The first part of this discussion I want to focus on the NASW Code of Ethics and what it says about Cultural Competency. Then I am going to bring into it a case that I consulted on in the last year. I apologize in advance for the length of this post.
The NASW Code of Ethics state:
1.05 Cultural Competence and Social Diversity (a) Social workers should understand culture and its function in human behavior and society, recognizing the strengths that exist in all cultures.
(b) Social workers should have a knowledge base of their clients’ cultures and be able to demonstrate competence in the provision of services that are sensitive to clients’ cultures and to differences among people and cultural groups.
(c) Social workers should obtain education about and seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical disability.
Next, I would like for us to think about and discuss times in our clinical work that we have seen diagnoses made without taking into consideration the clients cultural background.
For me, in the last 18 years as a Mental Health Clinician I have seen time and time again clients diagnosed in such a way that their culture was not taken into consideration.
A recent example was a case that I consulted on. The client was a late-30's, Black woman who was homeless and living in a shelter. She had a 3 month old baby. She was "asked" by the shelter to seek mental health treatment based on the fears she was relaying to her shelter counselor about her next door neighbor at the shelter.
This client recently moved to this area from Louisiana to escape her baby's father who had been abusing her.
The clinician who completed this Mom's assessment and was working with her, was a young, White, para-professional who was new to the mental health field.
One of the first questions I ask in consultation with clinicians is to identify any issues that the clinician asseses as being cultural "issues" that may impact the clinical relationship.
This particular clinician said that there were no cultural issues and that the client had Schizophrenia and was a danger to her baby because she believed the person living next to her in the shelter was putting a "hex" on her and her baby. The Mom was talking "crazy" and wanted to move from the shelter so she and her baby would be safe.
When I reviewed the file, I found that the client not only grew up in Louisiana but had a cultural background that included hoodoo and voodoo beliefs and practices.
During her assessment with the clinician, when she spoke of these practices, they were assessed to be psychotic symptoms. When the client was asked if she heard voices or saw images, she spoke of hearing her Grandmother talk to her and occassionally seeing her Grandmother in the room with her. She described her Grandmother as a loving and caring presence in her life which had been fraught with trauma and abuse. Neither of the assessed AVH impacted the client's functioning negatively.
What currently impacted her functioning was: a)an abusive partner who verbally berated her and physically abused her b) a brand new baby that she was hypervigilante about protecting from the trauma the client had experienced at the hands of the baby's father as well as other trauma she had experienced in her life c) the heightened level of stress of having a brand new baby and having to "escape" leaving behind her support system more than halfway across the country and d)seeking help from a system that immediately diagnosed her as having Schizophrenia and not taking into consideration her cultural background, possible postpartum depression and possible PTSD from not only the extensive abuse she received at the hands of her ex-boyfriend but also a lifelong history of trauma and abuse.
The clinician I met with felt like she had developed a "good" rapport with the client and did not understand why the client did not return following her initial assessment in which she had been given the dx of Schizophrenia and referred to a staff Psychiatrist for a medication evaluation. The clinician had also expressed to the client her concerns over the safety of the baby, although the clinician admitted that there were no signs that the baby had been neglected or abused. The baby appeared healthy and well-taken care of. The clinician based her concerns on the client expressing fears of a "hex" being placed on her and her baby. The client rarely left her room out of fear.
I understand that the mental health system is overburdened and under-funded but I do not believe that this ethically excuses the system from not fully assessing the culture and background that clients seeking help come to us with.
This particular clinician who had no mental health background but had been a case manager for a couple of years at a local social service agency, was hired and given a caseload of 80 clients, most of whom had a severe mental illness. She was a Bachelor's level "clinician" whose education was not in Social Work, nor a related field.
In reviewing the section on Cultural Competency in the NASW Code of Ethics, this clinician did not meet the criteria for a, b or c.
I also want to add that in the DSM IV TR there is a section in the back (Appendix I - Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes) that is the beginning of taking cultural issues into consideration when diagnosing people. 4 pages of cultural syndromes is what we get........
