IDD-MH Prescriber Guidelines
Cultural Competency and Prescribing
Roberto Blanco, MD
All psychiatric diagnoses are based on culturally accepted norms of behavior in a patient population. How much a behavior or symptom cluster deviates from these norms typically determines pathology. As with any other patient population, cultural factors are present and important considerations in the care of individuals with Intellectual and Developmental Disabilities (IDD) and it is important to understand how patients and families view themselves and their goals within their communities. Due to the increased effect of environment on symptom clusters in IDD, cultural factors may play an outweighed role. Knowledge of culture and cultural competency are critical role in assessing and optimizing care for individuals with IDD. Best practices include utilization of tools such as the Cultural Formulation Interview1, having individuals and families explain how their experiences would be explained to others, and any concerns they have with individuals from different cultures understanding symptomatology and diagnosis. While it’s impossible to have knowledge of every culture and sub-culture, a humble, caring, and curious approach to understanding family and individual beliefs about behaviors, diagnoses, and routines will likely yield improved information gathering. This also leads to improved diagnostic accuracy, treatment planning and ultimately, desired outcomes of treatment such as treatment fidelity, improvement in pathologic behaviors, and improved well-being.
As a physician working with individuals from varied cultural backgrounds and with diverse cultural identities, it is important to be aware of biases that may exist at an unconscious level. While these tools are not perfect, testing for implicit biases to a range of potential components of background and identity can be an effective tool in gaining a general awareness of an individual clinician’s potential biases. This awareness can be a good first step and can activate and engage providers in changing practices and providing more equitable care to groups of individuals that may have historically suffered from stigma and substandard care and health outcomes. To assess these implicit biases, one could utilize the implicit bias testing available for free at Harvard University’s Project Implicit: https://implicit.harvard.edu/implicit/education.html.
The following questions are useful to get to know someone’s cultural background, who they are as individuals, for diagnostic considerations which are based on culturally defined norms, and for culture-based beliefs about medications. Please also refer to the questions in the Cultural Formulation Interview in the DSM5 (American Psychiatric Association, 2013). The language in these questions may need to be modified due to communication difficulties, language barriers, cognitive difficulties or lack of access to natural supports:
- What kind of things are important to you? What kind of things are important to your family? Are the things that are important to you similar or different to the things that are important to your family? If so, in what ways?
- People have different ways of expressing symptoms. How would you explain your symptoms to someone who did not know you? How would you explain your symptoms to your friends and family?
- Why do you think this is happening to you? What do you think causes these symptoms? What does your family think cause these symptoms?
- What are the most important aspects of your background or identity? Are there any aspects of your identity that make a difference – either make things better or worse?
- Doctors can sometimes misunderstand patients for a variety of reasons. Are you concerned that we, as doctors, might misunderstand you?
- What supports do you have to help you manage? For instance, your family, friendship group, or general community?
- What kinds of activities and interests do you enjoy? Do you have unique or different ways of coping that we might not know about?
- How do you typically like to take medications? Are there situations in your life that might make it difficult to taking medications at certain times?
If family or natural supports are available, you may want to ask:
- What kinds of things are important to the person?
- How would you explain the person’s symptoms? What do you think has caused their symptoms?
- Doctors can sometimes misunderstand patients for a variety of reasons. Are you concerned that we, as doctors, might misunderstand this person?
- From your perspective, what would you say are the most important aspects of the person’s background? How about medication and wellness? Are there any components of background or identity that make a difference for the person?
Culturally Competent Prescribing Resources
The following resources are provided to the public at no cost and were curated by the editors of this guide.
- American Psychiatric Association. Resource document on cultural psychiatry as a specific field of study relevant to the assessment and care of all patients. In Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association; 2013. Accessed from: https://www.psychiatry.org/File%20Library/Psychiatrists/Directories/Library-and-Archive/resource_documents/rd2013_CulturalPsychiatry.pdf
- Cultural Context Important in Psychiatric Diagnosis, Says Bolivar Award Winner [Video]. YouTube. https://www.youtube.com/watch?v=fnxPf-G0i_Y. Published May 10, 2013. Accessed May 3, 2020.
- Psychiatry of Intellectual Disability [Video]. YouTube. https://www.youtube.com/watch?v=COoOtsWJAGU. Published June 15, 2018. Accessed May 1, 2020
- Using the cultural formulation interview [Video]. YouTube. https://www.youtube.com/watch?v=8SjBG9di8ss Published May 1, 2019. Accessed May 1, 2020.
1 American Psychiatric Association. Cultural formulation. In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013:749-759.