June 2012, Volume 62, Issue 6

Opinion and Debate

Need for training in Cultural Psychiatry: How relevant is it for Pakistan?

Amin A. Muhammad Gadit  ( Discipline of Psychiatry, Memorial University of Newfoundland, Canada. )

Influence of culture on mental health has been described in the literature widely. Concept of normal mental health, beliefs about causation of mental illness and traditional practices in treatment of mental illness open up a fascinating area in the academic literature. In the western world, more emphasis is now being given on training in Cultural Psychiatry in view of multicultural composition of their population. The importance of such training is not less important in the developing world. There is wider cultural diversity in many countries of the developing world too. In Pakistan, there are quite a few ethnic groups and have multiple local languages besides the approved national language. Every spoken language has a different vocabulary and people express mental health symptoms keeping in context the language and background culture.1
Hence, practitioners of mental health care come across a variety of patients with different cultural backgrounds, literacy levels and languages. A \\\'universal psychiatrist\\\' would be the one who could understand the patient\\\'s clinical problem and provide appropriate health care.2 Training for mental health professionals in cultural issues appear to be vital even in Pakistan. The subject of behavioural sciences has been introduced in Pakistan but there is no mention of a formal practical training in cultural psychiatry in academic literature.3
Western countries do have guidelines for management in terms of mental illness. Recently, Canadian Psychiatric Association (CPA) has produced a Position Paper entitled "Guidelines for Training in Cultural Psychiatry". This is based on a wide cultural diversity among the country\\\'s population, immigrants coming from all over the world and a huge number of refugees who are being granted asylum in Canada.4
It was vitally important for the government to understand the needs and issues of this population especially the adjustment, stress of migration, integration with a new society and the consequent effect on mental health. The key concepts that were worked upon for guidelines were: culture, race and ethnicity, cultural biology and cultural neuroscience, social and cultural determinants of health and health disparities, racism, prejudice and discrimination, institutional racism, migration, colonization and mental health,cultural influences on the mechanisms of psychopathology, illness and help seeking behaviours, cultural competence and cultural safety.4
In the United States, training in cultural psychiatry is on board keeping in view the need of time. The Oregon Programme is worth-mentioning.5 The Oregon Health and Science University has an ambitious curriculum that includes both didactic sessions devoted to core topics in the field and varied clinical experiences in community settings and the Intercultural Psychiatric Program under the supervision of experienced academic faculty. A review was undertaken with the findings that trainees had acquired specialized cross-cultural psychiatric knowledge and skills including treatment of refugees and immigrants, also became well versed with cultural dynamics that influence the doctor/patient relationship.5
The McGill University has an intensive programme that includes: core teaching, clinical rotations, an intensive summer programme and annual Advanced Study Institutes. The programme was reviewed and yielded the conclusion that an approach to cultural psychiatry grounded in basic social science perspectives and in trainees\\\' appreciation of their own background can prepare clinicians to respond effectively to the changing configurations of culture, ethnicity and identity in contemporary health care settings.6
There is an active programme on Cultural Psychiatry being run by the University of British Columbia that focuses on research in conjunction with post-secondary, professional and public education. This includes culturally sensitive approaches in communication, stigma, assessment and treatment of mental health issues and mental illness.7
Cultural formulation has also been deemed important in training. Proposed revisions were suggested to the DSM-IV Outline for Cultural Formulation for clinical practice. This was done through case presentation with a view to demonstrate short comings in the current implementation of the cultural formulation based on older definitions of culture.8
Understanding of cross cultural mental health is also important in legal systems. There is sensitivity around the issues of native language, religion and country of origin. Competency to stand trial or criminal responsibility also falls under this aspect of learning and training.9
A project by the name of Scotland Malawi Psychiatry Project (SMPP) provided a unique opportunity for specialist registrars to gain important insights into and experience of transcultural psychiatry. Such a venture would also meet the goal of the training recommended by the Royal College of Psychiatrists, UK.10
It appears that training in transcultural psychiatry is equally important for developing countries. In Pakistan, we do need training modules as described earlier in the text with the cultural diversity and forensic issues in perspective. We need to review the existing curriculum and revise /modify or introduce the modules with particular emphasis on training and re-training. What do you think?


1. Gadit AA, Mugford G. Expression of depressive symptoms, regional variations: A comparison of three cities in Pakistan. Psychiatric Annals 2008; 38: 474-7.
2. Gadit AA. Quest for a \\\'universal psychiatrist\\\'. How long is the journey? J Pak Med Assoc 2008; 58: 465-6.
3. Mubbashar MH.In Ghodse H (Ed) International Perspective on mental health; RCPsych publication; United Kingdom, 2011; pp 173-7.
4. Kirmayer LJ, Fung K, Rousseau C, Tat lo H, Menzies P, Guzder J, Ganesan S et al. Guidelines for Training in Cultural Psychiatry-Position Paper- Canadian J Psychiatry 2012; 57: 1-17.
5. Boehnlein JK, Leung PK, Kinzie JD. Cross-Cultural Psychiatric Residency Training: The Oregon Experience. Academic Psychiatry 2008; 32: 299-305.
6. Kirmayer LJ, Rosseau C, Guzder J, Jarvis GE. Training clinicians in cultural psychiatry: a Canadian perspective. Acad Psychiatry 2008; 32: 313-9.
7. Cross Cultural Psychiatry. (Online) (Cited 2012 March 27) Available from URL: http://www.psychiatry.ubc.ca/programs/cultural.htm.
8. Aggarwal NK. The Psychiatric Cultural Formulation: Translating Medical Anthropology into Clinical Practice. Journal of Psychiatric Practice 2012; 18: 73-85.
9. Layde JB. Cross-Cultural Issues in Forensic Psychiatry Training. Academic Psychiatry 2004; 28: 34-9.
10. Beaglehole AL, Baig BJ, Platt JE, Strachan J, Kauye F et al. Training in transcultural psychiatry and delivery of education in a low-income country. The Psychiatrist 2008; 32: 111-2.

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