Arika, Beautiful post! I love your passion. I want to give this some thought before I add my thoughts! But, way to go and to bring a very tangible piece in the DSM IV TR to support your Ideas. I can't wait to have this discussion.
I had no idea that the DSM IV had those pages in the back. I don't do a lot of diagnosing in my current job, but I was thinking back on a class in graduate school where we focused on this issue. We are in the process of moving and I found a diagnostic tool specifically made for Native American children. I remember being struck by the difference in focus of the Native American versus the standard version. When clinicians started using the Native American diagnostic tool with their Native American clients, the assessments were much more comprehensive and a lot more children were better served because of this. I have been thinking about this for a couple of days now, and I am sure there will be more thoughts about this.
In fact this discussion was on my mind yesterday during an interview with a client who is experiencing grief and loss issues. We were talking about 30-something women's roles in this society and to take it a step further, women of color's roles in this society. It was a great opening to a forthright discussion; if this hadn't been on my mind, I might not have taken it that far.
Generally the Patient's I work with are either Dialysis Patients and/or ECF Residents. One of the main components of my assessment is the identification of a patient's support systems. During this process caregiver identification for comprehensive care plans are discussed at length in order to ensure linkages to community resources. What I find most fascinating about this process are the preconceived beliefs amongst the health care team as to what "should" be a Patients' support system vs. what the Patient has defined as their support. The staff working from their frame of reference, aren't always hearing the patient for various reasons, one being that of misunderstanding pertinent cultural beliefs. I work with so many dedicated team members that strive to be very compassionate toward all patients but struggle when providing a broader scope of care. As Arika pointed out in her case study, the caseworker was unable to delve into her client's belief systems that I assume were very unfamiliar to her. In addition, Arika brought up another commonplace dilemma for social workers, overwhelming caseloads as well as inexperience.
For what it's worth here is a little workplace scenario from this week:
A Patient on my caseload who had a profound CVA earlier this year passed away. He was a white male in his 70's who had been married to his current spouse for 10 years. His spouse is a native of Indonesia who braved many barriers within the health care system. The patient's daughter, in her 40's, lived in another state and communicated through frequent phone calls and visits when able. Both supports cared for this patient very deeply but as the patient passed away, each grieved in very different manners. During the week several staff members discussed how these two family members presented their grief. Everyone realized the different roles these two women had in this patient's life but were struck by their individual displays of emotions. The Spouse "frantically" (as it was described) went to the patient's closet for appropriate clothes for "accepting guests" and the daughter who anticipated not being bedside when her Dad passed was in her home state by choice. Staff processed the events later with me describing their view of the Spouse's and Daughter's behaviors sharing quite openly their judgments. Many saw the spouse as overly reactive and the daughter as not caring. Ironically,end of life in the spouse's culture is in a home setting where it is the responsibility of the family to prepare the loved one, while the daughter, being of a different generation and culture was very comfortable with a loved one's end of life in a setting such as an ECF. So a very "normal" end of life act as preparing a loved one was misconstrued as "unusual" and the daughter's absence as distant.
Team, Can I just say this is beautiful work! Felicia I appreciate you humility and the comfort you show with making strides for improvement. I also appreciate your example with Native American Culture and diagnosis. Here in the NW we have a pretty substantial Native American Population and as your blog post illustrated there is so much opportunity to serve their needs by raising our cultural awareness.
You know it always makes me chuckle when I here the phrase cultural competency because I wonder if one can truly every be culturally competent. It just makes me think about how our own culture has this fixation on solving problems with a solution because when you can solve it you don't have to worry about it any more. But, nobody ever really champions worry or anxiety with respect to culture awareness. I think it is healthy to have anxiety and worry because it challenges our world views and our personal agreements and expectations.
I know that organizations nation wide have made movements towards this idea of "'cultural competency" and while I think there is value in this. I think that we have to be very cautious and mindful about not isolating cultural issues and thinking about them with every client.
