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Using Non-Feature Films to Teach Diversity, Cultural Competence, and the DSM-IV-TR Outline for Cultural Formulation Russell F. Lim, M.D., Ronald J. Diamond, M.D. Jacquelyn B. Chang, M.D., Annelle B. Primm, M.D., M.P.H. Francis G. Lu, M.D. Objective: Feature films have been used for teaching in psychiatry for many years to demonstrate diagnoses, but the use of documentary and instructional films in resident and staff cultural competence training have not been extensively written about in the medical and psychological literature. This article will describe the films that have been used by the authors and suggest methods for their use in cultural competence and diversity training. Methods: A literature search was done using MEDLINE and PsychINFO and the authors were asked to describe their teaching methods. Results: One article was found detailing the use of videotapes as a stimulus but not for cultural competence education, and two articles were found documenting the use of The Color of Fear as a stimulus for the discussion of racism. However, many educators use these films all across the country for the purpose of opening discussion about racism. Conclusion: Documentary, instructional, and public service announcements can be useful in teaching culturally competent assessment and treatment. Academic Psychiatry 2008; 32:291–298 Received September 27, 2006; revised February 1, 2007; accepted February 15, 2007. Dr. Lim is affiliated with the Department of Psychiatry and Behavioral Sciences at the University of California, Davis School of Medicine; Drs. Lim, Chang, and Lu are affiliated with the Department of Psychiatry at the University of California, San Francisco; Drs. Lim and Diamond are affiliated with the Department of Psychiatry at the University of Wisconsin, Madison; Drs. Lim and Primm are affiliated with the American Psychiatric Association Office of Minority and National Affairs in Arlington, Va. Address correspondence to Russell F. Lim, M.D., Associate Clinical Professor, Director of Diversity Education and Training, University of California, Davis School of Medicine, Department of Psychiatry and Behavioral Sciences, 2230 Stockton Blvd., Sacramento, CA 95817; rflim@ ucdavis.edu (e-mail). Copyright 䊚 2008 Academic Psychiatry

Academic Psychiatry, 32:4, July-August 2008

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ulturally diverse individuals have special needs and clinicians require special skills and knowledge to treat them both appropriately and effectively. This article will present different methods of using non-feature films for training cultural competence and diversity issues that can help medical schools and residency training programs comply with the new regulations from the Liaison Committee on Medical Education and the Accreditation Council of Graduate Medical Education (ACGME) concerning the teaching of cultural competence. The DSM-IV-TR Outline for Cultural Formulation is used as an organizing principle for describing the use of the films. We describe in detail how to use films such as The Color of Fear, The Way Home, and other films to stimulate discussion about racism, cultural mental health beliefs, the role of ethnicity in psychotherapy, as well as other themes. These films, showing either actual groups or therapy with actors, vividly portray emotional issues such as racism, prejudice, and discrimination. Finally, films like Black and Blue strive to break down racial barriers to psychiatric treatment, while The Culture of Emotions teaches mental health professionals how to use the DSM-IV-TR Outline for Cultural Formulation. Documentaries and training films can be important components of a cultural competence curriculum.

Background Information The Liaison Committee on Medical Education has recognized the importance of diversity in health care and has added the following objectives to its list of standards and objectives for the accreditation of American medical schools: • Medical students must learn to recognize and appropriately address gender and cultural biases in themselves and others and in the process of health care delivery; http://ap.psychiatryonline.org

