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Open Forum   |    
Cultural Competence, Evidence-Based Medicine, and Evidence-Based Practices
Rob Whitley, Ph.D.
Psychiatric Services 2007; doi: 10.1176/appi.ps.58.12.1588
Abstract

Cultural competence and evidence-based medicine are two powerful discourses that have become core components of contemporary psychiatry. Evidence-based medicine has particularly influenced psychiatry by spawning the enthusiastic creation and adoption of evidence-based practices. Despite their prominence, these paradigms have stood somewhat in isolation from each other. This Open Forum explores the relationship between these two conceptual paradigms, paying particular attention to implications for evidence-based practices. The author aims to stimulate a greater degree of mutual engagement and integration of these paradigms by examining epistemological, philosophical, and methodological overlap and discrepancy. Both paradigms can stretch and enrich each other in a positive manner. This could help achieve a situation where cultural competency becomes more evidence based and evidence-based medicine becomes more culturally competent. Such action would help bring to fruition a shared aim of both discourses—more humane, just, and effective patient-centered care. (Psychiatric Services 58:1588—1590, 2007)

Abstract Teaser
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Dr. Whitley is affiliated with the Department of Psychiatry, Dartmouth Psychiatric Research Center, 2 Whipple Pl., Suite 202, Lebanon, NH 03766 (e-mail: rob.whitley@dartmouth.edu).

It is almost impossible to read a mainstream psychiatric journal without encountering articles focused on either cultural competence or evidence-based medicine. However, I recently conducted a literature search that yielded few articles relating these two powerful paradigms. This Open Forum briefly describes and analyzes these paradigms, suggesting that both can mutually inform the development of the other in a positive manner.

The evidence-based medicine movement arose out of concern that many patients were receiving ineffective treatment that was grounded in tradition, outdated training, or practitioner caprice rather than scientific evidence. This generated an imperative for researchers to scrutinize and evaluate treatments in order to discern overarching efficacy. This process led to the development of evidence-based practices in psychiatry (1,2). These are discrete interventions deemed efficacious through analysis of accumulated randomized controlled trials and quasi-experimental studies (3,4). The New Freedom Commission has called for public mental health services to be centered on evidence-based practices (3). There is thus strong commitment to the paradigm of evidence-based medicine and its corollary, evidence-based practices.

Cultural competence has been defined as a set of skills and practices that lead to culturally appropriate services. Such services respect patients' ethnocultural beliefs, values, attitudes, and conventions (5). Interest in cultural competence has arisen as ongoing research has suggested large inequities in access to and quality of psychiatric care between ethnoracial groups, with members of minority groups seeking care less often and dropping out of care more often than others (6,7). Cultural competence was proposed as a concept that could help reduce these disparities by adjusting services and treatment options to account for ethnocultural differences. Indeed, the New Freedom Commission posited that individual treatment should be appropriately tailored in regard to ethnocultural particularities. Again, there is strong government and researcher commitment to this prominent paradigm.

Few studies exist that relate cultural competence and evidence-based medicine and practices in psychiatry. Indeed, both paradigms have developed somewhat independently. This may be a result of differing disciplinary and philosophical orientations. Evidence-based practices are embedded firmly within the disciplines of psychiatry and psychology and represent a "modernist" view of intellectual inquiry. This view indicates a commitment to post-Enlightenment beliefs that knowledge can be incrementally discerned through rational application of progressively refined scientific techniques. The application of this knowledge subsequently leads to the erosion of tradition, which is replaced by standardized measures supported by scientific evidence (1). Cultural competence is less modernist in orientation and is instead embedded more deeply in multiculturalism and, to a lesser extent, postmodernism. This theoretical view is an enduring political and philosophical movement that seeks to celebrate, understand, and perpetuate differences and local particularities and to strongly resist standardizing tendencies. Cultural competency's roots extend across other social science disciplines that are less positivist in orientation, such as anthropology and sociology. These are somewhat more critical of notions of scientific progress, standardization, and "truth." This difference in orientation may explain some of the disconnect between the two paradigms.

Likewise, cultural competence is more reliant on qualitative research than is evidence-based medicine, which traditionally has been quantitative. This quantitative orientation has allowed for the growth of a robust literature on measurement of the efficacy of evidence-based practices, their effectiveness, and their implementation. Such issues have been largely absent in cultural competence, where there is an acknowledged need to develop a critical evidence-based body of work. This is an area where evidence-based medicine can inform cultural competence. That said, there is a tradition of quantitative research in cultural competence (5,7). Likewise, there is growing acceptance that qualitative research can access important domains relevant to the development and implementation of evidence-based practices (4). Such developments suggest that vestigial tensions between qualitative and quantitative research may be in abeyance, with growing recognition that qualitative research can also be rigorous and robust. Still, broad methodological orientations persist in comparisons of the two paradigms.

