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Management and culture – relational interactions
POLICY AND MANAGEMENT
Management and culture e relational interactions
333e334). However, it is important to recognize that, in psychiatry e perhaps more than many other branches of medicine e the relational dimension to the therapeutic interaction from assessment onwards is an important aspect of the management strategy itself. It is always easier to gain assessment information with someone similar to oneself, as various verbal and non-verbal communication mechanisms are used and understood within a context of shared knowledge. Difficulties may arise as cultural differences grow, but communicating across these differences is an essential skill for any mental health professional to learn. Any of the descriptors of difference mentioned in Box 1 may form an important aspect of an individual’s identity and possibly a barrier to communicating with another who does not share it. Some of these barriers are obvious e such as language, on which much has been written on effective use of interpreters.1 However, some of these identities may result in emergence of subtler barriers, which may skew power balances and where trust becomes a vital commodity.
Sean Cross Dinesh Bhugra
Abstract Cultures influence individual identities and cognitive schema that influence the way help is sought and how the inner world of the individual is explored. Help-seeking and sources for help are identified through cultural explanations and expectations. Traditional ego-based psychotherapy may not work with various ethnic and cultural groups. Here, we highlight some of the factors that clinicians must be aware of when providing therapies related to relationships.
Keywords assessment and management; cultural competence; identity;
Identity
psychotherapy
Identity is understood in a variety of different ways but is most often used to describe some element of ourselves e which may be temporary or viewed as much more permanent e with which we have significant emotional attachment. The manner in which these potential identities interact is complex. Depending on circumstance, any of them may be of paramount importance or of insignificant importance; they may be strongly held or equally strongly rejected; they may interact in complicated and novel ways that have been described in terms of ‘identity intersections’; and, perhaps most importantly, they are fluid and dynamic in how they are displayed and can, in certain circumstances, change in importance in an instant. There is an enormous social science literature on the importance of identity in health interactions e in particular related to gender, ethnicity and sexual orientation. There have also been interesting recent attempts to try to measure identity multiplicity and intersectionality in mental health settings.2 Any of the identities (see Box 1) e if they differ e may result in a lack of shared knowledge between health professional and patient, and assumptions may arise from which prejudice may spring. Building shared knowledge requires an awareness of relevant issues, which, even if somewhat alien, are accepted as valid. Appropriate cultural management therefore begins at the very start of the relationship (Table 1).
Introduction An individual’s culture, in its widest possible sense, may have a significant impact on the way many different mental health problems are managed. It is necessary for mental health professionals to be aware of this for three important reasons. First, workers themselves increasingly move between different cultures bringing their cultures and cultural expectations with them. Second, individuals seeking mental health care management increasingly move between cultures (this may be briefly for work or pleasure or due to permanent or semi-permanent migration, leading to culturally diverse minority ethnic communities and multi-cultural settings). Third, different management strategies used in different cultural settings will allow better understanding of the complex aetiological drivers of the original mental health problem, which can be used in understanding needs and values of other cultures. Here, we summarize the importance of culture in relational mental health management e the personal interaction between patient and clinician. We focus initially on identity and its importance, particularly during the assessment and interview process, before turning to the issue of cultural impacts on longerterm psychotherapeutic interventions.
Assessment and basic interaction
Examples of some ways in which cultural difference may occur
Culturally aware assessment practices are summarized elsewhere in this chapter (see Gupta and Bhugra, pages 330e332 and pages
C C
Sean Cross BSc(Hons) MBChB Mst MRCPsych is a Specialist Registrar at South London and Maudsley Foundation NHS Trust, UK. His research interests include global mental health, deliberate self-harm and cultural psychiatry. Conflicts of interest: none declared.
C C C C
Dinesh Bhugra MA MSc MBBS FRCPsych MPhil PhD is a Professor of Mental Health and Cultural Diversity at the Institute of Psychiatry (KCL), London, UK. Conflicts of interest: none declared.
PSYCHIATRY 8:9
Age Gender Sexual orientation Job/profession Socio-economic class Educational level
C C C C C C
Race Nationality Ethnicity Language Political persuasion Religious beliefs
Box 1
368
Ó 2009 Elsevier Ltd. All rights reserved.