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• The objectives for clinical instruction should include student understanding of demographic influences on health care quality and effectiveness, such as racial and ethnic disparities in the diagnosis and treatment of diseases, as well as how people of diverse cultures experience health and illness; • The objectives should also address the need for selfawareness among students regarding any personal biases in their approach to health care delivery (1). The ACGME mandates resident competency in six core areas: patient care, medical knowledge, interpersonal and communications skills, practice-based learning and improvement, professionalism, and systems-based practice (2). Cultural competence is necessary in all six areas. In the area of patient care, residents are required to obtain a sociocultural history, write a case formulation integrating sociocultural factors, and develop a treatment plan sensitive to those factors, including culturally appropriate therapy and aspects of culturally specific medical knowledge. Cultural competence is also incorporated in practice-based learning and professionalism, as learning about the dynamics of cultural issues is a continuous process, and in systems-based practice, as the patients need to be referred to the proper agency. Residents must understand the patient’s cultural experience of the illness and communicate with the patient in a manner sensitive to cultural beliefs. These competencies are reflected in the residency review committee requirements for psychiatry (3), where it is specified that cultural competence issues will be addressed in the didactic, clinical experiences, supervision, and record-keeping aspects of the residency training program. Diversity training strives to raise awareness of biased behaviors that may be unintentional and based upon conscious or unconsciously held prejudices and biases. Thus, diversity training can help clinicians become more aware of how those beliefs may affect their interactions with others. It is a component of cultural competence training, whose purpose is to teach participants knowledge, attitudes, and skills that will help them work with people from different cultural, ethnic, and racial backgrounds. The traditional lecture format has been shown to be as effective as other modalities, such as small groups, to be able to change attitudes (4), but our experience has been that seeing a documentary film whose subject was racism was more effective than lectures or small group discussions in beginning a dialogue about racism. Films make a difficult topic safer by objectifying it. Discussion questions without a film tend to meet with resistance, such as comments that racism 292

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is not a personally relevant issue. Films demonstrate the emotional reactions to racism through the film participants, demonstrating the emotional impact of racism, and thus facilitating the uncomfortable self-reflection and selfrevelation necessary to build trust and facilitate understanding and change. Films also allow viewers to experience emotions vicariously, thus allowing them to acknowledge and process such emotions in a less personally threatening environment. APA published the DSM-IV in 1994, and the DSM-IVTR in 2000, and included in Appendix I the DSM-IV-TR Outline for Cultural Formulation. The Outline for Cultural Formulation includes five parts: cultural identity of individual, cultural explanations of individual’s illness, cultural factors related to psychosocial environment, cultural aspects of the relationship between individual and clinician, and overall cultural influence on diagnosis and approach to treatment (Table 1). Teaching the Outline for Cultural Formulation is difficult due to its complexity and its inclusion of challenging issues such as racism, discrimination, and stereotypes, and how these issues affect diagnosis and treatment. Our experience has shown that the use of non-feature films helps to remove some to the barriers to learning cultural competence, such as a belief that people are more alike than different, a lack of awareness of prejudice, or of cultural assumptions (5). Films can create an environment where trainees feel more comfortable discussing these personal issues in a group format, which facilitates the learning of the importance of these difficult topics by showing other people grappling with these issues. Feature films have been used for many years to teach, such as the use of Ordinary People to discuss psychodynamic psychotherapy (6), The Breakfast Club to demonstrate adolescent development (7), or other films to illustrate psychiatric diagnoses (8–10). Films have also been used in cross-cultural training (11–13). Non-feature films have been used to teach in psychiatric education, as reported by Fox (14), who suggested the use of documentaries to teach normal development. The Color of Fear has been the subject of two articles (15, 16) that reported on the film’s effectiveness to arouse strong and powerful emotions that facilitated discussion of racism.

The Cultural Identity of the Individual: The Way Home The Way Home is a 90-minute film about how women experience race-related issues and shows what happened when eight ethnic councils of women came together to talk Academic Psychiatry, 32:4, July-August 2008

