This investigation sought to understand the mental health needs of Black/African Americans during the COVID-19 pandemic and explore the church leaders' perspectives and experiences in supporting the mental health of their communities during this time. This exploratory qualitative study uses semi-structured interviews with 21 church leaders from predominantly Black neighborhoods in Brooklyn and Harlem, New York City (NYC), which were most adversely impacted by COVID-19. Neighborhoods were selected based on COVID-19 infection and mortality data from the NYC Department of Health. Transcripts were coded and thematically analyzed using Dedoose software. Four overarching themes and one subtheme emerged: (1) The COVID-19 pandemic amplified underlying community quality of life challenges, creating a "downward cascade" of mental health, (1a) COVID-19 is a source of collective grief and trauma; (2) Faith-based leaders play a key role in providing mental health support to their community; (3) Faith-based leaders seek strategies to reduce mental health stigma, normalize conversations around mental health; and (4) Faith-based leaders often operate in isolation from citywide mental health services, disconnected from existing programs and resources. Leaders anticipate a higher demand for mental health services. On the road to emotional wellness post-pandemic, public awareness of symptoms of mental health issues must be emphasized and available resources utilized to reduce stigma and encourage help-seeking behavior. Addressing these implications requires comprehensive multi-sector community driven efforts that include collaboration with faith-based communities to support community resilience and improve mental healthcare access.

For thirty years, psychiatrists and anthropologists have collaborated to improve the validity of psychiatric diagnosis. This collaboration has produced the DSM-IV Outline for Cultural Formulation (OCF) and the DSM-5 Cultural Formulation Interview (CFI). Nonetheless, some anthropologists have critiqued the concept of culture in DSM-5 as too focused on patient meanings and not on clinician practices. This article traces the evolution of the culture concept from DSM-IV through DSM-5-TR by analyzing publications from the American Psychiatric Association on the OCF and CFI alongside scholarship in psychiatry and anthropology. DSM-IV relied on a culture concept of coherent ethnic communities sharing coherent cultures, primarily for minoritized ethnoracial individuals in the United States. Changing demographics and newer immigration patterns around the world deminoritized the culture concept for DSM-5. After George Floyd's death and demands for social justice, the culture concept in DSM-5-TR emphasized social structures. The article proposes an intersubjective model of culture through which patients and clinicians work through similarities and differences. It recommends a revised formulation that attends to clinician practices such as communicating, diagnosing, recommending treatments, and documenting, beyond collecting patient meanings. It also raises the question of whether an intersubjective model of culture prompts reconsiderations of culture-related text in other sections of the DSM. The social sciences can redirect attention to the clinician's culture of biomedicine to close patient health disparities.

Mentalization-based Encounter to Challenges in Early Childhood Education with Refugee Families This article introduces the mentalization concept into the field of early childhood education suggesting that it can also provide a helpful framework for working with refugee families in these settings. Mentalization is identified as a crucial element in establishing and maintaining relationships that are developmentally conducive. It is argued that a mentalizing attitude is relevant for dealing with children with traumatic experiences as well as families with a different cultural background due to its emphasis on openness, curiosity, and (self)reflexivity. In stressful contexts, however, mentalizing can fail or become biased. After providing information on psychotraumatology and cultural influences on child development, the paper will therefore focus on specific ways in which the confrontation with traumatized children and families from diverse cultural backgrounds can interfere with professionals' mentalizing capacities.

The clinical encounter is still at the core of the psychiatric evaluation. Since the diagnostic process remains basically clinical in nature, several authors have addressed the complexity of the clinical reasoning process and highlighted the role played by intersubjective phenomena and clinician's feelings. Some recent studies have supported the view of a significant link between the clinician's subjective experience during the assessment and the diagnosis made. In a globalized world, this issue requires a careful reflection, since cultural differences may affect the intersubjective atmosphere of the encounter, which may indirectly influence the clinician's thinking.

We used a previously validated instrument, named Assessment of Clinician's Subjective Experience (ACSE), to compare the clinician's subjective experience during the evaluation of Italian patients with the subjective experience of the same clinician during the assessment of foreign patients. The 2 patient groups (n = 42 each) were individually matched for known potential confounders (age, sex, categorical diagnosis, and clinical severity).

We found no significant differences in mean scores on all ACSE dimensions (tension, difficulty in attune-ment, engagement, disconfirmation, and impotence), which suggests that cultural diversity did not substantially affect the clinician's subjective experience. However, the lack of information about the native country and linguistic proficiency of about a quarter of foreign patients may have limited the possibility to detect subtle or specific differences, especially with regard to the clinician's empathic attunement.