Hence, this is why I really appreciated Laura's example of the staff members world agreements impacted their perceptions about those clients. Team, needless to say this happens continually. In the coming discussion, I really want to challenge all of us and to really examine our own world agreements as well as others and look at things on the continuum. I want to examine at Racism, Institutionalized Racism, Ableism, heterosexism, sexism, ageism and other cultural issues as it relates to diagnosis. Felicia isn't on an Island, it's something we all need work and will continue to need work on as long as we live
I also have been thinking about culture and clinician's assumptions this week at work, as well as in my personal life.
I attempt to incorporate ethnicity, national origin, and mental or physical disability or mental issue in my hospital assessments.
I also check age, marital (or partner) status, religion, and immigration status, in my assessments.
I have not found a way (unless I see something in a pt.'s chart or they bring this up in discussing support systems) to discuss sexual orientation, gender identity or expression, or political belief in assessments yet.
One of the gaps of information I see is in a patient's mental health history noted. For example, I often see pt.'s with "depression/anxiety" or PTSD diagnoses, but rarely is it noted if the person has situational depression, recurrent depression, or a new episode or what a person's trauma history is. This information can be very helpful in assessing a pt. and also in relating to the pt. in a culturally appropriate way.
I often ask pt.s if they have have Native American tribal affiliation or are Native American, because I know this is not something I can definitively judge from physical appearance (though some co-workers think this is possible).
I think I could write a book about my thoughts and experiences with culture and relating it to diagnosing, and I'm sure most people in this field could. That is not to say I am an expert though.
I seem to work mostly with 55+ Caucasian patients, but I do also often work with people not in these categories. Just today I have a pt. who speaks only Vietnamese, is female, in her late 70's (I think), has a new cancer diagnosis but they are not sure what yet, and lives with her daughter and her family. The previous discharge planner set up for this pt. to have a translator today at 10am so that her doctors, nurses, myself, and the financial counselor could speak with her and her son in law. I gained a lot of information from participating in and observing this conversation, including about the other practitioners' assumptions.
I noted that people had difficulty speaking to the patient instead of the translator or the son, that people were hesitant to let the translator translate for the son (he spoke some English) and instead wanted him to speak in English with them, that people thought they were spending "a lot of time" with this pt./family, that people assumed the family had brought the pt. from Vietnam in her old age for the better health care here (though she has no insurance now), and that people thought the pt. knew much less than she showed she did with the interpreter present.
(Continued) I spent about 30 minutes meeting with just the son in law and the interpreter answering the SIL's questions, and I learned more about his definition of "family" and "household" and "dependent" (we were discussing these in a financial context but in helping him understand that I learned his thoughts as well).
I was glad that this translator had been set up and that she will continue to come daily to the hospital, because it of course proved very helpful to all involved.
I have also seen pt.s who do not speak English be simply bypassed by the clinicians who only speak with family members who do speak English. This does a disservice to the pt. and family member because in essence we are then treating the pt. as if he or she is not competent to participate in his or her own treatment and decisions about his or her care, and then the burden of translation and sharing medical news is left to the family member.
Also at the hospital I work at we have psych pt.s mixed in with the medical/non-psych pt.s and many of the people caring for the psych pt.s are not trained in mental health issues. This proves to be problematic and I often hear people complaining about a psych pt.'s attitude, "craziness", etc. I notice that the practitioners who only work with psych pt.s often show much more respect for the pt.s than other people, and I would posit to guess this is due to their deeper understanding of the issues the person is dealing with.
I also have heard people comment on the behavior of two different African American clients. It is difficult to know for sure, but I suspect that there was racism involved in their comments. Both pt.s also had mental health diagnoses, drug abuse histories, had financial issues, and I heard specific derogatory comments about their "work ethic" and "efforts".
I have heard such comments about other pt.s who have drug abuse issues or histories as well, though that seems to be somewhat different as it appears there is more respect for people who are "in recovery" from drug issues than for people who are in recovery from a mental illness.
I see racism and Institutionalized racism in these insidious ways, and because of that it is very hard to definitively label behavior and comments as such and I suspect easier for people to think "I would say/think that even if this pt. was not African American/mentally ill/poor/a former drug user/female/and on and on and on.
I have lots more thoughts on this but I will stop for now. I look forward to our discussion Monday!
