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Issues in parenting and dealing with mental

health across cultures

• Dr Rosie RooneyDr Rosie Rooney

• Curtin University of Curtin University of TechnologyTechnology

• CHIRICHIRI

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OverviewOverview

• Case and ValuesCase and Values

• Brainstorm about issues Brainstorm about issues that come up that come up

• Overview of cultural Overview of cultural awarenessawareness

• Explanatory modelsExplanatory models

• CAT toolCAT tool

• Multicultural counselling Multicultural counselling and therapy theoryand therapy theory

• Case study, CAT Case study, CAT

Case studyCase study

• 16 year old Johara is from an Iraqi background 16 year old Johara is from an Iraqi background and thinks that her parents are stuck in their and thinks that her parents are stuck in their old ways and feels angry that she is not allowed old ways and feels angry that she is not allowed to go on dates with her boyfriend Jeff. She has to go on dates with her boyfriend Jeff. She has felt unable to tell her parents, Nasira and felt unable to tell her parents, Nasira and Mohad that she has a male friend although they Mohad that she has a male friend although they suspect that she has. Nasira and Mohad suspect suspect that she has. Nasira and Mohad suspect that there is something going on and feel very that there is something going on and feel very let down that Johara may be seeing not only a let down that Johara may be seeing not only a male but a non-Muslim male. They feel that male but a non-Muslim male. They feel that Johara is very disrespectful of her culture, Johara is very disrespectful of her culture, religion and of them. They have told Johara that religion and of them. They have told Johara that she is not to go out for two months or see her she is not to go out for two months or see her friends unless they visit her at their home and friends unless they visit her at their home and only attend school. Johara’s school performance only attend school. Johara’s school performance has plummeted going from an average of A’s to has plummeted going from an average of A’s to C’s, she is not concentrating in class and has C’s, she is not concentrating in class and has been crying most days. The teacher has been crying most days. The teacher has referred Johara and her parents to the school referred Johara and her parents to the school counsellor. counsellor.

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Case cont…Case cont…

• Johara and her family have Johara and her family have been in Australia for 5 years been in Australia for 5 years and she has rapidly learned and she has rapidly learned English. However Johara’s English. However Johara’s parents feel uneasy about parents feel uneasy about coming in as they feel that they coming in as they feel that they will not be understood either will not be understood either culturally or when they talk culturally or when they talk with their accents. They think with their accents. They think that Johara’s symptoms are a that Johara’s symptoms are a punishment for not behaving punishment for not behaving according to the Koran.according to the Koran.

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Comments about Comments about case studycase study

• Get into groups of 3Get into groups of 3

• What are some key issues?What are some key issues?

• What would you do?What would you do?

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ValuesValues

• Think about:Think about:– your attitude to abortionyour attitude to abortion– Your political affiliationsYour political affiliations– Your religious affiliationsYour religious affiliations

• Think aboutThink about– How is these compare to How is these compare to

your parents’s views on each your parents’s views on each of theseof these

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Issues that occur working Issues that occur working with adolescents in CALD with adolescents in CALD families families

• Intergenerational Intergenerational differencesdifferences

• Differences in cultural Differences in cultural beliefsbeliefs

• Differences in values, e.g., Differences in values, e.g., boyfriends, sex before boyfriends, sex before marriagemarriage

• Language issuesLanguage issues

• RespectRespect

• ShameShame

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Some general Some general principals in cultural principals in cultural awareness: questionsawareness: questions

• Why culture Why culture awarenessawareness– Acculturation Acculturation

Theory (1997)Theory (1997)

• What is culture?What is culture?

• What is CALD?What is CALD?

• What is What is stereotyping?stereotyping?

• What is What is ethnocentrism?ethnocentrism?

• What is cultural What is cultural competence?competence?

• What are What are explanatory explanatory modelsmodels

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When we talk about When we talk about cultureculture what do we what do we mean?mean?• There are many definitions of There are many definitions of

culture. culture. • The one adopted by CAT is The one adopted by CAT is

culture:culture: • ““provides people with ways provides people with ways

to make sense out of life, to make sense out of life, aiding in imposing meaning aiding in imposing meaning on thoughts, behaviours on thoughts, behaviours and events, and allowing us and events, and allowing us to make assumptions about to make assumptions about life and how it ought to be life and how it ought to be led” (Chrisman, 1991).led” (Chrisman, 1991).