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honestly about race, gender, and class in the United States. The result is a series of conversations that reveal the far-reaching effects of social oppression and present an inspiring picture of women moving beyond the duality of black and white. The participants, 64 diverse women who met regularly over an 8-month period, met in councils separated by ethnicity: Indigenous, Asian, European, African, Arab, Jewish, Latina, and Multiracial. The women speak about ethnic identity, relationships, assimilation, beauty standards, power, school experiences, and other topics. Trainees have found the collages of historical and family photos, dance sequences, visual images, and music from over 20 cultures woven throughout the film to be particularly effective in engaging their interest, all of which expand the impact of the women’s words. The film also helps to open discussion on Part D of the Outline for Cultural Formulation, the relationship between the individual and the clinician as it is affected by the race, ethnicity, and culture of both participants in the therapeutic dyad. The film comes with a discussion guide but we also provide the viewers with a list of the 13 topics as many viewers have difficulty remembering the many key points brought out by the film’s ethnic councils. Participants are asked to comment on parts of the film that were particularly meaningful for them or if they were surprised by anything that they had seen. The film by itself can stimulate discussion, such that specific questions are frequently not necessary. Of note is that The Way Home is used by at least three institutions: UC Davis School of Medicine; the University of California, San Francisco; and the University of Wisconsin.

The Individual’s Cultural Health Beliefs: Black and Blue: Depression in the African-American Community Black and Blue is a 16-minute film about depression featuring African-American patients talking about their experience of the illness and clinicians talking about the scientific aspects of the illness. It was made primarily as a community education initiative but was later found to be useful in patient education and resident education. The intended purposes of the film were to increase awareness of depression as a medical illness among African Americans, to teach the importance of early recognition and treatment, to discuss treatments and the consequences of untreated depression, to give information on how to get treatment, to provide a culturally tailored audiovisual educational tool, and to maximize patient identification and trust by representing African-American consumers, mental health professionals, and clergy. African Americans found it easier to identify with the patients and clinician because of their shared ethnicity, cultural values, and beliefs (17). One key learning point from the film covered in the discussion was the patients’ health beliefs, which ranged from the belief that praying would help them through it, that depression was a matter of weakness, and that depression was caused by a character flaw or “nerves.” One patient stated that it was a weakening of his spirit that he was feeling and that he would get angry and “evil,” thus demonstrating how AfricanAmerican patients might present to the clinician in an unanticipated manner and illustrating the importance of the patient’s religious beliefs. Other beliefs were that suffering is an expected part of the life as a Black person, and that

TABLE 1. DSM-IV-TR Outline for Cultural Formulation A. Cultural identity of the individual An individual’s cultural identity includes the individual’s cultural reference group(s), languages spoken, cultural factors in development, and others. B. Cultural explanations of the illness The cultural explanations of the illness refer to predominant idioms of distress and local illness categories. Also includes meaning and severity of symptoms in relation to cultural norms, as well as perceived causes and explanatory models, and help-seeking experiences and plans. C. Cultural factors related to psychosocial environment and levels of functioning These include social stressors and supports such as family or religious groups, as well as levels of functioning and disability. D. Cultural aspects of the clinician-patient relationship This includes ethno-cultural transference and countertransference as well as the use of an interpreter and psychological testing. E. Overall cultural assessment The overall cultural assessment is a summary of all of the above factors and how they affect the treatment plan. Adapted from Manson SP: The wounded spirit: a cultural formulation of post-traumatic stress disorder. Cult Med Psychiatry 1996; 20:489–98



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African Americans are culturally “programmed” to struggle, “make do,” and “keep on keepin’ on.” Another health belief addressed was the belief that antidepressants were addictive and thus should be avoided. The difficult topics of suicide and substance abuse were also discussed. Lastly, the issue of stigma was explored; African-American patients were reluctant to admit that they had a mental illness because then they would be thought of as “crazy” in addition to being already stigmatized as African American (18). The film also hopes to overcome the African American community’s inherent distrust of the medical profession due to the community’s knowledge of the Tuskegee project. The Tuskegee Syphilis Study was a prospective research project of the U.S. Public Health Service designed to study the effects of untreated syphilis among AfricanAmerican men in the south. The project, which was in operation from 1932–1972, involved the active unethical denial of treatment to its research subjects. African American clients often state that they feel like “guinea pigs” when medications fail to work the first time, reflecting their lack of trust in physicians. Because of the African American community’s involvement with religion, spirituality and its role in mental health treatment must be addressed. An African-American pastor was interviewed for the film and he stated, “as a spiritual man, I look to God. But you know what God is going to do? He’s going to send you to a doctor.” An educational film is often more successful than conventional forms of patient education, such as brochures or doctor-led discussions, because it uses role-modeling to decrease anxiety and increase knowledge about health issues. Another benefit is that a videotape can communicate with people who have low literacy skills. The film was generally well received and was rated effective in improving knowledge about depression and its treatment. After watching the videotape, attitudes improved in several areas, including depression as a medical illness, effectiveness of treatment, negative perceptions of antidepressant medication, and reliance upon spirituality to heal depression (17). This culturally tailored film about depression is deemed acceptable and effective by most African Americans with depression participating in focus groups. It also improved knowledge and several attitudes about depression. Residents have found it useful as additional support for their recommendations to African American patients (17).

