"The Rowdy Ones:" Configurations of Difference in a Private Psychiatric Hospital.

Drawing on participant-observation and semi-structured interviews, this paper examines the local forms of clinical practice in a 26-bed acute psychiatric inpatient unit located within a private psychiatric hospital in the Northeastern United States. It focuses on how clinicians, staff, and management understand and utilize the concepts of culture, race, and ethnicity in their daily work, finding that a humanistic approach to care that that treats patients as "individuals" was dominant. Clinicians and staff categorized patients using descriptive, behavior based categories including language, propensity for violence, and whether patients are "from the streets." They also used additional forms of difference such as the patient's pathway to care, their illness category or severity, and whether they use drugs. These forms of difference were shaped by the urgent needs of daily work. These local practices of categorization directly affected the quality of care when staff members assigned cultural characteristics to group members and treated them differently as a result. These findings suggest that anthropologists and clinicians should focus on the way new forms of cultural difference are constructed in small social settings in order to provide equitable treatment to all patients.

"Shattering culture": perspectives on cultural competence and evidence-based practice in mental health services.

The concept of culture as an analytic concept has increasingly been questioned by social scientists, just as health care institutions and clinicians have increasingly routinized concepts and uses of culture as means for improving the quality of care for racial and ethnic minorities. This paper examines this tension, asking whether it is possible to use cultural categories to develop evidenced-based practice guidelines in mental health services when these categories are challenged by the increasing hyperdiversity of patient populations and newer theories of culture that question direct connection between group-based social identities and cultural characteristics. Anthropologists have grown concerned about essentializing societies, yet unequal treatment on the basis of cultural, racial, or ethnic group membership is present in medicine and mental health care today. We argue that discussions of culture-patients' culture and the "culture of medicine"-should be sensitive to the risk of improper stereotypes, but should also be sensitive to the continuing significance of group-based discrimination and the myriad ways culture shapes clinical presentation, doctor-patient interactions, the illness experience, and the communication of symptoms. We recommend that mental health professionals consider the local contexts, with greater appreciation for the diversity of lived experience found among individual patients. This suggests a nuanced reliance on broad cultural categories of racial, ethnic, and national identities in evidence-based practice guidelines.

Patrolling your blind spots: introspection and public catharsis in a medical school faculty development course to reduce unconscious bias in medicine.

Cultural competence education has been criticized for excessively focusing on the culture of patients while ignoring how the culture of medical institutions and individual providers contribute to health disparities. Many educators are now focusing on the role of bias in medical encounters and searching for strategies to reduce its negative impact on patients. These bias-reduction efforts have often been met with resistance from those who are offended by the notion that "they" are part of the problem. This article examines a faculty development course offered to medical school faculty that seeks to reduce bias in a way that avoids this problem. Informed by recent social-psychological research on bias, the course focuses on forms of bias that operate below the level of conscious awareness. With a pedagogical strategy promoting self-awareness and introspection, instructors encourage participants to discover their own unconscious biases in the hopes that they will become less biased in the future. By focusing on hidden forms of bias that everyone shares, they hope to create a "safe-space" where individuals can discuss shameful past experiences without fear of blame or criticism. Drawing on participant-observation in all course sessions and eight in-depth interviews, this article examines the experiences and reactions of instructors and participants to this type of approach. We "lift the hood" and closely examine the philosophy and strategy of course founders, the motivations of the participants, and the experience of and reaction to the specific pedagogical techniques employed. We find that their safe-space strategy was moderately successful, largely due to the voluntary structure of the course, which ensured ample interest among participants, and their carefully designed interactive exercises featuring intimate small group discussions. However, this success comes at the expense of considering the multidimensional sources of bias. The specific focus on introspection implies that prior ignorance, not active malice, is responsible for biased actions. In this way, the individual perpetrators of bias escape blame for their actions while the underlying causes of their behavior go unexplored or unaccounted for.