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Training Psychiatrists for Global Mental


Health: Cultural Psychiatry, Collaborative
Inquiry, and Ethics of Alterity

Article in Academic Psychiatry April 2016


DOI: 10.1007/s40596-016-0541-z

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Acad Psychiatry
DOI 10.1007/s40596-016-0541-z

COLUMN: EDUCATIONAL CASE REPORT

Training Psychiatrists for Global Mental Health: Cultural


Psychiatry, Collaborative Inquiry, and Ethics of Alterity
James L. Griffith 1 & Brandon Kohrt 2 & Allen Dyer 1 & Peter Polatin 1 & Michael Morse 1 &
Samah Jabr 1 & Sherein Abdeen 1 & Lynne M. Gaby 1 & Anjuli Jindal 1 & Eindra Khin Khin 1

Received: 7 July 2015 / Accepted: 21 March 2016


# Academic Psychiatry 2016

Awareness of the global burden of disease from mental ill- Program descriptions and surveys have revealed various
nesses, insufficient funding for services, and paucity of mental conceptualizations of GMH curricula without a unifying
health professionals for low- and middle-income countries thread, except for international training focused upon disad-
(LMIC) has spurred development of global mental health vantaged populations [1, 2].
(GMH) curricula in psychiatry residencies. According to a The mission of our George Washington University (GWU)
recent study, 17 psychiatry residencies offer research and clin- GMH curriculum has been to educate psychiatrists for service
ical opportunities in GMH. Most were offered through insti- in LMIC, in settings of disaster, war, and refugee crises, and
tution-wide, externally administered initiatives in which psy- with local immigrant and refugee populations in the USA.
chiatry residents could participate [1]. Learning objectives Residents first learn psychiatric care for immigrants and refu-
were mostly limited to acquisition of cultural competencies gees in our local community, including treatment and advoca-
for care of patients from different ethnicities. As Belkin et al. cy for political torture survivors seeking asylum [3]. Learning
([2] p. 403) noted: (Table 1). how to design effective interventions that counter stigma is a
major focus [4]. After acquiring sufficient competencies, res-
This emphasis on issues of cultural familiarity, as well as idents design mental health service projects and research stud-
reinforcing certain trainee personal and professional at- ies in LMIC countries and settings of refugee crises.
tributes, such as empathy and flexibility of thinking, also As an educational foundation, we first drew six themes
reflected relatively less consideration of how a more from the scholarship of cultural psychiatry and medical
synthetic, globalized, field and frame of reference anthropology about contextual, cultural, and health sys-
might shape and inform psychiatric knowledge, tems differences between mental health services in the
research, and practice. USA and those in LMIC, so that these themes could guide
selection of curricular content. Second, we utilized collab-
orative partnerships with mental health colleagues who
belonged to populations that we served so their critiques
Electronic supplementary material The online version of this article
(doi:10.1007/s40596-016-0541-z) contains supplementary material, and commentaries could inform our educational aims.
which is available to authorized users. Third, most GMH teaching was embedded within semi-
nars serving multiple educational roles for all our resi-
* James L. Griffith dents. Fourth, a Global Mental Health Track was designed
jgriffith@mfa.gwu.edu to provide more individualized study programs for resi-
dents seeking advanced levels of GMH expertise. This
approach has proven to be a pragmatic one for developing
1
The George Washington University, Washington, DC, USA a GMH curriculum, which we can recommend for consid-
2
Duke University, Durham, NC, USA eration by other US psychiatry residencies.
Acad Psychiatry

Table 1 GMH training embedded within seminars and supervisions that serve multiple educational roles

