Health care providers, bereavement anxieties and ethnocentric pedagogy: Towards a sense of otherness
Institute for the Advancement of Research, Australian Catholic University, Melbourne, Australia
College of Theology, The University of Notre Dame Australia, Fremantle, Western Australia
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culture, psychiatry, migrant, refugee, mental health, otherness
PP: 175 - 178
Religious and cultural diversity in Australia have been overlooked by many religious, educational, and health care institutions where practices and attitudes to death and bereavement are concerned. The formation of culturally appropriate treatment plans necessitates a radical turnabout, namely adjusting one's perception and awareness to different cultural and religious values. Likewise the need to develop new investigative instrumentation and culturally diverse health services is not to be underestimated. This editorial reveals the shortcomings of the mental health model of Western cultures such as in Australia where members of the community are no longer homogeneous in their cultural and religious background. In a multicultural society, where the basis of understanding traumas and stress is interconnected with religious and cultural undercurrents, myopic psychiatry and health approaches are rendered ineffective. We offer some suggestions on what needs to be done to better address the needs of people from culturally and linguistically diverse backgrounds.
Encountering culture beyond the limits of western psychiatry
Western psychiatry has developed as an ethnocentric discipline with illness as a basis for its model - a rationale which took precedence over anthropological considerations. In disregarding the presence of other racial and cultural perspectives, western health care institutions, of which psychiatry is a front-runner, failed to rid itself of culturally distorted perspectives and sensitivities regarding non-European, non-American communities (Fernando, 1991). What constitutes the foundations of western psychiatry and its rational scientific approach are cultural assumptions where individual, material and non-religious interests dominate. The result is a hierarchical order of human values which is fundamentally at odds with non-western psychiatry.
In the case of mourning rituals and ceremonies surrounding death, one finds vast differences between the two systems in terms of overall diagnosis and healing assumptions. Where rituals involving a dynamic relationship between the grieving and support-providers are used as healing powers in traditional spiritually-oriented societies, western psychiatry dismisses them as something irrelevant to its biomedical treatment methods. For example, culturally sanctioned expressions which are considered by many migrant communities as coping strategies, including passivity, euphoria, aggression, submissiveness, extroversion, self-flagellation, non-assertiveness, psychological martyrdom, hierarchical dependence, hearing voices, masculinity and femininity, are often described by western psychiatry as pathologies.
Discrepancies in mental health concepts
Health care providers view mental health as a by-product of what is culturally determined in anyone's psychological functioning, social conduct and holistic well-being. The way they perceive and judge others is also determined by how much their (the health care providers') culture has affected their awareness and concerns. Harry Minas (1990: 50) elaborates on this point:
A culturally diverse society is composed of groups with widely differing conceptions of what constitutes normal and abnormal experience and behaviour, differing attitudes to mental illness and sufferers thereof, different healing traditions and so on. In Australia, as in many other English-speaking and European cultures, the mental health system (including the education system that produces health professionals) is essentially monolingual and monocultural. The structures, priorities and programs of the system do not reflect the diversity of the population that it has a responsibility to serve.
Key factors which contribute to the shaping of mental health of migrants and refugees alike include: size and cohesion of the compatriot community; arrival and settlement as individuals or families; level of education; access to health services; and occupational skills. Any one or combination of these factors can set many of these communities apart, psychologically, from the mainstream society. There is no that doubt pre-migration experiences and dispositions tend to colour crisis-coping abilities and overall health conditions.
In considering how strongly the migration experience subjects immigrant communities to structural inequalities in Australia and the way it impinges on their well-being, one can understand the urgency of badly needed change in the health systems (Ferguson & Browne, 1991). But because of the great variability of these experiences, one could anticipate that the results of studies of psychiatric consequences of migration and bereavement will also show a great variability (Ata, Klimidis & Minas, 1992).
Minas (1990) and Fabrega (1969) suggest that psychological, social and cultural variables that most closely affect human behaviour, health and illness in society must be considered when studying migration and mental illness. According to Fernando (1991) it is this level of concern or state of consciousness which allows Western culture to view certain non-European experiences as abnormal; that is, as symptoms of mental illnesses. He explains that experiences which fall outside western cultures are viewed, at best, as not valid. One cannot help question the hidden agenda of western psychiatry in encouraging dependence of migrant communities on the services which western psychiatry itself provides. In so doing western-perceived mental illnesses are perpetuated in accordance with self-fulfilling prophesies, and the subsequent dislocation of individuals from their cohesive ethnic culture is speeded up.
What is labelled and perceived as illness in one culture could be different or opposite in many others, a persistent block in attempting to achieve a cultural comparability (Kleinman et al., 1984). Reference to cultural contexts thus becomes a prerequisite for attaching any meaning to the concept of 'illness' or 'health'. As a consequence, any attempt to view religion, psychology and philosophy separately from the fabric of immigrant culture, opting instead for a western medical dialectic of mind versus body, is a distortion of reality.
Another major incomparability between western psychiatric systems and others relates to acceptance of the kinds of emotions which constitute mental health and illness. In Western psychology, emotions are considered internal states or feelings, producing certain physiological states, and are recognised through one's verbal or non-verbal ways of behaving. The reduction of the individual's emotions to biological factors, and the disregard of the impact of social or cultural influences, transforms this subject matter into a simple and distorted jargon that makes accounting for a variety of cross-cultural dimensions of emotional expression impossible. Fernando (1991: 101) states:
Emotions may be suppressed, distorted or exaggerated for psychological, social or cultural reasons; and some feelings or the way they are expressed, may be designated as 'illness'. [For] feelings may be expressed in terms of idioms - complex behaviour patterns including music, poetry, dance, art forms, etc - that have become imbued with meaning through usage underscored by symbolic associations.
