Text by Hanna Grauert (Freie University Berlin)
© Lea Rebecca Minow
The world we live in is, due to globalization or political destabilization, a world in which people continually move and migrate. Mobilities alter all areas of human coexistence and triggers questions, such as: how do we want to live in transnational and multicultural societies and what kind of challenges do we have to cope with when different cultural perspectives come together? Amongst other topics, the term “cultural competency”, the ability to understand and interact with people across cultures (Kleinman and Benson 2006, 1673) has become a common concept. Especially in clinical settings “cultural competency” is seen beneficial , whenever professionals create and adapt new methods that touch cultural differences. In psychotherapy, much literature has been published to discuss in which ways cultural factors can be included in diagnosis, care and treatment procedures (Kleinman and Benson 2006, 1673; Lewis-Fernandez and Aggarwal 2015). It is acknowledged that a comprehensive assessment and successful treatment requires a consideration of the specific effects of culture on the differently socialized patients:
To provide effective psychotherapy for culturally different patients, therapists need to attain cultural competence, […] Specific cultural competence enables therapists to work effectively with a specific ethnocultural community and also affects each phase of psychotherapy. A comprehensive assessment and treatment approach is required to consider the specific effects of culture on the patient (Lo & Fung 2003, p. 161).
Let me trouble this statement from a constructive anthropological perspective: Too often the culturally different client is in the spotlight, on whom the strong and valid psychological and therapeutic assessment tools do not work as “efficiently as they are supposed to do. Due to the fact that psychotherapy is mostly derived from the scientific discipline of psychology, it claims a biological, holistic approach that presupposes that every human mind generally functions through the exact same bio-chemical, neurological procedures and is only secondarily shaped by cultural influences (Hoshamd 2006, 5 f.). Through an anthropological perspective, “culture” cannot be conceived as something commonly shared by all members of an ethnic or ethnological group or nationality. More specifically, culture is embedded in all parts of human cohabitation and can vary, depending on its socio-political structures (Berg and Fuchs, 1993) biographic, and subjective experiences. Arthur Kleinman and Peter Benson, both medical anthropologists (2006) are claiming, that indeed all social interactions are deeply cultural and the term “cultural competency“ has to be deconstructed: It would wrongly suggest that cultural competency can be learned by means of checklists, because culture would then be something static and could be reduced and accessed as a technical tool which clinicians and professionals can be trained for (Kleinman and Benson 2006, 1673).
From an anthropological perspective this essay raises the following question: If culture can be found in any social action or social interaction, can it also be found in the work of mental health professionals? More specifically, how can mental health professionals become “culturally competent” without scrutinizing their own professional ways of acting and training? Instead of only focusing on “cultural differences” concerning the patient, one might ask how the practice of psychotherapy and the work of professionals shape and influence the case of a patient. This essay critically reflects on the routinized, standardized and bureaucratic culture of a psychotherapy. It shall give an alternative insight on how psychotherapy itself is subject to certain cultural practices of mental health professionals which shape patients’ illness narratives and, might fundamentally affect their whole case.
Constitution of Psychotherapy and Professionals
It is commonly known that processes in psychotherapy are based on neurological and biological approaches that try to explain mental illness (Luhrmann 2001, Lewis-Fernandez and Aggarwal 2015). By conducting psychological testing or applying diagnostic categories (e.g. Diagnostic and Statistical Manual 1980), an ideology of objectivism is implied. This essay argues that psychological practices are themselves cultural phenomena and therefore, not an objective, universal methodology, but rather a cultural practice. The following example shall clarify this argument: Davies (2017), who is an anthropologist but also a qualified psychologist, gives an alternative insight into the Diagnostic and Statistical Manual (DSM). The DSM which is still the most commonly used companion for the classification of mental disorders, became a culturally constructed document. In his paper, he analyses how categories for mental diseases are only partly based on research, but mostly on the outcome of voted-based judgments, in which illnesses or categories were either incorporated into the DSM or left out (Davis 2017, 38). Furthermore, this process of voting and consensus decisions was largely conducted by a small and westernized group of “mental health professionals” (Davis 2017, 44). Insofar one could argue that the DSM can reveal more about their creators, their cultural worldviews and theoretical assumptions on mental health than on the concept of mental health itself.