POLICY AND MANAGEMENT
Important ideas in a culturally aware relational process Be aware of oneself
Be aware of the other
Be aware of circumstance
General assumptions and prejudices held by one’s own culture about others
The basic norms and values of other cultures without assuming they are automatically held Avoidance of both negative and positive assumptions of others Assessment of the impact of assumptions or prejudices directed at your culture The variety of symptom cluster profiles that may occur, e.g. different emphases on the somatic Variations in presentation of the same problem, e.g. different idioms of distress Other kinds of non-verbal communication methods
The wider socio-political context within which you are working
The way one has previously accepted or challenged these assumptions and prejudices Knowledge of the assumptions and prejudices made by other cultures about one’s own Beliefs about how certain problems should present according to one’s own cultural norms How one’s own cultural norms affect the formulation process One’s own non-verbal communication methods
Circumstances are often fluid and complex e embrace it Multiculturalism may mean different groups access and use the same services differently Understand that acculturation can result in hybrid responses becoming common Acceptance of the reality of institutionalized prejudice processes
Table 1
The psychotherapies
up psychotherapy and that there is a higher drop-out rate with those that do.8 It also appears that most people seem to prefer a therapist from the same culture, raising the controversial idea of ethnic or racial matching within the therapeutic relationship. The shared knowledge that such a situation would allow brings us back full circle to the important ideas of identity and the crucial development of cultural competencies that all mental health workers should be striving towards. A
Psychotherapy itself may be described as a culturally bound treatment, emanating for the most part as it did from a European/ North American position in the 19th century. That is not to say that individual-to-individual interaction for ameliorating distress or gaining greater insight into life does not occur as a universal phenomenon across all cultures. However, the theoretical framework of most of the psychotherapies aims to aid an individual’s greater understanding of self, thereby eliminating or reducing the impact of psychopathological processes. Therefore, at the very core of the one-to-one psychotherapeutic alliance is the fundamentally important cross-cultural question of what it means to be an individual. Over the course of the 20th century, further variations of talking therapies emerged from different intellectual traditions and have broadly been categorized as either supportive, reeducative or re-constructive in nature.3 Although a wide range of therapies have evolved on processes involving greater-than-self work e such as family or systems therapy e the basis for much of the work is the concept of the self. Within mental health research the disparity between the numbers of robust studies of effectiveness of psychotherapies as opposed to other forms of treatment is marked e although this is changing more latterly. Some useful summary evidence is available on the specific cultural management issues associated with certain forms of therapy, for example working with refugees and victims of torture.4 The importance of healthy support and supervision structures for those involved in such management is vital because of the stressors of complex case management, unexpected expectations and the dangers of secondary traumatization.5 The dearth of general empirical studies is worsened when considering cross-cultural complexities. The use of minority ethnic communities within trials remains rare,6 and therefore the effective use of psychotherapies in a multicultural setting is still little studied.7 However, it has been stated that there is little doubt that a smaller proportion of the ethnic minority groups of the UK and the US compared with their white neighbours, take
PSYCHIATRY 8:9
REFERENCES 1 Farooq S, Fear C. Working through interpreters. Adv Psychiatr Pract 2003; 9: 104e9. 2 Stirratt MJ, Meyer Ian H, Ouellette Suzanne C, Gara Michael A. Measuring identity multiplicity and intersectionality: Hierarchical Classes Analysis (HICLAS) of sexual, racial and gender identities. Self and identity 2007; 7: 89e111. 3 Wolberg LR. The technique of psychotherapy. 4th edn. New York: Grune & Stratton, 1988. 4 McColl H, McKenzie K, Bhui K. Mental healthcare of asylum-seekers and refugees. Adv Psychiatr Pract 2008; 14: 452e9. 5 van der Veer G. Counselling and therapy with refugees and victims of trauma: psychological problems of victims of war, torture, and repression. John Wiley, 1998. 6 Alvidrez J, Azocar F, Miranda J. Demystifying the concept of ethnicity for psychotherapy researchers. J Consult Clin Psychol 1996; 64: 903e8. 7 Bhui K, Morgan N. Effective psychotherapy in a racially and culturally diverse society. Adv Psychiatr Treat 2007; 13: 187e93. 8 Tantam D. Psychotherapy across cultures. In: Bhugra D, Bhui K, eds. Cultural psychiatry. Cambridge University Press, 2007. FURTHER READING Bhugra D, Bhui K. Textbook of cultural psychiatry. Cambridge: Cambridge University Press; 2007. Bhui K, Bhugra D. Culture and mental health. London: Arnold, 2007. Tseng W-S. Handbook of cultural psychiatry. San Diego, CA: Academic Press, 2004.
