Angela and Bridie’s article inJune’s Clinical Psychology Forum on cross-cultural practice

Angela Simcox, Director

Bridie Gallagher, Children’s Services Manager

Indigo International

No 28, Street 460, Phnom Penh, Cambodia

angela@indigo-international.org

Summary: We discuss the transferability of UK clinical psychologists’ core competencies in an international setting based on our own experiences in Cambodia. The complex cultural and contextual considerations lead us to advocate a top down approach in developing countries.

As clinical psychologists practicing in Phnom Penh, Cambodia we have accumulated an almost unique perspective on the challenges and usefulness of transferring NHS based training to an international setting. We work in private practice with Cambodian and expatriate families. Learning how to engage with and provide meaningful services for these families from all over the world with a range of cultural backgrounds, beliefs and experiences is challenging and exciting.  While the issues are vast and continue to leave us with more questions than answers, we have selected some key core competency related issues to provide some food for thought.

Supervision

When you work in a country that does not yet train and produce clinical psychologists, has few positions or services, and where the term “psychologist” is often interchangeable with “counsellor” – a role requiring little training or experience – finding supervision can be difficult.  As the only centre of its kind, we must rely on our team and a small citywide network for support. Regardless of our backgrounds we provide each other with supervision on professional issues and ensure we work as safe and reflective practitioners.  For more specialist issues we need to look to our UK colleagues. Long distance supervision can be invaluable but has many difficulties too; lack of familiarity with the context can result in half the session wasted explaining the intricacies of Cambodian daily life and practice within it.

Offering supervision to professionals working in NGOs and government institutions fits well with the role of a CP; Cambodia is flooded with (largely untrained) helping professionals offering support to local people who have experienced trauma, sexual abuse, trafficking, rape, and stigma.  After some misguided efforts to provide free albeit much-needed supervision in unstructured, chaotic settings over-run with bad practices which our presence simply supported, we quickly realised such an approach is unhelpful, disempowering, unsustainable and quickly under-valued with so many other pressures on staff time. We have repeatedly seen first-hand the many difficulties with volunteering as unsustainable, often badly managed and even harmful to those it is meant to benefit. This bottom up approach left us feeling frustrated and uncomfortable.  Alongside the powerlessness from the inability to affect change in the wider system, we also realised our presence reinforced the story of the omnipotent Westerner as the saviour of the poor helpless locals, representing volunteers as a positive factor in the children’s lives; a controversial and, to us, objectionable sentiment.

Surprisingly, it can be challenging to convince organisations of the importance of supervision but this is slowly changing and there is a growing interest in contracting us for properly organised, long term supervision. Offering supervision to Cambodian colleagues at our centre has been a rewarding and meaningful experience.  There is mutual learning regarding systemic and cultural issues for us and of those approaches not well taught in local universities for them. We have learned that helping local psychologists develop is a far better use of our time than trying to act in their place in contexts where we are out of our comfort zone. By supervising them they can use the new skills to make positive relationships with Cambodians in ways that we as outsiders simply cannot.  Our experience has shown that our time is better spent working in a more top down approach.  Supervision has to be accepted as a part of practice by the whole system not a “freebie” once a month because a Westerner feels pressure to “give something back”.  If we join in this way we do supervision a disservice.

Assessment

Assessment can be a minefield; it is amazing how many assumptions and cultural norms we innocently bring to the session simply through the questions we want answered. For Cambodian families it often appears baffling why we want to know about ‘common’ developmental milestones; we have now learned that other things are important to them, developmental tasks have different priorities, and there are different expectations on a child to those assumed by us Westerners. The conversation can be become nonsensical as they try to give the answers they think we are looking for and we both miss the mark. Here our Cambodian colleagues are invaluable. The issue of using standardized assessments is too great to discuss here but has obvious shortcomings; however, it seems to us that our qualitative frameworks for assessment are equally lacking in validity in many ways.  A simple concept like age may be interpreted differently (Cambodian families count how many years life has overlapped so a seven year old could be reported as nine); what do we mean by ‘a child’s first word’ (in the west it is often any babbled approximation to a word, is that the same everywhere?); what about the influence of spiritual interpretations of a child’s development?

Parents’ lack of education and differences in societal practices mean we are often faced with expectations from families that we had never contemplated; common examples include, previously being told the child would grow out of their difficulties by age seven or having been advised head massage would cure autism.

Formulation

In a country that has relatively recently emerged from a long civil war and lost an estimated third of the population just over 30 years ago, what is mental health and wellbeing?  In a collectivist society it is not fulfilling one’s personal hopes and desires but fitting into the family and fulfilling expected roles that are paramount for families seeking support.  Furthermore, Buddhism prevails as the prominent religion and ideas about karma inform families understanding of disability and behaviour.  The accepted understanding from a UK training perspective is that the past experiences of children and families, and their current environment, will shape their beliefs and behaviour. This understanding provides (alongside our westernised psychological models), the basis for formulating families’ situations.  However, the idea that their early experiences and current context have influenced development and behaviour is not necessarily intuitive or accepted by Cambodian families (not to say that formulation has not been used effectively to help Cambodian families to understand their child and how they can support them).

