Mental Health and Cultural Diversity in Therapy
We are a multicultural country
Canada prides itself on being a diverse and multicultural country where people are welcomed from all over the world. Our large cities have citizens speaking scores of different languages, worshipping in dozens of different religious houses, and maintaining hundreds of different cultural practices. It is important that our mental health system and schools reflect and respond to the diversity of our communities. What this means, is that mental health professionals need to understand the values and beliefs of the people we serve.
Adaptation and Values
Mental health is, in large part, the ability to adapt to one’s environment. Therefore, it is necessary to comprehend the relational and cultural environment of an individual to evaluate the success of his/her adaptation. Children develop in families who reside in communities, and those families and communities have beliefs, values, and expectations about what is important, what is good, and what is “normal.”
Mental Health Providers are Human
Mental health providers come from families, communities, and ethnic groups, and have biases and assumptions which affect the way they interpret behaviour and address specific mental health issues. There is no perfect, unbiased, or completely “objective” truth about mental health or illness. Professionals in our country are trained to assess and diagnose within a particular medical model but they also need to learn from and listen to, their patients/clients.
Who are included in the term ‘culturally diverse’?
We are not just referring to people from countries outside Canada and the western hemisphere but individuals who belong to minority groups, oppressed groups, the poor and disadvantaged. Included are persons who are LGBT, indigenous, and disabled.
Assessing normal verses abnormal
Some theorists argue that “because depression, schizophrenia, and sociopathic behaviours appear in all cultures and societies,” “western concepts of normality and abnormality can be considered universal and equally applicable across cultures” (Sue and Sue, p. 35). Others argue that western based mental health determinants, particularly, ‘independence’, can bias the assessment of individuals from more “collectivistic” cultures such as Asian and Indigenous, which prioritize the group over the individual (ibid). Western culture values the ability to ‘go it alone’, to be adventurous, and solitary, whereas other cultures view such behaviour as aberrant, even antisocial. Western clinicians may be inclined to view individuals belonging to collectivistic societies as excessively dependent and dysfunctional because they suffer when separated from their families, communities, or tribes.
It is frequently asserted that poverty, environmental violence, and minority status create “chronic narcissistic injury” which affects everyone who lives in such conditions. Treating such individuals requires special attention to their intense feelings of marginalization and degradation. It seems especially important to understand cultural expressions of grief and loss since some groups express and explain these phenomenon in somatic, spiritual, or other culturally specific ways that could be seen as evidence of delusions or hallucinations.
Some scholars argue that individuals are unique and that we can never understand anyone based upon generalizations about their race, ethnicity, cultural identity, sexual orientation, or disability. The truth is probably that individuals are affected more or less by cultural norms and values, and both the cultural context and the individual’s particular adaptation, need to be considered when assessing development and functioning.
How different world views affect therapeutic/counselling interactions
1. A fifteen year old boy is seeing his guidance counsellor for help deciding about his courses for the following year and tells her that he has just ‘come out’ as a gay teen and is very excited about it. Having come from a small town where homosexuals were routinely bullied and assaulted, the counsellor can’t believe the boy is happy about his sexual orientation, and wonders if his judgment is off, maybe he’s in a hypomanic state? She suggests a referral to a therapist and is surprised when he declines. She is puzzled when he doesn’t show up for their next appointment (turns out the teen comes from a family with an aunt and cousin who are gay, successful, and much beloved).
2. A teacher is quite concerned that a mother of one of her ten year old students refuses to allow her daughter to attend birthday parties and playdates by herself. The teacher “explains” to the mom that, in Canada, children are quite independent and it is “normal” for them to go to friends’ homes unescorted. The mother blushes and looks down at her feet and avoids the teacher thereafter. This mother is from Syria, and recently arrived from 5 years in a Lebanese refugee camp, where she lived and slept with her children in an 8X12 foot tent.
3. A teenaged girl from Asia is referred by her school psychologist for a psychiatric assessment, diagnosed with depression, and prescribed antidepressant medication. In the follow up appointment with the psychologist, the girl mumbles that her parents haven’t filled the prescription because they “don’t believe in it.” Instead of asking the parents about their views, and exploring other treatment options, such as psychotherapy, the psychiatrist simply told them that medication was the appropriate treatment, and to come back in six months.
4. African parents express horror and dismay that their seventeen year old son is refusing to take their advice about his summer job, is routinely late coming home, and is defiant and rude on a regular basis. They want the school counsellor and their family doctor to get him help at the local hospital. Both the counsellor and the doctor find the boy quiet, shy, and polite, and tell the parents their son is a ‘normal’ Canadian boy and that “normal Canadian boys” behave this way. Several months later, the boy is taken to the hospital by police officers when he is found wandering around his neighbourhood dazed and disoriented, and saying he needs to kill himself. He is diagnosed with Schizophrenia.
All of these examples show how biases and assumptions affect interpretations of behaviour, and how people in authority often privilege their own perspective, rather than others’ perspectives. We need to understand the individual and family’s cultural perspective in order to understand them better. This does not mean that we can know someone’s attitudes or experience because we know generalizations about a particular culture, but we do need to know what is considered normal and healthy, to better evaluate the individual’s behaviour and functioning. An important part of any assessment is how the family members view the behaviour/illness of the identified patient, how and why it began, and what it means.
Knowing Our Own Biases and Assumptions
Whether we recognize our assumptions and biases or not, they inform our perceptions, interpretations, conclusions and decisions, as clinicians. Moreover, our biases and assumptions can offend, shame, alienate, and even re traumatize our clients, patients, and students. We need to be open, engaged, and curious, rather than prescriptive. The best way to limit misunderstandings is for us to know ourselves, know our biases, and be alert to how these manifest themselves. And of course, to check in regularly with clients to wonder if they feel understood and supported or...not. We will never be able to eliminate small injuries or “micro aggressions” but if we catch them, we can limit their impact, and create new paths toward better understanding.
Resources
Joan Berzoff, Ed., Falling Through the Cracks: Psychodynamic Practice with Vulnerable and Oppressed Populations, New York, Columbia University Press, 2012.
Derald Wing Sue and David Sue. Counseling the Culturally Diverse, Theory and Practice, Sixth Edition, John Wiley & Sons, 2013.
About The Author
Janet Morrison, M.A., C. Psych Assoc. is a psychological associate in private practice and a senior lecturer at the Factor-Inwentash Faculty of Social Work, University of Toronto. Over the past 30 years she has assessed, treated and supervised treatment of children in long-term care, as well as, consulted for Children's Aid Society and group homes across Ontario.
Listen to our podcast episode on Racism and Mental Health: Episode 11 | Racism and Mental Health with Charmaine Williams