the-lancet---culture-and-health.pdf

7778 again competence is about making relationships

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77,78 Again, competence is about making relationships meaningful enough to limit the damaging effects of suffering. Mutual understanding provides a foundation for affective caring, but time and space should be provided for such new forms of clinical care to emerge and take root. Panel 1 : The Cultural Formulation The most pressing challenge for mental health therapists working with different cultures is to develop a sensitive and culturally viable method of improving the wellbeing of psychologically marginalised people. The Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV 65 (1994) and DSM-IV-text revision 66 (2000) of the American Psychiatric Association introduced, as an appendix, a method that used culture as the main focus for the generation of a clinical rapport between therapist and patient. The 1994 inclusion was the first attempt to promote widely what is now called the Cultural Formulation. 67 In this formulation, the patient is asked to develop a life story—ie, a culturally embedded biographical narrative. 64 The story forms the focus of the therapeutic environment. Published alongside a glossary of culture-bound syndromes, the formulation can mitigate some of the diffi culties associated with psychiatric assessment and diagnoses of patients from ethnic minorities whose frames of reference sometimes differ greatly from those of their therapists. 68 Its application is also effective for treatment of any illness for which cultural differences have an effect on care. Although the full clinical effectiveness of the Cultural Formulation has not yet been established, results of trials have shown promise for clinicians engaging, assessing, and treating those in need by taking into account local contexts and forms of meaning. 69 Derived from the insights of medical anthropology, 70 the formulation represents an attempt to transcend biomedical frames of reference that are often incompatible with individual ideas of being unwell. 71 As a result of its acknowledged potential, 72 the Cultural Formulation has been integrated into the 2013 DSM-5. 73,74 Although the new DSM-5 version of the Cultural Formulation enables mental health-care providers to assess the potential effect of cultural factors on development of mental illness, further elaboration (Bloomsbury Cultural Formulation) 75 invites caregivers to establish common ground with patients by providing personal narratives that mirror those of patients. Such reciprocal engagement therapeutically acknowledges both the perceived alienation of those in need and the cultural divide that has to be transcended to achieve good outcomes. 76 This expanded version of the Cultural Formulation therefore directly addresses a continuing criticism of the DSM, namely that it fails to acknowledge its own cultural orientation, maintaining a singular view of the causes and meanings of mental distress.
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The Lancet Commissions www.thelancet.com Vol 384 November 1, 2014 1615 Competence needs to include knowledge of how to develop new ways to evoke clinical meaning and acceptance that meanings can differ.
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