Often differences in development or behaviour can be thought of as either illness or predestined traits.  In a collectivist society the idea that the family can change to support the young person’s needs can be difficult to communicate and even more difficult to accept and implement.  Families can come to understand a diagnoses (as the medical model prevails), but explaining a child’s difficulties through their experiences and their interactions with other people is much more challenging.  Allowing families to “save face” and avoid blame is just as important as in any practice, if not more so; however helping them to understand the impact of their own behaviour is crucial. This is a tricky balance as simply accepting the existence of difficulties in the child or family (as opposed to medical problems) can mean a loss of face. Their origin can be a particular issue with it being easier to accept that a difficulty originates from an incident such as tripping over an hitting the head, rather than a congenital cause as the latter ‘taints’ the whole family and can impact how siblings are viewed by society. This leaves the dilemma of whether to challenge beliefs about origin of the problem when we know them to be misguided but possibly functionally beneficial for the family.

We have found that showing families results through therapeutic intervention can be the most useful way to help families understand a formulation.  We must respect and be aware of families understanding of why the child is different or difficult as this will have an impact on change and the intervention, but often it feels that these explanations are contrary to our own understanding.  We therefore often hold our own formulation and the one shared with the family quite separately and share it much more slowly.

Communication

In the UK we regularly used letters to communicate information, formulations, and to end therapy.  The use of written information for Cambodian parents, and even expatriate clients is extremely unusual as although spoken English may be excellent, understanding written information can be more difficult.  It is not always appropriate to ask about this either as cultural norms make it embarrassing to admit having poor skills. The challenge for the clinician is in using clear and simple language to communicate new and complex formulations and explanations of behaviour.  This can include careful considerations of your accent and colloquialisms, which can be a lot trickier than it sounds. A feedback session and report for a family with limited English and no previous understanding of psychological ideas and models can be a real challenge; one that we do not pretend to have met.

We try to avoid communicating through translators if possible as we have learned that, with those families without sufficient English we suffer a double difficulty in communicating our ideas due to differences in education and cultural beliefs and sessions can become nonsensical.  Many psychology-related words have no direct translation in Khmer so a translator needs a thorough understanding of the subject. Spending time discussing the aims of the session with a Cambodian colleague and supervising them to carry it out on our behalf is far more effective.

When people learn that we work in a developing country they assume we provide services for orphans and those affected by poverty.  Although many of our clients have very difficult histories they are predominantly educated and relatively wealthy families, as without some shared understanding of the wider world and development we cannot be effective.  A poor family in the provinces who has never left their village present a barrier to communication that we feel we cannot overcome.  This is not a language barrier as we have excellent translators, rather a cultural one.  We are like aliens whose world view and understanding of family make it very difficult for us to offer meaningful help.  Westerners are seen as the people who bring help, the people who give you what you need.  This does not fit with our provision of psychological services and ideas about empowerment.  Rather, by communicating and sharing our psychological knowledge and skills with those who are in a position to question and challenge our approach, we feel that we are communicating in the most effective way with the Cambodian community.  This top down model is rare in developing countries but we feel strongly that it is the most effective approach.

Intervention

So what works?  How do we make positive changes for families struggling with their child’s differences and behaviour?  Firstly, establishing effectiveness is difficult and the range of difficulties that families seek support for is great.  So we will focus on two of the most common; behavioural difficulties and children with atypical development.

The current generation of Cambodian parents are often lacking strong parenting models having lost their own parents during the Khmer Rouge, with those surviving suffering displacement and trauma. Meaningful intervention can range from information giving about effective strategies to shape behaviour, to practical and long term therapeutic intervention where parents can practice making relationships with their children using games and nurturing activities.

Play and praise can be very difficult for parents who never experienced these as children themselves.  In addition, there is a cultural barrier to praise as it is considered embarrassing and even representative of a ‘loss of face’.  Praise from your boss is not considered desirable, but instead recognition is delivered in the forms of certificates and concrete rewards.  The hierarchical structure of society where age confers status particularly within the family means that threats and admonishment is the more common form of discipline.  Parents often feel that they are relinquishing control by using “sweet words” with their children.  Seeing positive effects is the easiest way to convince parents of the effectiveness of such methods, but there is a further cultural “barrier”; large families with often only one parent signing up to the intervention. While this wider systemic support is a strength for the child, it can make for a confusing environment with little consistency; a disadvantage for the intervention and demoralizing for parents. We are still seeking a solution to how to engage and involve the whole family in the intervention.  The lack of English in the wider system and cynicism of the older generation about such unusual approaches are difficult barriers to overcome; the solution once again comes back to training and empowering our Cambodian colleagues to adapt the interventions appropriately. Many Cambodian families are hesitant to discuss difficulties of parenting or accept their child is anything other than a genius due to ideas about losing face.  We are currently designing research to find out more about these issues.