GMH training is located within 11 seminars and clinical rotations that are required for all residents
Theme IV PGY-II Seminar: Clinical Neurosciences (ethnopharmacology, local biologies) [20]
Themes I, II, V PGY-II Seminar: Global Mental Health and Cultural Psychiatry (adverse unintended consequences, ethics of alterity, dialogic
practices, Cultural Formulation Interview, distress vs. disorder, category fallacy, community mental health needs assessment, task
shifting/task sharing)
Theme VI PGY-II Forensic Psychiatry Seminar (forensic evaluation of human trafficking, psychiatric evaluation of political asylees)
Theme VI PGY-III Human Rights Clinic (at least two supervised political asylee evaluations with preparation of report)
Theme II PGY-II Rotation: Psychosomatic Medicine (distinguishing normal syndromes of distress from psychiatric disorders, supervised
bedside psychotherapy with interventions to counter demoralization)
Themes I, III PGY-III/IV Seminar Managing Stigma Effectively: Social Psychology and Social Neuroscience of Stigma [4] (assessment/
formulation/intervention to counter stigma in role as patients advocate; when stigmatized by a patient or medical colleagues; as
internalized stigma)
Theme II PGY-III Seminar: Resilience-Building Brief Psychotherapy with Medically-Ill Outpatients (mobilizing assertive coping;
activating common factors for therapeutic change, such as therapeutic alliance, hope, and expectancy for change)
Theme II PGY-III Supervision: Brief Psychotherapy Supervision (year-long weekly supervision of resilience-building brief psychotherapy)
Theme II PGY-II Seminar Hope Modules: Evidence-Based Practices for Mobilizing Hope (utilizing evidence-based practices for
mobilizing hope to counter despair)
Theme III PGY-III Seminar Family and Systems Therapy (family alliance-building skills; systemic assessment, formulation, and
intervention)
Themes V, VI PGY-III Health Policy Rotation (3-week full-time interdisciplinary immersion in health policy, with policy analysis and preparation
of brief as final exam)
Residents who elect the Global Mental Health Track complete an additional required seminar and rotation in immigrant and refugee mental health:
Themes I, II, IV, V PGY-III Seminar: Psychiatric Care for Immigrants and Refugees (CFI interview, ethnopharmacology, trauma-informed care,
ethnocultural transference, treating psychiatric sequelae of torture, interpreters)
Themes IV, V PGY-III/IV Clinical Rotation: Community Mental Health Services for Immigrants and Refugees (year-long, half- or whole-day
clinic with supervised treatment of immigrants and refugees from 30 or more countries)

Strategy One: Utilize Cultural Psychiatry health professionals and local recipients of services [8].
and Medical Anthropology Scholarship to Identify New dimensions of iatrogenic harm open when well-
Contextual, Cultural, and Health Systems intended HIC clinicians and researchers enter complex
Differences Between the USA and LMIC that Impact LMIC psychosocial eco-systems. To avoid adverse unin-
Experiences of Illness and the Delivery of Care tended consequences, a global mental health curriculum
needs to provide knowledge and skill sets for structuring
Cultural psychiatry and medical anthropology scholarship collaborative, egalitarian, and dialogical relationships, so
have clarified essential differences between LMIC and evidence-based psychiatric care is provided while preserv-
high-income countries (HIC) of North America and ing voice, agency, and cultural identity for LMIC and oth-
Europe in terms of ethnopsychologies, psychiatric er GMH recipients [9, 10] ([11], p. 21) ([12], pp. 245
diagnoses, morbidity of psychiatric illnesses, and social 251). This requires attunement to power dynamics and
suffering [57]. Six themes were selected that would com- differentials that shape interactions between HIC and
plement, but not replace, training in evidence-based prac- LMIC actors within clinical, academic, and social settings.
tices for treating severely ill patients, such as diagnostic
psychopathology and psychopharmacology. Table 1 lists II. Impaired mental health in LMIC and refugee populations
the location of each theme within our overall residency is commonly due to social suffering and demoralization
curriculum. Each of these six themes has been implement- that may not represent psychiatric disorders, but whose
ed through specific learning objectives and training expe- psychiatric care requires specific skill sets [13].
riences that also fulfill associated American Council for In LMIC, patients commonly present non-specific so-
Graduate Medical Education (ACGME) Milestones (de- matic symptoms or depression and anxiety symptoms
tailed in online Attachment A and our departmental that have proximal relationships to psychosocial stressors
website www.gwupsychiatry.org). (6). Cultural concepts of distress (idioms of distress, cul-
tural syndromes, and explanatory models) that a suffering
I. First, do no harm. Adverse unintended consequences can person presents for treatment often reflect social context
accrue in LMIC and refugee populations due to differ- and may not correspond to DSM-5 diagnostic categories
ences in resources, status, and power between HIC mental [6, 14]. Descriptive psychiatry has shown little
Acad Psychiatry