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What is CALDWhat is CALD

• Culturally and Linguistically Culturally and Linguistically Diverse backgroundsDiverse backgrounds

• Not simply just language Not simply just language basedbased

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Factors influencing Factors influencing Mental health and mental Mental health and mental illness in CALDillness in CALD-examples-examples• Pre-migrationPre-migration• The process of resettlementThe process of resettlement• Responding to the stressors of other Responding to the stressors of other

culturescultures• Discrimination and oppressionDiscrimination and oppression• Multicultural policyMulticultural policy• Individual characteristics, e.g., self-esteem, Individual characteristics, e.g., self-esteem,

coping strategies, ethnic identity, coping strategies, ethnic identity, acculturation strategy, history of acculturation strategy, history of depressiondepression

• Group characteristics, e.g., status of the Group characteristics, e.g., status of the groupgroup

• Recognising the cultural differences Recognising the cultural differences involved in the expression of mental health involved in the expression of mental health or illness as well as the types of or illness as well as the types of interventions (Rooney et al., 1997; Rooney interventions (Rooney et al., 1997; Rooney et al., 2006).et al., 2006).

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Problems with DSM-Problems with DSM-IVIV

• Lack of attention to criteria Lack of attention to criteria which may vary across which may vary across cultures, e.g., depression, cultures, e.g., depression, schizophrenia etcschizophrenia etc

– Lack of research across Lack of research across different cultures and many different cultures and many assumptions made about assumptions made about how the invariance of how the invariance of symptoms across culturessymptoms across cultures

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There are a number of There are a number of important things to important things to remember:remember: 1.1. The degree to which each The degree to which each

person identifies with a person identifies with a cultural group will varycultural group will vary

2.2. The number of groups with The number of groups with which a person may identify which a person may identify may varymay vary

3.3. Because of culture, people Because of culture, people are inclined to be are inclined to be ethnocentricethnocentric (Seah, Tilbury, (Seah, Tilbury, Wright, Rooney & Jayasuriya Wright, Rooney & Jayasuriya (2002)(2002)

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EthnocentrismEthnocentrism

• Ethnocentricism “occurs when Ethnocentricism “occurs when all behaviours and actions are all behaviours and actions are judged according to the judged according to the standards of one’s own culture.standards of one’s own culture.

– For example, in some cultural For example, in some cultural groups, spitting in the street is groups, spitting in the street is more socially acceptable than in more socially acceptable than in others.others.

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Cultural competenceCultural competence

• A process not A process not an endpointan endpoint

• Understand the Understand the concept of concept of cultureculture– Affects Affects

interpretations interpretations of behaviourof behaviour

• Willingness to Willingness to identify and identify and explore own explore own cultural cultural influencesinfluences– Own emotional Own emotional

reactionsreactions

• Willingness to Willingness to explore cultural explore cultural influences of influences of othersothers

• Ability to Ability to identify identify culturally culturally appropriate appropriate strategies fro strategies fro working with working with people from people from CALDCALD

(Fitzgerald et al. (Fitzgerald et al. 1996).1996).

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When dealing with When dealing with people on an people on an individual basisindividual basis• DoDo

– discovery of the discovery of the core issues for eachcore issues for each

– Acceptance of Acceptance of diversitydiversity

– CCommunicating ommunicating effectivelyeffectively

– Equity and accessEquity and access

• Don’tDon’t– maintaining lists of maintaining lists of

cultural cultural characteristics of characteristics of different ethnic different ethnic groups” (Carillo, groups” (Carillo, 1999, cited in Seah 1999, cited in Seah et al., 2001, p. 9).et al., 2001, p. 9).

– Stereotype: Stereotype: making making assumptions assumptions about the about the characteristics of characteristics of an individual, an individual, which are based which are based on a standard, on a standard, simplistic simplistic characterisation of characterisation of their culture (Seah their culture (Seah et al., 2001).et al., 2001).

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Explanatory ModelsExplanatory Models(Kleinman et al., 1978)(Kleinman et al., 1978)

• involve a set involve a set of beliefs of beliefs regarding regarding mental health mental health problems and problems and encounters encounters with health with health professionals. professionals.