On the one hand, there is a certain necessity to use common concepts in therapy for the categorization of “universal illnesses” in order to systematize diagnostic practice, regardless of the fact that those tests and classification documents are themselves a cultural contraction (Davis 2017). On the other hand, professionals study specific, psychiatric knowledge which influences the daily practices of therapeutic intervention (Luhrmann 2001). Therefore, the documentation and the routinized practicing of professionals can be defined as a culture of mental health professionals (Good et al. 2011).
The Culture of Mental Health Professionals
Psychotherapy is a complex social process, because all parties (u. o. therapist, client, neurologist, health insurance) play a decisive role in the constitution of a case. There are, however, also highly routinized procedures in the constitution of a case in the eyes of professionals (Luhrmann 2001). Apart from the interactions between client and therapist, it is often forgotten that there is an ongoing documentation of the case as well (Bergmann 2014, 23). More specifically, the professional practitioners, due to their expertise, are constantly developing a case further by writing records, notes or diagnostic reports and having their patients fill in questionnaires and tests. This ongoing documentation serves, above all, the reinsurance and objectivity of the whole therapy. Some processes of the case are then archived in a file where the work is validated and objectified. Additionally, the process of documentation allows a professional to capture the short-lived, interactive moments during a session. This documentation is problematic because a written record of human interaction can never be a mirror of the actual moment, but is rather a translation into professional jargon. An act of abstraction and of interpretation takes place continuously, even if unwillingly. This translation into professional jargon can also be seen as a “culture of mental health professionals” because therapists were trained for this process of interpretation (Luhrmann 2001). It is therefore important that a professional can always negotiate these standardized processes with his or her client in order to avoid misunderstandings or a misinterpretation of the situation. The following ethnographic example of a psychotherapy with a refugee shall give an insight into the “cultural” work of a professional and critically reflects institutionalized and unchallenged practices in psychotherapy.
Making it Fit: The Case of Mrs. K.
Mrs. K is a refugee from Syria, starting psychotherapy. For my anthropological fieldwork I was able to accompany Mrs. K during her therapy session. The following documents are crucial for the development of her case, because they will eventually be sent to the health insurance which will cover the cost for the therapy and will therefore also have consequences on the direction in which her case is going to develop. The first document is the request form for a psychotherapy, which reveals the kind and structure of the therapy. The second document shows the diagnosis made by a neurologist. Both documents were discussed in the therapy session as the transcription parts illustrate:
Figure 1- Application for Psychotherapy: The Document includes the type of therapy which will be conducted and further information about earlier psychotherapeutic treatment of the client. The document is required by the health insurance, which will cover the costs of the psychotherapy (Grauert 2018).
Figure 2 – Transcript “Application of Psychotherapy”: The transcript gives insight to the conversation of the document “Application of Psychotherapy” (see Figure 1) when it was discussed in the therapy session
This section reveals that Mrs. K (K) is not only insecure about the whole documentation process - the translator (D) is addressing her hope for a shrinking documentation process (L. 2) - but it is also interesting to observe that Mrs. K is not actively involved in this process. The therapist (T) has already filled out and completed the document before the session (L. 5), although this document initiates important details for the further process of the therapy. Instead of a psychotherapy that reflects analytic psychology and depth-based psychology, the behavioural therapy is perceptible in the document. This decision has already been made by the therapist and is not up for discussion. Although this will have consequences on the whole structure and the outcome of the therapy, it has never even been negotiated with Mrs. K. which kind of therapy is conducted, what the therapy would entail or if it meets Mrs. K.’s expectations. Furthermore, the translator’s question whether the whole conversation concerning the documents shall be interpreted (L. 8), reveals that the client is left outside this communicative process: Mrs. K. is only needed for her signature, not for discussing formats or structures of the therapy. This example shows that the procedure of a therapy can be highly routinized and standardized in the practice of professionals, because the responsibility and accountability of the documentation process lies only in the hand of professionals, and in this case, the client does not have any influence on the procedure. Nevertheless, sometimes the focus on these processes must be shifted to avoid misunderstandings or misinterpretations. The problematic of misunderstandings due to standardized processes shall be demonstrated in an additional example of a discussion between the therapist and Mrs. K. that took place in an earlier stage of the therapy:
Figure 3- Konsiliarbericht: Is the first diagnosis of a neurologist. The document is required by the health insurance, which will cover the costs of the psychotherapy (Grauert 2018).