Cultural difference is a topic that we should talk about more in clinical consultations at my work; I'm glad we're talking about it here. And I apologize for my wordiness in advance.
First, I've got to say that staying open to cultural differences and recognizing my own tendency to have preconceived ideas about people unlike me (white/middle income background/healthy/middle-aged/bisexual) is ongoing work. It's almost harder (though good, and necessary) to gain new knowledge, as it makes me feel more comfortable in my work, and maybe more likely to slip into unconscious thinking about the people I work with. For me, I have to think about each person as an individual, and take into account their cultural context, while at the same time realizing that I'm coming from a place of great deficit with most of the people I'm working with: I likely don't not have enough information, or, if I do have information, may not have gotten the nuances.
I think there's a tendency in social service agencies with a therapeutic focus to diagnose people without taking into account the trauma they've experienced as well as Maslow's Hierarchy of Needs. If someone's basic survival and safety needs aren't being met, it's hard to maintain a semblance of good mental health, and makes for a skewed assessment. Also, sometimes (I'm talking about my work here) it seems as though we're encouraged to look at our experiences with previous clients for answers about current clients - this shortcutting can lead to generalizing and stereotyping of clients, and can cause us not to see at the person in front of us.
Emma's comments about interpretation (talking above and around the client/patient) struck me as important, and as something that seems to happen a lot. The worker's insistence on making the son speak English is a good example of racism.
I thought Laura's example of the different ways of dealing with a family member's death was thoughtful and eloquent, in the way she noticed it and put it into words.
Felicia and I talked about her meeting with the woman where they talked about the differences between them, and I appreciated the reminder that trust has to be built and takes vulnerability on our parts.
Thank you for your thorough post Arika. I feel like a key issue that often times is over looked when working with patients/clients is meeting them where they are at. This means understanding their background, history, culture and letting them define things for them selves. This also includes not labeling people (as much as we can avoid) or feeling into the labels they may have already been given. I feel that good social work practice keeps the person we are working with in the center. So often, we are trying to make people fit into these prescribed roles and labels and boxes. As Arika said, we have an over-burdened and over extended mental health system, and unfortunately, to make it work, often times it seems to be at the expense of the patient/client. I feel another important point is to understand and recognize the culture we (as workers) represent to our patients/client. As Erin pointed out, we all represent something different and unique to as, as do our clients. I feel to truly be able to understand and recognize our clients/patients culture and history we have to do the same for our own. Self-reflection and analyzing is a very important piece of work for any social worker to do.
Arika, thanks for the great post. I really appreciated the example you provided. Since I don’t diagnose in my position, this brought up some interesting things for me to think about. For me it is a good reminder to be aware of cultural issues when looking at someone’s diagnosis, and not just assuming that because it is written in their chart that it is set in stone. Many of the patients who come for care in our clinic receive services through the mental health system, and it’s good to remember that there are limitations to the services that are provided. This is also a strong reminder for me that if I do eventually have a position where I am diagnosing, that I truly consider all aspects of a client and not just assume a diagnosis is correct because I can “check off” the right boxes.
The idea of cultural competency is certainly stressed at my job, because we serve people from so many different backgrounds. I agree with feeling like I am never “done” being culturally competent, I am always learning. Working primarily with parents and children now has certainly caused me to have to examine my own personal background and beliefs with regards to parenting and raising a family. Since I do not have children of my own, I feel like I especially have to work daily on meeting the client where they are. I can’t just impose my own views on people (especially since I haven’t even had the chance yet to see how it all works out in real life!). I also am constantly made aware of how privileged my upbringing was in comparison to many of the young parents I see daily struggling to do their best in raising their children and deal with problems that arise. I hope to continually be in the process of examining how my own lenses color each situation that I encounter, and work on identifying when I’m having difficulty in relating to where my patients are coming from.
Hi team, Arika is hosting the discussion this week
ReplyDeleteThe first part of this discussion I want to focus on the NASW Code of Ethics and what it says about Cultural Competency. Then I am going to bring into it a case that I consulted on in the last year. I apologize in advance for the length of this post.
