Resistance to Cross-cultural Psychosocial Efforts in Disaster and Trauma

Key Terms

Neocolonial -- the present-day asymmetrical influence of the West over the non-West. Neocolonialism is an indirect form of control through which the West perpetuates its influence over underdeveloped nations through marketing, development work, relief aid, cultural exchange and education.

Cultural Competence – the capacity of individuals and organizations to work effectively cross-culturally via appropriate behaviors, attitudes, policies, and structures. Treatment modalities remain Western; however, the presentation format is adapted to the recipient.

Ethnomedical Competence – term introduced in this paper meaning the capacity of individuals and organizations to discern, utilize, and preserve culturally-embedded self-concepts and effective healing practices. This transpires in democratic and symmetrical learning environments so as not to be neocolonial. The treatment modalities become plural and hybrid, mixing Western and non-Western treatments.

Resistance to and dissatisfaction with cross-cultural mental health responses (trauma relief) delivered by international relief agencies, hinders the ability of these international agencies to provide effective aid in cases of natural disaster, war, and displacement. International and native relief efforts frequently overlook culturally-embedded treatments and, instead, devote substantial resources to implementing Western therapies. This paper suggests guidelines for ethnomedical competence to reduce instances of resistance and inefficient treatment with regard to cross-cultural relief work.

Ethnomedicine is the study of culturally-embedded or alternative beliefs and practices for health care (Genest, 1978; Nichter, 1992). Ethnomedical competence demands an inquiry into how societies relinquish their culturally-embedded practices in favor of alternative or modern practices. Neocolonial pressures (see above) represent one of the many factors contributing to the loss of such practices. Ethnomedical competence, as an integration of approaches, should utilize democratic and symmetrical learning processes in order to counteract neocolonial pressures. Ethnomedical competence describes the capacity of individuals and organizations to discern, utilize, and preserve culturally-embedded self-concepts and effective healing practices. A.J.W. Taylor, who has written in support of encouraging native (local) practices in the South Pacific islands of Tuvalu and Fiji (Taylor 2000; Taylor, Nailatikau, & Walkey, 2002), supports this view when commenting that it is:

…not normally the function of trauma therapists to try to question the basic religious or non-religious belief system of any ethnic group. Rather in practice their job is to work within the given cultural parameters of a population to help to relieve symptoms and promote healing, no matter under what particular system of belief a community might be operating.

Ethnomedically competent treatment modalities are pluralistic and hybrid – mixing Western and non-Western treatments synergistically and appropriately into what can authentically be considered ‘best practices’ in the context of the meeting the needs of members of indigenous populations.

The December 26^th 2004 tsunami that impacted several populations in countries surrounding the Indian Ocean illustrates the scale of the problem that can arise. The world witnessed a substantial flow of resources and therapeutic methods from the West to the areas affected by the tsunami. The World Health Organization [WHO] predicted that 30–50% of the population would experience moderate to severe psychological distress that might resolve with time, or mild distress that could become chronic. In June 2005 it reported that half the affected population were actually experiencing psychological problems, 5–10% of which might require treatment (WHO, June 2005). In the context of an event that affected many different countries and cultures, the need for ethnomedically competent approach, designed to meet the specific needs of affected populations, is evident. However, this was not what was delivered.

Organizations in Indonesia, Thailand, India, and Sri Lanka, in keeping with dominant western conceptualizations of “mental health services,” diverted major resources and personnel to promote Western psychotherapy and psychiatry. Furthermore, to the extent that South Asian organizations emphasized western mental health concepts, they were opting for these methods rather than marshaling funds and attention for culturally-embedded treatments or community-based coping methods. These other treatments include South Asia’s culturally-embedded healing methods: therapeutic yoga, meditation, pranayama (breathwork), Ayurveda, Siddha Medicine, Unani, Tantric spiritualism, pranic healing, and shamanism. While native psychiatrists/psychologists have gone on record supporting these practices, Western agencies, however, rarely integrate these treatments at the official level. Taylor (2000) opined that, based on his experiences in the South Pacific, traumatic stress was addressed by “drumming and dancing” more effectively than anything “that authorities might have prescribed.” Community coping methods may include spiritual grounding and religious leaders, anecdotes of which are also found in the non-scientific literature (Ashraf, 2005). It is argued there that, in the absence of ethnomedical competence on the part of Western relief agencies, these natural coping resources will be underutilized. Furthermore, a failure to utilize them may undermine future community resilience by reducing the capacity of indigenous populations to utilize their intrinsic resources to confront and cope with the problems they encounter. For example, Fallot and Heckman (2005) noted that the prevailing religious philosophy and worldview helped people overcome their personal losses. That is, indigenous beliefs were well suited to facilitating adaptation.

Ethnomedical competence in larger community concerns is necessary for integrated mental health interventions, and often involve elements that would rarely be considered in western contexts. For example, burials, although not typically considered a mental health intervention, have a mental health impact on community members. In reviewing the joint PAHO/WHO guidelines for managing dead bodies, Taylor (2005) writes the following:

“[If] mass burials are to be utilised, individual plots should be provided in a ‘chain of recovery’ that respect the dead and allow for the exhumation of remains for delivery to family members…the humanitarian care and treatment of the dead has an important effect on the recovery of every community after any disaster.”

