Hermes in the room: Challenges and strategies in intercultural mediation in psychiatry

Transcription

1 Hermes in the room: Challenges and strategies in intercultural mediation in psychiatry Adil Qureshi Programa de Psiquiatria Transcultural Hospital Universitari Vall d Hebron, Barcelona

2 2001: Birth of the Transcultural Trained professionals on staff (1 psychiatrist, 1 psychologist)... BUT Psychiatry Program Patient base very culturally diverse (North and subsaharan Africa, South and East Asia, Eastern Europe, Latin America) Help needed to bridge the linguistic and cultural gap.

3 Context Dramatic increase in immigration over the past 15 or so years. Mental health profesionals not prepared; minimal cultural competence training available. Spanish healthcare system.

4 :Taller Ocupacional de Mediación Intercultural : Intercultural mediation in health care (8 students each year) 2008: Intercultural mediation in maternitypediatric health (16 students)

5 2007: Health care intercultural mediation training plan la Caixa Social and Cultural Outreach Projects took an interest in the experience of Vall d Hebron University Hospital Psychiatry Department-SURT in the training of healthcare intercultural mediators. Proposal of a training program in collaboration with la Caixa Social and Cultural Outreach Projects, certified by the Health Studies Institute, managed by the Department of Health, and coordinated and carried out by the Vall d Hebron University Hospital Psychiatry Department and SURT.

6 Challenges in intercultural mental health Racism & xenophobia Four Xs of difference Experience Expression Linguistic difference Communication style Explanation Expectations

7 Intercultural mediation as part of cultural competence Necessity of an immediate response. (No health professionals from the cultures in question; no authocthnonous professionals fluent in relevant languages nor culturally competent). Intercultural mediation as a response.

8 The Vall d Hebron Psychiatry Department-SURT model of intercultural mediation Based on: US Medical interpretation models. 1 The Belgian experience 2 ; conversations with Antoine Gailly Spanish social intercultural mediation tradition (AEP Desenvolupament Comunitari & Andalucia Acoge) Tribe, R. & Raval, H. (2003) (eds) Working with Interpreters in Mental Health. London & New York: Brunner-Routledge Cultural competence and cultural humility. 3,4 Our experience in training mediators, in providing training to health care professionals, and working as clinicians with mediators. 1 IMIA, 2007; 2 Verrept, 2008; 3 Qureshi et al., 2008; 4 Tervalon, 1998

9 What is intercultural mediation? Bridging of the linguistic and cultural gap in communication and facilitation of the therapeutic relationship between health profesionals and service users.

10 Role (in theory) Conduits, robots, and black boxes. Absent presence. Nothing more than a voice or a mailcarrier Message conversion

11 Absent presence in psy untenable The mediator is more than simply a voice. Regardless of the mediator s best efforts, the patient experiences her or his presence as more than just a voice. Presence of an "ally" inevitably means that the patient will look to the mediator as a referent. The presence of an additional person changes the system (e.g. systems theory); the mediator changes the dynamics.

12 For all that we tried to follow the absent present model, we just couldn t make it work. We tried cajoling the mediators, pestering the patients, but it made no difference. The presence of the mediator fundamentally changed the dynamic. No matter what.

13 Fragility of the triadic relationship Third presence Flow of information (gatekeeper*) Alliances Intercultural mediator as focal point Mediator *Davidson, 2002 Clinician Service user

14 Doctor-patient relationship and intercultural mediation In mental health care, the therapeutic relationship has been identified as one of the most important ingredients of positive outcome. The presence of the mediator all too often complicates or impedes the development of the therapeutic relationship The patient looks to (and at) the mediator rather than at the clinician.

15 Role complications in mental health care Role ambiguity/co-diagnostician/boundary crossings Discomfort with mental health issues and context Uncertainty inherent in mental health care Co-transference Prioritizing verbal over expressive-relational. Difficulties incoporating clarifications and contextualizations. Patients sometimes are not comfortable with the mediator (trust; shame; identity).

16 Role ambiguity Mental health professionals often expect the mediator to «do more».e.g.: Solve problems Explain the patient s behavior Make psychiatric diagnoses Visit and talk with patient since from same culture Healthcare professional? Person from such and so culture? Professional/personal/cultural ethics & expectations

17 Co-diagnostician/boundary crossings Intercultural mediators spontaneously adopt the "co-diagnostician" role: interpreters adopting strategies that extend beyond interpreters functions in bridging the linguistic and cultural difference and overlap with providers responsibilities and functions (Hsieh, 2007, p. 925). Boundary crossings (Bot, 2003).

18 Co-diagnostician/boundary crossings Comforting the patient Changing the message (sometimes known as making the message more culturally appropriate; taboos). Answering for the clinician; censoring what the patient or clincian say. Moralizing (i.e. the «right» thing to do). Confounding personal feelings with «cultural norms».

19 Co-diagnostician [Providers] ask about sexual contact outside of the marriage, which is really [a] bad question. BUT, I ask them. It is very offensive I said, Does your husband go with other women? In that way, you give responsibility to the husband, because Muslim women are very faithful to their husbands. Original question: How many sexual partners do you have? Hsieh (2008). I am not a robot! Interpreters views of their roles in health care settings. Qualitative Health Research, 18(10),

20 Discomfort Psychiatric context can be disquieting: mental health/illness in and of itself, but also Stigma Suffering Intimacy/personal issues addressed Lack of certainty Strong emotion No simple solutions/complexity

21 Emotional intensity Mediators report being overcome by emotion in psychiatry and psychology. They become, in effect, the «container» of the emotion, as it is through them that the patient expresses what he or she feels. Speaking in the first person can exacerbate this Mediators often feel a non-professional connection to the patient (by virtue of being a countryperson). This combined with over-identification with the patient (co-transference) can have a rather overwhelming if not debilitating impact.

