Declaración Informativa de Operaciones con Terceros (DIOT)

1.3.1 Intercultural, Transcultural, Cross-Cultural

It is not only patients who arrive in therapy with their differing “cultures”, the therapy itself may provide a different and alien experience. Therapists often fail to recognise that their ways o f working are predicated on their worldview. What therapy is offered, how the sessions are structured, where the sessions are, who (by profession, gender^"*) treats the patient and the length (of time) o f the sessions. All these constraints introduce different and complicated cultural contexts. Our difficulties (or different ways o f working) are evident in our use o f terms to describe our work.

Historically transcultural is associated with clinical psychiatry together with its concomitant power relationships (Mercer 1986), which o f course leads to much discussion as to the appropriateness o f transcultural diagnosis. It is viewed with concern, with some suggesting that it may be acting as a social controller by moderating conformity (see Ineichen et al 1984, D ’Ardenne 1986). It is perceived as the majority culture defining what is healthy (although in the 1990s, about 57% o f junior psychiatrists were themselves not bom in the UK, whilst significantly, only one in eight o f consultants were bom outside the UK- Littlewood and Lipsedge 1997). In the past, medical schools operated an allocation o f places that discriminated against potential students from ethnic minorities (see Lowry and McPherson 1988, McKeigue et al 1990).

Transcultural psychiatry in the last century was associated with colonialism, and earlier

I sh all u s e the term g e n d e r w h en I am considerin g both the p sy ch o lo g ica l and ph ysical a s p e c t s o f a p erso n , and the term “s e x ” w h en I am referring to physical characteristics.

with slavery. Currently it not only refers to work with the diverse ethnic minority population described above, but also can refer to specific diagnostic schemata considered across cultures, delineating cultural understanding o f mental illness e.g. cannabis psychosis (Lipsedge and Littlewood 1979 Littlewood and Lipsedge 1989), as well as “culture-bound syndromes” such as koro and amok.

It also refers to the ability o f a clinician from one culture to make a diagnosis for a patient from another culture (Westermeyer 1985, Littlewood 1990).

Some counsellors use the term transcultural (D’Ardenne and Mehtani 1989 and Eleftheriadou 1994) to delineate a cultural approach to counselling. However cross- cultural is more usually associated with counselling. It may focus on specific cultural attributes o f groups (cf. Speight et al 1996) or it may refer to the attitude o f the counsellor, but usually with reference to traditional counselling practices. The literature tends to report research into specific cultural groups and their specific needs with the emphasis ostensibly on intra-cultural counselling. As Thomas reminds us, such intra- cultural counselling raises its own problems. For example, he notes that the black therapist will need to have to have worked through (in their own training therapy) their issues about being black in British society, in order to understand and help their patients (Thomas 1992, 2000).

The problem with the notion o f cross-cultural is that it, in my opinion, tends to de- emphasise the role o f the ethnic minority practitioners working with patients culturally different to themselves (traditionally therapists tend to choose patients that are similar to themselves). This seemingly ignores the number o f ethnic minority practitioners and the specific experiences, skills and knowledge accrued during their own lives (as professionals training in predominantly white organizations - which might be expected

to have a differing worldview, and their personal experiences as migrants, refugees or British bom ethnic minorities).

The problem with some cross-cultural or transcultural (exceptions include Littlewood and Lipsedge 1997, and Eleftheriadou 1994) work, is that they both try to impose a western theoretical framework and practice on patients whose life experiences can be construed to be very different from a white British population. They do not seem to challenge the theoretical basis o f their skills nor recognise the inherent power relationships (for white therapists) in the therapy situation. They seemingly ignore the essential “working with loss” inherent in all intercultural work. Their work can variously imply work with migrants, with the British-bom children o f these migrants or with those whose parents are o f different cultures from each other, economic migrants or refugees - groups who might be expected to present with rather different problems, experiences and assets. They seem to regard cultural groups (e.g. Afro-caribbean) as homogeneous (cf. Say al 1990, Patel 1997) without assessment o f the level o f assimilation/ integration/ cultural pluralism (Verma 1985, Pederson et al 1981, 1987) o f individuals (consolidated during the acculturation process), their ethnicity, culture, language and current economic situation (such conflicts are well demonstrated in Guzder and Krishna 1991). Such experiences form the basis o f the term intercultural as previously used in the United States (Verma 1985, Pederson et al 1981, Pederson 1987).

One o f the fundamental differences between transcultural and cross-cultural on the one hand and intercultural on the other is that intercultural therapy in this context has not only tried to understand the inherently individual (internal, psychological) experience o f

patients. Kareem notes that therapy should be ^"taking into account the whole being o f the patient - not only the individual concepts and constructs as presented to the therapist, but also the patients ’ communal life experience in the world - both past and present. The very fa c t o f being from another culture employs both conscious and unconscious assumptions - both in the patient and in the therapist" (Kareem 1987, see also Hawkes 1997, Gaston, 1984). It also reflects upon the psychological “choices” made by bi-cultural patients^^. Intercultural therapists have tried to look at both the theory and practice o f therapy with ethnic minority patients. Moreover, they have accepted the notion o f a critical mass o f ethnic minority practitioners as fundamental to practice (Bender and Richardson 1990, but cf. McKeigue et al 1990 and Lowry et al

1988), but not necessarily matching patients and therapists and accepting that all practitioners need to be proficient in working with patients from backgrounds different to their own (Carstairs 1961, Pederson et al 1981). They have also lead the move towards the importance o f intercultural supervision as being vital to the process of successful therapy.

Intercultural therapy is therefore different from transcultural and crosscultural therapy. Although it uses the tools o f psychotherapy, those o f transference, countertransference, boundaries etc, the intercultural therapist will interpret in terms o f the patient’s cultural background, religion etc, making the connection that a person’s ethnic origin and ethnic identity have implications for therapy. Intercultural therapists will interpret (where appropriate) enculturative and acculturative aspects o f the person and the effects o f these on the therapy encounter.

Bicultural in this s e n s e not only in clu d es th o s e p e o p le w h o s e family b ack grou n d s are from two different cultures, but might a lso be usefully u sed for p eo p le w ho h ave sp en t tim e living aw ay from their h o m e cultures and h a v e e x p erien ced the culture o f a different so c iety (e .g . J a p a n e s e w orkers in Britain).

They work with, the often complex, geographical relocations experienced by minority patients, and help the patient to understand, and emotionally work through, the separations and losses that these entail.

Intercultural therapists are aware that psychotherapy itself has a cultural underpinning that may be different to the cultural experience o f the patient, they recognize that their own culture will impact on the session and that there is a potential for a power relationship to develop between patient and therapist, again this is dealt with within the therapeutic context.

They work with the external issues o f poverty, racism etc within the interpersonal relationship that is psychotherapy. Moreover, they make no assumptions about the homogeneity between persons from similar geographical, cultural, religious etc backgrounds, understanding that everyone is an individual with individual life experiences that shape our identities.

Table la

SOME DIFFERENCES BETWEEN TRANSCULTURAL, CROSSCULTURAL AND