If these, and other, indigenous customs are ignored, it is not surprising that resistance and protests occur when interventions fail to take native needs and capacities seriously. These are becoming increasingly more noticeable as international agencies become regular visitors to sites of natural disaster, war, and displacement. When direct public signs of resistance against international mental health responses occur, it is clear that the services being made available are not only ineffective, but may actually compound the very mental health problems they intended to remedy. Unless we Westerners practice self-examination through ethnomedical competence, we risk deafness to such protests from academia, field observations, popular media, policy makers, organization publications, uncooperative human resources, and risk creating secondary mental health consequences of a result of instigating inappropriate responses. Evidence for this is evident from the following excerpts:

1. A major English-language newspaper in Sri Lanka, the Daily News, published a story entitled “Responding to the aftermath of the tsunami: Counseling with caution” on February 11, 2005 with the following criticisms:

It is simplistic to view all those who have survived the tsunami as mere helpless victims who are unable to act on their environment or situation.

Sometimes it is the humanitarian aid community and general public, not the affected communities themselves, that (erroneously) attach high importance to individual counseling and therapy.

Often camp settings breach principles of involving locals in decision-making processes, where re-making of communities need local ownership and participation.

2. Recognizing the problems of neocolonial interventions by international agencies, the Psychosocial Working Group ^{(See footnote 1)} published guidelines for its member organizations:

A further principle is that agencies do not just ‘impose’ their intervention on a community but that they negotiate with the communities about what type of program people would like to participate in. The success of negotiating the type of intervention which will be implemented depends on how good the communication is between communities and agencies. If communities cannot influence the planning of the intervention it is likely that the interventions will be inappropriate and fail.

3. In a 2005 World Health Organization article entitled “What exactly is emergency or disaster ‘mental health’?”, Derek Summerfield (2005) writes that it is:

“…"category fallacy" to assume that, just because similar phenomena can be identified in various settings worldwide, they mean the same thing everywhere. Even the best back-translation methodologies cannot solve the problem, as it is not one of translation between languages but of translation between worlds. We need to remember that the Western mental health discourse introduces core components of Western culture, including a theory of human nature, a definition of personhood, a sense of time and memory, and a secular source of moral authority. None of this is universal”.

4. Detecting a lack of awareness and finesse in counseling relief efforts, a Sri Lankan non-governmental organization, the Psychosocial Support Programme, produced a tri-fold brochure for relief workers with seven provocative questions, including:

Most people have their own coping systems and support of their families, neighbors, and friends. Are you ready to recognize, respect, and learn from these?

Counseling training must help participants to understand and develop their own attitudes and beliefs to be able to provide an effective service. Have you considered this in your training program on counseling?

5. In a 2005 World Health Organization article entitled “Mental and social health during and after acute emergencies: emerging consensus?”, officers Mark van Ommeren, Shekhar Saxena, and Benedetto Saraceno write:

“The controversy is compounded by the recent development of a new field introduced by international organizations working in low-income countries that calls itself psychosocial. The term is used to indicate commitment to non-medical approaches and distance from the field of mental health, which is seen as too controlled by physicians and too closely associated with the ills of an overly biopsychiatric approach”, p.71.

6. In a 2005 World Health Organization article entitled “The best immediate therapy for acute stress is social,” Derrick Silove writes:

“The first challenge is changing entrenched perspectives and practices of international agencies and donors, so that they give priority to supporting integrated community-based mental health programmes that focus on social need arising from mental disturbance, rather than special issues or particular diagnoses”, p.76.

7. Carballo, Heal, and Hernandez (2005) observed improved resilience in tsunami-affected populations utilizing spiritual grounding and religious leaders and suggested the following:

“To date, most models of psychosocial assistance have come from Western countries and are based on Western notions of trauma (Summerfield, 1999).
Some of those affected by the Tsunami may react poorly to alien approaches.”

“…external (as well as internal) groups must always pay careful attention to local cultures, religions and traditional ways of coping with incidents such as the Tsunami.”

These seven sources highlight problems in adopting trans-cultural and trans-national assumptions regarding the implementation of mental health interventions to indigenous populations. The above sources attribute the problems to the lack of nuanced thinking on the part of the West.

One alternate explanation for native sources of protest is that an environment of anxiety and deprivation will stimulate a search for a scapegoat. Agencies and the monolithic “West” may be experienced as doing more harm than good or as interfering where they are not welcome. However, scapegoating is unlikely to explain the entirety of these native protests, and they do very little to explain the observations of Westerners.

A literature search yields very little in the way of guidelines for choosing or developing appropriate treatments when there is provider-client (cultural, ethnic and religious) heterogeneity. Ommeren, Saxena, and Saraceno (2005) make general mention of “collaboration with traditional resources such as faith healers may be an opportunity in terms of care, provision of meaning, and generation of community support.” Indeed, observations in Sri Lanka suggested that the prevailing religious philosophy and worldview helped people overcome their personal losses (Fallot & Heckman, 2005), the implication being that a failure to capitalize on natural recovery or healing resources resulted in a lost opportunity to assist recovery.

