Counselling in Transcultural Settings

Priorities for a Restless World

Patricia d′Ardenne

• Publisher: SAGE Publications Ltd
• Year: 2012
• Print ISBN: 9781446200674, 9781446200667
• eBook ISBN: 9781446292068
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Drawing on over 40 years experience, Patricia d?Ardenne provides the reader with a unique and practical introduction to counselling and psychotherapy in a world on the move, where ethnic, linguistic, religious, economic, political and environmental differences collide and create a rich and complex setting for contemporary therapeutic practice.

Positioning counselling within the shifting contexts of the modern world, this book:

- Examines anti-discriminatory practice - its origins and development

- The complexities of working effectively with refugees, asylum seekers, vulnerable migrants, and the victims of human trafficking

- Considers the needs of the cultural traveller

- Address the intricacies of faith and spirituality

- Provides a guide to assessing language and the role of interpreters

- Addresses ethics, the law and transcultural issues in Healthcare

- Looks at the importance of supervision, personal development and self care.

Counselling in Transcultural Settings is an essential companion for counsellors and psychotherapists at all stages of professional training looking to work beyond their own culture, where the demands of therapy are as dynamic as the political and social contexts within which people seek help.

Patricia D?Ardenne is a consultant clinical and counselling psychologist.

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1

ANTI-DISCRIMINATORY PRACTICE: ITS ORIGINS AND DEVELOPMENT IN TRANSCULTURAL COUNSELLING

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Science and experience has also shown that no race is inherently superior to others, and this myth has been equally exploded whenever blacks and whites are given equal opportunity for development.

Nelson Mandela, Robben Island, 1978

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Summary

Chapter 1 provides an historical account of transcultural counselling in the Western world, with its colonial past, from the study of madness and the exotic, to ideas of difference in recent psychiatry, psychology and counselling practice. Concepts of race, racial differences, culture-bound syndromes and cultural psychology are critically reviewed in the light of modern human rights, ethnic monitoring, personal and institutional racism, social identity theory, and what they tell us about the nature of human prejudice and exclusion. Current counselling theory is revisited and priorities identified for ensuring anti-discriminatory and anti-oppressive practice.

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Introduction

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This chapter shows how Mandela’s conclusion forms the basis of modern anti-discriminatory practice in caring professions. Science, however, has not always served this moral purpose, either by ignoring or perverting the evidence of different peoples’ outcomes in care, where there is unequal opportunity, wealth, or racism. Current anti-discriminatory practices in UK settings will be defined, as well as policies that have been introduced for more ethical and effective outcomes. What evidence there is for change in recent decades for all counsellors – both white and black – is described. Historical and political themes are considered for readers working in transcultural settings to understand better the impact of personal beliefs on the counselling process. Case examples are from mental health, but applications are possible in other counselling domains.

Beyond that readers need to read more widely and critically on the issues and debates in Mandela’s discourse. The paradox remains that our globalised world – some have called it a ‘village’ – with easier jet travel, the internet, instant messages and images from mobile phones remains as xenophobic as ever, divided by race, religion, culture, gender and ability (Bhugra and Bhui, 2007; Thomas, 2000). Many aspects of multiculturalism are reflected negatively in the media; for example, ‘social problems’, ‘language barriers’, ‘failed asylum seekers’, ‘our overcrowded island’, ‘undercutting local jobs and houses’, and, of course, ‘radicalisation’, ‘extremism’ and ‘terrorism’. Indeed, current British political leaders think that ‘state multiculturalism’ has failed, and that separate ethnic identities matter less than being assimilated into a British ‘Big Society’ (Hasam, 2011). The Prime Minister, David Cameron, said: ‘we have tolerated segregated communities behaving in ways that run counter to our values. All this leaves some young Muslims feeling rootless. And the search for something to belong to and believe in can lead them to extremist ideology’ (Hasam, 2011).

In addition there is a heavily politicised contemporary debate about how migration, policing, education, public housing, health and related social issues feature in an economic recession where resources are being cut. There are questions raised about why the West ‘should bother’ giving aid to developing countries. It is a rare event to hear a public figure speak of the benefits to society of multiculturalism (Abbott, 2012); it is just as rare to hear counsellors speak enthusiastically about diversity as providing them with the essential and unique knowledge and skills for a restless world.

Madness and the exotic

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Understanding the present requires consideration of the past. Historically, Britain has had a long-standing love affair with anthropology and the alluring pursuit of the foreign and madness – stemming perhaps from its seafaring tradition, its colonialism, its slave economy and its culture of excluding people, sometimes literally, ‘all at sea’. The Ship of Fools in the fifteenth century was an allegory of one such exclusionary practice, where mad people were sent away from their villages and actually packed into ships and sent ‘abroad’ (Foucault, 1988).