Prior to this report, different questionnaires and assessments were conducted. Due to the formal nature of the process, the diagnosis (“depression and insomnia”) of the neurologist is hard to reverse. On the one hand, these reports will serve to ensure the stability of the case due to the constant documentation (diagnosis, test and assessment, script of the therapist). On the other hand, this documentation can lead to an unsuccessful therapy if the client has insufficient knowledge about the process and its consequences:
Figure 4 - Transcript “Konsiliarbericht”: The transcript gives insight into the conversation of the document “Konsiliarbericht (see Figure 3) when it was discussed in therapy (Grauert 2018).
While Mrs. K. has too little knowledge about the document and therefore inquires again, the therapist goes on with her professional role, self-evidently assuming that Mrs. K. is aware of her “own words”. Since her original words are always translated by the interpreter or abstracted by the expert knowledge of the professional (e.g.: by terms like "depression"), Mrs. K. is constantly the subject that is talked about, but not talked to: Instead of creating possible explanations for the client, the therapist remains in the role of the professional and takes the next free speaking turn (actually the turn of the client) in order to change the subject (lines 8 f.). This is problematic and does not lead to an equally balanced interaction between all parties. Instead, documentation and diagnosis assessment predominate.
The two examples show how professionals (therapist and neurologist) create meaning and significance concerning the case of Mrs. K. However, these practices are so routinized, bureaucratic and standardized within the “culture of professionals” that it is not considered relevant to include Mrs. K. actively in the constitution of her case. These standardized methods must be critically reconsidered, as a crucial transformation of an already highly subjective matter (Luhrmann 2001, 20). In other words, we do not live as an individual inherently distinct from our environment. Rather, we are constantly in an ongoing interaction with our surrounding world, which has a large impact on how we think, act or even suffer. Nevertheless, although an illness narrative will always be shaped by a culture of mental health professionals, routinized practices have to open up: There has to be enough room for the afflicted’s own subjective and individual descriptions.
Cultural Competence – A Common Process
This essay intends to give an alternative insight into how psychotherapy is subject to a certain kind of culture – the culture of mental health professionals – which shapes and structures patients’ illness narratives and their whole case to a large extent. Not only are categories of an illness culturally produced (Davies 2017), but also the whole process of a therapy underlies an ongoing documentation, which is highly standardized and bureaucratic. Therefore, cultural competence is not only defined by the understanding of the “very different” patient, but also the mental health professionals’ rethinking of his or her own westernized practices. Anthropology provides the possibility to draw attention to these institutionalized processes and to highlight the importance of mutual (cultural) knowledge production.
References
APA (American Psychiatric Association). 1980. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. 1980. Washington, DC: AmericanPsychiatric Association.
Berg, Eberhard, and Martin Fuchs.1993. Kultur, soziale Praxis, Text. Die Krise der ethnographischen Repräsentation. Frankfurt am Main: Suhrkamp.
Bergmann, Jörg R. 2014. Der Fall als Fokus professionellen Handelns. In Der Fall. Studien zur epistemischen Praxis professionellen Handelns, edited by Jörg R. Bergmann, Ulrich Dausendschön-Gay, Frank Oberzaucher, 17-33. Bielefeld: Transcript.
Davies, James. 2017. “How Voting and Consensus Created the Diagnostic and Statistical Manual of Mental Disorders (DSM-III).” Anthropology & Medicine 24(1): 32-46.
Grauert, Hanna. 2018. “Verstehen und verstanden werden. Eine ethnographische Analyse zur Konstitution eines Falles in der psychotherapeutischen Versorgung von Geflüchteten“ thesis, University of Konstanz.
Hoshmand, Lisa Tsoi. 2006. Culture, psychotherapy, and counseling: Critical and integrative perspectives. London: Sage.
Lo, Hund-Tat, and Kenneth P. Fung 2003. “Culturally competent psychotherapy.” The Canadian Journal of Psychiatry 48(3): 161-170.
Kleinman, Arthur, and Peter Benson. 2006. “Anthropology in the clinic: the problem of cultural competency and how to fix it.” PLoS medicine 3(10): 1673-1676.
Lewis-Fernandez, Roberto, and Neil Kirshan Aggarwal. 2015. “Psychiatric Classification Beyond the DSM. An Interdisciplinary Approach.” In Re-Visioning Psychiatry Cultural Phenomenology, Critical Neuroscience, and Global Mental Health, edited by Laurence. J. Kirmayer, Robert Lemelson and Constance A. Cummings, 434-465. Cambridge: University Press.
Luhrmann, Tanya M. 2001. Of two minds: The growing disorder in American psychiatry. New York: Alfred. A. Knopf.