effectiveness in organizing treatment for such symptoms Strategy Two: Utilize Dialogue with Mental Health
[6, 15, 16]. HIC mental health professionals lacking un- Colleagues from LMIC or Refugee Populations
derstanding of local concepts of distress and societal roles to Inform Training Objectives for US Psychiatry
for healers can do harm by introducing diagnostic and Residents
treatment approaches that fit poorly with local meaning
systems or health care resources [6]. Patients may insist Educating psychiatrists for service to LMIC and other GMH
that their predicaments in living and subjective illness populations means building trustworthy relationships with pa-
experiences be understood and acknowledged before tients and clinical leaders [9]. Trustworthiness entails a com-
treatment progresses. mitment to dialogue and an explicit power sharing in decision-
making, access to resources, and implementing clinical prac-
III. Patients in LMIC may embrace identities that are fami- tices. The practice of trustworthiness seeks advisement from
ly-, clan-, religion-, or ethnicity-based as primary LMIC and other GMH colleagues for both mission and con-
identities. tent of GMH training [9, 10, 19].
Persons in LMICs may first see themselves as a fam- An initial draft of this manuscript was provided to GWU
ily member or an ethnic or religious group member, rath- Palestinian clinical faculty members living and working in
er than an individual [6, 10]. Determining which identity West Bank Palestine, site of our major departmental GMH
aspects are most important is crucial to respectful dia- mission. These Palestinian clinical faculties have served as
logue and successful clinical care [9]. Training in family supervisors and research collaborators for our West Bank
therapy to learn systemic assessment, formulation, and GMH residency rotation. In their personal lives, they have
intervention is key for effective clinical work [10]. lived with families under Israeli military occupation and have
experienced security searches, checkpoints limiting traveling,
IV. Local biologies influenced by infectious disease prev- and the loss of family members by imprisonment or murder
alence, diet, exercise, and genetic differences in pharma- during conflicts.
cokinetics influence psychiatric phenotypes and treat- We asked our colleagues to provide a critique of our GMH
ment response [17]. curriculumWere there any additional themes, learning ob-
Local biology refers to how diet, physical activity, jectives, or training experiences that they felt should be added
parasites and other infectious disease, other health to the psychiatric education of American psychiatrists plan-
burdens, and climate influence inflammatory re- ning to practice or teach in West Bank Palestine? Were there
sponses and psychoneuroendocrine pathways that any that should be dropped?
can shape psychiatric phenotypes [17]. Sensitivity Our Palestinian colleagues did not suggest alterations to
to local biology must be combined with awareness the themes or their derivative learning objectives. Rather,
of population genetic differences in medication phar- they requested a shifting of priority. Whereas the Do no
macokinetics to avoid risks from altered drug metab- harm and adverse unintended consequences theme origi-
olism and interactions. nally had been listed last, they requested that it be placed
first in order of importance. They noted numerous exam-
V. Mental health needs in LMIC vastly exceed the number of ples from the West Bank, where the economy is reliant for
mental health professionals required to respond. social services from American and European NGOs that
Major roles for a psychiatrist in a LMIC commonly are also unilaterally project their funders social agendas.
those of educator, supervisor, and consultant to primary They commented
care clinicians and community health workers who,
through task shifting and task sharing, provide direct care We have observed that the possibilities for unintentional
to psychiatric patients [5, 6]. Interventions often must harm are numerous and that even with reasonable fa-
focus upon communities as a whole, rather than symp- miliarity with the local culture, history, and current so-
tomatic individuals [18]. cial/political/and economic situation, outside mental
health professionals are likely to cause unintentional
VI. Promoting mental health in LMIC and refugee crises harm on occasion. The example that we find particular-
often entails human rights advocacy through political ly compelling based on our own personal experience is
activism and advocacy campaigns to protect vulnerable how international donors, INGOs, international mental
persons. health professionals, and other international actors can
In many LMICs, the impact of human rights viola- cause harm by either deleteriously reinforcing divisions
tions is so substantial that health policy initiatives, advo- within a society or papering over meaningful divisions
cacy, and activism must be core elements of an effective in effect forcing the less powerful party within the soci-
treatment program. ety to compromise principles in order to obtain funding.
Acad Psychiatry