22 Co-transference Reactions to others based not on the relationship as such but on past experiences, fantasies about the other and so forth. Complicates standard therapeutic dyads, exponentially so in a triadic relationship. Co-transference inevitably gets played out, however, it passes unseen and uncommented, most of the time, unless overtly addressed in a supervision context.

23 Co-transference

24 Mutuality Everyone affects everyone (in part through the co-transferential relationship). We are not billiard balls but relational creatures. The presence of each participant has an impact on the others; how the patient «is» is in part a function of how he or she feels with the other people present.

25 What is to be done? After much discussion with our team, with intercultural mediators, reflection, and experimentation, we realized that the problem was not that the mediators are poorly trained or inept, but rather that the absent present model is unworkable, at least for us. Furthermore, the presence of the mediator represents considerable therapeutic opportunities.

26 What is to be done? Training specific to the mental health context Dealing with emotion Psychiatric diagnosis Psychotherapy Personal work on co-transference Junior co-therapist role

27 Junior co-therapist Systems theory and contextualist approches. Bot s 3-person interpretation in mental health care (2003) Ethnospychiatry treatment teams. The mediator is overtly recognized as a part of the therapeutic relationship and process. The mediator always follows the clinician s lead.

28 Co-therapist Here-and-now relational issues. Role-plays. Sharing relevant lived experience. Overt message clarification. Metaphors Checking in Overt cultural contextualization. e.g taboos Overt alerts to communication problems.

29 Co-therapist Rather than univocally decide what is and is not appropriate for a patient-in-her/hisculture, in the face of taboo type issues that mediator can put the dilemma on the table. In the case of the question about sexual partners, the mediator could say In our culture such questions can be seen as offensive, yet these are standard medical questions, and then both patient and psychiatrist can comment.

30 Aisha, a 34 year old Moroccan woman was referred to the clinic for depression and a suspected psychosomatic paralysis. One of Aisha s chief issues was her timidity. She frequently lamented that she had few friends, asserting that she was very lonely. She felt that she was simply too shy to meet new people. She was increasingly aware that she was uncomfortable socially and that there was something in her interactions that did not serve her well. On the other hand, she noted that her brother was very effective socially. In order to explore in greater detail social interactions, the therapist asked her about her observations of the mediator. What was it that the mediator did? How did she engage with both the patient and clinician? As they explored Aisha s perceptions of the mediator s interpersonal styles, the clinician shifted the focus to differences between the two, and in the process asked both Aisha and the mediator to observe their experience of the other. In the following discussion, in which Aisha received empathic feedback from both mediator and clinician, she was able to get a sense of how her interpersonal style was socially detrimental, and then to identify strategies by which to shift her interactions with others.

31 Co-therapist Briefing and debriefing essential. Overview of session objectives. Clarification of interventions. Exchange and negotiation. Co-therapist role demands additional training for both clinician and mediator.

32 Need for regulated training and professionalization Effective use of a mediator requires clinician confidence. Professional identity key. The mediator must have a clear sense of her or his functions, but more importantly, the conceptual basis of the profession. Mere translation is not so mere. Intercultural mediation is a complex and difficult job, particularly in the context of mental health care.

33 Bicultural identity Bicultural identity can be stressful (acculturative stress). Culturally obliged to help community; professional identity limits role to that of bridge. Who am I? Where do I fit in? Clear impact on transferential relationship

34 : The Catalan Healthcare Intercultural Mediation Training Project of la Caixa Social and Cultural Outreach Projects

35 Healthcare Intercultural Mediation Training Project of la Caixa 202 hours of theory. 20 hours of group supervision. 18 hours of role-plays, experiential exercises 1200 hours of practica.

36 Training program modules MODULE I: Context of intercultural mediation (6) 1. Immigration and multiculturalism in Spain (3 hours) 2. Immigration, culture, and health: Medical anthropology (3 hours) MODULE II: The healthcare system (12 hours) MODULE III: Western biomedicine (40 hours) MODULE IV: Community health (40 hours) MODULE V: Cultural competence (30 hours) 1. Cultural competence (10 hours) 2. Intercultural communication and the therapeutic relationship (10 hours) 3. Linguistic interpretation (10 hours)

37 Training program modules MODULE VI: Intercultural mediation and professional identity (32 hours) 1 Intercultural mediation (16 hours) 2. Professional and personal identity of the intercultural mediator (16 hours) MODULE VII: Applications of healthcare intercultural mediation (32) 1. Contexts and settings of health care intercultural mediation (26 hours) 2. Bioethics and intercultural mediation (6 hours) MODULE VIII: Supervision and role-plays. (38 hours)

38 Supervision and role plays Each training session concludes with two hours of roleplays followed by two hours of group supervision. The role-plays draw from theatre improvisation and therapy, with the students participating in live mediations. We also use various experiential/corporal activities. The group supervision draws from IPR. It also includes a focus on the application of theory to practice, role confusion, management of complicated situations, and self-reflection. In situ individual supervision: the superviser visits the mediator in her or his practicum site. Ideally will accompany the mediator in a mediation.

39 Co-therapist role training The co-therapist role is under development. We work in such a manner in our Program. We meet regularly to facilitate the competent development of this role as well as the competent use of this role.

40 Student evaluation Portfolio evaluation: For each module, students will have to ensure that their portfolio is complete, demonstrating competence in each of the modules. Evaluation consists of, depending on the module: A test A written project Case analysis A video recording of a triadic interview Minimum 80% attendance At the end of the course a final interview will be held in which the student will demonstrate her or his competence, and in which he or she will show the capacity for self-evaluation, including strong and weak points.