Diversity in Action Case Studies in Cultural Psychiatry

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Editors
Steve H. Koh Gabriela G. Mejia
Department of Psychiatry Department of Psychiatry
University of California San Diego University of California San Diego
San Diego, CA, USA San Diego, CA, USA

Hilary M. Gould
Department of Psychiatry
University of California San Diego
San Diego, CA, USA

ISBN 978-3-030-85400-3    ISBN 978-3-030-85401-0 (eBook)

https://doi.org/10.1007/978-3-030-85401-0

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Contents

1 Introduction������������������������������������������������������������������������������������������������   1
Hilary M. Gould, Gabriela G. Mejia, and Steve H. Koh

Part I Survivors
2 Survivors of Torture���������������������������������������������������������������������������������� 15
Priti Ojha
3 Survivors of Human Trafficking�������������������������������������������������������������� 33
Joanna Ortega, Mollie Gordon, Kimberly Gordon-Achebe,
and Rachel Robitz
4 Survivors of Combat Trauma ������������������������������������������������������������������ 57
Savannah L. Woodward and David Nissan

Part II Special Populations

5 Co-occurring Disorders ���������������������������������������������������������������������������� 79
Aaron Meyer, Gabriela G. Mejia, and Hilary M. Gould
6 Telepsychiatry to Rural Populations�������������������������������������������������������� 105
Gregory Evangelatos, G. Andrew Valasquez, Christine Le,
Juan Sosa, Jessica Thackaberry, and Donald M. Hilty
7 Religion, Spirituality, and Mental Health������������������������������������������������ 139
Hannah Cherian Sweet and Rachel Ann Paul
8 Biculturalism: The Case of Two North American Neighbors���������������� 155
Bernardo Ng and Nancy Catherine Colimon-Ardila

Part III Systems and Settings

9 Correctional Psychiatry���������������������������������������������������������������������������� 181
Sanaz Kumar and Philip J. Candilis

v
vi Contents

10 Shifting Gears: Cultural Assimilation into Primary Care �������������������� 209

Teresa Pan, Rahul Lauhan, Jeanne Maglione, and Alan Hsu
11 Psychiatric Care in Residential Care Environments������������������������������ 227
Omar Ghosn, Steven Huege, and Daniel D. Sewell
Index�������������������������������������������������������������������������������������������������������������������� 249
Contributors

Philip J. Candilis, MD, DFAPA Department of Psychiatry and Behavioral

Sciences, George Washington University School of Medicine and Health Sciences,
Washington, DC, USA
Saint Elizabeths Hospital, Washington, DC, USA
Nancy Catherine Colimon-Ardila, MD Nuevo Atardecer, Geriatric Center,
Mexicali, BC, Mexico
Gregory Evangelatos, MD Department of Psychiatry, Kaweah Delta Medical
Center, Visalia, CA, USA
Omar Ghosn, MD Department of Psychiatry, University of California San Diego,
San Diego, CA, USA
Mollie Gordon, MD Menninger Department of Psychiatry and Behavioral
Sciences, Baylor College of Medicine, Bellaire, TX, USA
Kimberly Gordon-Achebe, MD Department of Psychiatry & Behavioral
Sciences, Tulane University School of Medicine, New Orleans, LA, USA
University of Maryland, New Orleans, LA, USA
Hilary M. Gould, PhD Department of Psychiatry, University of California San
Diego, San Diego, CA, USA
Donald M. Hilty, MD, MBA Mental Health Service, Northern California Veterans
Administration Health Care System, Mather, CA, USA
Department of Psychiatry & Behavioral Sciences, University of California Davis,
Sacramento, CA, USA
Alan Hsu, MD Department of Psychiatry, VA San Diego Healthcare System/
University of California San Diego, San Diego, CA, USA
Steven Huege, MD, MSEd Department of Psychiatry, University of California
San Diego, San Diego, CA, USA
Steve H. Koh, MD, MPH, MBA Department of Psychiatry, University of
California San Diego, San Diego, CA, USA

