Sunday, February 27, 2011

Learner therapist (2) – Are you culturally competent?


Learner therapist (2) – Are you culturally competent?
Torrey Orton
Feb.27, 2010


The same but different dilemma
I am a little apprehensive about writing this. The area of cultures and cultural differences is fraught with cross-currents of moral and political and social and personal energies in contest with each other. Any generalisation about cultures is an opportunity for claims of prejudice or factual doubt or moral obtuseness…. I want to acknowledge I'm inviting you into this territory because it is real territory seen from many perspectives in our culture and our world, hence conflicted. It is also inescapable, except in denial.


Cultures present therapists with a very prominent dilemma (which applies across the health sector) – we are all the same (human) and all different (individuals). The therapeutic challenge (amplified by medicalisation of our trade) is to integrate patient uniqueness with generic formulations and manual-driven treatments.


Unremarkably, I have had clients from places I scarcely know more of than their rough place on a map (and I don't' mean country Victoria!). While I speak some Chinese (lived there total of 3.5 years) and more French (lived there 1+ year), my Croatian, Hungarian, Booran, Farsi, Cantonese, Greek…and on and on… are limited to the English versions of what they each call their languages and ethnicities.


One of my best and bilingual (English / German) friends spent years saying "yes, but there's really no fundamental difference is there?" Only after 5 years back and forth did I succeed in bridging what I never imagined would be a resilient rift. My teaching failure, for sure. Most of the differences that matter are invisible. Most of us cannot talk clearly about our cultures except through stories which assume their contextual meanings - just what foreigners lack.


Why do cultural differences matter for therapy?
As therapists we engage with all manner of ages, genders, socio-economic, religious and professional backgrounds about all manner of complaints, issues and concerns, and recognise shared patterns among them (our eventual formulations) and offer them structured treatments (evidence-based therapies). They all speak English, so what's to worry about?


Well, here's a few things to worry about: basic ideas and beliefs may be misrepresented in translation or an inflexible second language – love in a personal choice culture and in a family choice culture may be quite different; getting fine points of client meaning, especially emerging ones, is difficult enough when a smile does not mean anxiety; there's too much to learn to really understand another culture – I barely understand my own!


Different therapies?
Finally, to admit a difference of conceptualisation of therapy into is to saddle myself with a potentially unbridgeable incompetence. For example, a non-judgmental, non-advisory relationship is not what is expected in many cultures; just the reverse. In such cultures, one consults a wise (by experience or profession) person for advice and insight, not facilitation. Of course it is understood the advice may be disregarded, but not getting any is dereliction of perceived professional duty.


So, what difference(s) matter?
In three ways, culture is critical to who we are. It determines (1) our first concepts and practices of family; (2) it provides core meaning systems (religion, values, assumptions, etc.); and (3) it models appropriate practices for relating to close (family) and distant (public, others) people, plus a host of everyday matters like what's right to eat, how to do so, and what to do with the results. These foundations survive into second and third generations, or further for some cultures, of displaced peoples - immigrants of various origins (trauma or economic; forced or chosen). These three areas are also principal domains of most therapeutic work.


For example, in some cultures the structure and meaning of family, and therefore individuality, is not comprehensible from within an Anglo/ western cultural frame – the assumptions and practices which underlie psychology here. In China,


"The relationship between family and family members can be likened to the relationships between a body and body parts. For example, I feel itchy on my leg and my hand comes to help by scratching it. Does my leg have to say, "Thank you, hand." Does my hand reply, "You are welcome." No, neither one does so. Why, because they are supposed to help each other as they belong to a single unit. Though parts can be distinguished, they do not function independent of the body. The mutual relationship between parents and children are understood by Chinese in the same way.

 
And that's why in a Chinese family, when parents do something for their children or vice versa, you hardly hear something like thank you and you are welcome. From the perspective of the Confucius tradition, the family as a unit of intelligence is fundamental and irreducible when children are young. Any attempt to further reduce a family to a collection of individuals violates the integrity and meaning of the family unit."
Chen Jie-qi, AERA, 2006, San Francisco - How MI Theory fits into traditional and modern China, pg 3




On the other hand, a Booran family in the borderlands of Ethiopia and Kenya is entwined with its clan and village in myriad ways. For example, a council of elder women oversees the treatment of married women and can authorise a divorce for mistreatment by husbands. Among other things, this judgment forces the return of the woman's bride gift cattle from the husband…possibly a more than 50-50 split. Being a child involves being under the constant care of all adults in the village, who share the responsibility for child-raising outside the home. Everyone is an uncle or aunt, grandmother or grandfather.



