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3.3.2. German experiences
Despite the situation several years ago, meanwhile a number
of cross- cultural training programmes for health care (budding)
professionals are offered. For example, medical students have
the opportunity to learn about a variety of cross- cultural issues
in some of the 36 German university medical centres. Other
educational institutions also offer cross- cultural training with
various perspectives catering for different occupational health
care groups. So far there are hardly any studies of evaluated
cross- cultural mental health training in Germany.
In general there is a high degree of interest in cross- cultural
educational programmes for this occupational group. The result
of a census of psychotherapists in private practice showed that
72% of mental health care providers think that cross- cultural
competence training is helpful for the therapeutic work for
patients with a different migration background [31]. Nine per
cent of the providers have already participated in such training.
The need for such training is also highly valued by medical
educational providers. More than 80% of the heads of these
psychiatric educational institutions see a great need for cross-
cultural issues in further education with focus on cross- cultural
competencies and cultural aspects of mental disorders [11].
Although health care providers and educational institutions
see the need for, and are interested in, cross- cultural issues there
is much work to be done before they are an integral part of the
educational curriculum for mental health care professionals in
Germany.
A promising development in further promoting cross-
cultural issues in the education of health care professionals is
characterised by two initiatives. Psychotherapeutic educational
institutions are doing more and more to integrate cross- cultural
issues in their curricula. Also, there is a national initiative for
developing a nationwide list of cross- cultural learning targets
for university medical education, which will be later integrated
in the teaching and examinations.
4. Discussion
4.1. On conceptualisation of training
Cross- cultural psychiatry, psychology, nursing and related
fi elds are important in the basic education of health and mental
health professionals. Institutionalised training of students as well
as mental health professionals is essential. In treating culturally
different people with mental disorders self- refl ection is a necessary
component. Developing, conducting and evaluating helpful,
adequate and sustainable cross- cultural training programmes
that fi t the very special needs of professionals in the particular
mental health care services is a major challenge.
So far research on cross- cultural training has often been
focused on the cultural competence perspective. However,
we consider using the cultural competence conceptualisation
in mental health care training to be a problematic issue as it
encourages an understanding of culture in biomedical terms. The
term cultural competence easily directs thinking towards some
form of specifi c entity or skill that one can achieve. In terms of
culture it also implies something static.
S. Bäärnhielm et al. / European Psychiatry 27 (2012) / supplement n°2 / S70-S75 S73
Medical professionals are trained to have faith in their own
competence. In cross- cultural encounters between patient and
provider the opposite stance is important, i.e. relinquishing the
stance of expert in the encounter and instead grasping the opportunity
to learn about patient’s culture. After basic knowledge in
topics such as intercultural communication and migration and
health, a humble self- refl ective position and an interest in the
individual and his/her sociocultural context should characterize
the care provider’s attitude. Ethnographic approaches, of
curiosity and a desire to learn about the culture and context of
the other, may contribute to non- stereotyping knowledge about
the individual patient and improve the interaction. Clinging to a
position of being a competent cultural expert may result in stereotyping
of the patient. In contrast, the professional who does not
feel culturally competent may refrain from continuing to help
the patient, thus excluding her/him. Further, current work in
anthropology looks at culture with a processual understanding,
whereby culture is located ‘between’ people and not in the minds
of individuals [27]. This interactive perspective on culture may
be diffi cult to grasp if the focus is mainly on competency.
For training and evaluation research an alternative conceptualisation
to the cultural competence framework needs to be
considered. Several interesting conceptualisations have been
suggested, such as culture humility and cultural safety. The
approach of the Transcultural Centre, by using a needs assessment
as a part of the training conceptualisation, can be one way
to meet the participants where they are. However, in the long
run, needs assessment has to be combined with theoretical conceptualisations.
Practical tools such as the Cultural Formulation
(CF) of the DSM- IV can be helpful to enhance the providers’ diagnostic
competence and to contribute to improvement of clinical
praxis. The CF means an ethnographic approach that supports
an individualised understanding of the patient’s perspective on
suffering, meanings given to illness and self- refl ection.
Additional to the problems with conceptualisation of
cross- cultural training, there is a lack of documentation about
training content and the didactics of cross- cultural training. To
promote further research on cross- culture training standardised,
psychometric evaluated and validated instruments need to
be developed and used [12,10]. The use of additional instruments
and qualitative methods like direct observations, videotaped
sessions, or Objective Structured Clinical Examination
(OSCE) [1] will be helpful. The improvement of content quality
can be achieved by evaluating different training components
of cross- cultural aspects related to diagnostically (e.g. cultural
formulation) and process- related issues. In the future, various
aspects of evaluation research should be focused. As the duration
of different training programmes varies greatly a dose- response
relationship has to be taken into account. If the dose is substantial
a catamnesis should be considered in order to evaluate the
long- term effect.
Due to the methodological restrictions of quantitative
evaluation, complementary qualitative analyses, particularly
in institutional settings, may enhance the validity of the study
results. Anthropological fieldwork can help to explore the
dynamics of the possible consequences of training by employing
a descriptive approach, as everyday experiences of prejudice
and hidden or open discrimination cannot be assessed with
self- reporting instruments.
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