Research and Evaluation

As you have probably already realised, there are a multitude of useful, fascinating and complex research questions emerging from our work. As with all research, funding is a major issue and psychosocial work in developing countries is only beginning to receive recognition.  Ethics procedures are flawed or non-existent so ensuring this is externally monitored is important. Consent is a major issue. The population are not accustomed to being asked for their views or encouraged to question, criticize or scrutinize. Despite having the usual information about their role and rights explained to them this is unlikely to be enough. In our experience, participants will they say they understand but may not; they will rarely ask questions; they will also overwhelming respond positively and with answers that they think they are expected to provide. In Cambodian culture it is rude to do otherwise and some may have never have considered the critical questions being asked as it is not encouraged to think this way. I have seen several research articles which appear to have fallen into the trap of taking data at face value and have reported a very positive view of some aspects of life in Cambodia which those of us living here know to be a misrepresentation. Without contextual and cultural knowledge it is very easy to generate meaningless data.

There seems to be a large, emerging role for CPs in the evaluation of the numerous projects run by NGOs and governments. Projects regularly need to be designed and monitored with mid-term and final evaluations required. Due to the issues already mentioned, local knowledge and access to good local staff is essential for success.

Personal and Professional Development

A huge challenge. As the best qualified professionals in the country training is impossible to come by. By linking into international events we can access some but this is costly. We have to do our utmost to share our varied in-team experience and take advantage of any willing external colleagues from similar lines of work. However, the opportunities for personal development are immense and it is important to use supervision to reflect on these. We are constantly experiencing conflicting ideas, challenges, and ethical dilemmas in a poorly supported system so different from the support (and confines) of the NHS.  We work with populations who have fundamental religious beliefs very different to our own that challenge us about our ability to work effectively with their children. We make important decisions about children’s future and development without the support of an MDT and management structure.  Although sometimes these challenges can raise anxiety it means that we are constantly reviewing our practice, questioning our biases, and growing in professional confidence.

Training and Consultancy

Training Cambodian professionals in government, NGO and private organizations, including international schools, to build local capacity is a feasible method for a Clinical Psychologist to have an impact on children and families and the quality of services that they receive.  We are regularly involved in developing and delivering such training.  Training through translation presents many problems as you can cover only half (or in Khmer a third) of the material and the trainer-trainee relationship is impeded. There is a stereotype of the Cambodian trainee as passive and the Cambodian education system focuses on rote learning, so making sessions interactive and engaging can be challenging already without the barrier of translation.  Demonstrations often fall flat with trainees embarrassed to speak and role-play.  Therefore, we have developed training outlines and manuals in conjunction with our Cambodian colleagues and enabled them to take ownership of the materials and deliver the sessions.  The results were remarkable. Whatever is lost from our more extensive knowledge of the content is more than made up for by the engagement and relationship they are able to develop and use to help the group learn; not just through their native language ability but also the subtleties of the culture and context

Sometimes volunteers or organisations come to Cambodia and offer one off training courses either in English or using translation.  We worry about the effects of this.  It is incredibly difficult to pitch training at the right level without knowing about the context and education levels; and little feedback on this will be forthcoming from the trainees. It is culturally accepted that in Cambodia you do not say “I don’t understand”, “I cannot” or “I do not know”.  Furthermore, this means that without ongoing monitoring and supervision a little knowledge can be easily misused.  Those who receive the training are, relative to their non-trained peers and colleagues “experts”. Our experiences in a small foreign language school demonstrated this clearly.  Training on identifying special educational needs led to a flood of inappropriate referrals and parents being told their children (who were completely typical) had “disorders”.  Thankfully we are available to provide feedback to the teachers and offer alternative models and teaching.  For those who “drop in” to the country without any idea of the cultural context, there is no follow up and supervision, a very real and dangerous problem in any setting.

 

A consistent theme is our experience of the failure of the bottom-up approach in developing countries. Psychology is a developing concept with complexities which mean there are a multitude of cultural and contextual variables to consider and research, meaning so many ideas do not easily transfer. We strongly believe that western psychologists have a role to play in empowering and developing local psychologists to develop the tools, theories and approaches needed to work in their own cultures and contexts, rather than coming in and clumsily trying to do this work for them.

Further reading;

Accra Agenda for Action (2008) Third High Level Forum on Aid Effectiveness. Sept 2-4 2008, Accra, Ghana.

DeLoache, J. & Gottlieb, A. (2000) A World of Babies: Imagined childcare for seven societies. Cambridge University Press, UK.

White, R. (2013) The Globalisation of Mental Illness. The Psychologist 26(3), pp182-5.

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