vii
viii Contributors

Sanaz Kumar, MD Department of Psychiatry and Behavioral Sciences, George

Washington University School of Medicine and Health Sciences, Washington, DC, USA
Rahul Lauhan, MD Department of Psychiatry, VA San Diego Healthcare System/
University of California San Diego, San Diego, CA, USA
Christine Le, MD Department of Psychiatry, Kaweah Delta Medical Center,
Visalia, CA, USA
Jeanne Maglione, MD Department of Psychiatry, VA San Diego Healthcare
System/University of California San Diego, San Diego, CA, USA
Gabriela G. Mejia, BS Department of Psychiatry, University of California San
Diego, San Diego, CA, USA
Aaron Meyer, MD Department of Psychiatry, University of California San Diego,
San Diego, CA, USA
Bernardo Ng, MD, FAPA Department of Psychiatry, University of California San
Diego, San Diego, CA, USA
Sun Valley Behavioral Medical and Research Centers, Imperial, CA, USA
Nuevo Atardecer, Geriatric Center, Mexicali, BC, Mexico
Mexican Psychiatric Association, Mexico City, Mexico
David Nissan, MD Department of Psychiatry, Naval Medical Center San Diego,
San Diego, CA, USA
Priti Ojha, MD Department of Psychiatry, University of California San Diego,
San Diego, CA, USA
Joanna Ortega, MPH Department of Psychiatry and Behavioral Sciences,
University of California Davis, Sacramento, CA, USA
Teresa Pan, PhD Department of Psychiatry, VA San Diego Healthcare System/
University of California San Diego, San Diego, CA, USA
Rachel Ann Paul, LCSW Department of Psychiatry, Rady Children’s Hospital,
San Diego, CA, USA
Rachel Robitz, MD Department of Psychiatry and Behavioral Sciences, University
of California Davis, Sacramento, CA, USA
Daniel D. Sewell, MD Department of Psychiatry, University of California San
Diego, San Diego, CA, USA
Juan Sosa, MD Department of Psychiatry, Kaweah Delta Medical Center,
Visalia, CA, USA
Contributors ix

Hannah Cherian Sweet, MD UCSD Division of Child & Adolescent Psychiatry,

Rady Children’s Hospital, San Diego, CA, USA
Jessica Thackaberry, MD Department of Psychiatry, University of California San
Diego, San Diego, CA, USA
G. Andrew Valasquez, MD Department of Psychiatry, Kaweah Delta Medical
Center, Visalia, CA, USA
Savannah L. Woodward, MD Department of Psychiatry, Naval Medical Center
San Diego, San Diego, CA, USA
Introduction
1
Hilary M. Gould, Gabriela G. Mejia, and Steve H. Koh

As a medical specialty often referred to as an art, psychiatry requires creative

approaches to assessing and treating patients with complicated histories across con-
texts. As each individual’s mental health experience is different within one’s cul-
tural construct, it is important to weigh how mental illness presents in specific
cultural settings [1]. The field of psychiatry has advanced significantly from utiliz-
ing a purely western perspective to interpret behavioral presentations to incorporat-
ing concepts of cultural competency and cultural humility [2].
Cultural psychiatry is a discipline formed out of medicine, anthropology, and
social psychology. Relative to other disciplines, it is a young and developing field.
The American Psychiatric Association initially focused on evaluating “cultural
bound syndromes” and symptoms experienced by non-majority populations through
a westernized and colonial lens [3]. This comparative approach focused on the
“exotic other.” Culture was defined as a specific unit characterized by a group’s race,
ethnicity, country of origin, and/or social status. As the field of cultural psychiatry
evolved, training and education emphasized understanding the cultural context of
specific mental illnesses and providing appropriate psychiatric care in ethnically
diverse populations. Psychiatric diagnoses and symptoms therefore are not strictly
biological and are influenced by experiences and environments, including transmis-
sion of generational norms and cultural manifestations of mental illness. Clinical
treatments address wide-ranging issues, such as bereavement after loss, psychiatric
sequelae of stigmatized subgroups, and the care of individuals with serious mental
illness. More recently, there has been a shift toward reducing inequities and under-
standing the larger structural and systemic contributions affecting mental health
prevalence and manifestation.
In a modern and globalized world, a broader idea of culture has developed.
Beginning in the twentieth century, anthropologists expanded their studies of

