Culture, Faith, and Psychotherapy

Extending from the brief post about the importance of Christian Unity, I wanted to drive home the importance of culture as it relates to the practice and perception of psychotherapy inspired by CBC's The Current episode found here.

There are two foundational concepts to this entry. First is understanding that our working definition of culture refers to the beliefs, ways of life, language, customs, expressions (art/music/literature), and behaviour of a particular group. The second is understanding that the conceptualization of mental illness is founded in behaviour in that the group in question has established a base practice of expression and that there are those who behave against that norm - literally, "abnormal behaviour". In order to diagnose a person with a mental illness, they must be behaving in ways that go against the norm usually caused by an underlying cognitive distortion (they aren't thinking properly and therefore they aren't acting properly). This is the entire focus of Cognitive Behavioural Therapy: change maladaptive behaviour by changing the maladaptive thoughts.

As you can already imagine, this can make the diagnostic and practical aspects of psychology (psychiatric and psychotherapeutic, respectively) extremely difficult and explains why a person has to be convinced that they are suffering before anything can be started, much less accomplished. Caucasian people, in particular, have this notion - generally speaking - that mental illness exists and that there are systems in place to assist once they are ready to seek and find treatment. In contrast, many cultures (ie. many Asian cultures) see depression, anxiety, and grief, especially, as being processes that need to simply be ignored ("swallow your bitterness"). There is also a deeper conceptualization of mental illness (in contrast to mental health) implying that there is something deeply wrong with you if those cognitive processes are occurring and admitting to such issues can create a sense of ostracization. Even the concept of emotional or cognitive vulnerability is taken in many cultures to be one of weakness.

And those are just from the clients' points of view. Few programs and even fewer practitioners really take the time to dig into these issues so they can be faced better when they are presented in the office. Despite what many believe, it's not as simple as accepting the client in a broad humanitarian perspective - an improper offshoot behaviour of Rogerian Humanism. Odds are, and I find this in my practice, that the individual does need some level of radical acceptance but it fails to recognize the necessitated level of introspection for effective counselling.

Okay, Dan, what do you mean by that? Call out the elephant in the room and work together to tailor unique care for that individual. I have dug into a wild amount of research on this specific topic and have come to the conclusion that colour-blind approaches, such as those called out in this episode of The Current, do not work because - despite what the social-left wants you to believe - individual, language, cultural, religious, and behavioural differences (just to name a few) matter deeply in the realm of practical psychology.

For example: Let's say a 37-year old Chinese-Canadian woman walks into your office and during your intake conversation you identify a strong accent, that she is a recent immigrant, that she brings with her a Catholic faith that she takes very seriously, symptoms of depression and anxiety, and that she was "orphaned" (her finger-quotes) shortly after birth. Where do you begin? What do you inquire about first?

The correct answer is: Her goals for treatment. Short of her saying that she doesn't know (which could happen), her goals will tell you what she wants inquired about first. Each of the surface points carry implications that most unacculturated therapists wouldn't understand making her goals that much more important in the process. In China, the Catholic Church is the most reviled of all religious sects and is difficult, if not impossible, to practice faithfully; her being orphaned is likely due to her being born a female in a time when or in a region where the One-Child Policy was not relaxed (natural disasters and parents being single-children, themselves, are relaxation components of the policy); her recent landing in Canada could have wide-spanning concerns; and, her symptoms of mental illness could literally mean nothing considering her cultural background.

Turns out, she's grieving her loss of culture and wants to be connected to a local Chinese cultural group in the area but doesn't know that her emotions and thoughts on that issue are related to what we call "Grief".

[This is part of the reason I have 25 symptoms (and an "Other" line) on my intake sheet. It's basically saying, "Here are my recent symptoms," but also inviting the, "Here's what I actually want to discuss."]

Now, given, that's an extreme example but reflects the importance of the practitioner's need for self-reflection - a behaviour that is required of practitioners but has been largely misinterpreted. In Canada, as a mosaic-Nation, we have macro-, micro-, and sub-cultures. A macro-culture can typically be defined as one of the dominant, if not the most dominant, of the practiced culture(s) in the region. It doesn't necessarily have to be practiced at all times but it is distinct from other cultures and is practiced autonomously with its own rules, regulations, norms, and alike. A micro-culture is typically defined by the distinct practices that take place inside the macro-culture(s) and moves autonomously as a result. A sub-culture is built in behind both of these forms. Equally distinct in terms of their behaviour, language, and norms, sub-cultures push the micro- and macro-cultures in many ways (ie. special interest political groups). In no way should a therapist be expected to know all of these concepts or who fits into what categories (that's in your capable hands sociologists, anthropologists, and politicians... well, two out of three) but there should be a stronger capacity to know how to indulge a client in the conversation about whether or not their cultural background matters and how to commit to a cultural appropriation (in contract to misappropriation).

Looking at the case of the 37-year-old Chinese Canadian woman, above, after identifying her goals for treatment I would have both her and I go back home and do research and see what is available in the area as a homework assignment and come back to the table and discuss what each identified option has to offer. In the 2016 Canada Census, 665 people in all of Renfrew County (approximately 102,000 people) identified themselves as being of Chinese ethnic origin (and that's actually an estimate extrapolated from acquired Census data) which automatically means that this will be no small task - well, that and when you do try to do a search you find out that Renfrew County probably has enough collective seating room in their Asian-inspired restaurants for all Asian-Canadians with room to spare.

BUT, at 402 Chamberlain Street in Pembroke and reachable at (613) 735-0368 you can find the Renfrew County Chinese Cultural Society. As the therapist, I would give them a shout myself and see what services they provide before sitting back down with my client.

And the same thing goes in other intrapersonal concepts in subcultures, too. Let's focus on this woman's Catholic faith for a moment. She is now able to practice her faith more freely than ever (unless she wants to hire someone under the Summer Jobs Grant) and so getting her in contact with the Diocese office may also be a wise decision, as would brushing up on your understanding of the connection between faith and mental health. Knowing the distinctions between denominations and faith practices inside the Christian faith and having a little bit of comparative theology is always useful (one good book here). In general, it would also be wise to help her improve her emotional vocabulary, emotion regulation, self-care, and distress tolerance, but her goals come first.

And this doesn't even dive into the micro-cultures, sub-cultures, and counter-cultures that have to do with forms of identity - such as gender and sexual, indigenous peoples, inter-culture languages, poverty, criminality, organizational/industrial, education, and alike that are consistently growing and persistently being advocated for and by those who are never caught-up on the issues or those who ignore the history of cultural competency in favour of what I typically deem as either pop- or fad-therapy (either/or because they aren't going to last without anchor points). You have to start at Mile Marker Zero: What are the sociological underpinnings inside the practice of mental health? and, What are the determinants of mental health?

If you don't start with these components you are guaranteed to fail.