Introduction

In recent decades, clinicians and clinical educators have increasingly turned to the “cultural competence” paradigm and its correlates (e.g., “cultural sensitivity,” “cultural humility,” “cultural safety,” etc.) in an effort to engage clinicians in the monumental task of redressing health disparities between privileged and disadvantaged populations.Footnote 1 Such efforts hinge on several key assumptions: first, that “culture” and disadvantage are related in significant and predictable ways, and second, that certain identifiable dimensions of clinical encounters are both (a) associated with meaningful differences in health outcomes and (b) amenable to change. A great deal has been written about the wide and disparate array of efforts that have developed under the “cultural competence” umbrella. At the same time, it has also become increasingly common to wield (sometimes devastating) critiques of such interventions, especially in an anthropological vein.

Given this swirl of enthusiasm and debate, it is striking how little is known about the “on-the-ground challenges, problems, and pitfalls that arise when clinician-educators attempt to render issues of racial/ethnic and cultural difference ‘teachable’ and ‘learnable’” (Willen et al. 2010: 247).Footnote 2 In the present special issue, we take this lacuna as point of departure. Without empirical clarity about the range of ways in which concepts like “cultural competence” and “cultural sensitivity” are translated into real-life pedagogical settings, the contributions to this volume contend, it is altogether too easy to critique cultural competence advocates—for instance, for reifying static or reductive conceptions of “culture,” or for overselling the capacity of educational initiatives to help close the gaps between rich and poor people’s access to both the social determinants of health and to health care itself. What is considerably more challenging, and what we aim to do in this special issue, is to critically examine the specific array of pedagogical strategies currently in place and generate ethnographically based insights that might help clinical educators—both in the United States, where much of this discourse has originated, and in other countries—do justice to the core challenges and dilemmas at stake.

The idea for this collection began to germinate several years ago when we had the good fortune of being postdoctoral fellows together in the long-running NIMH Program in Culture and Mental Health in the Department of Social Medicine at Harvard Medical School. At the time, our interest in how US psychiatry is engaging with matters of “culture” was fueled by the opportunity to work with Mary-Jo DelVecchio Good on a study designed to examine the increasingly “hyperdiverse” (Hannah 2011) milieu of contemporary psychiatric practice in Greater Boston. This project—a collaborative, multi-year, multi-sited ethnographic study of providers, patients, and support staff in hospitals and clinics, funded by the Russell Sage Foundation—provided fertile ground for intense engagement with these themes. In particular, the study provided ample opportunity to consider how broad shifts toward greater cultural and demographic diversity—among patients and providers alike—are shaping the practice and experience of US health care in general and of mental health services in particular. Key findings from this work were recently published in the edited volume, Shattering Culture: American Medicine Responds to Cultural Diversity (Good et al. 2011).

Our involvement in the study also led to two spin-off projects on a topic of increasing concern to clinical educators, health care providers, and health care institutions around the globe: how the culture concept and discourses on racial and ethnic disparities are deployed in contemporary medical education (Hannah and Carpenter-Song 2013; Willen 2013 Footnote 3).

As we realized through our involvement in these projects, discourse and practice around cultural competence may be most developed in the US, but this is increasingly a global conversation involving clinicians, educators, and researchers in other world regions as well (Dogra et al. 2010; Knipper et al. 2010a, b; Seeleman et al. 2009; van Wieringen et al. 2001; Wachtler and Troein 2003). In this special issue, we therefore eschew the prevailing US focus of most literature on cultural competence by juxtaposing US examples with perspectives from Canada and Germany that elucidate (a) the particularity of the US context, (b) how cultural competence efforts are adapted to suit local needs in local contexts, and (c) the value of broadening the dialogue to consider how issues of culture, difference, and inequality are, and could be, taken up by health care providers and clinical educators in different countries and different settings. Not all of the efforts described in these pages draw explicit ties to “cultural competence,” but all engage discourse around and practical efforts to provide culturally appropriate services for populations burdened by disparities in health, and especially mental health, care.

Despite the many limitations of contemporary cultural competence efforts, our position in this volume is thus that the impulse behind such efforts is a significant—indeed a crucial—one. We concur with Kirmayer’s contention that, “conceptual analysis and critique of cultural competence can point toward ways to improve the cultural responsiveness, appropriateness, and effectiveness of clinical services, and in doing so contribute to reducing health disparities” (2012b, p. 149). Our task, as we see it, is thus to scrutinize both baby and bathwater rather than tossing the whole enterprise aside as some of our colleagues might wish to do.