Although further investigation is needed, our preliminary findings may have significant implications for the reflection upon the clinician's empathic experience as well as pragmatic consequences for the act of psychiatric diagnosis in the cross-cultural encounter.

A position paper developed by the Canadian Psychiatric Association's Education Committee and approved by the CPA's Board of Directors on August 15, 2016.

A high prevalence of mental illness has been reported in asylum seekers. The present cross-sectional study examined suicidal thoughts, treatment modalities (outpatient crisis intervention, inpatient care), and their determinants in asylum seekers (n = 119) and permanent residents (n = 120) attending the same outpatient clinic in Geneva, Switzerland. The most frequent diagnoses were depressive disorders (64.7%) and posttraumatic stress disorder (34.5%) in asylum seekers and psychotic (55.0%) and depressive disorders (33.3%) in permanent residents. The frequency of suicidal thoughts was similar in both groups (>30%). Asylum seekers benefited from outpatient crisis intervention more frequently than residents did (26.9% vs. 5.8%), whereas inpatient care was less frequent (25.2% vs. 44.2%). In asylum seekers, acute suicidal thoughts were associated with increased frequency of outpatient crisis interventions, and, suicidal thoughts, psychosis, or personality disorders were associated with higher rates of hospitalization. Documenting clinical characteristics and service utilization of asylum seekers is a prerequisite to organizing targeted interventions.

Many individuals with schizophrenia have occasional difficulty defining both to themselves and to others who they truly are. Perhaps for this reason they make attempts to change core aspects of themselves. These attempts may be delusional, but are too often unjustly dismissed as delusional before the potential value of the change is considered. Instead of facilitation, obstacles are placed in the way of hoped-for body modifications or changes of name or of religious faith. This paper discusses the various changes of identity sometimes undertaken by individuals with schizophrenia who may or may not be deluded. Ethical and clinical ramifications are discussed. The recommendation is made that, when clinicians respond to requests for help with identity change, safety needs to be the main consideration.

Psychiatric practice in India is marked by an increasing gulf between largely urban-based mental health professionals and a majority rural population. Based on the premise that any engagement is a mutually constructed humane process, an understanding of the culture of psychiatry including social process of local knowledge acquisition by trainee psychiatrists is critical. This paper reviews existing literature on training of psychiatrists in India, the cultural construction of their professional identities and autobiographical reflections. The results reveal a scarcity of research on how identities, knowledge, and values are constructed, contested, resisted, sustained, and operationalized through practice. This paper hypothesizes that psychiatric training and practice in India continues to operate chiefly in an instrumental fashion and bears a circular relationship between cultural, hierarchical training structures and patient-carer concerns. The absence of interpretative social science training generates a professional identity that predominantly focuses on the patient and his/her social world as the site of pathology. Infrequent and often superfluous critical cultural reflexivity gained through routine clinical practice further alienates professionals from patients, caregivers, and their own social landscapes. This results in a peculiar brand of theory and practice that is skewed toward a narrow understanding of what constitutes suffering. The authors argue that such omissions could be addressed through nuanced ethnographies on the professional development of psychiatrists during postgraduate training, including the political economies of their social institutions and local cultural landscapes. Further research will also help enhance culturally sensitive epistemology and shape locally responsive mental health training programs. This is critical for majority rural Indians who place their trust in State biomedical care.

The different pathways chosen to efficiently and effectively provide relief to those struggling with mental health challenges reflect different assumptions about the human condition and have led to disagreements over which intervention strategies are best suited to particular individuals or populations. Evidence-based practice and culturally competent services, as discussed within the United States, have been characterized as opposites. However, neither approach captures all of the elements that embody the full treatment experience. This article offers a framework that includes the personal identity of the practitioner and the organizational context as two elements that serve as active agents in the helping relationship, although they have rarely been included in the discourse about evidence-based practice or cultural competence. Suggestions for practice, education, and research are included based on this analysis.

The Outline for Cultural Formulation (OCF) introduced with DSM-IV provided a framework for clinicians to organize cultural information relevant to diagnostic assessment and treatment planning. However, use of the OCF has been inconsistent, raising questions about the need for guidance on implementation, training, and application in diverse settings. To address this need, DSM-5 introduced a cultural formulation interview (CFI) that operationalizes the process of data collection for the OCF. The CFI includes patient and informant versions and 12 supplementary modules addressing specific domains of the OCF. This article summarizes the literature reviews and analyses of experience with the OCF conducted by the DSM-5 Cross-Cultural Issues Subgroup (DCCIS) that informed the development of the CFI. We review the history and contents of the DSM-IV OCF, its use in training programs, and previous attempts to render it operational through questionnaires, protocols, and semi-structured interview formats. Results of research based on the OCF are discussed. For each domain of the OCF, we summarize findings from the DCCIS that led to content revision and operationalization in the CFI. The conclusion discusses training and implementation issues essential to service delivery.

