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Chapter Eight: A working model of a community based, culturally sensitive counselling service

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Beverley Costa

This chapter outlines the development and the delivery of a culturally sensitive counselling service, in response to the needs of Black and Minority Ethnic (BME) communities, entitled Mothertongue. Clinical examples and experiences are used to illustrate the way in which a bridge is forged between clinical and community development work, in order to provide a relevant service to the target client group. It examines how the therapeutic boundaries have to be renegotiated, as the work is located in a particular social and political context.

Over a number of years, there had been growing concern on the part of professionals in health and social care that the ethnic minority communities in Reading were not receiving the type of help with mental health issues that they needed. Ethnic minorities in Reading account for some 13% of the population, and they were barely figuring on the statistics for clients attending local counselling services.

Some assumptions of traditional counselling services are that:

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Chapter Eleven: Psychodynamic considerations for diversity consultancy in organizations

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Aileen Alleyne

This chapter discusses psychodynamic considerations for diversity consultancy in organizations where the challenge to address wide-ranging issues of difference is paramount. To put this topic into context, we must first acknowledge that the workplace can be a major source of daily stress, conflict, and disruptive change. Harm to personal well-being and poor organizational relationships can be the result, and these factors can threaten workplace efficiency as well as the organization's reputation. Added to this, when tensions and misunderstandings from cultural and racial differences exist, workplace difficulties can often be exacerbated, leading to gridlock and breakdown. External consultancy can be an important intervention to enable organizations to work with these conflicts and develop ways of reducing conflict and boosting workplace morale and productivity.

Organizational consultancy can provide a range of services that could incorporate training, supervision, independent and impartial advice, direction, group facilitation, and mediation. The consultant's role is to work collaboratively with employers and their employees to help them examine both their individual and organizational work practices, set realistic goals, develop ways to work effectively with diversity, and create an atmosphere of equality and inclusion for all. External consultancy can also be seen as an investment, which may work out as being cost-productive to organizations that may otherwise become trapped and embroiled in expensive complaints procedures. Consultancy, in this respect, can help repair damage brought about by old workplace cultures that have gone unchallenged over time. Experienced consultants will be able to offer a combination of psychotherapeutic, organizational, groupwork, coaching and teaching skills, as well as provide impartial and expert support designed for damage limitation and developing reflexive practices for achieving effective organizational outcomes.

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Chapter Five: Clinical assessment

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Zack Eleftheriadou

This chapter provides information on the first meeting of the therapist and client. Although many of the therapeutic issues are connected to the next chapter, it is believed that the first session is so important to how the scene is set for the therapy and the therapeutic relationship that it warrants special attention. If the client has a positive experience from the first meeting(s), they are more likely to return and engage in further therapeutic work.

During the assessment stage or initial sessions, information is gathered which may indicate the potential course of the therapeutic relationship. The first meeting can be used to find out about the client's world, their trust in people, and what are their significant intimate attachments (past and present), which includes family history, parenting experiences, and relationship with siblings, significant current or past losses, relationship history, parenting (if applicable). Furthermore, we could be interested in their work and educational history and whether their familial/parental job/careers led them to particular areas (consciously or unconsciously). Additionally, one can establish if there is any psychiatric history and any medication in the present or past, any link with other mental health services, and contact with other related agencies. A therapist can find herself trying to balance obtaining enough background information with, at the same time, leaving room for the relationship to unfold at its own pace. Some therapists send a questionnaire beforehand, but many prefer to wait to meet the patient and let their history unfold in the course of the sessions. It is important to take a good history, however, as this may be difficult once the therapy progresses; one does not want to interrupt with questions as it disrupts the flow of the communication (particularly unconscious communication).

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Chapter Four: Barriers to cross-cultural work

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Zack Eleftheriadou

This chapter will outline potential barriers to cross-cultural work and some thoughts on how to work with them. The setting, verbal communication (such as working in another language or working with interpreters), non-verbal communication, direct/indirect style of communication, and the variation of emotional expression across cultures will be examined.

Careful planning has to take place to determine a “good-enough” location for a cross-cultural therapy service, and whether one is aiming to serve a particular community group. Although there is not an ideal location to serve all communities, a centre should be near the communities it aims to serve, and yet not too central to the community. Discretion is essential, as for some communities there is embarrassment and shame about coming to therapy, fears that they are going “mad,” or in some cases they can really be alienated from the family and community for seeking outside support (Lago & Thomson, 1996).