H. M. Gould · G. G. Mejia · S. H. Koh (*)

Department of Psychiatry, University of California San Diego, San Diego, CA, USA
e-mail: [email protected]; [email protected]; [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 1

S. H. Koh et al. (eds.), Diversity in Action,
https://doi.org/10.1007/978-3-030-85401-0_1
2 H. M. Gould et al.

village communities to industrial enterprises. They used ethnographic principles to

examine workforce, college campuses, labor unions, prisons, and other groups that
shared a common cultural system. The study of these groups helped provide an
understanding of unique dynamics and hierarchies, how organizational principles
evolved over time, and the relationship between the institution and larger society.
Inherent in this framework is a recognition that cultural worlds are “temporary,
ever-changing constructions that emerge from interactions between individuals,
communities, and larger ideologies and institutional practices” [4].
Furthermore, in clinical practice, it is critical to not focus exclusively on the
dyadic cultural differences between the psychiatrist and the patient. The larger envi-
ronment or cultural context in which the two individuals interact must be understood
to provide optimal care. This larger context extends beyond the physical space (e.g.,
outpatient clinical practice versus hospital-based consult liaison practice) and is
influenced by legal and institutional constructs (e.g., legal aspects involved in human
trafficking or military culture). It is not sufficient to deliver psychiatric care without
an understanding of the larger construct within which a patient exists. Therefore,
throughout this book, a broad view of culture is used when presenting research, clini-
cal case examples, and training recommendations across unique settings and patient
populations. It is hoped that the reader will benefit from understanding the dynamic
aspect of a culture which spans beyond racial and ethno-specifics of our patients and
encompasses the larger context in which we find them.

Cultural Constructs in the DSM-5

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [5]
incorporates more elements of culturally competent care than any previous edition
of the manual. The DSM-IV listed culture-bound syndromes (i.e., pattern of aber-
rant behaviors that are localized to a specific society or culture, such as ataque de
nervios), while the current edition dedicates more thoughtful and updated context to
cultural presentations. It includes a clinical interview tool (i.e., “Cultural Formulation
Interview,” CFI) and describes elements critical to culturally sensitive diagnoses
and care (e.g., “Glossary of Cultural Concepts of Distress”). Recommendations
include attending to cultural factors when contemplating specific diagnoses. For
example, considering primary language when diagnosing specific learning disor-
ders or intellectual disabilities, understanding religious beliefs and practices when
psychotic symptoms are present, and appreciating trends unique to certain cultural
groups regarding over or underemphasized cognitive or somatic complaints. Rather
than the notion of the culture-bound syndrome from older editions of the DSM,
three new concepts are presented in the DSM-5: (1) cultural syndrome, or symp-
toms found in specific cultural groups; (2) cultural idioms of distress, the shared
way of communicating suffering; and (3) cultural explanations, the perceived
cause(s) and etiology of symptoms [5].
The DSM-5 defines culture as “systems of knowledge, concepts, rules, and prac-
tices that are learned and transmitted across generations. Culture includes language,
1 Introduction 3

religion and spirituality, family structures, life-cycle stages, ceremonial rituals, and
customs, as well as moral and legal systems” [5]. This definition primarily focuses
on cultures specific to race/ethnicity and country of origin. The CFI includes 16
questions intended to highlight key elements of the patient’s cultural identity (e.g.,
values, orientations, knowledge, practices, geographical origin, migration, lan-
guage, religion, sexual orientation, race/ethnicity, developmental experiences), their
social network’s influence as sources of stress or support, cultural interpretations of
presenting symptoms, and factors affecting help-seeking behavior [5]. Cultural con-
siderations are deemed critical for evidence-based psychiatric care, including
enhancing the therapeutic relationship, accurately diagnosing disorders, obtaining
relevant clinical information (e.g., coping strategies), and improving efficacy of
treatments.

