Q&A: How to be more culturally competent in your patient practice

A holistic approach is essential while addressing issues of race with patients in order to give them better, more informed care, according to Anjali Ferguson, PhD.

Ferguson is a clinical psychologist with an expertise in trauma-informed care, early childhood mental health, and culturally responsive care located in Richmond, Virginia. Along with managing her website, ParentingCulture, an online resource that aims to provide an inclusive space for conversations around parenting, Ferguson provides training and workshops across Virginia on culturally competent models of care.

We spoke with Ferguson about how practitioners can incorporate more informed, culturally responsive care into their patient practice.

Integrative Practitioner: To start, can you explain the effects that racism and discrimination have on the mental health of people of color?

Anjali Ferguson: We have well-documented literature and research that shows racism and discrimination can have significant mental and physical health outcomes for people of color. Racism and discrimination can impact things like anxiety; you can have a PTSD [post-traumatic stress disorder] response, a distress response, and heightened depression. Witnessing that kind of racism and discrimination can also trigger those types of responses in folks.

There are also microaggressions which are more subtle forms of racism and discrimination that people of color experience day to day and those can also have significant impacts on mental health. A recent statistic said that Black children experienced about five microaggressions a day, which is a significant number. When we think about those experiences compounding across the lifespan, that can really impact people’s mental capacities and coping.

Integrative Practitioner: How do experiences of racism and discrimination manifest in the physical health and overall wellbeing of patients of color?

Anjali Ferguson: There are direct correlations between racism and discrimination and physical health outcomes. If you've experienced chronic distress related to racism, there’s risk of inflammation and a host of health problems that can result in chronic illnesses. We've also seen with the Adverse Childhood Experiences (ACE) study that you can have significant physical health outcomes when experiencing trauma, like heart disease, diabetes, [and] a heightened risk for substance abuse. It's like a wear and tear of the body when you're experiencing that type of stress long term. Then, when you look at our health disparities, we see Black and Indigenous groups being at higher risk for health complications. The health effects of racism begin at birth if we consider maternal mortality rates and infant care quality. The effects of racism are felt across the lifespan, and it can have a physical toll on the individual and physiological impact on communities.

Racism can also manifest intergenerationally. Many different communities have intergenerational traumas and stressors. When one generation experiences racism and distress, that gets passed on epigenetically to the next generation. We've seen this in literature with Jewish communities after the Holocaust, with Indigenous communities, and more recently with Black communities. There's also evolving research now with Asian communities and how immigration processes impact intergenerational trauma.

Integrative Practitioner: Can you discuss the social determinants of health and how these impact the health and healthcare of marginalized communities?

Anjali Ferguson: When we talk about social determinants of health, we’re usually referring to social and environmental factors that might impact health. Those can include access to housing, nutrition, healthcare, employment opportunities, and educational access.

Traditionally, we look at disparities and we're like, ‘Here's a ton of social determinants of health that explain why we're seeing the presentation we're seeing.’ Instead, we need to peel the onion back a little bit more and look at the situation under a critical lens. What we have to consider is that social determinants of health don't just exist, they don't just pop up. They're there because of where systems have been placed and how systems operate. And, because of how they operate, they disenfranchise certain communities and groups, which then places certain communities and groups at higher risk for health complications.

Integrative Practitioner: How can practitioners begin to better educate themselves on the cultural experiences of patients who are outside of their own race and give these patients better, more informed care?

Anjali Ferguson: That's a tough question, but an important one. Originally, we thought if we educated people about disparities, that would lead to better healthcare for marginalized groups. However, there's been recent literature that showed with the COVID-19 pandemic, knowing about disparities actually made some groups care less about taking precautions against risk. White community members who learned that COVID-19 was impacting Black and Latino communities disproportionately decided to take less precautions in their COVID care. That highlighted knowledge of disparity alone isn't going to motivate folks unless there's some type of emotional connection, some type of relational connection, that inspires folks to do something different. That starts with us acknowledging that racism is really prevalent in healthcare systems across the board, even in psychological spaces.

Of course, a lack of diversity in the field is an issue, but also when we think of our training, all our interventions, all of our research, it really adopts a very Eurocentric lens. When you think of who created interventions, who is writing research articles, and publishing data, they don't often come from marginalized communities. It's rare to see that which then means that we're missing a big piece of the puzzle of understanding those needs of marginalized community members. There’s an awareness piece, but then we have to adjust what we're doing.

