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Cultural Competency in Forensic Assessments

Overview | Clinical Scenarios | Additional Tips | References
By Reema Dedania, MD, MPH and Susan Hatters Friedman, MD

OVERVIEW

Definitions

There is an increasing recognition that the culture, ethnicity, race, traditions, and values of patients and forensic evaluees is an important part of psychiatric assessment.1 

Culture

  • Culture is defined by the unique “behavioral patterns and lifestyle that encompass a set of views, beliefs, values, and attitudes shared by a group of people that distinguish [them] from other groups.”2 
  • “Culture and people influence each other reciprocally and interactionally—on a conscious and unconscious level.”2

Cultural competence

  • Cultural competence is “the ability to understand, appreciate, and interact with people from cultures or belief systems different from one’s own” in a knowledgeable and sensitive way.3

Cultural bias

  • Cultural bias involves the tendency to interpret and judge situations, actions, or data based on the standards of the culture, beliefs, or other characteristics of the community to which one belongs. 
  • This sometimes leads people to form opinions about others in advance of the evaluation.
  • Cultural bias hinders the ability to objectively assess another’s beliefs, which can lead to a misunderstanding of experience and a potential overestimation of risk.4

General Principles 

  • Be aware of the culture of the evaluator, the evaluee, and the legal setting. Understanding these differing dimensions can facilitate a culturally competent forensic assessment.
  • Consider that we each have our own preconceived notions, attitudes, and value systems. Religion, race, and culture can each impact a psychiatrist’s worldview, causing bias (or an appearance of bias).3,5,6
  • Pay attention to Countertransference in cross-cultural contexts; self-examine your potential for bias.3,6 
  • Consider the impact of culture at various points in the psychiatric assessment including, as per Practice Guidelines:
    • “Diagnosis 
    • Identification of relevant cultural factors 
    • Consideration of evaluee’s distinctiveness 
    • Avoidance of stereotyping 
    • Validation of testing 
    • Consideration of the meaning of language 
    • Respect for and knowledge of cultures”6

CLINICAL SCENARIOS

Scenario #1:  The psychiatry service is consulted to conduct a violence risk assessment for a 32-year-old Black man in the emergency room who was found acting bizarrely while wandering along a bridge on the highway. He cannot remember his mental health diagnosis, but indicates that he was previously prescribed Quetiapine, Fluoxetine, and Lithium by various providers. How do you approach his psychiatric assessment?

  • Recognize that race permeates clinical decision-making and treatment including through a psychiatrist’s implicit biases. Providers should use caution not to conflate being Black with criminality and assume there is an elevated violence risk based solely on race. Studies show that clinicians tend to overpredict violence even when other factors such as psychiatric diagnosis, substance abuse, and past violence are controlled for. 7,8
  • Black people who have a mood disorder are more likely to be misdiagnosed with a psychotic disorder. As a result, providers may miscalculate risk of harm to others based on implicit or explicit bias. Be aware of these biases and ensure a thorough, complete risk assessment giving equal weight to evidence-based risk factors known to elevate both violence and suicide risk.9
  • Conducting a psychiatric evaluation independent of historical diagnoses, prescribed medications, or racial biases is critical to accurately evaluate risk. Although this patient was previously prescribed an antipsychotic, the exact indication for this medication is unknown, and should not be presumed to be for a diagnosis of a psychotic disorder without corroborating information.

Scenario #2: A 28-year-old Somali mother of three who is seeking asylum in the United States presents for a mental health evaluation in your outpatient clinic. She asks for you to write a letter about her diagnosis. She reports feeling irritable, withdrawn, and is having trouble sleeping. She fled her home country in the context of religious persecution and is the victim of emotional and physical abuse. What are important factors to consider in your evaluation?

  • Psychiatrists have an important role to play in facilitating asylum claims because psychological symptoms manifest with considerable frequency in refugee populations. A systematic review considering psychological symptoms shown by refugees demonstrated prevalence rates of 32% for posttraumatic stress disorder (PTSD) and 35% for depression.10
  • Credibility assessment plays a key role in asylum evaluation. Federal law allows immigration judges to base their conclusions upon “the demeanor, candor, or responsiveness of the applicant or witness, the inherent plausibility of the applicant’s or witness’s account, the consistency between the applicant’s or witness’s written and oral statements.”11
  • Although the Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (DSM-5-TR) provides a framework for criteria of trauma disorders, careful consideration should be given to various expressions of trauma and grief based on culture. The psychiatrist should inquire about manifestations of grief, adjustment, and sadness in the context of traumatic experiences unique to this patient’s culture.  
  • Gain collateral information from this patient’s and family if available to complete the clinical picture in the context of cultural norms. The use of an interpreter should be offered. 
  • Consider levels of acculturation among Somali immigrants in her community and the role this plays in their decision-making regarding treatment and value system.
  • Since treating psychiatrists should not write a forensic opinion on their own patients wherever possible, you (as the treating psychiatrist) should not proffer a forensic opinion. Rather, you may write a letter indicating that you have evaluated her and that she is now under your care, and list her diagnosis. Provide her with resources for pro bono attorneys and evaluators in your community.12,16
  • Free, online trainings in conducting such evaluations are provided throughout the year by organizations including Physicians for Human Rights, HealthRight International, and the Society of Asylum Medicine.13

Scenario #3: A 71-year-old immigrant man who speaks little English refuses treatment for his stage 4 renal disease. He provides little explanation for his decision except to reference his religious beliefs. the patient has a history of depression and the consulting team is concerned that he lacks capacity due to depression but patient is citing religious beliefs as the reason to refuse. Psychiatry is consulted by the nephrology team to assess his capacity to refuse dialysis treatment. How do you approach this evaluation?

