© Springer International Publishing Switzerland 2015
Meryam Schouler-Ocak (ed.)Trauma and Migration10.1007/978-3-319-17335-1_44. Cross-Cultural Communication with Traumatised Immigrants
(1)
Department of Clinical Neuroscience, Transcultural Centre, Stockholm County Council & Karolinska Institutet, Stockholm, Sweden
(2)
Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Study Group on Psychosocial Migration Research, Hamburg, Germany
Introduction
Culture affects communication of trauma, coping, help-seeking, and expectations of treatment. Expressions of symptoms of post-traumatic stress may vary according to cultural and contextual factors. Culture affects how people make sense of post-traumatic distress. In this chapter, we discuss cross-cultural communication in clinical settings with patients having an immigrant and refugee background as well as symptoms of post-traumatic stress. Cultural aspects of communication related to language, idioms of distress, discourse systems, help-seeking, and identification of signs of trauma and assessment and treatment will be considered. Barriers to communication and support for overcoming barriers in cross-cultural communication will be discussed. Consideration will also be given to how to create a trustful relationship and therapeutic alliance. Theoretical aspects will be presented together with a case illustrating communication and interaction with health care.
Traumatic experiences can lead to the development of post-traumatic stress disorder (PTSD) but also to major depression and several other psychiatric disorders, such as specific phobias, disorder of extreme stress not otherwise specified (DESNOS), personality disorders, and panic disorders (Foa et al. 2000). Depression is common, especially after personal loss (Silove 2007). The prevalence of post-traumatic stress symptoms varies among refugees. In a systematic review of surveys about post-traumatic stress disorders in general refugee populations in western countries, Fazel et al. (2005) found 9 % diagnosed with PTSD, 5 % with depression, and evidence of much psychiatric comorbidity. Refugees who have had severe exposure to violence often have chronic pain or other somatic syndromes (Kirmayer et al. 2011). PTSD is associated with ill-defined or medically unexplained somatic syndromes, such as dizziness, tinnitus, and somatoform syndromes, and several medical conditions such as cardiovascular, respiratory, musculoskeletal, neurological, gastrointestinal, endocrine, pain, sleep problems, and immune-mediated disorders (Gupta 2013).
Refugees often do not have experience of just one single trauma, but of multiple traumas, and hardship related to premigration and migration experiences, and additional acculturation difficulties in the new host society. Most people experiencing trauma recover in socially safe situations. Also, a majority of those having acute stress reactions or PTSD improve, but for some the symptoms may remain for a long time (Pottie et al. 2011). To identify patients in need of help, it is important to recognise that signs of post-traumatic stress can vary and be combined with psychiatric and somatic comorbidity. For immigrants and refugees living in exile, this can be of special concern as people in their new context might have poor knowledge about harsh conditions in their countries of origin and on migration routes.
It is often the case that immigrants and refugees, especially newly settled, have poor knowledge about how the health-care system works, what help they can obtain, and how to communicate their suffering and need for help and support in an understandable way in the new context. It is therefore necessary for health and mental health services and professionals to be sensitive to cultural and contextual aspects of communication.
Cross-Cultural Communication
The term cross-cultural communication refers to situations of communication between two persons of different cultural backgrounds. Most clinical encounters are in a sense cross-cultural as a layperson’s perspective on health and illness often differs from the medical understanding. In the literature, the concepts of intercultural communication are more commonly used than cross-cultural communication. Ting-Toomey (1999/2001) relates intercultural to communicating meaning. One person tries to convey meaning and the other tries to interpret it. Both verbal and nonverbal information are important for conveying meaning. When conveying and interpreting are confirmed, a shared meaning is constructed. Also, culture, age gender, and social reference group may all contribute to diversity in styles of communication.
Cross-cultural communication often includes trying to penetrate the immediate surface of words in order to understand the meaning of the other. The anthropologist Ulf Hannerz (1992) discusses communication in culturally complex versus small-scale societies in terms of communication in social situations of greater or smaller cultural asymmetry. He compares communication in situations of small asymmetry with the tip of an iceberg. What is explicitly communicated can be largely tacit as much is known and already shared. In situations of greater asymmetry, more needs to be explained and contextualised in order to attain a shared understanding.
Hannerz argues for taking the perspective of the other in order to create a shared meaning. This view is also emphasised by Scollon and Wong Scollon (2001) who define successful communication as based on sharing as much as possible the assumptions we make about what each other means. They state, ‘When we are communicating with people who are very different from us, it is very difficult to know how to draw inferences about what they mean, and so it is impossible to depend on shared knowledge and background for confidence in our interpretations’ (p. 22).
When health professionals encounter patients with an immigrant and refugee background, much often needs to be asked and explained. What is under the tip of the iceberg needs to be visualised and verbalised. The clinician may only have scanty knowledge of the patient’s context and social background leaving much to be discussed and explained. Vice versa, the patient might have poor knowledge about how the mental health-care system works and what sort of help is available. Trust and confidence are central to good-quality cross-cultural communication. A trustful relation in which the patient and the clinician want to convey and understand the meaning of the other is the basis for overcoming communication barriers.