What do our cultures do for us?
We tend to think our culture is good. It must be, otherwise we would not be good, which apart from our psychological injuries, we tend to think we are. If we do not, we can see ourselves to be good by identifying with our culture of origin. Mostly we don't think about this, so it is out of our awareness.


Automatically we judge other cultures by our standards. So does pretty much everyone else, with a few exceptions who I hope will become more numerous. But even they will have moments of deciding that their own culture is best. Having a culture is like having a family – even if it's bad for us we give it a break at our cost, and sometimes the cost of others of different cultures.


In the public domain this plays out in the form of persistent expectations, if not demands, that the rest of the world follow our path to human improvement. For instance, follow the commentary about China in which the assumption they have to become democratic, and free-marketers, too, is often not even stated as the ground of critiques being made of their pathway for the last 30 years.


What does being in a minority do to minorities?
In contexts where one culture is presumed to be right (like national cultures tend to do of themselves), minority culture members are subjected to three pressures: one, to delete characteristics which are unsettling to majority culture members, like speaking their own language in public; two, to keep to themselves the fact that this is painful and feels unjust to them.


As well, third, they know that much of what they carry as their culture of origin cannot be explained to people who can't see further than their own next footy game, school fete, meat pie, etc.….Their attention span isn't long enough. Even members of the majority culture can't get their foreign experiences listened to when they come home from some time in other peoples' cultures, an experience in which some may be in the minority in a clear way for the first time in their lives.


Culturally literate therapists?
So, what should be done to increase the numbers of the culturally literate? A few pathways:


Try the story Meat for a shock to the assumption that we are all the same. Similar effects can be found in a variety of science fiction works (eg. Isaac Asimov – I Robot, Robert A. Heinlein: Stranger in a Strange Land, William Gibson: Neuromancer
as well as utopias and dystopias. Then, add the factoid that the divorce rate in China exceeded the marriage rate by 10+% last year, proving at once that things change while remaining consistent.


If you have little experience of foreignness it can be had at home by experiments like walking into a pub you aren't sure you 'belong' in. A seriously country town can provide this quite well (if you are not and never have been a farmer). You should get that odd-one out feeling. Failing to find a pub to test, recall a moment of adult embarrassment or shame for a related feeling – misfit isolation.


Education agencies should include a cultural perspectives course as a requirement for graduate psychs of all varieties, but especially those in front line heath care provision. These courses should include a non-negotiable behavioural segment challenging participants' mono-cultural perspectives.


Join the Psychology and Cultures Interest Group of the APS and get on the mailing list from Multicultural Mental Health Australia.

 
Finally, ask questions when you feel an assumption coming on.

 
And, delight in difference.

Monday, February 14, 2011

Learner therapist - a proposition


Learner therapist - a proposition
Torrey Orton
Feb.14, 2011


Dear PsychologyMelbournePartners colleagues and others,


I want to talk to other therapists more than I can now. There are some opportunities at a clinic I share with 10+ other interestingly different psychs. I also share with them very restricted times of exposure to each other (scheduling) and small windows of engagement (diary again).From the two kinds of structured sharing events we have monthly – staff meetings and a couples therapy group – I have never failed to get useful prompts to my own perspectives and access to tools of our trade.


And, more important for me, this group in various configurations shows a consistent development in openness. Members both offer unsolicited, critical self revelations and respond supportively to others' revelations, while keeping the task(s) of the moment in view. For me, this group capacity is essential to engaging challenging therapy issues and cases.


But, it's still not enough, partly because I'm finding myself home to a bunch of somewhat developed insights and tools which need assessment of their real potential in the view of fellow practitioners. The other problem is limited access, so find a way to expand the group!! Now there's a problem. By what means should I try to do this? I know what a blog cannot do without massive efforts. There are a lot of activities competing for therapists' attention, including many mandated ones fulfilling professional development requirements whose attractiveness is compelling if not always entrancing.


In earlier lives of mine I've set about somewhat similar objectives by network building – looking up people I knew who 'should' have an interest in what I was proposing: an experimental school, a commune, a protest about some public issue, an alternative to a moribund union. This was actually community building since it was based in a small city where most of the players knew each other, or of each other, or could get a personal connection in two degrees to each other. That was then. A TV, telephone, radio and newspaper community.