Stressors and Supports: The Color of Fear We showed The Color of Fear to our students and assessed their reactions in order to determine its effectiveness. The film is “an insightful, groundbreaking film about 294


the state of race relations in America as seen through the eyes of eight North American men of Asian, European, Latino, and African descent. In a series of intelligent, emotional, and dramatic confrontations the men reveal the pain and scars that racism has caused them. What emerges is a deeper sense of understanding and trust. This is the dialogue most of us fear, but hope will happen sometime in our lifetime” (19). A cluster analysis of a group of students’ reactions to the film reveals its effectiveness with five separate reactions, including: emotional reactions; use as a learning tool (awareness, sensitization); exemplar or role modeling; strategies (how to eradicate racism); and privilege, raising the awareness of white privilege to students (15). We have used the film several ways, such as splitting the film into two sessions versus editing the film to fit a 60minute time slot, but what works best, in our experience, is a 21⁄2-hour session with 30 minutes for eating, 90 minutes for the film, and 30 minutes of discussion. The film’s emotionally laden content does not support its use in split sessions, and the ritual of providing a meal for the residents not only increases the attendance but serves as an important social function. Watching the film is a powerful and emotional experience, as the participants reveal their innermost thoughts and anger toward the mainstream culture for marginalizing them. The video acts as a powerful stimulus for discussion of one’s own experiences with racism and raises the consciousnesses of the mainstream participants regarding the power and privilege that they take for granted. The Color of Fear brings to the discussion the difficult topics of racism, discrimination, power, and privilege that many people feel uncomfortable talking about, especially in a mixed racial group. Using the film can help trainees understand some of the stressors that members of nonmajority groups have to deal with on a daily basis and it can also help them understand the impact of racism on the therapeutic alliance. The film is used both at UC Davis and at the University of Wisconsin. We ask residents to talk about their emotional reactions to the film, such as which person in the film they identified with. We then broaden the discussion to ask if residents have been in similar situations, such as not speaking out against racism, or have been victims of discrimination like the people in the film.

The Relationship between the Individual and Clinician: The Cross-Cultural Therapeutic Alliance: The African-American Client In 1994 Irma J. Bland, M.D., made a 41-minute film called The Cross-Cultural Therapeutic Alliance: The AfricanAcademic Psychiatry, 32:4, July-August 2008

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American Client, which explores the difficulties that can be created between therapists and patients of different races and offers methods to create a therapeutic alliance across cultures. Although the film is currently out of print, copies may be borrowed from many libraries across the country such as at the University of Pittsburgh. The videotape portrays a psychotherapy case between a Caucasian therapist and his African-American client by using an actor as the patient and a psychiatrist with a scripted case. Dr. Bland felt that a videotaped case would be more relevant to trainees than a typical written and read case presentation and it would make the emotional material more accessible. The depiction of a psychotherapy session and the reluctance of the African American patient to engage in the therapeutic alliance—due to a perceived lack of understanding of the African American experience by a Caucasian therapist—are shown for recognition by trainees. The patient projects onto the therapist that he is “rich and upper class” because of his dress and social status as a physician and that he would not understand why the patient feels that he has had fewer opportunities in life because he is an African American. The suggested intervention is a “dissimilarity confrontation,” advocated by Poston et al. (20), which suggests that the therapist talk about the “elephant in the room,” the perception of the client that since the therapist is Caucasian, he cannot understand the African American experience. Dr. Bland also suggests that a varied life experience and exposure to other cultures is helpful for therapists to understand other world views. This understanding helps develop the therapeutic alliance, which is the most critical component of psychotherapy. The depicted case shows what happens when this alliance is not effectively established. The case is also used to discuss general psychotherapeutic concepts, such as engagement, rapport, and alliance, which is created by the identification by the patient that the therapist is trustworthy. This is more difficult when there are fewer significant and easily recognized external factors, such as race, ethnicity, gender, religion, age, or socioeconomic status that can be shared. Dr. Bland also discusses the defenses that are used by therapists to avoid the issue between clinical recreations. The patient is described as “uncooperative,” “unpsychologically minded,” or unable to use psychotherapy. The therapist’s empathic understanding of the patient helps the patient develop a sense of trust. The barriers that are overcome are lack of perception of commonality, lack of ethnic identification, and differing socioeconomic status. They needed to work through their transference and countertransference issues