Definition of Culture to Improve Clinical Care

In the modern world, culture has multiple meanings that affect understanding
and applications in psychiatry [6]. Throughout this book, chapter authors define
culture broadly and explore several aspects of social behavior and norms, includ-
ing attitudes, beliefs, habits, rituals, behaviors, values, interactions, language,
knowledge, and stories as depicted in Fig. 1.1. Inherent in its definition is

• Habits
Behaviors • Rituals
• Practices

• Beliefs
Values and
attitudes • Orientations
• Stories

Culture

Relationships • Language
and • Communication
interactions • Dynamics
• Roles

Knowledge • Settings
and • Training
experiences • Skill-set

Fig. 1.1 Schematic of elements that define culture

4 H. M. Gould et al.

recognition that culture has both external and internal representations [7].
External representations encompass institutions, traditions, and activities. In
contrast, internal representations include interpretations, ascribed meaning, and
importance set by the individual. Culture affects all aspects of mental health care
delivery, including identification of a problem, acceptable treatment options, and
access to services.
In addition to examining specific subgroups with shared backgrounds, chapter
authors will aim to look at cultures across experiences and settings. For example,
anthropologists have studied psychiatry training as assimilation into a shared cul-
tural organization [8]. In a department of psychiatry, there is a unique culture of
shared characteristics passed down from experts in the field, as well as faculty, prior
trainees, and cohort members in the university and hospital settings. This “culture”
of academic psychiatry encompasses language (e.g., psychiatric terminology),
interests and values (e.g., improving patient outcomes), training backgrounds and
skill sets (e.g., medical school and residency), beliefs (e.g., medical model and sci-
entific method), habits and daily rituals (e.g., meetings and sessions), and so on.
There are subgroups within the larger cultural group, such as residents, attendings,
allied health professionals, and administrative support; those who work in inpatient,
consult-liaison, outpatient, or research settings; and those in general clinics/tracks
compared to specialized or disorder-specific clinics or research laboratories. While
these subcultures exist, the group members may be further categorized by member-
ship to other subgroups, identities, and cultures that they may share with their col-
leagues (e.g., race, class, sexual orientation, gender identity, age). Individuals are
not limited to one cultural group and instead are often impacted by the intersection
of several cultural identities coupled with their unique experiences and
interpretations.
Cultural groups are constantly changing in response to both internal and external
factors derived from shared experiences. For example, although generational trans-
mission of cultural norms is inherent in the definition, other local and global changes
of the era contribute to adaptations in cultural beliefs and practices. Even the authors
of the DSM-5 echo this sentiment, “like culture and DSM itself, cultural concepts
may change over time in response to both local and global influences” [5]. Using the
department of psychiatry example, residents 10 years ago are likely quite different
from present day residents due to a number of local (e.g., current leadership within
the department) and large-scale external factors (e.g., less national stigma around
mental health, advances in treatments). These factors can span across space and
time to include geographical regions, time, historical events, and political ethos.
Current and emerging leaders in cultural psychiatry examine institutions and
larger concepts, including community and population health, systems of care, and
models of healthcare delivery. Cultural factors affect access to and quality of care in
nearly every country, such that minority groups are subject to lower standards of
care. By attending to these larger contextual factors, there is a call for focus on
equity, appropriate service delivery models, and contribution to political justice [9].
Table 1.1 outlines key constructs related to cultural psychiatry. Additionally, schol-
ars posit the importance of a historical and politically informed perspective to better
1 Introduction 5

