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Cultural Competence

Psychiatric Diagnosis
HPRT currently works with survivors using a bicultural model of diagnosis. The HPRT clinician is trained in the use of Western DSM-IV diagnostic criteria, but also in local folk diagnoses.

All cultures have their own diagnoses, explanations and treatments for emotional suffering. HPRT calls these “locally defined Categories of Emotional Distress” (CEDs). CEDs include local definitions of human suffering, the social stigma associated with these symptoms as well as traditional means of treatment. Unfortunately, many CEDs can be highly stigmatizing of the patient. Most CEDs, however, provide cultural prescriptions for healing that are readily available to the patient. The symptoms of CEDs can completely or partially overlap, or have no relationship at all with Western DSM-IV diagnoses. HPRT’s “Pathways to Healing” gives several examples of Cambodian CEDs and their relationship to Western psychiatric diagnoses. HPRT’s staff generally makes both a CED and DSM-IV diagnosis of the patient’s psychological distress, which is then shared with the patient. Bicultural diagnosis using CEDs and Western diagnoses allows the clinician the opportunity of maximizing the healing and recovery potential of each diagnostic system and medical worldview. It also increases the patient’s understanding of his/her symptoms and trust in his/her provider.

The Bicultural Clinician
The approach that many physicians use to work with bicultural clinicians/medical interpreters (i.e., paraprofessionals who are trained health care workers from the local community) is seriously flawed. Even within the most culturally sensitive medical settings, the “interpreter” is viewed simply as an extension of the diagnostic process. Little cross-cultural literature exists on the relationship between patient, Western professional, and bilingual interpreter, and there have been few discussions what can be learned by Western professional from paraprofessionals within this unique triad.

Because of the hierarchical relationship assumed between doctor and interpreter, the interpreter often gives literal translations of the doctors’ words that are meaningless to the patient. Most bicultural clinicians resent being treated as the physician’s personal mouthpiece, as if they were inanimate medical instruments.

Refugee paraprofessionals should just be seen as “interpreters” or “translators.” They should be specialized mental health clinicians who must move conceptually between Western models of disease and treatment and the unique medical and psychiatric worldview of their own culture. Unless a refugee clinician is professionally trained and supervised, he/she will not know how to adequately convey the subtle medical and cultural meaning between patient and physician.