They provided examples in which NGO funders agendas care of immigrants, refugees, and political torture survi-
forced collaborations between Israelis and Palestinians that vors;
had not been preceded by building person-to-person relations And/or, acquisition of advanced expertise in human
upon which reconciliation could be built. They felt trapped rights advocacy and psychiatric assessment of political
between the need for resources and acceptance of roles felt asylees.
to be integrity violations. Illustrations of dialogical practices
and collaborative relationships involving other LMIC have
been previously published [10, 19]. Outcomes for Our GMH Program

The major measure of success for a GMH program lies in its


Strategy Three: Embed GMH Learning Objectives impact upon career trajectories, professional competencies,
Within Seminars and Supervisions that Can Serve and future contributions of its trainees. Six residents in the
Multiple Simultaneous Educational Roles in Order GMH Track since 2011 accomplished during their
to Conserve Program Resources residencies:

Since its 1998 inception, our GMH program has been chal- & Training experiences and research projects in seven
lenged by both insufficient funds to compensate residents LMIC;
out-of-country travel and an absence of institutional global & Publication of 15 journal articles and one book chapter;
health programs to which a psychiatric component could be & Professional recognitions that included an APA/Substance
attached. Consequently, we prioritized the teaching of GMH Abuse and Mental Health Services Administration
skills with local immigrant and refugee populations (3). We (SAMHSA) Fellowship and leadership roles in the
placed GMH training objectives within seminars that also American Psychiatric Associations Council on
served multiple educational aims for all our residents. For International Psychiatry and Global Mental Health
example, distinguishing depression as psychopathology from Caucus.
demoralization as a normal stress response matters similarly
for a medically ill patient in US hospital as for a politically After graduation, a consistent long-term outcome has been
oppressed villager in a LMIC (13). Table 1 lists 11 multi- commitment to human rights advocacy, with most GMH
purpose seminars in which learning objectives for the six Track graduates continuing to conduct Physicians for
themes were inserted. Human Rights (PHR) psychiatric evaluations for political
asylees and two graduates serving as adjunct law school fac-
ulty for immigration clinics. All six have continued to teach
Strategy Four: Provide a Global Mental Health global mental health as full time or adjunct psychiatry faculty
Track for Motivated Residents Who Seek Advanced members. Profiles of these graduates illustrate the breadth of
Levels of GMH Expertise influence of the GMH Track upon career development:
Resident A traveled to Cambodia during her PGY-IV year
A formal Global Mental Health Track (GMH Track) was to study how testimonial therapy had been employed as a
established in 2011 with specific expectations for training community-based therapeutic ritual aiding recovery of survi-
and scholarship. Residents in the GMH Track were provided vors of Pol Pot genocide. She and other residents then adapted
with highly individualized programs of study reflecting each testimonial therapy for a domestic violence survivors group of
residents aptitudes and career aspirations. Residents fulfilled Spanish-speaking women. Their project was subsequently
the following expectations over the 4 years of residency (see presented at an international conference on testimonial thera-
www.gwupsychiatry.org for further details): py. Resident A is now a full-time GWU psychiatry faculty
member who teaches the Psychiatric Care for Immigrants
& Regular participation in monthly Global Mental Health and Refugees Seminar, provides PHR asylum evaluations,
seminars in which residents and faculty present research and is co-investigator on funded PTSD research.
projects for discussion and critique; Resident B utilized funding from his American Psychiatric
& Completion of a scholarly project meriting presentation in Association/SAMHSA Fellowship to conduct program out-
a research conference or publication; reach that linked the GWU refugee mental health program
& Specific expertise regarding a selected ethnicity, country, with other regional immigrant advocacy organizations. He
or region of interest; also produced the first mid-Atlantic regional conference of
& Completion of clinical rotation in a low- or middle-income torture survivor programs. As a community psychiatrist, he
country or armed conflict zone; currently directs mental health services at a major community
And/or, acquisition of advanced expertise in psychiatric health agency serving minority and immigrant populations,
Acad Psychiatry