ReplyDeleteThe NASW Code of Ethics state:
1.05 Cultural Competence and Social Diversity
(a) Social workers should understand culture and its function in human behavior and society, recognizing the strengths that exist in all cultures.
(b) Social workers should have a knowledge base of their clients’ cultures and be able to demonstrate competence in the provision of services that are sensitive to clients’ cultures and to differences among people and cultural groups.
(c) Social workers should obtain education about and seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical disability.
Next, I would like for us to think about and discuss times in our clinical work that we have seen diagnoses made without taking into consideration the clients cultural background.
ReplyDeleteFor me, in the last 18 years as a Mental Health Clinician I have seen time and time again clients diagnosed in such a way that their culture was not taken into consideration.
A recent example was a case that I consulted on. The client was a late-30's, Black woman who was homeless and living in a shelter. She had a 3 month old baby. She was "asked" by the shelter to seek mental health treatment based on the fears she was relaying to her shelter counselor about her next door neighbor at the shelter.
This client recently moved to this area from Louisiana to escape her baby's father who had been abusing her.
The clinician who completed this Mom's assessment and was working with her, was a young, White, para-professional who was new to the mental health field.
One of the first questions I ask in consultation with clinicians is to identify any issues that the clinician asseses as being cultural "issues" that may impact the clinical relationship.
This particular clinician said that there were no cultural issues and that the client had Schizophrenia and was a danger to her baby because she believed the person living next to her in the shelter was putting a "hex" on her and her baby. The Mom was talking "crazy" and wanted to move from the shelter so she and her baby would be safe.
ReplyDeleteWhen I reviewed the file, I found that the client not only grew up in Louisiana but had a cultural background that included hoodoo and voodoo beliefs and practices.
During her assessment with the clinician, when she spoke of these practices, they were assessed to be psychotic symptoms. When the client was asked if she heard voices or saw images, she spoke of hearing her Grandmother talk to her and occassionally seeing her Grandmother in the room with her. She described her Grandmother as a loving and caring presence in her life which had been fraught with trauma and abuse. Neither of the assessed AVH impacted the client's functioning negatively.
What currently impacted her functioning was:
a)an abusive partner who verbally berated her and physically abused her
b) a brand new baby that she was hypervigilante about protecting from the trauma the client had experienced at the hands of the baby's father as well as other trauma she had experienced in her life
c) the heightened level of stress of having a brand new baby and having to "escape" leaving behind her support system more than halfway across the country and
d)seeking help from a system that immediately diagnosed her as having Schizophrenia and not taking into consideration her cultural background, possible postpartum depression and possible PTSD from not only the extensive abuse she received at the hands of her ex-boyfriend but also a lifelong history of trauma and abuse.
The clinician I met with felt like she had developed a "good" rapport with the client and did not understand why the client did not return following her initial assessment in which she had been given the dx of Schizophrenia and referred to a staff Psychiatrist for a medication evaluation. The clinician had also expressed to the client her concerns over the safety of the baby, although the clinician admitted that there were no signs that the baby had been neglected or abused. The baby appeared healthy and well-taken care of. The clinician based her concerns on the client expressing fears of a "hex" being placed on her and her baby. The client rarely left her room out of fear.
I understand that the mental health system is overburdened and under-funded but I do not believe that this ethically excuses the system from not fully assessing the culture and background that clients seeking help come to us with.
This particular clinician who had no mental health background but had been a case manager for a couple of years at a local social service agency, was hired and given a caseload of 80 clients, most of whom had a severe mental illness. She was a Bachelor's level "clinician" whose education was not in Social Work, nor a related field.
In reviewing the section on Cultural Competency in the NASW Code of Ethics, this clinician did not meet the criteria for a, b or c.
I also want to add that in the DSM IV TR there is a section in the back (Appendix I - Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes) that is the beginning of taking cultural issues into consideration when diagnosing people. 4 pages of cultural syndromes is what we get........
ReplyDeleteArika, Beautiful post! I love your passion. I want to give this some thought before I add my thoughts! But, way to go and to bring a very tangible piece in the DSM IV TR to support your Ideas. I can't wait to have this discussion.