Table 1.1 Key constructs of cultural psychiatry

Cultural psychiatry constructs

Public and community systems of care
Cultural variability in expression and understanding of symptoms
Culturally competent care and adaptations to delivery of services
Mental health inequities
Globalization

inform global mental health as the world further shrinks and diversity in those that
we care for becomes the norm [10, 11]. The importance of these issues cannot be
overstated when evaluating how to best care for our patients. As mental health pro-
fessionals, we are often relied on to know about behavioral health insurance cover-
age, available social supports in a community, how to best navigate a complicated
behavioral health network, and patients’ legal environment. Some may argue that
these elements are not within a psychiatrist’s scope. However, the reality is that our
patient’s clinical presentation and the best treatment modalities exist in the context
of the larger cultural constructs that surround them. A patient in a primary care set-
ting, for example, may present their psychiatric symptoms differently than in a psy-
chiatric environment. An active duty military patient may understand their symptoms
differently and mistrust civilian medical providers. Interaction with the legal system
in context of asylum seeking process may change the ways in which a torture victim
expresses their distress. Patients living in two different countries likely differ in the
resources available for their care. As we intersect with colleagues, we also need to
be mindful of how to best communicate and collaborate within their cultural norms.
A psychiatrist’s interactions with chaplains or patients with strong religious beliefs
will likely vary significantly from how one would best provide care in a largely pri-
mary care delivery environment. By understanding the importance of different cul-
tural constructs in which care is being delivered, we can best tailor the approach to
benefit our patients.

Culture and Mental Health Conceptual Model

Culture affects the manifestation, development, and treatment response of mental

health illness via multiple pathways. Generally, cultural factors are not considered
“etiological agents of mental illness,” or direct causes of psychiatric disorders, but
instead pathogenic factors or etiopathogenic interactions which fit within our bio-
psychosocial framework [1]. It has been well documented that mental health ineq-
uities are present and influenced by a combination of systemic and structural
systems, as well as exposure to adverse childhood experiences and environmental
stressors. While the geopolitical and cultural context of where these stressors take
place may affect the development of mental health symptoms, exposure to trau-
matic situations or chronic stress are universal triggers. Furthermore, culture
affects more than just the prevalence of psychiatric illnesses. Stigmatization of
mental health, or disapproval and discrimination toward the individual, greatly
6 H. M. Gould et al.

Prevalence (K)

Policy
(J)
(L)
(D) (I) (H)
Cultural Cultural Expression Treatment
Diagnosis
background meanings
and
norms
(E) (G)
(A) (F)
(C)

(B) Mental Help seeking

illness

Etiology

Fig. 1.2 Hwang and colleagues Cultural Influences on Mental Health (CIMH) model. (Reproduced
with permission from: Hwang et al. [12])

affects the severity of illness and treatment outcomes. Identified supported means
of healing can affect outcomes in both positive and negative ways. Given the broad,
complex, and variable definitions of culture, few models have been posited to
establish and understand the directionality and intersectionality between psycho-
pathology and culture.
The Cultural Influences on Mental Health (CIMH) model provides a framework
for how culture permeates and influences several core domains of the psychiatric
illness process. Hwang and colleagues suggest several pathways relating how cul-
tural background affects etiology of mental illness and how cultural meanings and
norms influence expression of illness. They then relate symptom expression to both
diagnosis and help-seeking behaviors, and how both issues, along with prevalence
and policy, ultimately affect treatment outcomes [12]. The CIMH model is depicted
in Fig. 1.2. The model considers the effects of generational traumas and accultura-
tive stress (e.g., linguistic difficulties, pressures to assimilate, separation from fam-
ily, experiences with discrimination) [12]. Conceptualization of the many
complex ways that culture can impact mental health expression, identification,
diagnosis, treatment, and outcomes is essential for the field of psychiatry.

Training and Education

Cultural competence is a journey, not a destination [13, 14]. No one can ever truly
reach terminal “competence” in appreciating, integrating, and understanding cul-
tural differences for all people and settings. Instead, as Cross and colleagues
wrote, “becoming culturally competent is a developmental process for the individ-
ual and for the system. It is not something that happens because one reads a book,
attends a workshop, or happens to be a member of a minority group. It is a process
born of a commitment to provide quality services to all” [13]. Exposure to diverse
1 Introduction 7

groups including patients, colleagues, and faculty is essential to training and educa-
tion. Additional strategies for increasing clinicians’ cultural competence are pre-
sented throughout several chapters in the book, and key strategies and tools are
outlined in Table 1.2.
Medical trainees and clinicians should also reflect on their own cultural identi-
ties, assumptions, and interactions with patients. They should evaluate weaknesses
in their knowledge and willingness to collaborate with cultural brokers and people
with lived experience to enhance clinical delivery and care. Additionally, “it is best
to frame issues of cultural difference not simply in terms of the characteristics of
patients or communities, but in terms of differences in the perspectives of patient
and clinician in what is always, to some degree, an intercultural encounter” [4].
Every interaction with a patient is an interpersonal exchange and involves cultural