The Collection: Structure and Distinguishing Features

In this special issue, we approach this task by “lifting the hood” on four long-standing initiatives designed to disseminate and advance clinical understanding at the intersection of culture and health. The volume is structured around four pairs of papers that focus, respectively, on (1) a required course for 3rd-year psychiatry residents, (2) a multi-year research and training collaborative that links a Historically Black University and an Ivy League institution, (3) a continuing medical education course for clinical faculty, and (4) an annual intensive summer program for a diverse, international cohort of clinicians and researchers. The first three initiatives are US-based, while the fourth is Canadian. Each pair of papers includes (a) an ethnographic analysis of a particular program that discusses its history, aims and structure and considers its real-life dynamics alongside (b) a brief reflective essay by a clinician-educator who has been centrally involved. In these brief companion essays, authors bravely consider their programs’ strengths and successes as well as their warts, disappointments, and even failures. Collectively, the assembled papers shine light on a particular corner of the culture of biomedicine: real-world efforts to teach clinicians and health researchers to think about, and respond to, issues of culture, difference, and inequality. The four pairs of essays are followed by three commentaries from experienced clinical educators, including two from the United States and one from Germany.

Several features set this collection apart from related recent work by clinical educators (Betancourt 2003, 2006; Fung et al. 2008; Kripalani et al. 2006; Smith et al. 2007; Sumpter and Carthon 2011) and anthropologists alike. First, our aim is not to document or propose any specific pedagogical models or “best practices,” but rather to present complex, multi-faceted portraits of four long-standing programs whose successes and failings provide valuable insight into the everyday life of “culture” in clinical education and clinical research training.

Second, we are indebted to earlier contributions and analyses by anthropologists and cultural psychiatrists (Desjarlais et al. 1995; Good 1977, 1994; Good and Good 1980; Guarnaccia and Rodriguez 1996; Kleinman 1980; Kleinman and Good 1986; Lakes et al. 2006; Sargent and Larchanché 2009), especially those that critique reductive approaches to the culture concept and instead advance a process-oriented, anthropologically-informed conception of culture (Carpenter-Song et al. 2007; Gregg and Saha 2006; Kirmayer 2012b; Kleinman and Benson 2006; Taylor 2003). Contributors to the collection are especially sensitive to the fact that “culture” is often deployed as either a euphemism or an empty category. Sometimes it is thrown around without any clear definition, operational or otherwise; at other times, concepts like “culture”—or “race,” or “ethnicity”—are employed as though their meaning, ideological valence, and salience can be held constant across sociocultural or national contexts which, as the Canadian and German contributions to the collection clearly reveal, is not the case. As Kirmayer notes,

The cultural competence literature tends to treat culture as a matter of group membership (whether self-assigned or ascribed). This assumes that members of a group share certain cultural “traits”, values, beliefs, and attitudes that strongly influence or determine clinically relevant behaviour. Unfortunately, this approach tends to reify and essentialize cultures as consisting of more or less fixed sets of characteristics that can be described independently of any individual’s life history or social context—hence the plethora of textbooks with chapters on specific ethnocultural groups. This is an old-fashioned view, now largely abandoned by anthropology. (2012b, p. 155)

And still, as Kirmayer observes in his contribution to the present collection, “the term culture remains a useful placeholder for many important dimensions of social life and experience” (this volume).

Other anthropological critiques raise other important concerns including, for instance, lack of attention to the culture of biomedicine in cultural competence efforts (Carpenter-Song et al. 2007; Fox 2005) and inattention to the structural factors that often play much weightier a role than cultural factors in affecting health circumstances and health outcomes (Jenks 2011; Metzl 2009, 2012).

It is important to note that all four of the initiatives examined in this special issue are grounded in sophisticated understandings of culture, and all were designed to facilitate sustained inquiry into how culture shapes the provision of care and the subjective experience of illness and recovery. As such, we might expect that these programs in particular would be poised to avoid the mistakes of simplistic “trait-based” approaches and brief cultural competence workshops. Yet, as the papers reveal, such promising conditions of possibility alone do not always yield success. Careful empirical attention to well-conceptualized—but not always successful—pedagogical interventions thus represents the third key contribution of this volume.

As a result, and this is its fourth distinguishing feature, the collection leverages the strengths of both ethnography and personal reflection to present robust, and often unusually frank, assessments of specific courses and programs. The authors do not attempt to round corners, smooth edges, or shy away from the deep reservoir of emotion often tapped by issues of and institutional responses to difference (e.g., “political correctness”, “diversity talk”, “multiculturalism”). Given the affectively potent nature of this work, we have struggled collectively to achieve a tone that balances honest critique with acknowledgment of, and genuine respect for, the aspirations and good intentions of those involved in the various teaching, training, and research efforts described here. This has not been an easy task, and we hope our readers will appreciate the courage and humility many contributors have evinced in discussing and writing about professional challenges that often bear powerful personal implications as well.