Language
Language is central to clinical communication and affects patients’ experience and expression of distress. Language provides both possibilities for expression and limits for communication. It is hard to communicate what we lack words for. With language, we can approach and distance ourselves from memories and experiences. Words and phrases do not just have cognitive meaning but also emotional and symbolic meanings (Westermeyer 1990). Language has also a dialogical character, and the meaning of words and concepts are partly influenced by interaction (Bot and Wadensjö 2004).
Cross-cultural communication often involves communication in a second language, translations, and working with interpreters. Westermeyer and Janca (1997) suggest that symptoms are subjectively experiences that are often not easily translated into numerous languages. They exemplify this with words for sadness, anger, anxiety, pain, boredom, weakness, and fatigue that may require more lengthy explanations. The capacity for using a second language may deteriorate due to age, stress, illness, and crisis.
For example, in psychotherapy as a verbal treatment approach, language can also be overrated in cases. If, for instance, a patient with a recurrent depressive disorder (current episode severe without psychotic symptoms) seeks for help in an inpatient mental health-care setting and speaks a different language than the professionals, it happened that the institutions refused to treat the patient with the argument that ‘due to the communication barriers he is not able to take part in the [fundamental treatment component] group therapy’. As a consequence, the patient was refused in different institutions until one offered a treatment focussing in the nonverbal treatment components in terms of building up activities and daily structure.
Health Literacy
Health literacy is regarded as the ‘degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions’ (National Institute of Health 2000, p. iv). Patients with a lower literacy level can have problems reading prescriptions or following medical recommendations. Lower health literacy can lead to poorer knowledge of the patient’s disease and worse clinical outcomes (Rothman et al. 2004). There are specific vulnerable groups that have higher proportions of limited health literacy than the general population in Europe. This includes older people, members of ethnic minorities and recent immigrants, people with lower levels of education and/or low proficiency in the national language, and those who depend on public transfer payments (WHO Regional Office for Europe 2013).
Idioms of Distress
People may use different ‘idioms of distress’ for communicating suffering. The concept, idiom of distress, was coined by Mark Nichter (1981). He defines it as a socially and culturally resonant means of experiencing and expressing distress in local worlds (Nichter 2010). Idioms of distress may convey signals and information about past traumatic events, memories, and present stressors. The concept of cultural idioms of distress was introduced in the American psychiatric Diagnostic and Statistical Manual of Mental Disorders, DSM-5, in 2013. There it refers to linguistic terms, phrases, or ways of talking about suffering among individuals of a cultural group using shared concepts of pathology and ways of expressing, communicating, or naming essential aspects of distress.
In cross-cultural communication, it may be useful to be sensitive to patients’ use of different idioms of distress when communicating experiences of trauma and sequel of trauma. DSM-5 emphasises that idioms of distress may influence expression of distress of PTSD and comorbid disorders. Examples of this are given, e.g. that panic attacks may be prominent in PTSD among Cambodian and Latin American patients due to the association of traumatic exposure with panic-like ‘khyâl’ (Cambodians) attacks (wind-related panic attacks including symptoms of panic attacks and other symptoms) and ‘ataque de nervios’ (Latin Americans characterised by symptoms of intense emotional upset and panic attacks).
In an overview of trauma survivors, Hinton and Lewis-Fernández (2010) discuss the clinical utility of the concept of idioms of distress. They suggest that idioms of distress may influence the personal meaning of trauma-related disorder, shape the course of the disorder, determine the pattern of help-seeking and self-treatment, but also help clinicians understand the patient’s view of distress. Rasmussen et al. (2011) studied refugees from Darfur and identified the trauma-related idioms of distress, ‘hozun’ and ‘majnun’. These concepts shared symptoms with both PTSD and depression but were not identical.
Studying social representation of trauma among Palestinians in the Gaza Strip, Afana et al. (2010) identified three types of concepts communicating post-traumatic distress: the concept ‘sadma’ referring to trauma as a sudden blow with immediate impact, ‘faji’ah’ meaning tragedy, and ‘musiba’ referring to calamity. The authors describe the meaning of the concepts in terms of how they function in communicating the meaning of suffering to others, the context of suffering, and how to mobilise social support.
Various somatic symptoms, for example, headache, pain, and sleeping problems, are common triggers for seeking care for post-traumatic stress. Kirmayer and Young (1998) suggest that somatic symptoms may be a culturally salient idiom of distress. Not only PTSD, but also depression and other mental disorders and illnesses, and conditions of distress can be expressed by culturally patterned idioms of distress. Depression is a major post-traumatic response, especially after loss. Migration often includes several and important losses for immigrants and refugees. In a Dutch study of depressive disorders among female Turkish immigrant patients, depression was characterised by a wide range of somatic complaints with anxiety and agitation (Borra 2011). DSM-5 (2013) points out that there are substantial differences in expressions of major depressive disorders. At the same time, it is emphasised that there is no simple linkage between cultures and symptoms and that clinicians should be aware that in most cultures most cases go unrecognised.