Table 1.2 Strategies and tools for trainees and clinicians to increase cultural-competence and
humility
Strategies and
tools Definition
DSM-5 Cultural Training and practice with the DSM-5 CFI [5] can be used to enhance
Formulation clinical understanding and decision-making related to diagnosis and
Interview (CFI) treatment. Sections include cultural definition of the problem; cultural
perceptions of cause, context, and support; cultural factors affecting
self-coping and past help seeking; and cultural factors affecting current
help seeking
Cultural Consult-liaison with cultural brokers or leaders/experts in their cultural
consultation/ group to improve patient-provider communication and understanding. The
brokers broker should be trusted in the cultural community and well versed with
local knowledge, values, beliefs, and practices
Knowledge and Cultural competence training for healthcare providers is important to
education increase knowledge and sensitivity regarding systemic/structural issues,
culture-specific considerations, and social determinants of health. It can
also be used to teach skills, such as working with interpreters, cultivating
cultural humility, and avoiding overgeneralizations
Self-reflection and Considering one’s own personal identity, experience with people from
awareness diverse backgrounds, and knowledge of stereotypes/overgeneralizations.
Clinicians can learn to slow down when assessing patients from different
backgrounds and try to evaluate each person as an individual. This is an
important topic to discuss in supervision
Implicit bias Taking implicit association tests, practicing self-awareness, and
training challenging internalized assumptions
Cultural Learning healthcare and psychosocial assessments and treatments tailored
adaptations to to specific cultural groups. For example, this may include adapting patient
healthcare materials to reflect patients’ culture, language, or literacy skills [15]
Exposure working Medical education and training that offers rotations or tracks to
with diverse underserved and diverse populations, such as uninsured, underinsured,
patient populations migrants, rural populations, LGBTQIA+, physical disabilities, etc.
Diversity in cohort Trainees benefit from working with colleagues, supervisors, and faculty
and leadership from different cultural backgrounds and experiences
Trauma-informed Framework adopted at an organizational level to reflect an understanding
care of the widespread impact of trauma and actively seeking to prevent
re-traumatization [16]. Strategies may include trauma screening, providing
a safe space, and shared decision-making with patients [17]
8 H. M. Gould et al.

contributions from different community groups and larger institutions. Recognizing

the history and exercising cultural sensitivity is paramount to demonstrating cultural
competence [18].
Lastly, equitable care relies heavily on clinicians’ awareness of the limitations of
psychiatric diagnosis, assessment, and treatment. There are many issues with valid-
ity of categorical psychiatric diagnoses and challenges in measurement and method-
ology, which may disproportionately disadvantage certain cultural groups. This
may include overdiagnosing, underdiagnosing, or misdiagnosing. To improve diag-
nostic accuracy, Marsella and Kaplan recommend considering the following factors
when choosing diagnostic screening instruments: (1) appropriate items and ques-
tions, including idioms of distress; (2) opportunities to index frequency, severity,
and duration of symptoms since groups vary in their reporting within certain modes;
(3) establishment of culturally relevant baselines in symptom parameters; (4) sensi-
tivity to the mode and context of response (i.e., self-report, interview, translation
issues); (5) awareness of normal behavior patterns; and (6) symptom scales should
be normed and factor-analyzed for specific cultural groups [7]. Accurate screening,
identification, and diagnosis are often the first step to providing equitable mental
health care. Additionally, behavioral interventions are often studied in majority
populations and may need to be tailored or individualized to be sensitive to the cul-
ture of an individual patient. Culturally informed adaptations to empirically sup-
ported treatments to modify language, metaphors, values, and context (while
maintaining active components of interventions) have proven important to increase
acceptability and efficacy of treatments [19, 20].