Finally, as noted above, the collection explicitly aims to transcend the often unspoken US-centered assumptions that characterize so much of the current literature on cultural competence and its correlates. Juxtaposing US examples with evidence from Canada and Germany obligates us to reflect critically on how the particularities of the US context—legacies of slavery, Jim Crow laws, and enduring legacies of racial/ethnic tension; the US census framework, which has long classified people according to social constructions of “race”; unvoiced inclinations to conflate racial/ethnic and class differences; contemporary patterns of (im)migration and racialization; etc.—have shaped broader pedagogical conversations about how clinical rapport might flourish even in the presence of human difference. Critical and comparative reflection reveals some key limitations of US approaches and, at the same time, opens up new questions about the shape and content of this area of clinical education in other countries and contexts.

The Papers

The first pair of papers, by anthropologist Sarah Willen and psychiatrist Antonio Bullon, examines a course for psychiatry residents that did not succeed in meeting residents’ or instructors’ expectations. Willen’s ethnographic paper illuminates key shortcomings of “knowledge-based” approaches to teaching about culture and difference. In particular, she observes that courses that fail to engage the emotional, especially counter-transferential valences of these issues do so at their peril. Notably, the course “missed the mark” very much despite the instructors’ own powerful personal and professional investment as well as their openness to critiquing the culture of psychiatry itself. Still, these seemingly ideal conditions of possibility did not yield a successful course. The resulting lecture-based, top–down format misconstrued residents as “blank slates”, failed to engage them at the level of their own personal or clinical lived experience, and sidestepped the powerful counter-transferential dimensions of the course themes and content. Willen suggests that a more interactive and participatory classroom dynamic might have fostered the kind of “safe space” necessary for the articulation of anxieties and sensitivities and, ultimately, a more successful experience. The companion essay by Bullon, one of the two course instructors, offers a humbling narrative of personal commitment and professional frustration. Despite his deep-rooted motivation to help residents prepare to work effectively across clinical manifestations of human difference, he and his colleague struggled with a series of conceptual, practical, and institutional challenges that continually impeded their best efforts. Concurring with others’ assessment of the course as unsuccessful, his essay leaves readers with a number of valuable insights that he hopes will prove useful to other clinician-educators who find themselves in his shoes.

The second pair of papers, by anthropologists Elizabeth Carpenter-Song and Rob Whitley and Mansoor Malik, a psychiatrist-researcher, takes a “confessional”, auto-ethnographic approach to examining the messy dynamics of a federally funded research and training collaboration between a Historically Black University medical center and an Ivy League research center. The official aims of the collaboration are to enhance the knowledge base pertaining to mental illness and recovery among African-Americans and build the capacity to conduct meaningful research in this arena. The collaboration is motivated by robust findings pointing to the persistence of gross inequalities in access to mental health care and quality of services received by racial/ethnic minorities in general and by African-Americans in particular. Carpenter-Song and Whitley take the reader “behind the scenes” to examine the complex “dance” that emerges as the individuals involved in the collaboration navigate across racial, disciplinary, and institutional boundaries. Further, they explore how hidden transcripts of race, power, and privilege shape the on-the-ground realities of their research and training efforts. Malik’s companion essay, which situates his motivation to work with vulnerable populations within his own personal and professional trajectory, offers an insider’s view of the impact of the collaboration on residents. He argues for the crucial role that Historically Black Colleges and Universities can play in reducing disparities in mental health training and research. In his role as training director of the psychiatry residency program, Malik brings a unique perspective from his position on the front lines of cultivating the next generation of minority psychiatrists and researchers.

The third pair of contributions, including an ethnographic paper by sociologist Seth Hannah and anthropologist Elizabeth Carpenter-Song and a companion essay from clinician-educator Roxana Llerena-Quinn, pulls focus on a clinical faculty development course whose pedagogical approach foregrounds introspection and the personal experiences of participants. Through exercises designed to offer a platform for articulating one’s personal, familial, social, and cultural positioning, the course encourages participants to discover and confront “blind spots” that may compromise the care they provide in ways that unintentionally produce unequal treatment. According to the course framing, such blind spots operate below the level of conscious awareness but can be brought to the surface, to positive effect, if conditions are appropriate. The paper explores how the course instructors strive to create a “safe space” in which participants might reveal and reflect collaboratively upon uncomfortable, painful, or shameful personal experiences within the context of a “no blame” environment. When this dynamic is successful, at least some course participants find themselves and their clinical perspectives substantively transformed. As Llerena-Quinn points out in her companion essay, designing and teaching a course of this nature is inherently challenging and fraught with emotion, yet the stakes are high—especially in light of the rapidly changing demographics of the US—and the potential benefits great.