ReplyDeleteI had no idea that the DSM IV had those pages in the back. I don't do a lot of diagnosing in my current job, but I was thinking back on a class in graduate school where we focused on this issue. We are in the process of moving and I found a diagnostic tool specifically made for Native American children. I remember being struck by the difference in focus of the Native American versus the standard version. When clinicians started using the Native American diagnostic tool with their Native American clients, the assessments were much more comprehensive and a lot more children were better served because of this. I have been thinking about this for a couple of days now, and I am sure there will be more thoughts about this.
ReplyDeleteIn fact this discussion was on my mind yesterday during an interview with a client who is experiencing grief and loss issues. We were talking about 30-something women's roles in this society and to take it a step further, women of color's roles in this society. It was a great opening to a forthright discussion; if this hadn't been on my mind, I might not have taken it that far.
Love the comprehensive post Arika!
ReplyDeleteGenerally the Patient's I work with are either Dialysis Patients and/or ECF Residents. One of the main components of my assessment is the identification of a patient's support systems. During this process caregiver identification for comprehensive care plans are discussed at length in order to ensure linkages to community resources.
What I find most fascinating about this process are the preconceived beliefs amongst the health care team as to what "should" be a Patients' support system vs. what the Patient has defined as their support. The staff working from their frame of reference, aren't always hearing the patient for various reasons, one being that of misunderstanding pertinent cultural beliefs. I work with so many dedicated team members that strive to be very compassionate toward all patients but struggle when providing a broader scope of care. As Arika pointed out in her case study, the caseworker was unable to delve into her client's belief systems that I assume were very unfamiliar to her. In addition, Arika brought up another commonplace dilemma for social workers, overwhelming caseloads as well as inexperience.
For what it's worth here is a little workplace scenario from this week:
A Patient on my caseload who had a profound CVA earlier this year passed away. He was a white male in his 70's who had been married to his current spouse for 10 years. His spouse is a native of Indonesia who braved many barriers within the health care system. The patient's daughter, in her 40's, lived in another state and communicated through frequent phone calls and visits when able. Both supports cared for this patient very deeply but as the patient passed away, each grieved in very different manners. During the week several staff members discussed how these two family members presented their grief. Everyone realized the different roles these two women had in this patient's life but were struck by their individual displays of emotions. The Spouse "frantically" (as it was described) went to the patient's closet for appropriate clothes for "accepting guests" and the daughter who anticipated not being bedside when her Dad passed was in her home state by choice. Staff processed the events later with me describing their view of the Spouse's and Daughter's behaviors sharing quite openly their judgments. Many saw the spouse as overly reactive and the daughter as not caring. Ironically,end of life in the spouse's culture is in a home setting where it is the responsibility of the family to prepare the loved one, while the daughter, being of a different generation and culture was very comfortable with a loved one's end of life in a setting such as an ECF. So a very "normal" end of life act as preparing a loved one was misconstrued as "unusual" and the daughter's absence as distant.
Team, Can I just say this is beautiful work! Felicia I appreciate you humility and the comfort you show with making strides for improvement. I also appreciate your example with Native American Culture and diagnosis. Here in the NW we have a pretty substantial Native American Population and as your blog post illustrated there is so much opportunity to serve their needs by raising our cultural awareness.
ReplyDeleteYou know it always makes me chuckle when I here the phrase cultural competency because I wonder if one can truly every be culturally competent. It just makes me think about how our own culture has this fixation on solving problems with a solution because when you can solve it you don't have to worry about it any more. But, nobody ever really champions worry or anxiety with respect to culture awareness. I think it is healthy to have anxiety and worry because it challenges our world views and our personal agreements and expectations.
I know that organizations nation wide have made movements towards this idea of "'cultural competency" and while I think there is value in this. I think that we have to be very cautious and mindful about not isolating cultural issues and thinking about them with every client.
