This part refers to Part D of the DSM V – Cultural Elements of the Relationship Between Client and Clinician.
Researchers commonly relate low compliance and premature termination of treatment when reporting on challenges in interventions with CALD clients. For many ethno-cultural groups, symptoms relating to depression and anxiety are not seen as psychological or psychiatric problems and so interventions in these domains are often dissonant with cultural perceptions – it is not surprising that some CALD clients do not remain in treatment or follow the plans. The metaphor for compliance is a telling one since it implies the client needs to subject themselves or acquiesce to the clinician’s or system’s model and does not suggest a collaborative approach (Kirmayer, 2001).
Kirmayer (2001) suggests that collaboration is the key, as well as working with cultural advisors and colleagues from other cultures. Collaboration will not only make it possible to “better identify their patients’ problems, but also will uncover cultural resources that can complement and, at times, supplement conventional psychiatric treatment”. The relationship between client and clinician, particularly in mental health, will often determine whether a client remains in a treatment process or not.
- In particular, negotiating the differences between explanatory models is critical in maintaining client follow-through. After eliciting the client’s explanatory model the clinician needs to find common ground with their own model. Being able to enter into the world of the client through a common framework will enhance the understanding of the psychological problem and the client’s distress as well as assist the acceptance of diagnosis and treatment (Cross & Bloomer, 2010).
- The clinician must also be able to explain the Western model in plain language and be concise about the seven key concerns – name, cause, reason for time of onset, pathology, severity, course and outcome, and treatment (Andary et al., 2003). Metaphors and examples may help explain incomprehensible names, bearing in mind a concept/terminology in one language/culture is not always directly translatable.
- Communicating respect and understanding of the client’s explanatory model will go a long way towards their accepting and adapting to a new way of perceiving their situation. Making explicit comparisons and pointing out similarities and differences in the client and clinician models will convey understanding of and interest in the client’s culture. The clinician should encourage questioning from the client as this will help in assessing the client’s or family’s understanding.
- As part of acknowledging and valuing the client’s model, working with a religious leader or traditional healer may need to be incorporated into treatment in ways that do not conflict with the clinical treatment.
- It is important to make a distinction between accommodating the client’s treatment expectations and adopting the client’s model. Andary et al. (2003) point out that a clinician trying to accept a model that they don’t believe in is not authentic and can discredit them. Credibility is an important aspect of the relationship, more so for some groups than others. Although credibility is generally enhanced when there is more similarity between the parties, if the person is honest in their communications it is possible to convey respect and acceptance while holding a different approach. For example: “In New Zealand culture, we don’t … but I understand that this is important to you and your family and so we can try to include this by ….” Respect, credibility and provision of benefit are the important factors in contributing to successful negotiation (Andary et al., 2003).
- Cultural influences on transference and counter-transference in a clinical setting require awareness and management throughout the relationship.
Cross and Bloomer (2010) emphasise the importance of dialogue in a mental health or psychiatric interview. Language problems need to be clearly differentiated from mental health problems and working with an interpreter who is bilingual and bicultural will be essential for some clients. Working with an interpreter and/or cultural case worker can also enhance the therapeutic relationship if the clinician manages the relationship so that a good therapeutic triad is established. Providing an interpreter who speaks the preferred language of the client, who is ethnically appropriate and is competent to work in mental health and maintain confidentiality are important. These principles are covered in the "CALD 4: Working with Interpreters" course– particularly the three distinct phases of the session with an interpreter – pre-briefing, structuring the session and post-briefing.