As late as the nineteenth century, criminals, dissidents, trade unionists – anyone who was different or undesirable – could be deported on a ship to penal colonies, as far away as possible, to Britain’s dominions on the other side of the world. Even in the mid-twentieth century, orphans or children in care could be shipped to Australia, for which the British Prime Minister, Gordon Brown, apologised in 2010 (Bowcott, 2010; Barnados, www.barnados.org.uk). In 1948, the first ship, MV Empire Windrush, brought black families from the Caribbean to the British Isles. These men and women, direct descendants of those enslaved and shipped from Africa by British traders for plantation work in the seventeenth, eighteenth and nineteenth centuries, were actively recruited to run UK transport, postal and health services in the twentieth century (Lago and Thompson, 1996; National Archives, www.nationalarchives.gov.uk). The ship had come home.

The definition of race, ethnicity and culture

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The West has had many debates about the meanings of the terms ‘race’, ‘ethnicity’ and ‘culture’. The first 1790 US census referred to ‘free white men’, ‘free women’ and ‘slaves’ (United States Census Bureau, 1790). The Office of the High Commission for Human Rights (OHCHR) (1949) defines not racism, but racial discrimination, as ‘any distinction, exclusion, restriction, or presence based on race, colour, descent or natural or ethnic origin, which has the purpose or effect of nullifying or impairing the recognition, enjoyment or exercise, or an equal footing, or human rights and fundamental freedoms in the political, economic, social, cultural or any other field in public life’ (www.ohchr.org). By 2010, the American Anthropological Association recommended the term ‘race’ be eliminated from the census, since ‘race has been scientifically proven to not be a real, natural phenomenon’. It recommended that ‘ethnicity’ or ‘ethnic group’ was more salient and had fewer racist connotations. At the same time it acknowledged the damage done by ‘racial’, i.e. racist, terms to the many diverse people within the US population (American Anthropological Association, 1998; United States Census Bureau www.census.gov).

In the UK, racial and ethnic data have been collected only since the 1991 Census – notably after a decade of ethnic tensions and urban conflict. Concern was then expressed about the lack of information on families who had migrated to the UK after World War II, including their access to education, work, health and housing. The Census used a process of self-definition, where ethnicity and culture remain dynamic and complex, and hotly debated (Office for National Statistics (ONS), 2011). Some of these categories may have been fit for purpose but not applicable to health and social care. McKenzie and Crowcroft (1996) recommended that clinicians describe individuals being studied or treated and avoid depending on categorisations. Since ethnicity and culture are confounding variables, it is often not possible to have a specific ethnic hypothesis at the start of research. Rather, they recommended that the Census categories be used, but additional personal historical information be added. The British Medical Journal suggested: country of birth; parents’ country of birth; first language; special diets; religion practised; years in the UK; and socioeconomic status (McKenzie and Crowcroft, 1996).

Anthropology, psychiatry and the alienists

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It is 30 years since a white psychiatrist and an anthropologist published a seminal work on the impact of racism on mental health in the UK (Littlewood and Lipsedge, 1982, 1997). They argued, with plenty of evidence, that the consideration of ‘culture’ as a variable in an otherwise value-free pursuit of therapeutic objectivity, was unsustainable. They highlighted two disciplines that consider its subject as aliens, namely anthropology and psychiatry, where race and madness have been considered as indices of ‘otherness’. More importantly, they showed that alienists (once the actual word for psychiatrists in France) are active agents who create aliens: alienation itself is thus a social and political process.

The tragedy revealed by their analysis was that black people, especially immigrants to the UK, have been alienated by a dominant white culture that more readily diagnosed madness (psychosis) in black people than white (Bhugra and Bhui, 2007; Burke, 1984; Sashidharan, 2001; Sproston and Nazroo, 2002). Nor has this process been confined to history. Fernando (2002) showed that when identical case histories were given to UK psychiatrists using either English or foreign names, that psychosis was diagnosed more frequently in the latter group than by chance. Practitioners were ‘ethnocentric’, i.e. locked in the cultural assumptions of their own ethnic histories, and frequently confused the social with the biological.

