Background policy and research
The challenges faced by people from a black or minority ethnic group when they come into contact with psychiatric services are well documented in previous research reviews and in evidence-based policies [1, 2]. These highlight ethnic inequalities of experiences and outcomes, including concerns about patient safety, disproportionate number of admissions and detentions in psychiatric hospitals, conflict with carers and staff, fear of services, lack of engagement or poor access to effective services, anxieties about contact with the criminal justice system and police, a lack of available psychological therapies and inequalities in pharmacotherapy.
Culture and communication
Clearly, the ability to communicate effectively and in a culturally appropriate manner underpins successful diagnosis and therapy. For example, linguistic isolation at the time of illness can lead to further anxiety and uncertainty in communication during assessment, diagnostic practice and clinical decision-making. Inappropriate use of family or friends as an interpreter to address this issue may still undermine precise assessment; use of bilingual professionals or interpreters with special expertise in mental health settings can improve this [3–5]. However, dissatisfaction and inequalities are also prominent among Anglophone migrants and other people from BME groups who speak English [4, 5].
Therefore, the causes of dissatisfaction with care, failure to engage with services or accept treatment, and fears about safety may be explained by inherent communication problems that reflect different underlying assumptions and expectations about the causes and treatments of mental and emotional distress . Ineffective communication and failed negotiation because of these differences may then lead to a feeling of not being understood, omissions of important information from the clinical assessment, conflict with staff, disengagement and/or a failure to take up interventions [6, 7]. This may lead to more severe and more frequent episodes of illness and in turn the use of coercion, which is also associated with a higher rate of adverse incidents. Such a cycle undermines the therapeutic potential of existing care practices and processes, but may also add additional burdens on the mental health of service users. Thus, improving therapeutic communications may permit maximum benefits to be realised from existing care and services, improve safety and avoid adverse incidents in care.
Effective communication is central to psychiatric assessment, diagnosis, engagement and treatment, and ultimately recovery [6, 7]. Effective communication has proven more difficult to achieve where there are differences in culture or language between those delivering and receiving care . Of course, communication difficulties might also arise from any encounter between a patient and professional because of differences in age, gender, social status or perceived power status. However, cultural differences between patient and professional add additional challenges, for example, the ability of the professional to:
identify with and empathise with a patient from a different culture [8, 9]
understand symbolic and metaphorical language that varies by culture 
understand differing expectations of health care professionals in different countries and cultures (e.g. authoritarian versus egalitarian approaches, medication as treatment rather than discussing emotional issues) ;
appreciate the differences in illness perceptions and explanatory models of patients from different cultures .
Cultural factors amplify the limitations of therapeutic communications and are of importance given the potential to compound inequalities in the social determinants of illness and to perpetuate inequalities in health care outcomes following contact with health systems [11–13]. Therapeutic communication can be central to reducing inequalities. For example, Lorenz and Chilingerian, using visual supports for communication, have recently argued that these help address inequalities and gender disadvantage by introducing a more ‘fair process’ of assessment . They define a fair process as one that involves patients in a collaborative approach to explore diagnostic issues and treatments, explains the rationale for decisions, sets expectations about roles and responsibilities, and implements a core plan and ongoing evaluation. Fair process opens the door to bringing patient expertise into the clinical setting and the work of developing health care goals and strategies. Although improved therapeutic communication is at the heart of this fair process, the evidence base to support professionals in achieving this is currently scattered across a number of disciplines and based on different theoretical models. There is a therefore a need to pull this evidence together and appraise its quality in the main areas highlighted in the research brief.
One proposed solution has been the dissemination of ‘cultural competency’ training . A review of the international literature on cultural competency suggests that it is best conceptualised as a systemic and deep-seated process of change in both organisations and professional practice . This requires a change in the attitudes of staff and a change in the way they assess, diagnose and treat people with different expectations and perceptions about what is illness and what is recovery. At an organisational level, changes required include developing values that are more welcoming of culturally diverse populations and changes in management styles and HR practices that reflect an understanding of the influence of culture on communication. Alongside these macro-level interventions, educational solutions have been proposed including training to address individual staff attitudes and stereotypes, in order to permit staff to work more effectively with culturally diverse populations. However, the complex introduction of change at an individual and organisational level, linked by changing values and attitudes, has not been widely applied in the UK. Short-term educational solutions have been more popular and therefore more widely reported in the literature. These have varied in quality and focus, with some attending to communication, some to clinical skills and practices, some to the attitudes of practitioners and their cultural biases, and some to specific groups such as faith groups, refugees, migrants, gypsies, or racialised groups. This has made the development of a robust evidence base problematic.
Some cultural competency training has included information on race equality and recruitment legislation mainly to ensure compliance. The Department of Health rolled out a race equality and cultural competency framework to address stigma, race equality and cultural factors . This attempted to present communication issues and sensitivity to stereotypes according to race and culture, but included a limited focus on clinical assessment, diagnosis or specific treatment strategies. Bennett et al. mapped cultural competency training and its content in the UK and concluded there was insufficient attention to clinical interventions and to racial issues, suggesting instead that non-therapeutic communication issues were more prominent in the literature . A systematic review of the international literature on cultural competency interventions in mental health settings has similarly identified few evaluations, and none with patient reported outcomes . A systematic review of therapeutic communications is necessary to synthesise the findings across these many approaches and identify lessons for policy, practice and research.
Narratives, ethnography and diagnosis
The meaning a person assigns to an illness may be quite different from the formulation of the health professional . This issue is not confined to the UK and reflects fundamental differences across national, cultural, ethnic and religious groups in the way mental distress and illness is understood and defined, and related to expectations of recovery and treatment [19, 20]. Canales et al. describe ‘narrative interaction’, sharing of personal stories, as a form of therapeutic communication that permits the gendering of inequalities to be addressed in nursing practice .
Making a more detailed assessment of patients’ illness models is advocated by some medical anthropologists; for example, ‘mini-ethnography’ has been used in the clinical assessment in cultural consultation . Studies of cultural consultation have demonstrated improvements in diagnostic precision, diagnostic depth and care plans. Attempts to introduce ethnography in the diagnostic process have led to support for a ‘cultural formulation’, which is highlighted in the diagnostic and statistical manual (DSM-IV, 4th edition) . This advocates that assessment includes ethnography and narrative by asking questions about cultural identity and explanatory models. Explanatory models in the anthropology literature are similar to illness perceptions reported in the psychology literature, and both refer to concepts about what causes illness, what it is called, who might help in recovery and what expectations there are of potential carers. In addition the cultural formulation also asks about psychosocial factors and brings the clinician’s perspective into play by openly seeking comment on interpersonal interactions before seeking an overall judgement about diagnosis and formulation. Although cultural formulation has been reported to be helpful in clinical practice, the published literature mainly contains qualitative and descriptive papers, including case reports; evaluative studies may only appear in the grey literature. Other developments in the UK include a conflict resolution and mediation approach pioneered by Kilshaw et al.  and a cultural consultation service that is collecting pilot data on workforce development, cultural competency and organisational narratives of care and communications; the data will show if these influence care practices [22, 23]. At the heart of these approaches, ethnography, patient narratives and negotiations of meaning seem to be the key ingredients that benefit patients in these pioneering services .