provides PHR asylum evaluations, and teaches immigrant and Input from colleagues who are members of LMIC and refugee
refugee mental health in our GWU psychiatry residency and populations can guide selection of relevant content. We have
school of public health. employed both methodologies to design a Global Mental
Resident C, now a forensic psychiatrist, directs our GWU Health Track that is largely embedded within a GWU residen-
Human Rights Clinic, trains residents to conduct asylum eval- cy curriculum that provides GMH training for all residents.
uations, and conducts human trafficking forensic evaluations. Additional enrichment experiences for Global Mental Health
She teaches in the Global Mental Health and Cultural Track residents are provided through study groups, mentors,
Psychiatry Seminar and works with the American international training experiences, and professional confer-
Psychiatric Association to implement immigrant mental ences and workshops. This curriculum has proven effective
health, education, and advocacy projects. She provides con- not only for clinical service and research in LMIC but also for
sultation to a low-income countrys ministry of health in its community psychiatric care of local immigrant and refugee
revision of mental health law. populations. It has established GMH as a core element of
Resident D had already created an NGO that educated our departments national identity and an impetus for residen-
mental health clinicians in West Bank Palestine and Gaza prior cy recruitment, teaching, and scholarship.
to arrival in our GWU residency. During each PGY-I through
IV residency year, resident D conducted periodic training ex- Implications for Educators
periences in a Bethlehem Community Mental Health Center Distinctions between US mental health services and conditions in low-
under supervision of local psychiatrists who were appointed and middle-income countries and refugee populations in terms of
as GWU adjunct faculty. This arrangement enabled resident D ethnopsychologies, psychiatric diagnoses, morbidity of psychiatric ill-
to continue administrative leadership of his NGO, which re- nesses, and social suffering can guide selection of learning objectives
and training experiences for a global mental health curriculum.
ceived European grant funding for new primary care and
Dialogue with colleagues in low- and middle-income countries can
school-based mental health programs during his PGY-IV year. further guide curricular priorities and demonstrate a commitment to
Resident D now serves on our GWU GMH faculty as Director collaboration, mutuality, and respect across gaps of culture and socio-
of Global Community Psychiatry Programs. economic status.
Resident E joined our GWU residency with ongoing GMH A global mental health curriculum can be largely implemented by
collaborations in South Asia and Africa. During residency, embedding its learning objectives within seminars serving multiple
educational roles and by supervised psychiatric care of local immigrant
resident E received grants and support from NIMH, Grand and refugee populations, thus sparing programs with limited resources
Challenges Canada initiative in GMH, and The Carter undue stress from investing in new curriculum.
Center which enabled three PGY-III months and eight PGY-
IV months in mental health services research projects in
Nepal, Uganda, and Liberia. After graduation, resident E Compliance with Ethical Standards
joined the faculty of a global health institute where the major- Disclosure On behalf of all authors, the corresponding author states that
ity of his academic time to focus on GMH initiatives. He there is no conflict of interest.
continues to mentor GWU GMH Track residents.
Funding The authors acknowledge salary support for Dr. Kohrt
through K01MH104310.
Limitations and Further Research