Clinicians and researchers have pointed to the need for culturally sensitive mental health interventions. Yet it has not been determined if the inclusion of cultural elements affects the way mental health clients experience services. This study examined 102 clients who had received mental health treatment from outpatient mental health clinics to investigate whether culturally related elements involving race and ethnicity were important to clients and whether they were related to client satisfaction and perceived treatment outcomes. Ethnic minority clients generally felt that issues regarding race and ethnicity were more important than did White clients. When these elements were considered important but were not included in their care, clients were less satisfied with treatment. Consistent with the notion of cultural responsiveness, these findings provide empirical evidence that culturally relevant aspects of the mental health service experience are salient to ethnic minority clients and can affect how they respond to services.

In his seminal volume From anxiety to method in the behavioral sciences, George Devereux suggests that any therapeutic or scientific engagement with another human being inevitably will be shaped by one's own expectations, assumptions, and reactions. If left unacknowledged, such unspoken and unconscious influences have the capacity to torpedo the interaction; if subjected to critical reflection, however, they can yield insights of great interpretive value and practical significance. Taking these reflections on counter-transference as point of departure, this article explores how a range of unacknowledged assumptions can torpedo good faith efforts to engender "cultural sensitivity" in a required course for American psychiatry residents. The course examined in this paper has been taught for seven successive years by a pair of attending psychiatrists at a longstanding New England residency training program. Despite the instructors' good intentions and ongoing experimentation with content and format, the course has failed repeatedly to meet either residents' expectations or, as the instructors bravely acknowledged, their own. The paper draws upon a year-long ethnographic study, conducted in the late 2000s during the most recent iteration of the course, which involved observation of course sessions, a series of interviews with course instructors, and pre- and post-course interviews with the majority of participating residents. By examining the dynamics of the course from the perspectives of both clinician-instructors and resident-students, the paper illuminates how classroom-based engagement with the clinical implications of culture and difference can run awry when the emotional potency of these issues is not adequately taken into account.

This article examines Russian-Jewish immigrant clients' attitudes toward death and dying in the context of today's health care system. Aspects of individuals' collective past--such as the traumatic history of their country of origin; cultural prohibitions against discussing pain, suffering, and death; and the lack of familiarity with palliative care that are likely to affect their decisions about end-of-life care--are discussed. Case vignettes are provided, with a discussion on how best to engage these clients in therapeutic work.

This article reviews proposed revisions to the DSM-IV Outline for Cultural Formulation for clinical practice. The author begins by exploring the theoretical development of and assumptions involved in the Cultural Formulation. A case presentation is then used to demonstrate shortcomings in the current implementation of the Cultural Formulation based on older definitions of culture. Finally, the author recommends practical questions based on the growing anthropological literature concerning the interpersonal elements of culture and the social course of illness. A simple clear format that clinically translates social science concepts has the potential to increase use of the Cultural Formulation by all psychiatrists, not just those specializing in cultural psychiatry.

Most case studies of the cultural formulation have focused on encounters with a single clinician. This article examines the assessment of a patient across different settings in which multiple clinicians developed separate understandings of the patient's identity. The formal cultural formulation prepared by the last clinician to work with the patient revealed a vastly different picture than what was previously recognized, reflecting both the impact of the identity of the clinician and the systematic evaluation process on the nature of the patient's responses. This suggests that cultural hybridity can stimulate new modes of inquiry as people integrate disparate cultural references to fashion a new identity. Intersubjectivity can also alter information elicited by clinicians. The conclusion highlights the need for practice guidelines for use of the cultural formulation across treatment settings.

In this consensual qualitative research study, 23 ethnic minority clients were interviewed to assess perceptions of race in their recent therapy with a White therapist. Participants' responses were coded into an average of seven (out of 22) categories. The majority believed that White therapists could not understand key aspects of their experiences and subsequently avoided broaching racial/cultural issues in therapy. However, many felt that racial differences were minimized if the therapist was compassionate, accepting, and comfortable discussing racial, ethnic and/or cultural (REC) issues. A subgroup expressed positive expectancies of racial mismatch, and perceived disadvantages associated with racial matching. Results suggest that participants' constructions of race are multidimensional and support recommendations that therapists acquire skills for addressing racial perceptions that may impact the therapy relationship.