369
Ó 2009 Elsevier Ltd. All rights reserved.
Management and culture e relational interactions
333e334). However, it is important to recognize that, in psychiatry e perhaps more than many other branches of medicine e the relational dimension to the therapeutic interaction from assessment onwards is an important aspect of the management strategy itself. It is always easier to gain assessment information with someone similar to oneself, as various verbal and non-verbal communication mechanisms are used and understood within a context of shared knowledge. Difficulties may arise as cultural differences grow, but communicating across these differences is an essential skill for any mental health professional to learn. Any of the descriptors of difference mentioned in Box 1 may form an important aspect of an individual’s identity and possibly a barrier to communicating with another who does not share it. Some of these barriers are obvious e such as language, on which much has been written on effective use of interpreters.1 However, some of these identities may result in emergence of subtler barriers, which may skew power balances and where trust becomes a vital commodity.
Sean Cross Dinesh Bhugra
Abstract Cultures influence individual identities and cognitive schema that influence the way help is sought and how the inner world of the individual is explored. Help-seeking and sources for help are identified through cultural explanations and expectations. Traditional ego-based psychotherapy may not work with various ethnic and cultural groups. Here, we highlight some of the factors that clinicians must be aware of when providing therapies related to relationships.
Keywords assessment and management; cultural competence; identity;
Identity
psychotherapy
Identity is understood in a variety of different ways but is most often used to describe some element of ourselves e which may be temporary or viewed as much more permanent e with which we have significant emotional attachment. The manner in which these potential identities interact is complex. Depending on circumstance, any of them may be of paramount importance or of insignificant importance; they may be strongly held or equally strongly rejected; they may interact in complicated and novel ways that have been described in terms of ‘identity intersections’; and, perhaps most importantly, they are fluid and dynamic in how they are displayed and can, in certain circumstances, change in importance in an instant. There is an enormous social science literature on the importance of identity in health interactions e in particular related to gender, ethnicity and sexual orientation. There have also been interesting recent attempts to try to measure identity multiplicity and intersectionality in mental health settings.2 Any of the identities (see Box 1) e if they differ e may result in a lack of shared knowledge between health professional and patient, and assumptions may arise from which prejudice may spring. Building shared knowledge requires an awareness of relevant issues, which, even if somewhat alien, are accepted as valid. Appropriate cultural management therefore begins at the very start of the relationship (Table 1).
Introduction An individual’s culture, in its widest possible sense, may have a significant impact on the way many different mental health problems are managed. It is necessary for mental health professionals to be aware of this for three important reasons. First, workers themselves increasingly move between different cultures bringing their cultures and cultural expectations with them. Second, individuals seeking mental health care management increasingly move between cultures (this may be briefly for work or pleasure or due to permanent or semi-permanent migration, leading to culturally diverse minority ethnic communities and multi-cultural settings). Third, different management strategies used in different cultural settings will allow better understanding of the complex aetiological drivers of the original mental health problem, which can be used in understanding needs and values of other cultures. Here, we summarize the importance of culture in relational mental health management e the personal interaction between patient and clinician. We focus initially on identity and its importance, particularly during the assessment and interview process, before turning to the issue of cultural impacts on longerterm psychotherapeutic interventions.
Assessment and basic interaction
Examples of some ways in which cultural difference may occur
Culturally aware assessment practices are summarized elsewhere in this chapter (see Gupta and Bhugra, pages 330e332 and pages
C C
Sean Cross BSc(Hons) MBChB Mst MRCPsych is a Specialist Registrar at South London and Maudsley Foundation NHS Trust, UK. His research interests include global mental health, deliberate self-harm and cultural psychiatry. Conflicts of interest: none declared.
C C C C
Dinesh Bhugra MA MSc MBBS FRCPsych MPhil PhD is a Professor of Mental Health and Cultural Diversity at the Institute of Psychiatry (KCL), London, UK. Conflicts of interest: none declared.
PSYCHIATRY 8:9
Age Gender Sexual orientation Job/profession Socio-economic class Educational level
C C C C C C
Race Nationality Ethnicity Language Political persuasion Religious beliefs
Box 1
368
Ó 2009 Elsevier Ltd. All rights reserved.