The four educational strategies employed by our curriculum


contribute to its generalizability. However, our program is
largely shaped by our local patient populations, academic fac- References
ulty, and institutional resources that may limit the generaliz-
ability of its specific features. Input from the single LMIC 1. Tsai AC, Fricchione GL, Walensky RP, et al. Global health training
should be compared to feedback from other LMIC and refu- in US graduate psychiatric education. Acad Psychiatry. 2014;38:
gee populations, which might highlight other needs. Further 42632.
longitudinal study of impacts of GMH training upon profes- 2. Belkin GS, Yusim A, Anbarasan D, et al. Teaching global mental
health: psychiatry residency directors attitudes and practices re-
sional development for psychiatrists is needed for our program
garding international opportunities for psychiatry residents. Acad
and others. Psychiatry. 2011;35:4003.
In conclusion, contextual, cultural, and health systems dis- 3. Levin A. Psychiatry residency builds global reach by using local,
tinctions between high resource settings in North America and overseas setting. Psychiatry News, September 5, 2014, pp 18, 45.
LMIC cultures in terms of ethnopsychologies, psychiatric di- 4. Griffith JL, Kohrt BA. Managing stigma effectively: what social
psychology and social neuroscience can teach us. Acad Psychiatry.
agnoses, psychiatric illness morbidity, and social suffering can 2016;40(2):33947.
guide selection of learning objectives and training experiences 5. Kirmayer LJ, Pedersen D. Toward a new architecture for global
for a global mental health program in psychiatry residencies. mental health. Transcult Psychiatry. 2014;51:75976.
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6. De Jong JTVM. Challenges of creating synergy between global 14. Lewis-Fernandez R, Aggarwal N, Hinton L, Hinton D,
mental health and cultural psychiatry. Transcult Psychiatry. Kirmayer LJ, editors. DSM-5 Handbook on the Cultural
2014;51:80628. Formulation Interview. Washington: American Psychiatric
7. Kleinman A. Rethinking psychiatry: from cultural category to per- Pub; 2016.
sonal experience. New York: Free Press; 1988. 15. Jacob KS, Patel V. Classification of mental disorders: a global men-
8. Kleinman A. Four social theories for global health. Lancet. tal health perspective. Lancet. 2014;383:14335.
2010;375:15189. 16. Kohrt B, Rasmussen A, Kaiser BN, Haroz EE, Maharjan SM,
9. Roberts LW. Community-based participatory research for im- Mutamba BB, et al. Cultural concepts of distress and psychiatric
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cultural psychiatry on research and interventions. In: Kirmayer L, approaches to public health paradoxes. Soc Sci Med. 2005;61(4):
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Attachment A

Addressing Training Gaps for U.S. Psychiatry Residency


Graduates in Low- and Middle-Income CountriesEducational
Themes, Learning Objectives, Training Experiences, and ACGME
Milestones.