Hence, this is why I really appreciated Laura's example of the staff members world agreements impacted their perceptions about those clients. Team, needless to say this happens continually. In the coming discussion, I really want to challenge all of us and to really examine our own world agreements as well as others and look at things on the continuum. I want to examine at Racism, Institutionalized Racism, Ableism, heterosexism, sexism, ageism and other cultural issues as it relates to diagnosis. Felicia isn't on an Island, it's something we all need work and will continue to need work on as long as we live
Thanks for all of the great posts so far.
ReplyDeleteI also have been thinking about culture and clinician's assumptions this week at work, as well as in my personal life.
I attempt to incorporate ethnicity, national origin, and mental or physical disability or mental issue in my hospital assessments.
I also check age, marital (or partner) status, religion, and immigration status, in my assessments.
I have not found a way (unless I see something in a pt.'s chart or they bring this up in discussing support systems) to discuss sexual orientation, gender identity or expression, or political belief in assessments yet.
One of the gaps of information I see is in a patient's mental health history noted. For example, I often see pt.'s with "depression/anxiety" or PTSD diagnoses, but rarely is it noted if the person has situational depression, recurrent depression, or a new episode or what a person's trauma history is. This information can be very helpful in assessing a pt. and also in relating to the pt. in a culturally appropriate way.
I often ask pt.s if they have have Native American tribal affiliation or are Native American, because I know this is not something I can definitively judge from physical appearance (though some co-workers think this is possible).
I think I could write a book about my thoughts and experiences with culture and relating it to diagnosing, and I'm sure most people in this field could. That is not to say I am an expert though.
I seem to work mostly with 55+ Caucasian patients, but I do also often work with people not in these categories. Just today I have a pt. who speaks only Vietnamese, is female, in her late 70's (I think), has a new cancer diagnosis but they are not sure what yet, and lives with her daughter and her family. The previous discharge planner set up for this pt. to have a translator today at 10am so that her doctors, nurses, myself, and the financial counselor could speak with her and her son in law. I gained a lot of information from participating in and observing this conversation, including about the other practitioners' assumptions.
I noted that people had difficulty speaking to the patient instead of the translator or the son, that people were hesitant to let the translator translate for the son (he spoke some English) and instead wanted him to speak in English with them, that people thought they were spending "a lot of time" with this pt./family, that people assumed the family had brought the pt. from Vietnam in her old age for the better health care here (though she has no insurance now), and that people thought the pt. knew much less than she showed she did with the interpreter present.
(Continued) I spent about 30 minutes meeting with just the son in law and the interpreter answering the SIL's questions, and I learned more about his definition of "family" and "household" and "dependent" (we were discussing these in a financial context but in helping him understand that I learned his thoughts as well).
ReplyDeleteI was glad that this translator had been set up and that she will continue to come daily to the hospital, because it of course proved very helpful to all involved.
I have also seen pt.s who do not speak English be simply bypassed by the clinicians who only speak with family members who do speak English. This does a disservice to the pt. and family member because in essence we are then treating the pt. as if he or she is not competent to participate in his or her own treatment and decisions about his or her care, and then the burden of translation and sharing medical news is left to the family member.
Also at the hospital I work at we have psych pt.s mixed in with the medical/non-psych pt.s and many of the people caring for the psych pt.s are not trained in mental health issues. This proves to be problematic and I often hear people complaining about a psych pt.'s attitude, "craziness", etc. I notice that the practitioners who only work with psych pt.s often show much more respect for the pt.s than other people, and I would posit to guess this is due to their deeper understanding of the issues the person is dealing with.
I also have heard people comment on the behavior of two different African American clients. It is difficult to know for sure, but I suspect that there was racism involved in their comments. Both pt.s also had mental health diagnoses, drug abuse histories, had financial issues, and I heard specific derogatory comments about their "work ethic" and "efforts".
I have heard such comments about other pt.s who have drug abuse issues or histories as well, though that seems to be somewhat different as it appears there is more respect for people who are "in recovery" from drug issues than for people who are in recovery from a mental illness.
I see racism and Institutionalized racism in these insidious ways, and because of that it is very hard to definitively label behavior and comments as such and I suspect easier for people to think "I would say/think that even if this pt. was not African American/mentally ill/poor/a former drug user/female/and on and on and on.