POLICY AND MANAGEMENT
Important ideas in a culturally aware relational process Be aware of oneself
Be aware of the other
Be aware of circumstance
General assumptions and prejudices held by one’s own culture about others
The basic norms and values of other cultures without assuming they are automatically held Avoidance of both negative and positive assumptions of others Assessment of the impact of assumptions or prejudices directed at your culture The variety of symptom cluster profiles that may occur, e.g. different emphases on the somatic Variations in presentation of the same problem, e.g. different idioms of distress Other kinds of non-verbal communication methods
The wider socio-political context within which you are working
The way one has previously accepted or challenged these assumptions and prejudices Knowledge of the assumptions and prejudices made by other cultures about one’s own Beliefs about how certain problems should present according to one’s own cultural norms How one’s own cultural norms affect the formulation process One’s own non-verbal communication methods
Circumstances are often fluid and complex e embrace it Multiculturalism may mean different groups access and use the same services differently Understand that acculturation can result in hybrid responses becoming common Acceptance of the reality of institutionalized prejudice processes
Table 1
The psychotherapies
up psychotherapy and that there is a higher drop-out rate with those that do.8 It also appears that most people seem to prefer a therapist from the same culture, raising the controversial idea of ethnic or racial matching within the therapeutic relationship. The shared knowledge that such a situation would allow brings us back full circle to the important ideas of identity and the crucial development of cultural competencies that all mental health workers should be striving towards. A
Psychotherapy itself may be described as a culturally bound treatment, emanating for the most part as it did from a European/ North American position in the 19th century. That is not to say that individual-to-individual interaction for ameliorating distress or gaining greater insight into life does not occur as a universal phenomenon across all cultures. However, the theoretical framework of most of the psychotherapies aims to aid an individual’s greater understanding of self, thereby eliminating or reducing the impact of psychopathological processes. Therefore, at the very core of the one-to-one psychotherapeutic alliance is the fundamentally important cross-cultural question of what it means to be an individual. Over the course of the 20th century, further variations of talking therapies emerged from different intellectual traditions and have broadly been categorized as either supportive, reeducative or re-constructive in nature.3 Although a wide range of therapies have evolved on processes involving greater-than-self work e such as family or systems therapy e the basis for much of the work is the concept of the self. Within mental health research the disparity between the numbers of robust studies of effectiveness of psychotherapies as opposed to other forms of treatment is marked e although this is changing more latterly. Some useful summary evidence is available on the specific cultural management issues associated with certain forms of therapy, for example working with refugees and victims of torture.4 The importance of healthy support and supervision structures for those involved in such management is vital because of the stressors of complex case management, unexpected expectations and the dangers of secondary traumatization.5 The dearth of general empirical studies is worsened when considering cross-cultural complexities. The use of minority ethnic communities within trials remains rare,6 and therefore the effective use of psychotherapies in a multicultural setting is still little studied.7 However, it has been stated that there is little doubt that a smaller proportion of the ethnic minority groups of the UK and the US compared with their white neighbours, take
PSYCHIATRY 8:9
REFERENCES 1 Farooq S, Fear C. Working through interpreters. Adv Psychiatr Pract 2003; 9: 104e9. 2 Stirratt MJ, Meyer Ian H, Ouellette Suzanne C, Gara Michael A. Measuring identity multiplicity and intersectionality: Hierarchical Classes Analysis (HICLAS) of sexual, racial and gender identities. Self and identity 2007; 7: 89e111. 3 Wolberg LR. The technique of psychotherapy. 4th edn. New York: Grune & Stratton, 1988. 4 McColl H, McKenzie K, Bhui K. Mental healthcare of asylum-seekers and refugees. Adv Psychiatr Pract 2008; 14: 452e9. 5 van der Veer G. Counselling and therapy with refugees and victims of trauma: psychological problems of victims of war, torture, and repression. John Wiley, 1998. 6 Alvidrez J, Azocar F, Miranda J. Demystifying the concept of ethnicity for psychotherapy researchers. J Consult Clin Psychol 1996; 64: 903e8. 7 Bhui K, Morgan N. Effective psychotherapy in a racially and culturally diverse society. Adv Psychiatr Treat 2007; 13: 187e93. 8 Tantam D. Psychotherapy across cultures. In: Bhugra D, Bhui K, eds. Cultural psychiatry. Cambridge University Press, 2007. FURTHER READING Bhugra D, Bhui K. Textbook of cultural psychiatry. Cambridge: Cambridge University Press; 2007. Bhui K, Bhugra D. Culture and mental health. London: Arnold, 2007. Tseng W-S. Handbook of cultural psychiatry. San Diego, CA: Academic Press, 2004.
369
Ó 2009 Elsevier Ltd. All rights reserved.