Some thought needs to be given to how to make a setting welcoming to those of different backgrounds. Visual images and décor have to be chosen carefully, reflecting the client group(s). More notably, the staff team, to a large extent, will be seen as potential role models and as holding a certain level of power and authority. If the team is predominantly white, then it will give a particular message about race, culture (and even class and gender dynamics) to the clients. Furthermore, their reputation for liaising with community groups, traditional healers, and religious leaders, among others, quickly becomes known (see “External section” for further discussion of networking).

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Chapter Nine: The stories of four Bosnian women

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Edina Dzeko

We have seen and witnessed many wars and political conflicts in recent history. The war in Bosnia broke out in April 1992, after the country's independence from the former Yugoslavia. Over many centuries, different ethnic groups lived in harmony, sharing their religious beliefs. This was the nature of the country that people were most proud of. Mosques, synagogues, Catholic and Orthodox churches have been the symbol of Bosnia as well as the presence of Gypsy/Roma people. This tranquillity changed when the war from neighbouring countries came to Bosnia. The phrases such as ethnic cleansing, genocide, concentration camps, mass graves, all happening in the middle of Europe, became Bosnia's everyday reality that the world watched on television screens. Sarajevo, the capital, was under the siege, the longest lasting siege since the Middle Ages. Most cultural and religious institutions across the country were destroyed. The extent of this war was directly reflected in the number of Bosnian refugees worldwide.

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Chapter One: Introduction

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Zack Eleftheriadou

This chapter introduces the wider socio-political context, including multi-culturalism issues, and outlines the reasons why the needs of Black Minority Ethnic (BME) populations have not adequately been met within the mental health services. It also aims to provide an overview of the relationship between culture and psychiatry. Although the focus of this book is on those clients who attend counselling and therapeutic support, a significant proportion of BME clients will have had some link with the psychiatric services.

The world we live in has become pluralized, culturally, racially, and religiously. When different cultures come into contact, it can sometimes be explosive, as different regions/individuals have such different levels of tolerance and expectations. Multi-culturalism has a long history, in how countries have negotiated their differences and similarities. Generally, increasing communication and travel have improved international communication, which is evident in many educational and professional spheres. We have seen both sides of the spectrum, events that have pushed us into peace and increased communication, and others into war, forcing us into alienation. Therefore, multi-cultural work and research are not always positive, helpful, or even successful because of misunderstandings of cross-cultural behaviour and values. Nowadays, there are still remnants of some old, colonial types of thinking. If we just pay attention to the language used to explain differences, it quickly becomes evident how the words reflect the political arena; for example, terms such as “Third World” have their own negative connotations and are still used in some contexts. All these experiences are emotionally powerful and (often) have a lasting impact on people's psyches. Although we try to keep the fear of the unknown and unfamiliar at bay, it often becomes distorted and can reach the destructive divide, such as the disturbing events we are faced with historically and currently “in the name of religion”. Of course, this fear can be located in all of us, but we like to think it is located in the “other”.

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Chapter Seven: The psycho-social experiences of different immigrant groups and the multi-faceted migration journey

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Zack Eleftheriadou

The first aim of this chapter is to outline the psycho-social experiences of different immigrant groups. It is not intended to create or reinforce stereotypes about particular groups, but rather to educate the therapist on the reality and difference of the client's external world. The second aim is to examine what it means to move from one cultural context to another. The whole psychological journey, from the point of thinking of moving to the actual move and the whole “settling experience” will be explored, using clinical case material and drawing from non-clinical populations’ written accounts. People demonstrate vast differences in their capacity to be in a new cultural environment.

Currently, the predominant minority ethnic groups in the UK come from India, Pakistan, the West Indies, Africa, Cyprus, and Turkey, and more recently, Eastern European countries such as the Czech Republic, Slovakia, Poland, Bulgaria, and Romania. These populations share commonalities in that they are often seen to be “different;” “foreign,” and they are even labelled as being “alien”. Although they are perceived to be rather different from the majority population, they have just as many differences between and within them as they do when compared with the majority population, particularly in terms of languages and religions.

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Chapter Six: The therapeutic relationship

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Zack Elefetheriadou

This chapter will examine the clinical arena further, after the initial assessment meeting has taken place, thinking about how to develop a therapeutic alliance with a new client and utilizing the concepts of transference and countertransference (see Chapter Three). The clinical framework will be a relational one, drawing from psychoanalytic concepts, such as “holding,” and their application to multi-cultural settings. The focus is the exploration of different cultures/realities, and the engagement with our clients, as it is meaningful to them at a particular time and how it influences current psychological issues and the expression of psychological distress.