I have lots more thoughts on this but I will stop for now. I look forward to our discussion Monday!
Cultural difference is a topic that we should talk about more in clinical consultations at my work; I'm glad we're talking about it here. And I apologize for my wordiness in advance.
ReplyDeleteFirst, I've got to say that staying open to cultural differences and recognizing my own tendency to have preconceived ideas about people unlike me (white/middle income background/healthy/middle-aged/bisexual) is ongoing work. It's almost harder (though good, and necessary) to gain new knowledge, as it makes me feel more comfortable in my work, and maybe more likely to slip into unconscious thinking about the people I work with. For me, I have to think about each person as an individual, and take into account their cultural context, while at the same time realizing that I'm coming from a place of great deficit with most of the people I'm working with: I likely don't not have enough information, or, if I do have information, may not have gotten the nuances.
I think there's a tendency in social service agencies with a therapeutic focus to diagnose people without taking into account the trauma they've experienced as well as Maslow's Hierarchy of Needs. If someone's basic survival and safety needs aren't being met, it's hard to maintain a semblance of good mental health, and makes for a skewed assessment. Also, sometimes (I'm talking about my work here) it seems as though we're encouraged to look at our experiences with previous clients for answers about current clients - this shortcutting can lead to generalizing and stereotyping of clients, and can cause us not to see at the person in front of us.
Emma's comments about interpretation (talking above and around the client/patient) struck me as important, and as something that seems to happen a lot. The worker's insistence on making the son speak English is a good example of racism.
I thought Laura's example of the different ways of dealing with a family member's death was thoughtful and eloquent, in the way she noticed it and put it into words.
Felicia and I talked about her meeting with the woman where they talked about the differences between them, and I appreciated the reminder that trust has to be built and takes vulnerability on our parts.
Thanks for the great post, Arika.
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ReplyDeleteThank you for your thorough post Arika. I feel like a key issue that often times is over looked when working with patients/clients is meeting them where they are at. This means understanding their background, history, culture and letting them define things for them selves. This also includes not labeling people (as much as we can avoid) or feeling into the labels they may have already been given. I feel that good social work practice keeps the person we are working with in the center. So often, we are trying to make people fit into these prescribed roles and labels and boxes. As Arika said, we have an over-burdened and over extended mental health system, and unfortunately, to make it work, often times it seems to be at the expense of the patient/client.
ReplyDeleteI feel another important point is to understand and recognize the culture we (as workers) represent to our patients/client. As Erin pointed out, we all represent something different and unique to as, as do our clients. I feel to truly be able to understand and recognize our clients/patients culture and history we have to do the same for our own. Self-reflection and analyzing is a very important piece of work for any social worker to do.
Arika, thanks for the great post. I really appreciated the example you provided. Since I don’t diagnose in my position, this brought up some interesting things for me to think about. For me it is a good reminder to be aware of cultural issues when looking at someone’s diagnosis, and not just assuming that because it is written in their chart that it is set in stone. Many of the patients who come for care in our clinic receive services through the mental health system, and it’s good to remember that there are limitations to the services that are provided. This is also a strong reminder for me that if I do eventually have a position where I am diagnosing, that I truly consider all aspects of a client and not just assume a diagnosis is correct because I can “check off” the right boxes.
ReplyDeleteThe idea of cultural competency is certainly stressed at my job, because we serve people from so many different backgrounds. I agree with feeling like I am never “done” being culturally competent, I am always learning. Working primarily with parents and children now has certainly caused me to have to examine my own personal background and beliefs with regards to parenting and raising a family. Since I do not have children of my own, I feel like I especially have to work daily on meeting the client where they are. I can’t just impose my own views on people (especially since I haven’t even had the chance yet to see how it all works out in real life!). I also am constantly made aware of how privileged my upbringing was in comparison to many of the young parents I see daily struggling to do their best in raising their children and deal with problems that arise. I hope to continually be in the process of examining how my own lenses color each situation that I encounter, and work on identifying when I’m having difficulty in relating to where my patients are coming from.
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