Learner therapist (2) – Are you culturally competent?
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!
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.