There are some basic ingredients necessary for any successful therapeutic encounter, such as the concepts of “therapeutic alliance,” “containment” and “holding”. First and foremost, the therapist begins by nurturing the “therapeutic alliance,” or what Erikson (1950) called the “basic trust,” referring to the early trust of the infant developed towards the primary care-giver. If the person has been able to “internalize” (or, literally, take something into one's mind as a mental representation) something positive in their early relationship, and has not experienced a high degree of emotional deprivation, then this will be transferred to the therapeutic relationship. However, if a positive relationship has not been internalized, people may find the intimacy and commitment of the therapeutic relationship simply overwhelming. Different theorists have different ideas on the actual “start” of therapy and whether, as Anna Freud (1928) suggested, a “pre-treatment” or “introductory phase” is necessary. Although Anna Freud later dropped this emphasis, it is a concept to be considered in transcultural work when there may not be any trust that people of other races/cultures can (emotionally) bear clients’ stories. If trust is allowed to develop, then clients can address more culturally conflicting material.

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Chapter Ten: Psychotherapeutic work with refugees: understanding the therapist's countertransference

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Zack Eleftheriadou

Most therapists are chosen to work with refugees because they speak the language or come from the same cultural or racial background and/or have had experiences that resonate with those of the client. They are often people who can easily understand the clients’ experiences, which creates interesting and potent therapeutic dynamics. They can offer a great deal of support to the person, but often with the high risk of over-identification. This chapter is an attempt to examine the complex dynamics from the therapist's perspective when working with refugee clients. (The word “therapist” is used to refer to the professional working with refugees, using a psychodynamic therapeutic framework.) It is a collection of thoughts and feelings expressed in psychotherapeutic and supervisory work from different types of refugee mental health workers. It is an attempt to understand further the therapeutic relationship by focusing on the therapist's psychological response to the client. The chapter will outline briefly some of the common themes reported by refugees, but the primary aim is to focus on the therapist's countertransference feelings. Countertransference, in this context, is defined as a personal psychological response, as well as consisting of socio-political components.

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Chapter Three: Pre-transference, transference, and countertransference

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Zack Elefetheriadou

This chapter will outline the psychoanalytic concepts of pre-transference, transference, and countertransference in detail. They are such significant aspects of the clinical work that they warrant a detailed explanation alongside case material before further aspects of the clinical relationship are outlined. Although some of the issues discussed in this chapter relate to working with refugees, they also have their own unique dynamics; hence, issues directly related to refugees are discussed in separate chapters (see Chapters Nine and Ten).

From the first session, the therapist takes into account the dynamics of transference and countertransference. Transference and countertransference are psychoanalytic concepts that are used to describe the feelings evoked between the client and the therapist. Freud (1895d) was the first to talk about the concept of transference when he outlined his observations on how (as they were then described) “hysterical patients” were falling in love with their physicians. At first, he wrote about this as a hindrance, but he later realized that this could be useful in therapeutic work. Today, it is believed that this is part of every encounter, and clinically it is extremely informative about the client's emotional state and relationships. Transference includes the feelings a client holds for those who are most intimate to them (usually stemming from childhood relationships with their primary care-givers) and how they were treated by them. These are projected to (or placed on to) the therapist. Similarly, countertransference refers to the way the therapist may also place, or, in psychoanalytic terms, project, their own feelings on to the client, or the way in which their own feelings can be triggered by a similar emotional experience to that of their client. These feelings can often be intensified when the therapist belongs to the same culture as the person or their care-givers (Akhtar, 2006). Countertransference is such a useful tool, even with clients who are not fluent in the English language. Acquarone says,

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Chapter Two: Culture, race, and identity: meanings and complexities

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Zack Eleftheriadou

The aim of this chapter is to examine in depth the meanings of culture, race, and racism, and to emphasize how multi-faceted they are. There will be discussion of how human beings have a tendency to stereotype, or behave in a prejudiced manner, and how, as a result, we rigidly apply the concepts of race and culture, perceiving others as belonging to specific criteria. The emphasis here is to explore socialization as interplay between individual, familial, and cultural factors.

A good starting point is to consider what are all the “constructs” which constitute culture and how we can identify them. Culture is such a complex concept (Eleftheriadou, 1996), which has a profound influence on us, and yet its influence can be so subtle. It can be described as altering our lives intravenously, just like the air we breathe. The experience of living in one specific milieu places us in a particular “atmosphere,” with which we become intertwined. It is a profound experience, and one that is often difficult to convey to others. This is because we live culture. Describing the true meaning of culture is not an easy process, as we are deeply emotionally involved with it. We absorb it in a way that we do not even realize it has filtered in. The word “culture” encompasses our total way of life.

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