and stereotyping to develop a true cross-cultural therapeutic alliance (21).



Overall Cultural Formulation: The Culture of Emotions The Culture of Emotions is a 58-minute film that shows interviews with over 40 of the leading mental health professionals in the field of cross-cultural psychiatry demonstrating different approaches toward using the Outline for Cultural Formulation. The Outline for Cultural Formulation offers a conceptual bridge between Euro-Western diagnostic concepts and explanations and traditional worldviews of health and pathology from a variety of societies. The film was designed to be used in a cultural competence and diversity training program to introduce cultural competence assessment skills. It is an excellent overview of how to utilize the Outline for Cultural Formulation, especially when it is used in concert with the facilitator’s guide (22) and the background article (23). There are many clinical pearls contained within the film. Our experience has been that it is best discussed in parts, using one part of the cultural formulation at a time and applying it to a case, which requires about three to four hours total. For example, the first section, the cultural identity of the individual, could be used with a case discussion to guide the group to exploration of the different aspects of the cultural identity, such as acculturation level, language, identified ethnic group association, or country of origin. It has recently been released on DVD, allowing for direct and immediate access to particular sections. The films that have been discussed so far are not the only films that can be used. Table 2 and Table 3 contain a list of documentaries and instructional videos that we believe may be useful for medical educators in enhancing cultural competence. For example, Essential Blue Eyed is a film that has been used at University of Wisconsin to explore racial identity, among others (Table 2). Other films, such as the films listed in Table 3 that have been used at University of California, San Francisco, could be used to explore multiple areas of the Outline for Cultural Formulation by stimulating discussion about racism, stereotypes, and prejudice. Space limitations prevent us from describing each in detail. Interested developers of cross-cultural curricula are encouraged to see them and decide for themselves which would be the most useful for their purposes. Conclusion In our experience, non-feature films can be very useful in diversity training—an essential component of cultural 295


competence training. More research needs to be done to qualitatively and quantitatively assess the effectiveness of the use of film, such as seen for the Color of Fear (15, 16).

When used with the DSM-IV-TR Outline for Cultural Formulation, the films are very helpful in engaging the participants in a discussion about difficult topics such as racism,

TABLE 2. University of California San Francisco Video Library for Enhancing Cultural Competence Documentaries

Date

Running Time

Topic

All God’s Children Ethnic Notions Color Adjustment Black Is . . .Black Ain’t Carved in Silence Days of Waiting Girls Like Us A Question of Color Sewing Woman Shattering the Silences Slaying the Dragon The Way Home

1996 1987 1991 1995 1988 1990 1997 1992 1982 1997 1988 1998

26 min 57 min 87 min 86 min 45 min 28 min 57 min 58 min 14 min 86 min 58 min 92 min