I'm imagining potential participants in this exploration will be therapists who want more engaged, challenging peer reflection, who want more challenging perspectives on the purposes, processes and contexts of therapy, and who are computer comfortable but prefer face-to-face work…
For me writing is part of learning. As I build a picture of what I'm trying to understand, the process itself contributes new understanding. As well, written learning makes understanding open to critique, a necessary step for getting outside of myself!


So, I'll start with a few trial articles: my general objective is to identify and break through the black and white, either/or, and digital thinking patterns which abound in our trade. These areas of practice tend to summon up exclusive responses to proposed therapeutic interventions. In some cases I will be commending new competences as mandatory for effective therapeutic practice - e.g. intercultural competence and knowledge. Possible topics include:
  • Power in recovery from anxiety/depression – learning to convert anger into relevant power in appropriate relationships
  • Cause and patient injuries – a blame free world is a cause-free world; post-modern dilemmas
  • The world we are in as a background facilitator of injury – see eco-anxiety for instance.
  • Culture difference and therapeutic competence – a minimum requirement for a multi-cultural country
  • Commercialisation and bureaucratisation constraints and facilitation effects on practice - the Medicare 'service' conundrum
  • Couple conflict and shared 'facts' – finding things to agree on in areas of dispute
  • Competing therapeutic paradigms?? How do therapies relate to each other?
  • What research is really worthy of report? How to tell evidence from research.
  • The biopsychosocialcultural perspective in practice
  • Where do you stand on the boundaries of life – IVF, abortion, euthanasia, suicide??


I'll be inviting feedback from PMP colleagues in the following areas:
  • Interest of the topic itself?
  • Accessibility / clarity of the writing?
  • Suggestions re: topic/style improvements, extensions
  • Others who might be interested in such matters??
  • Venues for exploring / presenting such matters??


The invitation will be personal and declinable; if declined I will appreciate a few words of explanation since these may also help identify different approaches I might use to finding and connecting with therapists. If accepted, I expect the feedback process will take 10-20 mins. by phone; no writing required.

Wednesday, February 9, 2011

Appreciation (33) … Frogal fugue


Appreciation (33) … Frogal fugue
Torrey Orton
Feb.9, 2010


What four different frog families and three different crickets (?) sound like in celebration of the refilling of their water hole.


We've just had 100-150 mm of rain in the last three days in Melbourne…remnants of cyclone Anthony which dumped a small ocean on Queensland three weeks ago (that flood). Under the right conditions these things peter out over central Australia. Their warm, damp leftovers may get sucked down south by a weather system gliding out of the Indian Ocean 3000 ks. away from here. It's clearly visible on national weather maps, the one system sliding along the edge of the other. What doesn't show immediately is what the slider picks up – water!


And this was our first real walk in four weeks due to my recovery from a week incarcerated for acute pancreatitis*. As we started out a small rain shower kicked off and we stepped under some path bordering trees to get out the wet weathers. In the midst of covering up I felt a pinch on my ankle, looked down and spotted a bull ant having a nibble through my walking sock and a small troop of its colleagues wandering up my shoes to get in on the fun. Turned out we had setup the changeover to wets on an ant mound hidden under track gravel. Bitey, indeed!! No harm but the withdrawal took some doing. They stick as well as bite.


Towards the end of our ramble (slight incline over 1500 meters or so) we began to hear a somewhat mechanical noise ahead of us, guessing that the neighbouring quarry was being pumped out after the rain. Another 150 meters and the real sound became very clear to our left in an old fire fighting pond refilled by the rains. It was the frogal fugue…a low thunder of different frogs and crickets and who knows what celebrating the possibility of a late season mating melee. We are quite used to a small version in our garden, the remnant players of an original gene pool established there 25 years ago by a neighbour's child. But they all play the same come hither tune, in near perfect timing. And there's seldom more than 3-4 players.


This was something different – thundering almost, and so many notes played in different volumes and keys; an orchestra in olive drab variations. The attached file will give as good a rendition of the experience as a mobile's note facility can produce. Jack up the volume a bit til you feel slightly overwhelmed and you'll have the feel of it.


Enjoy…we did.

Nuts!!! - I've just discovered audio files cannot be uploaded to the blog!!! If you want one, email and I'll send it by return!!! Worth the effort for us both.


*A not-to-be-recommended event which left me 10kgs lighter (which could have taken months of training to achieve but only a week of nil-by-mouth in hospital). The standard recovery period is 3-6 weeks, of which I am now into the fifth week, restarting moderated work today (therapy) and developing new self-management regimes in eating (no coffee or alcohol, neither of which I miss at all; smaller meals, etc.) and morning relaxation and exercise practices with daily consistency, so far!