In many Western communities special value is given to the bereaved exercising full control over their emotions, unperturbed by any sense of obligation to those around them. By attributing the final authority to the individual, societies in the west perceive their approach as humanistic. By contrast, in non-western communities, which include the majority of Australian immigrants, a closer relationship and identification with the immediate (bereaved) group provides an irreplaceable means of healing and fulfilment; certainly a different variation on the meaning of 'humanistic'.
Fernando (1991: 17) explains that the 'group' or 'society' may be the same as an ethnic group, an immediate or extended family, a nation, or a system of ancestors or god(s), and can be extended to other times or births. Hence, spiritual beliefs, ethical values and identity are all associated with mental health, and not just as individual aspects of mental health but as an integrated whole. The concept of mental health must be seen in the relevant social, cultural, political and religious context.
Graham (1986) offers the following interpretation: 'Eastern culture, in its concern with intangibles rather than 'facts', with emotionality rather than rationality, gives pre-eminence to the subjective and experiential'. This is a major reason why neither approach has a monopoly on the truth or a superior methodology.
Needs of refugees
Little attention has been given to the pre-migration traumas and inequalities experienced by refugees and their influence on their mental health experiences. Yet research is consistent in showing a relationship between trauma or great emotional stress and disposition to mental illness. Pathological bereavement anxieties may result from pre-migration traumas (Ata et al., 1992; Kinzie, Tran, Breckenridge & Bloom, 1984).
The relationship between mental health after settlement and the migration experience of refugee communities (such as the Vietnamese, Arab-Lebanese and Palestinians) may be differently interpreted by health care providers and the bereaved because of their contrasting cultural backgrounds.
It has also been observed that feelings of sorrow and loss for abandoning the country of origin add to the confusion, anxieties and chronic depression of refugees, particularly in times of family crisis (Schofield, 1990). One study established that those who left members of their family behind were found to be more at risk in the deterioration of their health (Burke, 1980).
Although the risk of developing mental disorders is higher among refugees than other groups, precise measurement of late symptoms of guilt and disorders is difficult (Van Drunen, 1982). The cumulative emotional distress further develops in the absence of cohesion and support from the extended family and the wider refugee community. Ironically, other studies have likened the experience of bereavement to that of becoming a refugee who has been through stressful pre-migration ordeals, and suffered greatly in health (Eisenbruch, 1984).
Suggestions: Towards developing a sense of otherness
We have to leave this mentality in which we are in-ourselves and for-ourselves. Thinking and understanding in-ourselves, we are left to the tyranny and totality of our own experiences and perceptions. Being for-oneself, we are again left in another tyranny or totality, namely the narcissistic desire of seeking one's own possibilities in life without reference to others. If we are going to have any chance of being committed to the needs of people from culturally and linguistically diverse backgrounds, we need to let ourselves be encountered by a spirit of other-centeredness. We need not necessarily be so active with our judging and inquiring minds, but rather have the wisdom of passivity, that is, an openness to understanding difference.
When we are open to the other in our midst, that is to difference, we can experience a new way of being, a way which transcends our own western-cultural mind. We can begin to discover the depth of humanity. If we have the humility and openness to enter into another cultural perspective, we can discover ways in which to benefit those from different cultures and diverse backgrounds who are experiencing mental illness. We can begin to learn that our individual way of addressing situations needs to be challenged by a spirit of other-centredness, that is to say, a difficult freedom in which we become exposed to the different forms of expressions of feelings and behaviour.
Western psychiatry needs to be exposed to various cultures not just to learn from them, but to let itself be encountered and enriched from their perspectives. Such an encounter will give the necessary time and space for reflection, sharing and research. It will bring a change of heart, indeed a revived heart, to the giving of care in mental health. The question is not, 'To be or not to be?' We must perceive that there is no definite answer to the riddle of being human, of suffering, of finding death and life together. A resolution, we suggest, is to embrace a sense of going beyond ourselves so that we might be encountered by the face of the other. Granted the possibility of this encounter, we will find that our experience, presence and objectivity will not be the defining categories, but rather the fact of being exposed to the other's suffering expressed in their cultural milieu.
To western psychiatry, the model of mental health may be considered beneficial in direct proportion to the extent to which it is influenced by members of the culture it hopes to treat. That is, it can be considered as useful as it is sensitive and open to diverse cultures. However, in a multicultural society, where the basis of understanding trauma and stress is interconnected with religious and spiritual undercurrents, western-style psychiatry is rendered ineffective as far as it is in-itself and for-itself. In other words, because it carries with it the assumption of superiority, it will not be open to integrating approaches which others regard as effective.
The assumption that what is diagnosed in Euro-American cultures as psychopathological must by necessity be universal, is not only indicative of myopic vision but also evokes dissatisfaction among other cultures. Western psychiatry cannot assume a universally established context from which it can deal with culturally conditioned fears, or a variety of other feelings and behaviours. Western psychiatry has a duty to grow within our postmodern world to a maturity in which difference and otherness are encountered with wisdom, service, and a heart.