care professionals.
According to the nine evaluated North American cross- cultural
competence programmes for mental health care staff [9] there is
limited evidence for their effectiveness, as quantitative measurements
are missing in most of these studies. Very little has been
published with regard to content methods.
3.3. Experiences of cross- cultural training
in Sweden and Germany
3.3.1. Swedish experiences
In Sweden, cross- cultural mental health training for students
and clinical professionals has until recently been limited.
In 1997, a public health report by the Swedish Board of Health
and Welfare [39] drew attention to the fact that education for
health professionals included little training time for issues
related to cultural diversity. Some improvement has occurred
with lectures about Transcultural issues introduced in some
educations, a one week course in Transcultural psychiatry for
residence in psychiatry at the Karolinska Institutet, and some
training about working with trauma for health professionals.
Still, the situation means that after basic training many professionals
still start working with little or no training in the fi elds
of migrant health and cultural diversity. This in turn implies a
great need for training of clinical professionals.
The Transcultural Centre in Stockholm has conducted
some pioneering cross- cultural training for mental health and
health professionals. An advanced course in “Transcultural
psychiatry” was, for several years, supported by the Division of
Social and Transcultural Psychiatry of McGill in Canada, one of
the important cross- cultural training and research institutions
worldwide. Over the years, cultural perspectives on mental
health care were introduced to a large number of practitioners
in Sweden [3]. More and more of the programmes organised by
the Transcultural Centre have taken place at local work places.
The planning of such in- house training starts with a contact
from the local units followed by an survey of the needs and
expectations of the health care professionals.
Through in- house training new knowledge can be transferred
to whole work places or a group working together. Themes that
professionals have often raised over the years are: diffi culties in
cross- culture encounters; infl uence of migration on health and
mental health; cultural variety in expressions of distress; challenges
in cross- cultural communication; consequences of trauma and
social upheaval; medical ethics, and conventions and regulations
guiding care for asylum seekers and undocumented refugees. These
themes give the opportunity to convey new research fi ndings from
cross- cultural psychiatry/psychology, social sciences and other disciplines
to clinicians and to connect theory to daily clinical praxis.
In the training programmes special attention has been given
to the outline for Cultural Formulation in DSM- IV [2] as a practical
model to improve cross- cultural diagnosis of mental disorders [6].
Psychiatric diagnosis is today a gateway to mental health care
and planning of treatment. The Cultural Formulation in DSM- IV
consists of five sections: cultural identity of the individual;
cultural explanations of the individual’s illness; cultural factors
related to psychosocial environment and levels of functioning;
cultural elements of the relationship between the individual and
the clinician and the overall cultural assessment for diagnosis and
care [2]. As a support for training and clinical implementation an
interview guide has been used [5,6]. The training in the use of the
Cultural Formulation has been the hub around which different
topics related to cross- cultural psychiatry have been introduced
and linked to clinical situations. So far there has been little evaluation
of cross- cultural mental health training in Sweden.
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