Yeshiva University geropsychology training director Richard A. Zweig, PhD, finds that his psychology supervisees often lack the cultural-competence skills necessary for their geropsychology doctoral practica.
"Our university's multicultural training consists of one required course in multicultural issues, and occasional infusion of multicultural issues into other coursework," said Zweig, of Yeshiva's Ferkauf Graduate School and Albert Einstein College of Medicine, at APA's 2005 Annual Convention. "We're at best at a level of precultural competence."
What's more, even good multicultural knowledge doesn't translate into the sort of multicultural clinical skills needed to serve Yeshiva's elderly, economically disadvantaged minority clientele, said Zweig.
So he's set out to teach his practicum students those skills with the help of a Graduate Psychology Education (GPE) geropsychology training grant--$195,000 annually over three years--from the Bureau of Health Professions. GPE grants support interdisciplinary training for work with underserved populations, and Yeshiva's patients fit that bill. Yeshiva's grant also supports multicultural curricula, recruitment and support of diverse students and faculty, and program self-assessment.
Guided by Yeshiva faculty with expertise in cultural-competence training, Zweig bases the multicultural-skills training on two main tools (see "Further reading"):
Culturally educated questioning, in which clinicians carefully weigh cultural influences when interviewing patients.
The patient's explanatory illness model, in which clinicians determine how culture affects a patient's illness interpretation and probable treatment response.
The methods help capture both cultural and individual differences among minority elders, said Zweig at the session, co-sponsored by APA's Committee on Aging and Board for the Advancement of Psychology in the Public Interest.
Also emphasizing the importance of those differences were fellow panelists and psychologists Martha Crowther, PhD, of the University of Alabama, and Susan Krauss Whitbourne, PhD, of the University of Massachusetts Amherst. Whitbourne noted that professors can infuse diversity into undergraduate aging courses by, for example, explaining how people within and across minority groups experience aging differently. Crowther urged researchers studying rural, older adult minority populations to personally connect with participants: "Let them teach you," she said.
Culturally educated questioning
Similarly, in clinical interviews, students must allow patients to teach them about their backgrounds, said Zweig. He advises students to learn traditional beliefs, values and family relationship patterns of different cultural groups, and to use this knowledge to devise clinical questions that gauge culture's relevance in a patient's treatment.
He shared a vignette of a typical Yeshiva patient to illustrate a student's effective use of culturally educated questioning: "Mr. T," a 60-year-old Asian-American man comes to a primary-care clinic complaining of headaches, lower back pain and nightmares. He lacks formal education, is unemployed and lives alone. He says he saw family members, soldiers and strangers die in the China-Vietnam War, and their ghosts haunt and threaten him.
The student is aware of a tendency for older Asian men to express emotional problems somatically. Based on this, he quizzes Mr. T about his headaches and other somatic problems to grasp the emotional problems beneath.
The student also seeks Mr. T's own cultural read on his condition with such questions as: "How would others in your culture understand your problem?" "Would it be viewed as common?" "What type of treatment do you hope to receive from me for your problem?" "In your country of origin, what type of healing would others with this problem receive?"
Culturally tailored treatment
Mr. T answers that he finds his psychological symptoms stigmatizing and fears that others think he's "crazy." He also says he wants the ghosts to leave him alone, that he lacks U.S. friends and family to support him, and that if he were in China, he'd visit a Buddhist temple for solace and seek a traditional healer.
Mr. T's answers reveal that his traditional Chinese background has strongly shaped his perceptions of his illness--what Zweig called his "explanatory illness model." However, a student treating Mr. T with a classic medical model might ignore such key cultural factors and recommend the usual medications and counseling for post-traumatic stress disorder, noted Zweig. As a result, Mr. T would likely not fully comply with treatment, he said.
By comparison, the culturally guided student might recommend some medications and counseling, but also spiritual guidance and social support--visits to priests at a local Buddhist temple or to a local healer, for example, and letters to relatives back in China seeking their guidance. Also key is that Mr. T agrees to such an East-West blend of treatment--that the clinician and patient negotiate a shared treatment model, said Zweig.
He also related a hypothetical example of an older Hispanic man who suffers a disabling back injury. Under the medical model, a clinician might prescribe pain medication and advise him to be realistic about his inability to return to work. But in a traditional Hispanic family, job loss might jeopardize his position as the family head and breadwinner, putting him at risk for developing depression.
"So, if the patient's explanatory model is not elicited, and the cultural issues are not appreciated," said Zweig, "this could not only affect treatment adherence, but also the development of psychological problems that might then go undetected."
In the case of the back-injured Hispanic man, a clinician might work to keep depression at bay by helping the man negotiate a revised work schedule with his employer as his back heals. Zweig called for other geropsychology training programs to weave such culturally informed treatment into students' work with minority elders.
Kleinman, A., Eisenberg L., & Good, B. (1978). Culture, illness, and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88, 251–258.
Rodriguez, R.R., & Wells, N.E. (2000). Culturally educated questioning: Toward a skills-based approach in multicultural counselor training. Applied and Preventive Psychology, 9, 89–99.
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