  • An appropriate interpreter should be used in the evaluation since the patient speaks little English. Familiarize yourself with strategies that will lend to a more successful evaluation while using interpreting services.14
  • First, judge the extent to which the patient is familiar with a psychiatric interview. Resist assumptions. Clarification using examples may help with understanding. 
  • Explore his religious beliefs and their intersection with his current presentation. Explore the patient and family’s concept of illness and sickness and how it relates to religious values and expectations. Ask whether the patient or family had other experiences in which treatment was declined in favor of non-western remedies and how he arrived at his decision-making, which confirms the consistency of the patient’s religious beliefs.
  • Pay attention to communication styles (asking open-ended questions where possible) and narrate the patient’s preferences in documentation with quotes to avoid misinterpretation in the medical record for future providers who may treat the patient.

ADDITIONAL TIPS

Additional Tips for Psychiatrists Working with Interpreters

  1. Schedule a pre-session with the interpreter to gain an understanding of the interpreter’s English proficiency level and to identify any barriers that may surface during the evaluation. 
  2. Family members or friends should not be used as interpreters in mental health.
  3. Explain to the patient that both the psychiatrist and the interpreter are bound by confidentiality—which is especially critical in smaller communities. 
  4. Speak directly to the patient rather than to the interpreter. 
  5. If you receive an unexpected answer to a question you asked, then restate the question and confer with the interpreter to determine if there is an unanticipated cultural barrier to understanding.
  6. Use simple sentence structure and avoid idioms. 
  7. Ask one question at a time, and be careful not to change your question in the middle of asking.14,15

REFERENCES

  1. Bergkamp, J., and Agassiz, K. Competency in Forensic Practice: Bridging the Divide. Expert Opinion. (2018).
  2. Wen-Shing T. Cultural Competence in Health Care. Springer Publishing. (2008).
  3. American Academy of Psychiatry and the Law. AAPL Practice Guidelines for the Forensic Assessment. Volume 43, Number 2, 2015 supplement. 
  4. Friedman, SH. Culture, Bias, and Understanding: We Can Do Better.  J Am Acad Psychiatry Law 45: 136–39, 2017.
  5. Boehnlein JK, Schaefer MN, Bloom JD: Cultural considerations in the criminal law: the sentencing process. J Am Acad Psychiatry Law 33:335– 41, 2005.
  6. American Academy of Psychiatry and the Law. Ethics guidelines for the practice of forensic psychiatry adopted May 2005.
  7. Shadravan, S., and Bath. E. Invoking History and Structural Competency to Minimize Racial Bias.  J Am Acad Psychiatry Law 47: 2-6, 2019.
  8. McNeil DE, Binder RL: Correlates of accuracy in the assessment of psychiatric inpatients’ risk of violence. Am J Psychiatry 152:901–906, 1995.
  9. Gara, M, Minsky, S, Silverstein, S, Miskmen, T, Strawkowski, S. A Naturalist Study of Racial Disparities at an Outpatient Mental Health Clinic. Psychiatric Services. Dec 2018.
  10. Lindert J, von Ehrenstein OS, Wehrwein A, et al. Anxiety, depression and posttraumatic stress disorder in refugees – a systematic review. Psychother Psychosom Med Psychol. 2018 Jan; 68(1):22–9.
  11. 8 U.S.C. § 1158. Asylum (2005). Available from: https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title8-section 1158&num=0&edition=prelim. Accessed January 5, 2022.
  12. National Immigrant Justice Center. https://immigrantjustice.org/immigration-legal-services.
  13. Disla de Jesus, V and Appel, J. A Call for Asylum Evaluations and Advocacy in Forensic Psychiatry. J Am Acad Psychiatry Law 50: 342-345, 2022.
  14. Dos and Don’ts: Guidelines for Clinicians Working with Interpreters in Mental Health Settings. NY State Psychiatric Institute Center of Excellence for Cultural Competency. https://nyculturalcompetence.org/wp-content/uploads/2014/04/DosANDDonts_V5_4-22-14.pdf
  15. Best Practices for Communicating Through an Interpreter. Refugee Health Technical Assistance Center. https://refugeehealthta.org/access-to-care/language-access/best-practices-communicating-through-an-interpreter/
  16. Sorrentino, R., Belcher, R., McLean, R., Friedman, S.H. Dear Patients: Letters Psychiatrists Should and Should Not Write. Current Psychiatry, 2023; in press.  

Additional Reading

  1. C-L psychiatry and cultural considerations: https://doctorlib.info/psychiatry/handbook-consultation-liaison-psychiatry/22.html
  2. Aggarwal NK: Adapting the cultural formulation for clinical assessments in forensic psychiatry. J Am Acad Psychiatry Law 40: 113–18, 2012
  3. Weiss, R. A., & Rosenfeld, B. Navigating cross-cultural issues in forensic assessment: Recommendations for practice. Professional Psychology: Research and Practice, 43, 234-240. doi: 10.1037/a0025850. (2012).

 

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