Other Points: Part 1
I didn't know what to label this article, so I just called it "Other Points" (Maybe someone can try and think of a name for it in the comments). I realised something while reading articles and talking to other colleagues at work, evidence-based psychological interventions, i.e., Cognitive Behavioural Therapy (CBT), the NHS provide, are based on research data and psychological theories representative of a demographic of individuals with similar cultural, religious, social, economic and ethnic backgrounds (Specifically, people from the white, middle-class upper class, males and the western world). This is know as the WEIRD problem in psychology.
I even remember discussing how assessment questions and diagnostic criteria is Westernised and how this could lead to information that might not accurately represent a client's difficulties (especially individuals from or brought up with the non-Western world, beliefs and values). See Scenario 1 & 2 below to see what I mean.
Scenario 1:
In most non-Western cultures, respect for your elders is a massive message taught (I was), and you are taught never to interrupt or answer back anyone older than you. So, as a parent from this culture (who has raised their child with the same value), You're in an ADHD assessment, and a clinician is trying to assess whether your child is impulsive (a diagnostic criterion for ADHD). The clinician asks you the standard question, "Does your child interrupt you or talk over teachers?" or "Do they blur out answers before questions have been completed?". They then follow this up with an example of whenever you talk to your child, does he interrupt you, or when he speaks to other adults, does he? Naturally, you will say no because your child has probably learnt that behaviour and is conditioned not to interrupt when an adult is talking and has never done it in Infront of you. This may cause the clinician to think there isn't any impulsivity and not ask follow-up questions.
But what if a different example was used. for example, does your child interrupt younger children when they talk, or their peers. The response might be different as your child may display their impulsivity in this way as its not deemed as culturally unacceptable to do this.
Scenario 2:
So, let's say you're a clinician conducting a child interview or observing a child at school for an Autism assessment, and you observe an ethnic minority child not providing eye contact with you or their teachers in the classroom. You might note that this is a behavioural sign of autism. However, in some non-Western cultures, especially African culture, giving direct eye contact to an elder is seen as disrespectful and rude. So, it would be essential to explore cultural upbringing with this child's family before saying that lack of eye contact is only explained by autism alone.
The above scenarios are just a few prominent examples of why It's important to hold cultural factors at the back of your mind throughout assessment, formulation and intervention, as they can impact the formulation of a client's needs. Now, coming back to my point about the NHS using evidence-based psychological interventions based on research data and psychological theories representative of a specific demographic of individuals. I completely get that they are evidence-based and have been shown to support various conditions. However, we wouldn’t prescribe medication for a condition where research only indicates it can help a specific demographic of individuals to every demographic with the condition. That would be unethical. To even have medication approved by the FDA, it must go through a series of drug trials, using participant from a range of different demographics.
So, why as psychologists do, we still worship CBT and other psychological therapies? I can't answer that question, but since they are the norm, what I can do is to provide cultural adaptions to the CBT/Psychological therapies assessment and intervention (Don’t worry, I will be going into this in another article).
Lastly,
What your reflections on this blog?
How do you adapt the therapeutic or diagnostic process to clients from different ethnic background?
What should I name the blog?
Comment your views below
The Big MAC event
The Big MAC event brings together lived experience experts and NHS professionals from various fields to discuss NHS service management, operational and strategic matters, and major developments in services and trust.
Overview of the Event
The challenges of working within the NHS
A consultant psychiatrist facilitated this part of the talk. There were discussions about the following:
Moral Injury and how NHS clinicians are working in an under-resourced system and then being abandoned to inevitable failure.
We talked about how systems are designed to exclude client and give any possible reason to keep people out. We talked about how services may not accept client based on the following:
postcode,
diagnosis,
complexity,
comorbidity.
Too much need or not enough need.
Too high Risk or for not being risky enough, lack of motivation,
A client's readiness for change
The language used in psychiatry (applicable to other professions, too) adds to the exclusion culture within NHS.
Professionals hear traumatic event from client they are working with, and this in-turn influences professional perceptions and beliefs of the world, leading to self-protection behaviours I.e., exclusion criteria.
How in only the pandemic has this been brought to light, and efforts have started to have been made towards supporting staff.
The use of terms such as "low risk" so we do not have to deal with it immediately, or they don't meet the criterion to access a service they need as the case is not "Complex enough."
How we continue to behave as if the risk is both predictable and quantifiable, using risk categorizations (low, medium, and high) even though this system is not evidence based.
The tendency to stray from objectivity into judgement in psychiatric notes. For example, using terms like 'manipulative' and 'behavioural' infer that a patient is doing something consciously and deliberately.
P.S. For more detailed information on the topics above, type the article "Magical Thinking and moral injury: exclusion culture in Psychiatry" into Google
The Impact of Moral Injury and Magical Thinking on Clinical Practice
Another consultant psychiatrist facilitated this part of the talk. There was a discussion about the following:
Exclusion in mental health is a long-standing concept, but it's just changed over the years and how excessively risk-averse and under-resourced system may drain its clinicians of compassion, losing sight of the human being behind each 'protected' bed and rejected referral.
In psychiatry, when professionals are distressed, clients are more likely to be looked at like scientific objects, which can lower the professional's ability to care for and be compassionate to clients.
How service could exclude via magical thinking (thinking that if we refer clients to another service that can offer more support, they will get help there). However, we need to realize they will sit on another year or months-long waiting list for this support.
Importance of organizations and services being able to support professionals even when in a distressing environment so that professionals can provide care not based on their superego.
The impact on Service user experiences of the NHS
A Service user facilitated this part of the talk. There was a discussion about the following:
Their diagnosis of borderline personality disorder (BPD) and the treatment they received in the NHS (known as MBT therapy), and how to benefit from the skills they were taught in this therapy.
They further discussed their experience with NHS services and barriers to obtaining support. These are listed below:
The impact of having the diagnosis and how, because BPD is still stigmatized, how professionals treat them differently because of their diagnosis
How medication is not always the answer to mental health conditions.
The assessment process can be challenging and make clients feel as though they must be assessed to see if they are good enough for services, and how professionals should always think of ways to reduce the power dynamic in the assessment phase.
How some people or clinicians see the behaviour but not the pain behind the behaviour.
Potential Solutions: What can we do next?
Realism and honesty should be embedded in the training rather than teaching perfect medicine in an imperfect world. The client will have more trust in us if we are open about the scarcity of resources and restrictions on referrals; if we acknowledge that we cannot provide all we would like to.
Being uncomfortable and having adequate Staffing support.
Meaningful training and service development should be truly involve service users throughout and how a fundamental problem is focusing on beds, breaches, and targets instead of the human story behind each number.
Organizations hierarchical changes.
Lastly, As the reader, what are your views:
Whilst reading this article, do any reflections or viewpoints come to your mind?
Do you agree or disagree with some of the points made?
Comment your views below.