A final point of divergence is related to differential orientation toward top-down and bottom-up interventions. Evidence-based practices are generally created, tested, interpreted, and disseminated by expert specialists within academia (1,4). Cultural competence is less committed to top-down interventions, placing a greater degree of emphasis on bottom-up collaboration in the development of culturally appropriate care (6,7). Such collaboration has been shown to have a positive effect on recruitment and retention of clients (6). This may be an area where cultural competence can inform evidence-based medicine. Cultural competence literature may assist those attempting to make evidence-based practices more widely available—replete as the literature is with examples of community collaboration and participatory research. This may be crucial if evidence-based practices are to become more accessible across the ethnocultural spectrum.

I have argued that there are foundational differences between evidence-based medicine and cultural competence. However, I believe there are also fundamental similarities. Evidence-based medicine and cultural competence share origins in that both may be considered epiphenomena of the wider shift toward patient-centered medicine. Both share a targeted objective of reducing health disparities by providing effective and appropriate care. Such an approach involves an implicit commitment to justice, which has been posited as one of the four guiding principles of medical ethics (8). Both are also somewhat hermeneutic in orientation (in theory), in that they recognize the dialectic between the nomothetic and the idiographic in the clinical encounter. In a seminal article, evidence-based medicine was described as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients" (2). In other words, advised application in a discrete clinical encounter requires a bridging of nomothetic (the best evidence) and idiographic (the individual patient) knowledge. Such an approach is consistent with models of cultural competence that emphasize tailoring of treatment in the light of ethnocultural particularities (3,5,6).

Hence, a strength of evidence-based medicine may be what it can provide to the clinician in terms of the nomothetic, whereas that of cultural competency may be what it can provide in helping to elicit and assess the idiographic. Focus on eliciting the idiographic will allow for the integration of factors pertaining to the individual patient's sociocultural milieu, without recourse to misplaced ethnoracial stereotypes. These stereotypes are sometimes (usually unwittingly) perpetuated by persistent themes in social and cultural psychiatry, for example beliefs surrounding religiosity of African Americans, individualism among Caucasians, or family ties among Latinos. Obviously, training in eliciting the idiographic will prevent misapplication of stereotypes. It will also give clinicians information that can be married to nomothetic knowledge, which can then be brought to bear on diagnosis and treatment decisions. Clearly, such a model is as applicable to white as to nonwhite patients in that everyone has important sociocultural beliefs, values, and practices that may affect treatment preferences, retention, and adherence.

Of interest, the Surgeon General noted that cultural competence was not a practice in itself but should be a core component of any service (6). This statement suggests that the range of evidence-based practices used in psychiatry can aspire to be culturally competent, provided that latitude and training are given to elicit and integrate the idiographic perspective. In fact, bringing the two paradigms to bear upon each other in this regard may act as a check and balance on the overzealous and extreme operationalization of either paradigm used in isolation. Cultural competence can ensure that evidence-based practices do not transmogrify into one-size-fits-all mindless technical application. Similarly, evidence-based medicine can ensure that cultural competence does not dissolve into the anarchic reinvention of treatment for every individual patient.

The argument thus far represents an optimistic view of how cultural competence and evidence-based medicine can complement each other. A less sanguine view is that the professional knowledge garnered by randomized controlled trials within evidence-based medicine will in practice dominate the "folk" knowledge or subjective preferences of individual patients. The relative status of mainstream professional "knowledge" in contrast to patients' less authoritative "beliefs" could lead to minimal tailoring of treatment according to the particularities of the idiographic case. This would simply perpetuate the alienation and disempowerment felt by many members of minority groups (and indeed whites) that contribute to inequities in service utilization, treatment adherence, and retention.

As previously stated, there is a large body of evidence suggesting general efficacy of various evidence-based practices (4). In contrast, it has frequently been noted that cultural competence lacks an evidence base and is not supported by robust evaluation research (9,10). There is thus an urgent need to develop models of cultural competence that can (and should) be rigorously assessed. These endeavors may benefit from the methodological experience yielded by development of evidence-based practices in psychiatry.