– why it why it occurred, occurred,

– the the consequenceconsequences of the s of the problem, problem,

– how the how the problem will problem will unfold unfold

– the the appropriate appropriate intervention intervention that is that is involvedinvolved

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Failure to recognize Failure to recognize and incorporate and incorporate explanatory modelsexplanatory models

• when working with CALD when working with CALD communities can result communities can result – in misinterpretationin misinterpretation– failure of the client to failure of the client to

engage in services engage in services – poor treatment outcomes poor treatment outcomes

(Kleinman, 1978; Bhui & (Kleinman, 1978; Bhui & Bhugra, 2002; Rooney, Bhugra, 2002; Rooney, Wright & O’Neil, 2006)Wright & O’Neil, 2006)

– Less likely to maintain client Less likely to maintain client in therapy (Barrett, 1997) in therapy (Barrett, 1997)

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Pilot study evaluating Pilot study evaluating explanatory models or explanatory models or Iraqi womenIraqi women

• Specifically, there was a Specifically, there was a significant decrease in significant decrease in scores from pre-test to scores from pre-test to post-test – a decrease that post-test – a decrease that was maintained at the 5-was maintained at the 5-week follow-up (Gent et al., week follow-up (Gent et al., 2007). 2007).

• Very positive social validity Very positive social validity datadata– e.g., 4-5/5 satisfaction for e.g., 4-5/5 satisfaction for

every moduleevery module

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Beliefs about the Beliefs about the causes of mental causes of mental illness illness (Rooney et. al., 1997)(Rooney et. al., 1997)

• mental illness mental illness occurs occurs because of because of bad deeds bad deeds

• mental illness mental illness occurs as the occurs as the result of a result of a previous bad previous bad life in one’s life in one’s ancestryancestry

• Bad KarmaBad Karma

• mental illness is mental illness is a disease that a disease that you can catchyou can catch

• if you talk about if you talk about mental illness, mental illness, you may become you may become mentally illmentally ill

• if you help if you help someone with a someone with a mental illness mental illness you may become you may become mentally illmentally ill

Example of Example of explanatory model explanatory model for CALD for CALD adolescence and adolescence and their parentstheir parents

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• Adolescent – Greek familyAdolescent – Greek family– Mum and Dad are so interfering and Mum and Dad are so interfering and

controlling they say I don’t love them controlling they say I don’t love them when I won’t wear a jacket when it is when I won’t wear a jacket when it is cold at night. I am not cold and I am cold at night. I am not cold and I am going to overheat if I wear the jacket. going to overheat if I wear the jacket. They can just F… off. They can just F… off.

– Mum and Dad. He doesn’t care or Mum and Dad. He doesn’t care or respect us. He never listens to what we respect us. He never listens to what we say. I can’t stand his disrespectful say. I can’t stand his disrespectful attitude. He can just move out. He attitude. He can just move out. He clearly doesn’t love us. He won’t wear clearly doesn’t love us. He won’t wear his jacket when we know he will get a his jacket when we know he will get a bad cold if he doesn’t wear it. We bad cold if he doesn’t wear it. We should never have moved to Australia. should never have moved to Australia.

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The Cultural The Cultural Awareness Tool Awareness Tool (CAT; Seah et (CAT; Seah et

al., 2002).al., 2002).

1.1. What do you think What do you think caused your caused your problem [use problem [use client’s words]?client’s words]?

2.2. Why do you think Why do you think it started when it it started when it did?did?

    3.3.      What do you think What do you think

your [*] does to your [*] does to you? What are the you? What are the chief problems it chief problems it has caused for has caused for you?you?

4.4.  How severe is your How severe is your [*]? What do you [*]? What do you

fear most about it?fear most about it?

  

5. Within your culture, 5. Within your culture, how would your [*] how would your [*] be treated?  be treated?  

    6. How is your 6. How is your

community helping community helping you with your [*]?you with your [*]?

7. W7. What kind of hat kind of treatment/help do treatment/help do you think you you think you should receive?should receive?

8.8.        What have you been What have you been doing so far for [*]?  doing so far for [*]?  

9.9.          What are the most What are the most important results important results you hope to get you hope to get from treatment?from treatment?