AfA, G AfA AfA AfA, G AsA AsA mix, F AfA AsA mix AsA, F mix, F

1989 1994 1994 1989 1990 1994 1992 1992 1994

75 min 68 min 60 min 64 min 105 min 85 min 57 min 44 min 68 min

mix NatAm LatAm mix mix AsA AfA AfA LatAm

Lectures Barriers to Effective Multicultural Counseling Counseling and Therapy with Native American Indians Cultural Considerations for Working More Effectively with Latin American Individuals Cultural/Racial Identity Development Culture Specific Strategies in Counseling Guidelines for Counseling Asian American Clients Issues in Counseling African American Clients Managing Issues in African American Clients Specifics of Practice for Counseling with Latinos

Jacquelyn B. Chang, M.D., Grand Rounds San Francisco General Hospital, 2001 AfA⳱African Americans; AsA⳱Asian Americans; F⳱Feminist Issues; G⳱Gender Issues; LatAm⳱Latino Americans; NatAm⳱Native Americans

TABLE 3. Mental Health Center of Dane County Training Videos on Cultural Competence Cultural Competence

Film Title

Race Focused

Gay/Lesbian/Bisexual/Transgender Focused

Diversity Counseling Series

Distinguished Lecture Series: Race Matters, Cornel West The Color of Fear The Way Home Skin Deep Question of Color Essential Blue Eyed Blue Eyed Eye of the Storm Straight from the Heart All God’s Children Another Side of the Closet Speaking for Ourselves: A Portrait of Gay and Lesbian Youth In the Life PBS: GLBT Teens Issues in Counseling African American Clients Working Effectively with Latin American Clients Specifics of Practice for Counseling with Latinos Guidelines for Counseling Asian American Clients Counseling and Therapy with Native American Indians

Mental Health Center of Dane County, 625 W. Washington Ave., Madison, WI 53703-2637. http://www.mhcdc.org/default.html

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LIM ET AL. TABLE 4. Contact Information for Films Mentioned in this Article Black and Blue: http://www.bluerockproductions.com Blue Rock Productions, 4226 Amos Avenue, Baltimore, MD 21215. Purchasers are requested to specify the nineminute or 16-minute version, as well as preferred format: VHS, CD-ROM, or DVD, and enclose a check for $35. The Color of Fear: http://www.stirfryseminars.com/pages/ coloroffear.htm The Culture of Emotions: http://www.fanlight.com/catalog/ films/361_coe.shtml The Way Home: http://www.newday.com/films/ TheWayHome.html Out of print: Check libraries for copies. The Cross-Cultural Therapeutic Alliance: the African-American Client: http://www.unitedlearning.com/ Distributed by United Learning (previously The Altschul Group), 1560 Sherman Ave., Suite 100, Evanston, IL 60201

discrimination, power, and privilege, and how those issues affect work with clients. We discussed The Way Home, The Color of Fear, Black and Blue, and The Cross-Cultural Therapeutic Alliance: the African American Client, but they are not the only films that could be used for this purpose. The Culture of Emotions would be a helpful complement to these films, as it is an instructional videotape designed for the instruction on the use of the Outline for Cultural Formulation, and it has clinical advice from over 40 crosscultural psychiatry experts. A key to the use of these films is having adequate time to view and discuss them. Any cross-cultural curriculum could benefit from the thoughtful use of one, a few, or many of the films mentioned, depending upon the total time in the curriculum allotted for this important and essential topic, now required by the residency review committee. Table 4 is included as a source guide for the films discussed in detail in this article. Portions of this article were presented at the American Psychiatric Association’s Institute for Psychiatric Services, October 2001, in Orlando, Fla., and at the Annual Meeting of the Association of Academic Psychiatry, October 2002, in Toronto, Ontario. We would like to acknowledge the contribution of Shannon Suo, M.D., who presented for Dr. Chang in the symposium, as well as Irma Bland, M.D., to this paper. Dr. Bland passed away in 2003.

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TEACHING THROUGH NON-FEATURE FILMS Clinical Methods in Transcultural Psychiatry. Edited by Okpaku SO. Washington, DC, American Psychiatric Press, 1998, pp 266–278 22. Koskoff H, Lu F: The Culture of Emotions: Facilitator’s Guide. Boston, Fanlight Productions, 2005

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