I. First, do no harm. Adverse unintended consequences can accrue in low-


and middle-income countries (LMIC) due to differences in resources, status,
and power between high-income country (HIC) mental health professionals
and local recipients of services [8].
Medical ethics around "First, do no harm originated from adverse outcomes in
dyadic doctor-patient relationships. New dimensions of iatrogenic harm open when well-
intended HIC clinicians and researchers enter complex LMIC psychosocial eco-systems.
LMIC recipients can be silenced from protesting adverse impacts due to funding needs.
Increasing availability of GMH training in distant countries risks "medical tourism if the
underlying motivation for a resident is adventure or international travel, which can
negatively impact practice in low-resource settings.
To avoid adverse unintended consequences, a global mental health curriculum
needs to provide knowledge and skillsets for structuring collaborative, egalitarian, and
dialogical relationships, so evidence-based psychiatric care is provided while preserving
voice, agency, and cultural identity for LMIC and other GMH recipients [5, 6, 9]. This
requires residents become attuned to power dynamics and differentials that shape
interactions between HIC and LMIC actors within clinical, academic, and social settings.
French philosopher and Holocaust survivor Emanuel Levinas provides guidance
for residents to understand these processes through the concept of the Other, wherein
the Other is infinitely unknowable, but can be engaged through dialogue in a relationship
organized by a commitment to care and concern for the Other. In all clinical and cross-
cultural interactions, a resident is interacting with an Other, while also being experienced
as an Other by persons in LIMC. ([11], p. 21) ([12], p. 247).
Levinass ethics of alterity provides a useful heuristic that:
Violence does not consist so much in injuring and annihilating persons as
in interrupting their continuity, making them play roles in which they no
longer recognize themselves. (11, p. 21).
Sensitivity to Otherness and awareness of risks for inadvertent violations of identities of
Others are critically needed in GMH.
Learning objectives to address this theme have included:
Discuss the social theory of unintended consequences [8];
Discuss the relational ethics of Emanuel Levinas with its commitment to respect,
care, and protection for the Other as guiding principles for preventing inadvertent
violence [11], ([12], pp. 245-251);

1
Discuss dialogic practices as a conceptual tool for organizing treatment inclusive
of a patients voice, agency, and cultural identity within a collaborative
relationship [9, 10];
Demonstrate awareness of power differentials through a sociocultural assessment
of a clinical problem with a patient from an unfamiliar culture, as demonstrated
by the DSM-5 Cultural Formulation Interview [14].
ACGME Psychiatry Milestones: This theme is reflected in two milestones:

Professionalism 1.1, which invokes compassion, integrity, respect for others,


sensitivity to diverse patient populations and adherence to ethical principles
Systems-Based Practice 1.12/B, which refers to competencies to recognize
failure in teamwork and communication as leading cause of patient harm

II. Impaired mental health in LMIC is commonly due to social suffering and
demoralization that may not represent psychiatric disorders, but whose
psychiatric care requires specific skill sets [13].
In LMIC, patients commonly present non-specific somatic symptoms or
depression and anxiety symptoms that have proximal relationships to psychosocial
stressors [6]. Cultural concepts of distress (idioms of distress, cultural syndromes, and
explanatory models) that a suffering person presents for treatment often reflect social
context and may not correspond to DSM-5 diagnostic categories [6, 14]. Descriptive
psychiatry has shown little effectiveness in organizing treatment for such symptoms [6,
15, 16], and idioms of distress often are more reflective of social context than specific
psychopathology [16].
HIC mental health professionals lacking understanding of local idioms of distress
and societal roles for healers can do harm by introducing diagnostic and treatment
approaches that fit poorly with local meaning systems or healthcare resources [6].
Misinterpretation of idioms risks an overemphasis on physical complaints, neglecting
psychological and social interpretations [7, 16]. Patients may insist that his or her
predicaments in living and subjective illness experiences be understood and
acknowledged before treatment progresses.
Learning objectives to address this theme have included:
Discuss the category fallacy as a test for psychiatric diagnoses validity in LMIC
and other GMH populations [7];
Articulate diagnostic distinctions between mood, anxiety, and psychotic mental
disorders and non-psychopathological syndromes of distress as demoralization,
grief, loss of dignity, and spiritual anguish [13, 16];
Demonstrate specific therapeutic methods for building resilience, including
mobilization of family strengths [10] and spiritual resources ([12], pp. 56-95).
Demonstrate implementation of the common factors of psychotherapy in
routine clinical encounters: methods for discerning a patients knowledge, skills,
and competencies; strengthening therapeutic alliances; and mobilizing hope and
expectancy of change [10].
ACGME Psychiatry Milestones
Medical Knowledge 4 (competency in psychotherapy common factors);

2
Patient Care 2 (developing a differential diagnosis and psychiatric formulation);
Information and Communication Systems 2, competency #3.1 (working with
interpreters).