Although research has demonstrated that mental health services function with patients from different cultural backgrounds, a variety of culture- and race-related factors can result in services being of lower quality than that which occurs when the clinician and patient are from the same culture. The provision of culturally competent care requires many institutional and organizational adaptations that lie beyond the control of most mental health professionals. The therapeutic relationship, however, remains a key factor of mental healthcare that can be attended to by individual therapists. The therapeutic relationship plays an important role in almost every therapeutic approach, and has been increasingly recognized as representing a means to the provision of quality intercultural and interracial treatment. At the same time, a host of cultural and racial factors relating to both the patient and clinician can compromise the development of the therapeutic relationship. This paper will explore some of the key issues that complicate therapeutic contact and communication, and will outline means by which to strengthen key components of the therapeutic relationship.

Anne Alonso was passionate about the practice of supervision. An excellent supervisor herself, she sought to identify and teach the ingredients of effective supervision throughout her career. Her first book, The Quiet Profession (1985), was about the supervisory relationship and the various influences on it from within and without the relationship, and she insisted that the Center for Psychoanalytic Studies training program that she directed for many years include a required course on supervision. While the usual focus in supervision is on the supervisee and the clinical material presented, supervisors often experience powerful emotional reactions. Sometimes this is parallel process, in which the dynamics of the psychotherapy are replayed in the supervisory relationship. However, many other sources can contribute to supervisory affect, including the personality, background, and developmental stage of the supervisor, the impact of the clinical material, and the setting in which the supervision takes place. Supervisory reactions can be informative about the psychotherapy being supervised, about the supervisory relationship, or about the supervisor. Supervisors need self-awareness in order to identify their own contribution to their affective responses in supervision. The use of a supervisor decision tree of 1) awareness of reaction, 2) identification of its source, 3) relevance to current supervision, and 4) appropriate use of the reaction in the current supervision is recommended.

The purpose of this guidance is to review currently available evidence on mental health problems in migrants and to present advice to clinicians and policy makers on how to provide migrants with appropriate and accessible mental health services. The three phases of the process of migration and the relevant implications for mental health are outlined, as well as the specific problems of groups such as women, children and adolescents, the elderly, refugees and asylum seekers, and lesbian, gay, bisexual and transgender individuals. The concepts of cultural bereavement, cultural identity and cultural congruity are discussed. The epidemiology of mental disorders in migrants is described. A series of recommendations to policy makers, service providers and clinicians aimed to improve mental health care in migrants are provided, covering the special needs of migrants concerning pharmacotherapies and psychotherapies.

This article reviews, consolidates, and enhances current knowledge about the issues and problems child and adolescent psychiatry international medical graduates face. Their training, work force issues, and establishment and advancement of professional identity are presented. Acculturation and immigration dynamics include facing prejudice and discrimination, social mirroring, and difficulties with language. Treatment issues are discussed with a special focus on therapeutic alliance, resistance, transference, countertransference, and child rearing practices. Recommendations for training and future goals are considered.

Child and adolescent psychiatrists are already serving an increasing population of culturally and ethnically diverse patients and families in their practices and in different agency settings. This article discusses adaptations to practice that enable child and adolescent psychiatrists to address the diverse clinical and cultural needs of this emerging population. Special attention is given to work in psychotherapy and in agency settings where diverse children and youth are found in large numbers.

A phenomenological/consensual qualitative study of clients' lived experiences of cross-racial therapy was conducted to enhance our understanding of whether, how, and under what conditions race matters in the therapy relationship. The sample consisted of 16 racial/ethnic minority clients who received treatment from 16 White, European American therapists across a range of treatment settings. Participants who reported a satisfying experience of cross-racial therapy (n=8) were examined in relation to gender- and in most cases, race/ethnicity-matched controls (n=8) who reported an overall unsatisfying experience. Therapy satisfaction was assessed during the screening process and confirmed during the research interview. Therapy narratives were analyzed using consensual qualitative research to identify the client, therapist, and relational factors that distinguished satisfied from unsatisfied cases. Findings reveal substantial differences at the level of individual characteristics and relational processes, providing evidence of both universal (etic) as well as culture/context-specific (emic) aspects of healing relationships. Recommendations for facilitating positive alliance formation in cross-racial therapy are provided based on clients' descriptions of facilitative conditions in the therapy relationship.