  

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Theories of Theories of counselling and counselling and psychotherapypsychotherapy

• ExamplesExamples– Behavioural, Behavioural, – Cognitive-behavioural,Cognitive-behavioural,– Humanistic,Humanistic,– Psychoanalytic,Psychoanalytic,– HumanisticHumanistic

• Emerged from Euro-American Emerged from Euro-American cultureculture

• values and customs of values and customs of counselling and psychotherapy counselling and psychotherapy are not universally trueare not universally true– e.g., individualism versus e.g., individualism versus

collectivismcollectivism

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In Euro-American In Euro-American culturescultures

• = individualism= individualism

• Individualism: a high value Individualism: a high value placed on the individualplaced on the individual

• Collectivism: the majority Collectivism: the majority of cultures in the worldof cultures in the world

• e.g., Japanese has no e.g., Japanese has no pronoun equivalent for “I”pronoun equivalent for “I”

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In counselling, individual In counselling, individual autonomy expressed in autonomy expressed in the following ways:the following ways:

• in individual counselling “I-in individual counselling “I-thou” relationship is valuedthou” relationship is valued

• responsibility for change responsibility for change rests with the individualrests with the individual

• problems rest primarily problems rest primarily with the personwith the person

• mental health linked with mental health linked with increased autonomy, increased autonomy, independence and independence and personal self-actualisationpersonal self-actualisation

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Other culture-bound Other culture-bound values:values:

• rational empiricism and rational empiricism and symbolic logic symbolic logic

• openness, honesty and openness, honesty and self-disclosure. self-disclosure.

• verbal, articulate, assertive verbal, articulate, assertive and able to express and able to express feelings and emotionsfeelings and emotions

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Metatheory that is Metatheory that is culture centredculture centred

• to overcome these to overcome these problemsproblems

• a theory about theoriesa theory about theories

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Basic Assumptions of a Basic Assumptions of a theory of multicultural theory of multicultural counselling and therapy counselling and therapy (MCT)(MCT)

• (Sue, Ivey, and (Sue, Ivey, and Pederson, 1996)Pederson, 1996)

• Proposition Proposition 1:1:– MCT is a MCT is a

metatheory metatheory of of counselling counselling and therapyand therapy

• Proposition Proposition 22::– Both Both

counsellor counsellor and client and client identities are identities are formed and formed and embedded in embedded in multiple multiple levels of levels of experiences experiences and contexts and contexts

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Cont…Cont…

• PProposition 3roposition 3::– Development of cultural Development of cultural

identity is a major identity is a major determinant of counsellor determinant of counsellor and client attitudesand client attitudes

• Proposition 4Proposition 4::– modalities and goals modalities and goals

consistent with the life consistent with the life experiences/cultural values experiences/cultural values of the client.of the client.

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Cont…Cont…

• Proposition 5Proposition 5::– multiple helping roles developed multiple helping roles developed

by many culturally different by many culturally different groups and societies. groups and societies.

– one-on-one encounter, one-on-one encounter, – larger social units, larger social units, – systems intervention, systems intervention, – prevention.prevention.

• Proposition 6Proposition 6::– The liberalisation of consciousness The liberalisation of consciousness – self-in-relation.self-in-relation.

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Practice implications Practice implications of MTCof MTC

• Widen perspective from individual focusWiden perspective from individual focus• Consider context or self in-relationConsider context or self in-relation• FamilyFamily• Incorporate explanatory models, e.g., Incorporate explanatory models, e.g.,

spiritual/religious interventionsspiritual/religious interventions– Growing evidence that use of explanatory models Growing evidence that use of explanatory models

in interventions in interventions reduces distress and increases reduces distress and increases compliance in clients (Barrett, 1997; Bhui & compliance in clients (Barrett, 1997; Bhui & Bhugra, 2002)Bhugra, 2002)

– further research is needed to develop models of further research is needed to develop models of intervention based on explanatory models intervention based on explanatory models

• = cultural issues = cultural issues • = significant others= significant others• = may mean “out of office” activities= may mean “out of office” activities• = asking questions, paraphrasing and = asking questions, paraphrasing and

interpreting world views as they relate to family interpreting world views as they relate to family and cultural issuesand cultural issues

• Further research evidence needed, e.g., Further research evidence needed, e.g., evaluated intervention studies for adolescent evaluated intervention studies for adolescent issues incorporating explanatory models of issues incorporating explanatory models of clientsclients

StrategiesStrategies

--Being Culturally sensitive--Being Culturally sensitive

-Understanding the explanatory model -Understanding the explanatory model of adolescent and adult- CAT toolof adolescent and adult- CAT tool

-Being aware of differences in -Being aware of differences in acculturationacculturation

-Being neutral-Being neutral

-Systems/family theory-Systems/family theory

-Negotiation-Negotiation

-MCT-MCT

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Case studyCase study

• HandoutHandout

• CAT toolCAT tool