That said, the literature supporting evidence-based practices in psychiatry is somewhat remiss if ethnocultural matters are taken seriously. It has been noted that "scientific evidence (for evidence based practices) is limited for cultures other than the major culture" (10). This limitation raises the question of theoretical extrapolation: can a practice with efficacy in a predominantly white American sample be considered evidence based for other ethnocultural populations? It has been argued that speculation based on theory is an example of nonscientific evidence in evidence-based medicine (4). This suggests a need for specific research within ethnocultural minority groups.

In an ideal world, existing evidence-based practices would be tested in the various minority and immigrant populations, in their routine settings with their routine clinicians. Similarly, new evidence-based practices could be developed in a bottom-up manner in collaboration with distinct ethnocultural groups. In reality, there are insufficient resources to conduct such research with the hundreds of ethnocultural groups in the general population. Still, greater efforts need to be made in expanding this research so that researchers may better judge the applicability of treatments to distinct ethnocultural groups. Such a research agenda could help achieve a situation where cultural competency becomes more evidence based and evidence-based practices become more culturally competent—outcomes desired by all committed to equity and effectiveness in mental health care.

The author thanks Robert E. Drake, M.D., Ph.D., for extremely helpful comments on drafts of this article.

The author reports no competing interests.

Tomes N: Patient empowerment and the dilemmas of late-modern medicalisation. Lancet 369:698—700, 2007
 
Sackett DL, Rosenberg WMC, Gray JAM, et al: Evidence based medicine: what it is and what it isn't. British Medical Journal 312:71—72, 1996
 
Achieving the Promise: Transforming Mental Health Care in America. Pub no SMA-03-3832. Rockville, Md, Department of Health and Human Services, President's New Freedom Commission on Mental Health, 2003
 
Mueser KT, Drake RE: How does a practice become evidence-based? In Evidence-Based Mental Health Practice: A Textbook. Edited by Drake RE, Merrens MR, Lynde DW. New York, Norton, 2005
 
Bhui K, Warfa N, Edonya P, et al: Cultural competence in mental health care: a review of model evaluations. BMC Health Services Research 7:15, 2007. Available at DOI 10.1186/1472-6963-7-15
 
Mental Health: Culture, Race, and Ethnicity: Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md, US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2001
 
Vega WA: Higher stakes ahead for cultural competence. General Hospital Psychiatry 27:446—450, 2005
 
Beauchamp TL, Childress JF: Principles of Biomedical Ethics, 4th ed. Oxford, United Kingdom, Oxford University Press, 2001
 
Kleinman A, Benson P: Anthropology in the clinic: the problem of cultural competency and how to fix it. PloS Medicine 3:1673—1676, 2006
 
Siegel C, Haughland G, Schore R: The interface of cultural competency and evidence-based practices, in Evidence-Based Mental Health Practice: A Textbook. Edited by Drake RE, Merrens MR, Lynde DW. New York, Norton, 2005
 
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References

Tomes N: Patient empowerment and the dilemmas of late-modern medicalisation. Lancet 369:698—700, 2007
 
Sackett DL, Rosenberg WMC, Gray JAM, et al: Evidence based medicine: what it is and what it isn't. British Medical Journal 312:71—72, 1996
 
Achieving the Promise: Transforming Mental Health Care in America. Pub no SMA-03-3832. Rockville, Md, Department of Health and Human Services, President's New Freedom Commission on Mental Health, 2003
 
Mueser KT, Drake RE: How does a practice become evidence-based? In Evidence-Based Mental Health Practice: A Textbook. Edited by Drake RE, Merrens MR, Lynde DW. New York, Norton, 2005
 
Bhui K, Warfa N, Edonya P, et al: Cultural competence in mental health care: a review of model evaluations. BMC Health Services Research 7:15, 2007. Available at DOI 10.1186/1472-6963-7-15
 
Mental Health: Culture, Race, and Ethnicity: Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md, US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2001
 
Vega WA: Higher stakes ahead for cultural competence. General Hospital Psychiatry 27:446—450, 2005
 
Beauchamp TL, Childress JF: Principles of Biomedical Ethics, 4th ed. Oxford, United Kingdom, Oxford University Press, 2001
 
Kleinman A, Benson P: Anthropology in the clinic: the problem of cultural competency and how to fix it. PloS Medicine 3:1673—1676, 2006
 
Siegel C, Haughland G, Schore R: The interface of cultural competency and evidence-based practices, in Evidence-Based Mental Health Practice: A Textbook. Edited by Drake RE, Merrens MR, Lynde DW. New York, Norton, 2005
 
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