Specific culture-bound syndromes

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In the last century much emphasis was placed on understanding exotic psychiatric disorders. Recurrent, locally specific patterns of atypical behaviour and troubling experiences have now been mapped out and are all examples of culture-bound syndromes, which may or may not be attached to international diagnostic categories such as the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychiatric Association, 2000). Here are some of them: rootwork, amok, brain fag, dhat syndrome, koro, latah, evil eye spell, susto and zar. These are all culturally accepted explanatory mechanisms or idioms of illness that do not match Western models of distress (Bhugra et al., 2007). These syndromes cannot be considered outside their wider social and historical meaning. For example, Kirmayer (2007) cites Dick (1995) with the following example of Pibloktoq or ‘Arctic Hysteria’: ‘Inuit women were seen by European explorers under Admiral Peary becoming agitated and stripping off, running out on the ice, needing to be restrained for their inexplicable “hysterical” behaviour’ (p. 6). In fact Peary had sent their menfolk off when the ice was dangerously thin, and their protests had not been heard. The women were engaged in Shamanistic prayer to intercede for their safe return. Thus, an abuse of power by the white explorers led to the development of a bogus psychopathology. In an overview of Western culture-bound syndromes, Bhugra et al. (2007: 154) conclude: ‘There are significant problems in the use of terms such as culture-bound syndromes, because all psychiatric conditions are culture bound, and the time has come to abandon the concept...Such usage indicates its colonial heritage.’

Racism in psychiatry

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Jahoda (1961) describes how odd or deviant behaviour used to be seen as having travelled from abroad. There was a nineteenth-century discourse about how ‘superior’ white Europeans could tame and civilise primitive people. Of interest, the colonial psychiatrists who established Western hospitals in the Empire noted lower instances of mental disorder, and believed that the simple, i.e. primitive, lifestyle was less stressful and therefore less pathogenic. By contrast the West, with its use of industrialisation, technology and urbanisation, invented ‘neurasthenia’ and a range of neurotic disorders, presumed to be the product of a more sophisticated and demanding social order (Kirmayer, 2007). Some of the studies they quoted, such as alleging that black brains were smaller, therefore individuals were less intelligent, now seem almost comic in their racist naivety. But race was the centrepiece of the concept that distinguished white people from the rest of the world, and accounted for national differences or inequalities. For example, one bizarre hypothesis was that black people had underdeveloped frontal lobes and were thus more uninhibited in their behaviour. This has left us with the racist legacy that young black men are deemed less likely to benefit from, or be offered, talking therapies. They are also more likely to be detained under the Mental Health Act 1983 than their white counterparts (Fernando, 2002).

Multiple studies since have shown that distressed black patients are more likely to end up in forensic environments, be offered less psychotherapy and be more heavily medicated. Cochrane and Sashidharan (1996) describe the combined effects of racism and prejudice, economic uncertainty, poor housing and harsher working conditions on the reduced psychological well-being of black and minority ethnic (BME) patients of all backgrounds. There have been major developments in transcultural psychiatry in the last two decades of the twentieth century – at the time when the UK was (reportedly) becoming a multicultural society. Three topics have dominated the psychiatric agenda: the use of the Mental Health Act 1983; the rates of schizophrenia among young black men (Cochrane, 1977; Fernando, 1989); and suicide and eating disorders among the Asian communities (Littlewood and Lipsedge, 1996; Fernando, 2002). Even in the twenty-first century, there is evidence that black people of African and Caribbean heritage are six times more likely to be sectioned than white people, and Asian people are four times more likely to commit suicide than white people (Fernando, 2010).

Ethnic cleansing, genocide and the Holocaust

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Europe struggles to forget its slave-owning history; but gross human rights abuses persist in our restless world. There is a tradition in psychiatry and psychoanalysis concerning the impact of the Holocaust (the specific mass murder of Jews and other persecuted groups by the German Nazi regime 1941–1945) on its survivors, in studies carried out over the last six decades (Levav et al., 1998). Sigmund Freud (who himself barely escaped the...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Dedication
• Contents
• About the Author
• Foreword by Colin Lago
• Foreword by Dinesh Bhugra
• Preface
• Acknowledgements
• 1 Anti-discriminatory Practice: Its Origins and Development in Transcultural Counselling
• 2 Transcultural Counselling for International Workers
• 3 Transcultural Counselling for Refugees
• 4 Using Interpreters in Transcultural Counselling
• 5 Religion and Spirituality in Transcultural Counselling
• 6 Transcultural Counselling in Healthcare
• 7 The Voice of Users in Transcultural Counselling
• 8 Ethics and Governance in Transcultural Counselling
• 9 Supervision, Personal Development and Self-Care in Transcultural Counselling
• 10 An Evidence Base for Transcultural Counselling
• 11 Future Directions for Transcultural Counselling
• Appendix
• References
• Index