Communicative Style and Discourse Systems
Groups of people can have different cognitive styles and ways of communicating. Analysing intercultural communication, Scollon and Wong Scollon (2001) use the concept of discourse systems. They suggest that discourse systems might differ according to culture, as well as also being related to other factors such as age, generation, gender, and professional affiliation. The concept of discourse system refers to groups having a kind of self-contained system of communication with a shared language or jargon. Scollon and Wong Scollon characterise discourse systems according to the following: (1) ideology, (2) socialisation, (3) forms of discourse, and (4) face systems.
Ideology refers to holding a common ideological position and recognising a set of extra-discourse features defending the group. Socialisation is accomplished especially through the preferred form of discourse. Forms of discourse are performing models for identification and in- and out-group markers. Views about hierarchies and about who is the correct person to talk with might differ between discourse systems. People are members of many different discourse systems simultaneously. Differences in communicative style, and discourse system, between patient and clinician may lead to misunderstandings and prejudice evaluation. Differences can also be a way to manifest group belonging and identity.
With regard to trauma, different discourse systems can be manifested in, for example, different views about when to talk about trauma and who to talk about it with, or even whether or not it should be talked about. In clinical situations, a shared communicative style and discourse system can become a fast track for an in-group communication and relation. In-group communication can, for example, include situations of encountering patients with one’s own social and cultural background. For the in-group member, small signals can convey information about communicating likelihood of traumatic experiences. On the other hand, in-group communication may entail a risk of false understandings and of a shared unformulated agreement to avoid sensitive areas.
Culture, Trauma, Emotional Reactions
Communication is both a cognitive and an emotional process in which both patients’ and clinicians’ emotional reactions affect communication. The clinician’s encounter with immigrant and refugee patients with a different cultural background may touch deep unconscious feelings. Comas-Díaz and Jacobsen (1991) use the concept of ethnocultural transference in discussing how culture and ethnicity may be played out in emotional responses. Transference refers to the patient’s emotional reactions and countertransference to the clinician’s emotional reactions in psychodynamic psychotherapy. The concepts have relevance also outside psychotherapy and show how easy it is to involve one’s own stereotypes about the other in communication. Stereotypes can play an important role in the manifestations of transference and countertransference.
Comas-Díaz and Jacobsen exemplify reactions of ethnocultural transference, for example, how ethnicity and culture can be denied to the extent of obscuring and avoiding any issues related to culture and ethnicity. Mistrust, suspicion, and hostility may be reactions to unacknowledged ethnocultural differences. Denial of ethnocultural differences may lead to countertransference reactions of thinking that one is above the cultural or political influence of the society. They also describe the opposite reaction of turning into a clinical anthropologist overly curious about the patient’s ethnocultural background.
The encounter with patients who have experienced severe trauma can also evoke strong feelings affecting interpersonal communication. Clinicians may experience, for example, countertransference feelings such as despair and hopelessness but also feelings such as mistrust and denial. If the feelings are not identified by the clinician, they may easily be played out in actions. For example, feelings of despair can lead to avoiding listening to the patient and hopelessness to not trying to help the person, as no way of helping seems possible. Mistrust and denial may lead to not taking seriously information given by the patient.
David Kinzie (1994) discusses countertransference from his experience of treating Southeast Asian refugees. Although Kinzie refers to psychotherapeutic treatment, this has relevance also for other clinical encounters. Kinzie addresses a broad range of possible reactions and emotions such as sadness and depression. He suggests that these reactions may spring from both empathy and a realisation that what happened to the refugees could have happened to anyone. From his experience, anger and irritability to an unknown perpetrator can last for a long time after a patient has left and spill over into other activities and the private life of the therapist. As a frequent side effect for therapists working with traumatised refugees, Kinzie points to the risk of finding it difficult to work with non-traumatised patients, whose problems may appear trivial. In cross-cultural communication with traumatised patients, identifying one’s own reactions and feelings may be a way to understand and improve the communication with the patient.
Cross-Cultural Communication Barriers
There are often several barriers facing immigrants and refugees when communicating post-traumatic distress to health professionals. Patients usually do not spontaneously talk about experiences of trauma, not even to health professionals (Westermeyer and Wahmenholm 1989; Norström 2004). Health professionals seldom ask patients with an immigrant and refugee background about previous trauma and signs of post-traumatic stress (Al-Saffar et al. 2004; Shannon 2012). Lack of trust in the health-care system can be a barrier for communication. Patients with a refugee background can even have experiences of health care being a part of a repressive state and of health professionals participating in torture. The lack of communication about trauma means that there is a risk that experiences of severe trauma and signs of post-traumatic stress are not identified.
Related posts:
The Epidemiology of Post-traumatic Stress Disorder: A Focus on Refugee and Immigrant Populations
Special Problems in the Assessment of Psychological Sequelae of Torture and Incarceration
Introduction: The Relevance of Trauma Among Immigrants
Gender and Trauma
Traumatised Immigrants in an Outpatient Clinic: An Experience-Based Report
A Therapy Model for Traumatised Refugees in Denmark
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