While we have well-established, evidence-based models of care, again, there's still some areas of need and weakness in them because of how they've been developed and who's developed them. We have to start to adjust and tweak and be flexible. What that means is really thinking about the patient and the family that's in front of us and taking a more person-centered and family-centered approach to our care. This approach means being more collaborative with the patient than us being the all-knowing medical providers, which is a bit of a shift mentally. This approach involves deferring to what the family in front of us wants and what they need resource-wise, too. That might mean we do things untraditionally from how we were taught in our training. Sometimes our role might be connecting patients with community partners who can better serve a need for them.

We need to be thinking holistically. We cannot limit ourselves to thinking just of our expertise or specialty. Instead, we need to acknowledge all the traumas and social factors that could impact patients’ experiences. We need to try to build partnerships in the community that can then address these needs holistically. We have to talk about race, which makes a lot of us uncomfortable. Mostly as adults we get uncomfortable because we've never learned how to talk about race, how to talk about differences, but differences exist. Every single one of us is different and the minute we can acknowledge that and acknowledge that race is a part of the picture for many folks, then we can start to address those things. Making space for race, making sure we're talking to our patients about race, and how systemic issues might be impacting them is really important and really necessary. Then we need to let them know their experiences with racism are not personal issues or deficits, rather they’re related to external systems and factors.

Integrative Practitioner: What are the questions practitioners should be asking in order to make space for race, acknowledge their patients' cultural backgrounds, and make sure they're seeing the situation as a whole?

Ferguson: When you come into an interview or clinical space, you can say things like, ‘I am wondering if you've ever felt like you have been treated differently because of the color of your skin. Or if you felt like maybe doctors or professionals haven't really listened to your needs. What does that look like? Do you ever feel like there's a cultural difference between your provider or yourself and how does that make you feel? Are you willing to share that?’

It’s just putting it on the table. Being a part of a marginalized group myself, the minute I meet somebody who's able to be that upfront about race and acknowledge that we have a different experience, I open up a little bit more. Then, once you open that door, it's the family's decision on whether they want to share and go there with you or not, that's totally their prerogative, but you acknowledging it is necessary.

Sometimes, especially in the last several years, I like to tie in current events because they really do impact mental health. Just weeks ago, 10 Black individuals were shot in a grocery store because they were Black. I’ve asked the families that I worked with since then, ‘Hey, how are you doing? That is really traumatic. How are you coping? What's going on?’ Even asking that the first time I meet them, they're like, ‘Oh, okay, she gets it,’ and they can tell me more about what's happening for them, about their fears for their kid, whatever it is. But if you're not asking, then you're missing that piece of the puzzle. There's a Cultural Formulation questionnaire in the Diagnostic and Statistical Manual of Mental Disorders and it's a good starting point for folks if they don't have the language or know how to format the language.

Integrative Practitioner: What does more informed care look like and how can practitioners help patients who are struggling with mental health problems associated with discrimination and racism?

Anjali Ferguson: When we talk about informed care or responsive care, we want a streamline approach that we could do with everybody. Responsiveness is flexibility and openness to knowing again, that differences exist, and not one person from a group is going to be the same as the next person. It's trying to understand the patient as an individual and their experiences. That is where the patient-centered, and family-centered focus comes in. It’s explicit discussions about the patient’s identity, goals, and the barriers getting in the way of them accomplishing those goals. It's really collaborative.

It also important to learn our own histories, understanding trauma, how that impacts groups, and maybe impacts their response to treatment or lack of response to treatment. This means informing yourself and not relying on members of those groups to educate or teach you about those things.

It’s also essential that we stay curious and stay open to being wrong. Learning is a lifelong process and the more we can acknowledge that, the more grace we have and the better we will understand the individual when it comes to healing racial trauma.

It is incredibly complex because the fears of racism are very valid. You treat other anxiety disorders with exposure. When a patient is anxious about something, you expose them to that anxious stimulus. How do you expose somebody to more racial trauma and say, ‘Hey, there's nothing to worry about?’ Because the reality is there's a lot to worry about surrounding racism. So, the way in which we do that is acknowledge that the fears are valid, and that, again, the fears are not a product of the individual, but the systems. Then we can work on helping folks channel the very strong emotions that come with their trauma to something else that's more productive. We need to build a safe and productive environment for our clients which could also mean connecting them with community organizations or advocacy groups.

Integrative Practitioner: Do you have anything else that you'd like to add?

Anjali Ferguson: The biggest thing practitioners need to do is to remember the human aspect of it all. Even though folks are different from us, we're all human. Understanding a patient’s experience is so important. If we are choosing to ignore such a big part of their identity, and a big part of their experience, we're ignoring them as a person. It’s hard sometimes as practitioners. It’s easy to lose sight of the connection and the relational piece of things, but building connection and building relations is how we move forward through some of these systemic issues.

Editor’s note: This Q&A was edited and condensed.