Frameworks of cultural safety in family work: there is always more than one story CCMHS Vancouver October 2011 Jaswant Guzder Center for Child Development and Mental Health Jewish General Hospital

Cultural Formulation Outlines:DSM V I. Cultural Identity 1.Cultural reference groups 2.Language 3.Cultural factors in development 4.Involvement with culture of origin 5.Involvement with host culture II. Cultural Explanations Of The lllness 1.Predominant idioms of distress and local illness categories 2.Meaning and severity of symptoms in relation to 3.cultural norms 4.Perceived causes and explanatory models 5.Help seeking experiences and plans III. Cultural Factors Related To Psychosocial Environment and Levels Of Functioning 1.Social stressors 2.Social supports 3.Levels of functioning and disability 4.Cultural Elements Of The Clinician-Patient Relationship 5.Overall Cultural Assessment for Diagnosis and Treatment IV. Cultural Elements Of The Clinician-Patient Relationship V. Overall Cultural Assessment for Diagnosis and Treatment

- REFUGEE VS IMMIGRANT (STATUS) -PERMANENT VS TEMPORARY (GENERATIONAL ASSIMILATION ISSUES) -FORCED VS VOLUNTARY (COLLECTIVE TRAUMA VS AGENCY) -EXILE VS REFUELLING ( AKHTAR: THIRD INDIVIDUATION PROCESS; FAMLY REUNIFICATION TRAUMA) -HYBRIDIZATION (HOST AND MIGRANT) ATTACHMENT AND IDENTITY

Location of Culture -Transitional phenomena (Winnicott) -Third Individuation (Akhtar) :exile, identity, generational refuelling and acculturation are lifelong processes -Psychic Skin (Bick): eg.Princess Frog myth metaphor -Embodiment: visible minorities, body as a identity eg. Eating Disorders ( rates increase with migration/acculturation) -Optimal distance: ontological security, internal continuity of narratives, ethnic match in therapy -Voids and Gaps: alienation, mourning, -Resilience and Creative reconstruction of identity over life cycle and trans-generationally, historical gaps of denial or overdetermination -legal gaps: family reunification, host legal parameters of child laws -code switching across generations

Therapeutic Agendas: Otherness vs Dominant Culture - DELUSIONS of NEUTRALITY VS CULTURAL SAFETY/INSTITUTIONAL RACISM -TRANSLATION OF EXPLANATORY MODELS AND BELIEFS VS VS CULTURAL CAMOUFLAGE -LANGUAGE TIED WITH AFFECTIVE STATES -INSTRUMENTAL/HIERARCHY DIMENSIONS -ATTACHMENT AND IDENTITY :MYTHIC WORLDS -DEVELOPMENTAL AGENDAS IN LIFE CYCLE -COLLECTIVIST VS INDIVIDUALIST FRAMES -GENERALIZING COMPLEX ETHNIC IDENTITIES IE; HOMOGENEITY WHERE HETEROGENITY EXISTS

Cultural Safety “..any actions that diminish, demean or disempower the cultural identity and well-being of an individual..” (Cooney 1994 ) a concept that rests on an analysis of power imbalances, institutional discrimination, colonization and our relationship with colonizers (internalized, real or phantasy)

Institutional Racism …..the collective failure of an organization to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behavior that amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping, that disadvantages minority ethnic people… 1999 Stephen Laurence Report UK ( quoted by Suman Fernando. 2009)

Suspension of “disbelief”: failures of imagination. narratives inspired by (collective) cultural symbols enacted in specific interpersonal and social contexts..require a culturally sensitive “reading” of such a process combined with strategic psychological considerations..important for diagnosis, successful therapy, empathy and therapeutic alliance … (E. Witzum, Y. Goodman Narrative Construction of Distress and Therapy: a model based on work with Ultra-Orthodox Jews)

ADHD or Djinn Possession? 8 yr.boy K. born in Canada, expelled from school, diagnosed with developmental delays,?ADHD: formulation is related to maternal depression;4 years of non response to treatment interventions Diagnosis of mother: take your Paxil and “leave your superstitions behind” Diagnosis of child was ascribed to cultural reasons without testing or evaluation of severe learning disabilities Separation anxiety of child : related to unreported Djinn possession of his mother, fear she would die, father’s suicidial depression related to Interferon

The Family Tree

Black Canadian families at risk Quebec: recent increase in diversity and black population : black adol. Are 6 % of Montreal population but 24 per cent of youth in child protection placement ( stable for past 15 yr) Major issues for youth protection cases of black youth in placement : in order of priority: neglect ( majority), conduct disorder, physical abuse, abandonment Major focus of needs: parenting skills, attachment, isolation, acculturation, poverty,substance abuse, racism, family reunification Most Canadian immigrant children second generation have higher university training than host culture, NOT the majority of Caribbean and other Latin American origin migrants

Risk forDisruptive Disorders High rate of elementary school aged onset and increased risk is in adolescence for conduct disorders, school drop out and placement Self report studies : denial of problems or needs; stigma in mental health domains Risk issues: high levels of perceived racism, low collective self esteem, absent fathers, father hunger, attachment disruptions : immigration, reunification, antisocial, post slavery issues, low rates of family self referral for treatment, maternal depression

Alliance issues Highest rates of placement in urban Montreal is amongst black adolescents and youth ( conduct disorder, violence, school problems, substances abuse): forced rather than voluntary alliance Preference for ethic match in health care providers (Malat 2006): populations institutionally ignored by therapists recommend screening for African American adolescents without or without DSM disorders for suicide recommended for black adolescents particularly females (Joe et al. 2009) who used to have lower rates of suicide High value on education in Caribbean community surveys: Toronto and Halifax (Smith 2001) but barriers to success ?

Case Study 8 year old boy and 6 year girl in placement, mother had drug charges; girl was hospitalized for refusal to eat, boy referred to our day hospital for consult : ADHD; mother was homeless and complying with DYP : optimal conditions for family treatment? Delayed admission : framed conditions for treatment and avoided decisions on medication or diagnosis Admission : youth protection reunited family, testing : ADHD, severe learning problems; mother : PTSD, BPD Sexual abuse and violence history, collective denial of social- historical context, fatherless child,”blackest” child, impact on her family’s fundamentalist framework, legal framework: migration of her mother when she was aged 13 yr, her criminal charges, education potential and motivation

Psychosis Misdiagnosed 17 yr old South Asian boy with 2 older sisters, parents and maternal grandmother under DYP since age 15yr for school refusal -did well in short placement after violence at home and school refusal; diagnosis of first episode psychosis ( refused meds); anger management “a joke”;a process of “finding the real patient”; Possessed? Depressed? Highly Entitled? Immature? Triangulated?

Family Tree

Family systems approach Use of structural Minuchin approach, narrative methods, strategic intervention and other models must be modified with an appreciation of cultural axis, institutional context, mythic and life cycle development aims of the client in order to co-construct a working alliance that will promote accurate diagnostics and shifts in problem solving capacity, functioning or resilience

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