III. Patients in LMIC may embrace primary identities that are family-, clan-,
religion-, or ethnicity-based.
Persons in LMICs may be first a family member or an ethnic or religious group
member, rather than an individual [6, 10]. Determining which identity aspects are most
important is crucial to respectful dialogue and successful clinical care [9].
Effective psychiatric practice requires conceptualization within interpersonal
relations, social groups, and cultural institutions. Training in family therapy to learn
systemic assessment, formulation, and intervention is key for effective clinical work [10].
Learning objectives to address this theme have included:
Demonstrate interview methods for eliciting a patients personal, familial, and
collective identities, including attention to traditions and customs
Demonstrate systemic assessment, formulation, and intervention for clinical
problems
Demonstrate expertise in the applied social psychology, including skills for
managing stigma, prejudice, and discrimination [4]
ACGME Psychiatry Milestones:

Medical Knowledge 4 (family therapy)


Medical Knowledge 3 (social neuroscience of stigma reduction).

IV. Local biologies influenced by infectious disease prevalence, diet,


exercise, and genetic differences in pharmacokinetics influence psychiatric
phenotypes and treatment response [17].
The concept of local biology refers to how diet, physical activity, parasites and
other infectious disease, other health burdens, and climate influence inflammatory
responses and psychoneuroendocrine pathways that can shape psychiatric phenotypes
[17]. Sensitivity to local biology must be combined with awareness of population genetic
differences in medication pharmacokinetics to avoid risks of altered drug metabolism and
interactions.
Learning objectives to address this theme have included:
Demonstrate knowledge of ethnopharmacology [20];
Describe pathways through which diet, activity levels, local pathogens, and
climate impact the manifestation of mental illness and pharmacokinetics of
psychiatric medications [17];
Demonstrate prescribing practices that counter psychiatric medication stigma by
normalizing emotional distress, honoring patients struggles, and sensitivity to
cultural values [4].
ACGME Psychiatry Milestones:
Medical Knowledge 5 (somatic therapies)

3
V. Mental health needs in LMIC vastly exceed the number of mental health
professionals required to respond.
Major roles for a psychiatrist in a LMIC commonly are those of educator,
supervisor, and consultant to primary care clinicians and community health workers who,
through task-shifting and task-sharing, provide direct care to psychiatric patients [5, 6].
Interventions often must focus upon communities as a whole, rather than symptomatic
individuals, in order to promote health or to reduce risks for illness [18]. This shift from
care provider to supervisor and consultant can feel jarring to psychiatry residents
accustomed to ownership of patient care.
Learning objectives to address this theme have included:
Articulate the major points of mental health Gap Action Programme (mhGAP),
and other guidelines for global mental health initiatives [18];
Demonstrate teaching, supervision, and clinical consultation to mental health
workers on interdisciplinary treatment teams;
Conduct a community mental health needs assessment that is translatable into a
public mental health program, e.g. a community-based response to catastrophe or
complex emergency [18].
ACGME Psychiatry Milestones:
Social and Behavioral Psychiatry 4 (engagement with non-psychiatric and non-
medical providers).

VI. Promoting mental health in LMIC often requires promoting human


rights through political activism, advocacy, and protection of vulnerable
persons.
In many LMICs the impact of human rights violations are so substantial that
health policy initiatives, advocacy, and activism must be core elements of an effective
treatment program.
Learning objectives to address this theme have included:
Discuss empirical research on social determinants of mental health, including
national health policies and human rights [18]
Conduct a policy analysis and prepare a policy brief regarding mental health
problems in a LMIC;
Discuss therapeutic principles for aiding recovery from categorical violence, such
as stigmatization, racism, genocide, or other social violence [4];
Conduct supervised psychiatric evaluations for refugees seeking political asylum
ACGME Psychiatry Milestones:
Medical Knowledge-6, Practice of Psychiatry 5.2/C (advocacy and policy
development)
Patient Care-1, Psychiatric Evaluation 4.1A and 4.1B (identifying subtle and
unusual findings in patient evaluations and pursuing identification of relevant
historical findings in complex clinical situations)

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