Survivors, Special Populations, and Systems and Settings

Throughout these chapters, authors aim to define the culture of their setting, patient
population, and subspecialties within the field of psychiatry. Part I of this book cov-
ers the special population of survivors of trauma. The term survivors is used here
rather than victims, denoting the cultural landscape (i.e., the term survivors or
victim-­survivors is often used in recovery settings, while the term victim is regularly
used in the criminal justice system). In Chap. 2, Dr. Ojha details the experience of
survivors of torture, particularly of asylees, and highlights the critical components
of trauma-informed care. Next, in Chap. 3, authors Ortega, Gordon, Gordon-­
Achebe, and Robitz present on survivors of human trafficking, including the inter-
connection of structural and individual factors affecting the psychiatric illness
process, such as socioeconomic status, family structure, race, gender, criminal jus-
tice, and experience of adverse childhood experiences. Finally in Chap. 4, Drs.
Woodward and Nissan describe military culture, changes throughout service eras,
and posttraumatic stress disorder in survivors of combat military trauma. Data on
pharmacotherapy monotherapy and augmentation, as well as psychotherapy, are
presented. By examining the experiences of a range of survivors of traumatic expe-
riences, it is hoped that the reader can better understand the shared factors of
1 Introduction 9

etiology, trauma response, and evidence based practices, as well as the collective
and unique cultural elements that comprise survivors of torture, human trafficking,
and combat trauma.
The purpose of Part II of this volume is to examine special populations that
often present with mental health challenges related to specific group factors or
experiences. In order to optimally treat these populations, foundational knowledge
and a conceptual framework for establishing assessment and treatment is required.
Meyer, Mejia, and Gould present the latest research on patients with concurrent
substance use and mental illness disorders. In Chap. 5, they discuss factors affect-
ing treatment, including experienced, perceived, and internalized stigma, as well as
criminalization of substances and challenges receiving appropriate treatments,
such as medication-assisted therapies. In Chap. 6, Drs. Evangelatos, Valasquez, Le,
Sosa, Thackaberry, and Hilty present essential components to consider when deliv-
ering telepsychiatry services to rural populations and strategies for enhancing tele
modalities. Sweet and Paul discuss the role of religion and spirituality in diagnosis
and treatment of patients, including positive and protective factors, in Chap. 7.
They also share research on the changing role of religion in the USA and among
psychiatrists. Lastly, Drs. Ng and Colimon present the historical and cultural con-
structs related to bicultural groups, specifically Mexicans and Americans. Research
and models comparing and contrasting the two countries on religion, socioeco-
nomic status, and the shared border regions are presented alongside a theoretical
framework to understand and predict future development of biculturalism and
bilingualism.
The final section of this volume, Part III, covers systems and settings that pro-
duce their own cultural environments. Patients that are treated within these larger
institutions are often exposed to new cultural elements that intersect with their
identities. Additionally, two of the chapters in this section discuss attempts at wide-
spread organizational cultural change movements within healthcare systems, spe-
cifically the movement toward patient-centered care. In Chap. 9, Drs. Kumar and
Candilis outline the unique challenges present while attempting to deliver optimal
psychiatric care in correctional settings where the penal system’s need for punish-
ment and security must be balanced with the physician’s oath to treat and rehabili-
tate. The authors also dissect the effects of structural racism and how to combat the
continuous overrepresentation of people of color in these settings. In the case of
Chap. 10, the cultural transformation of primary care is described as a shift from a
traditional medical model to a collaborative care model. Drs. Pan, Lauhan,
Maglione, and Hsu outline a psychiatrist’s role in facilitating this model with pri-
mary care providers and how this model allows for increased shared decision-
making with patients and better treatment outcomes. Lastly, in Chap. 11 Drs.
Ghosn, Huege, and Sewell outline the unique cultural challenges present across the
various residential care environments and the framework necessary when provid-
ing care to these older adults. They provide recommendations on how to best
accommodate and integrate the patient’s cultural identity within the parameters of
long-term living facilities.