The final pair includes a paper by child psychiatrists Jaswant Guzder and Cécile Rousseau and a companion essay by cultural psychiatrist Laurence Kirmayer focusing on an annual, month-long training program in Québec for clinicians and social scientists of Canadian and international origin. Guzder and Rousseau, clinicians of South Asian Canadian and French Euro-Canadian backgrounds respectively, discuss a seminar they have taught for 15 years that offers hands-on experience working with the cultural axis in clinical contexts. Its primary aims involve dethroning the “expert” position, recalibrating the power dynamics between patient and healer, and helping healers cultivate the capacity to listen differently. Built on reflective process rather than a didactic approach to cultural competence, the seminar aims to initiate a decentering process that promotes self-reflection and systemic thinking. Instead of focusing narrowly on reified concepts of “culture”, “race/ethnicity”, or other categorical labels, the course instead prepares participants to engage with complex clinical realities shaped by refugee and asylum-seeking processes, migration, local familial and sociopolitical circumstances, and individuals’ particular intra-psychic worlds. The seminar atmosphere is designed to model clinicians’ cultivation of a “holding environment” (Winnicott 1967) that engenders feelings of rapport, safety, and trust. In these respects, the seminar is meant to mirror the dynamics of the clinical encounter and model a time-tested array of therapeutic strategies: acknowledging and welcoming a multiplicity of meanings and a plurality of voices, tolerating “uncertainty,” encouraging narrative co-construction, engaging countertransference issues, and encouraging clinicians to acknowledge the limits and fragility of their professional knowledge. Accompanying their contribution is a companion essay by cultural psychiatrist Laurence Kirmayer that situates this seminar in the broader Canadian and Québecois context and in terms of the unique annual training program of which this seminar is part. He highlights several unique features of the course Guzder and Rousseau teach. These include the seminar’s recognition of the many forms of uncertainty that operate in clinical settings (practical, psychological, social, intersubjective); its skillful modeling of ways to manage uncertainty and tolerate indeterminacy; and its emphasis on partnering with, and advocating on behalf of, patients and their communities.

These four pairs of papers, which comprise the backbone of the collection, are followed by reflective commentaries from three experts in the field of culture and mental health: Michael Knipper, a German physician and social scientist; Robert Drake, an American psychiatrist; and Mary-Jo DelVecchio Good, an American medical anthropologist and sociologist.

Cross-cutting Themes: Safe Spaces, Hidden Curricula, and the Moral Dimensions of Clinical Training

A number of key themes cross-cut the papers in the collection. Many call attention to the importance of creating a safe space or “holding environment” (Winnicott 1967) before matters of culture and difference can be engaged effectively. In tandem with this observation, all acknowledge that culture operates below the level of conscious awareness and, therefore, that efforts to reflect on the role of culture in clinical settings often call forth powerful, hidden feelings and beliefs. Failing to acknowledge or engage this hidden curriculum (Llerena-Quinn 2013) may ultimately derail a well-intentioned course, as Willen (2013) shows, or it may inadvertently contribute to harmful forms of “color blindness” in the medical and social sciences, as Carpenter-Song and Whitley (2013) suggest.

At the same time, these essays also point to the value and potential of multi-disciplinary reflection and collaboration, a point the volume makes explicit by pairing anthropological interpretations with reflections by clinical educators. In this respect the collection transcends mere critique by amplifying the voices of those who are “in the trenches” teaching and conducting research in the area of culture, difference, and inequality. The insightful—and often personally revealing—papers by clinicians illuminate the deeply moral dimensions of clinical training and practice (Good 1994, 1995; Kleinman 1988, 2006). As Kirmayer, among others, has observed, successful clinical engagement across cultural differences hinges on both the person of the clinician and the clinician-patient relationship (2012, p. 4). “Ultimately,” he writes, “it is by seeing oneself as an other that the clinician can achieve greater empathy and understanding” (ibid. 11). This ethical stance is undoubtedly true for all patients, but it may be especially so when clinical encounters traverse borders of race, ethnicity, gender, language, nationality, age, etc. (Carpenter-Song 2011).

Conclusion

The papers in this special issue examine a range of approaches to cultural competence training and education—from required knowledge/skills-based courses, to elective seminars that encourage personal reflection, to collaborative research and training efforts. Readers are invited to consider the relative merits and pitfalls of each. As the papers illuminate, the work of teaching and collaborating in matters of culture, difference, and inequality—and, we might add, the work of reflecting critically on, and writing about, such work—is messy, and we provide no easy answers or formulas in these pages. We do, however, hope that the endeavors described here—ethnographically, frankly, at times courageously—provide insight for those engaged in, or pondering, similar efforts.