Ethnomedical competence is hampered by solely focusing attention on the diversity of culturally-embedded beliefs (e.g., emphasizing dichotomies in psychotherapeutic content and client characteristics) rather than focusing also on utilizing diverse culturally-embedded providers or treatment choices. Notable exceptions are the writings of 1) Bemak and Chung (2004) stating “…it is recommended that practitioners present an openness to traditional healers and at times even forge partnerships…” and 2) Karl Peltzer (1995 and 1996) who has himself blended Western interventions with African healing rituals [adapting treatment choices] and has advocated that we “involve local healers in the programme and achieve that they work side-by-side with health workers” [expanding our acceptance of alternative providers].

Readers may suggest that cultural competence is the appropriate orientation with which to address these trans-cultural and trans-national problems. In the United States, at least, the cultural competency canon aims to improve the capacity of individuals and organizations to work effectively across cultures via appropriate behaviors, attitudes, policies, and structures. It hardly questions the primacy of Western perspectives and allopathic treatments. Although there may be individual trainers who question this primacy, the core of cultural competency involves a translation of knowledge, attitudes, and behaviors that allow the Western practitioner to deliver Western treatments -- operationally formatting patients to accept Western biomedicine.

Cultural competence curricula make the ethnomedically incompetent mistake of believing that people primarily need to understand their Western treatment options – accordingly, to understand any other treatments is secondary or negligible. Non-western societies undergo a process of enculturation adopting Western concepts with a corresponding loss of potent culturally-embedded and alternative treatments that may not be codified. These treatments can disappear without institutional power. In the case of psychosocial relief work, there are approaches that are culturally competent but at the same time ethnomedically incompetent. This critique of cultural competence should be expanded by both academics (teaching our psychologists, psychiatrists, and other clinicians) and managers (guiding workers in the field). Ethnomedical competence is an opportunity to expand the delivery of accurate services and best practices.

How do we conduct ourselves as representatives of Western psychotherapy so that culturally-embedded and alternative practices are not inappropriately de-emphasized? For those in the West who are involved in teaching or using psychotherapies trans-culturally and trans-nationally, a set of eight guidelines that can be used to ameliorate this harmful trend are described in the next section.

Guidelines for Ethnomedical Competence in Psychosocial Work

To act on the issues outlined in this paper, organizations will benefit from having a set of guidelines that can be used to facilitate the development of ethnomedically competent practices. These are:

Negotiate mutually agreeable therapy goals and exercise maximal flexibility consistent with those goals (Draguns, 2004).
Learn about culturally-embedded self-concepts and healing practices.
Ascertain how and why culturally-embedded treatments are (or are not) being utilized.
Determine the advantages and/or feasibility of integrating psychotherapy services with currently available treatments.
Develop and implement a plan of integrated services. Expand program evaluation terms and outcomes studies so that the measured parameters do not myopically favor Western treatments.
Re-double efforts to practice client-centered evaluations and treatments (Castillo, 1997).
Utilize anthropology and related disciplines to critique cultural competence appropriately within graduate education of psychologists, psychiatrists, and other fieldworkers
Be mindful of neocolonialism, the Western institutional and cultural power/privilege to influence audiences. Learn to balance cultural power so that all parties collaborate in democratic and symmetrical learning environments. Consider utilizing a consultant with ethnomedical experience to provide perspective and cultural skills sets (Ashraf, 2005; Carballo et al., 2005).

The above guidelines are conservative. They are also preliminary. We should invite additional guidelines and enhanced recommendations from colleagues in academia and experts working in the field. Scholarly and practical critique would help bring this topic to a level of greater precision and intellectual accountability.

Conclusions

It has been the thesis of this paper that international relief efforts inappropriately de-emphasize culturally-embedded treatments, and that change is feasible. Enormous funds and personnel are mobilized in order to implement the spread of Western therapies. If there are culturally embedded treatments that are more effective, more cost-effective, or less disruptive, then recipients of Western therapies are harmed -- at least by opportunity cost, at most by inadequate treatment and negligence. Cultural competence is described to be an incomplete response to complexity, and academics can further refine graduate education to include ethnomedical competence. This paper maintains that best practices in psychological work will include pro-active discernment, utilization, and preservation of culturally-embedded and alternative practices.

References

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Footnote: 1 Made up of five academic partners (Centre for International Health Studies, Queen Margaret University College, Edinburgh; Columbia University, Program on Forced Migration & Health; Harvard Program on Refugee Trauma, Solomon Asch Center for the Study of Ethnopolitical Conflict and University of Oxford, Refugee Studies Centre) and five humanitarian agencies (Christian Children's Fund; International Rescue Committee, Program for Children Affected by Armed Conflict; Médecins Sans Frontières - Holland; Mercy Corps and Save the Children Federation).