When only considering the microsocial level of care does not seem to be enough

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When only considering the microsocial level of care does not seem to

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Name student: Yosheng Liu Student number: 11777044 University of Amsterdam

Program: Master Medical Anthropology and Sociology Supervisor: Marianne Vysma

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1. Introduction

I was prepared for it. I did my preliminary research, wrote a decent research proposal and found a fitting intercultural psychiatric clinic to do my research. Above all, this clinic allowed me – a medical anthropology student – to come and do whatever he was supposed to do for his thesis project. Everything was going as planned… Until the fieldwork actually started. Soon it seemed there was more to this clinic. I could not ignore some of the big elephants in the room. They were too big to ignore. This is how my research turned from focusing on ‘cultural competencies’ 1_{and ‘diversity among} patients’ to looking at what seemed to be a bureaucratic labyrinth.

May (2007) critiques the dominance of the ‘Parsonian Paradigm’ in social scientific inquiries on the clinical encounter. He argues that this results in an analytical separation of the dyadic encounter from its social context, and demonstrates how this is reflected by the fractured disciplinary focuses within clinical research. He further points out to an increasing reliance on corporate patterns and managerial regulations in the organisation of care, and refers to this as the “deprivatisation of the clinical encounter” (ibid.: 11). In response to such a change, May proposes a more dynamic social scientific approach, away from a mere focus on therapeutic relationships and its inherent power asymmetries towards a consideration of the multiple interfaces between the content and context of the clinical encounter.

This mirrors the shift of interest I experienced during my fieldwork at the psychiatric clinic. Starting off by looking at ‘cultural communication strategies’ during the intercultural clinical encounter, it turned into scrutinising corporate structures in relation to therapeutic practices. An impetus towards such a change of scope was driven by the fact that I was impressed by how broader organisational structures seemed to influence therapists’ experiences on a daily basis. It pointed out to the importance of looking at the broader context of therapeutic practices. May’s (2007) argument on reconceptualising the clinical encounter therefore constitutes a fundamental starting point for this case study. My aim here is twofold: a) to investigate the multiple interactions between broader social structures and discourses, and daily therapeutic practices; and b) to explore how those interactions affect the provision of care. I develop my argument by discussing some of the challenges therapists face when working at an intercultural psychiatric clinic, and continue by elaborating on how corporate and technocratic management of care influence the microsocial level, and conclude by pointing out to issues of trust in professional expertise.

I adopt a therapist perspective because I consider the clinician an embodiment of multiple junction points where context and content of the clinical encounter meet. Assuming that they have caring intentions, therapists are furthermore fundamental in the provision of a safe therapeutic space wherein healing of patients can take place. For that reason, I deem it important to further explore therapist perspectives on how a changing professional context (May 2007) affects professional practices of intercultural mental health care.

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Cultural competencies: “a set of congruent behaviours, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situations” (Kirmayer 2012a: 151).

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To my knowledge there has been little-to-none empirical inquiry into this specific subfield of mental health in relation to its broader organisational context. Therefore, this qualitative case study is exploratory in nature and aims at identifying interesting issues for follow up investigations (Green & Thorogood 2004). This study is focused on a Dutch intercultural psychiatric clinic that provides ambulatory care to patients with migration backgrounds, and is part of a larger specialist mental healthcare provider (specialist GGZ2_{). However, I have decided to keep the name and place of the clinic anonymous for ethical} reasons (see 4.3). In the following, I present the major theoretical concepts that I employ for my argumentation.

2. Theoretical orientation and major concepts

One major concept for approaching broader social structures surrounding this psychiatric clinic is ‘governing at a distance’ coined by Rose (1999). In the context of neoliberal government this approach offers ‘technologies of governing at a distance’ as an analytical tool for exploring how broader discourses affect the professional conduct of therapists. Kleinman’s (1977) notion of ‘category fallacy’ is further useful to grasp how broader discourses affect the microsocial level of care, by leading to ‘strategic categorisations’ of migrant patients into diagnostic categories (Watters 2001). Furthermore, an elaboration of ‘linguistic and ethnic matching practices’ (Van Dijk & Ghane 2013) contributes to a better understanding of a common practice at the clinic. Looking at matching from a dynamic perspective on ‘culture’, ‘culturalisation’ constitutes another tool to comprehend a challenge the clinic faces, with regards to patient referrals. A brief elaboration on these concepts will enable and facilitate a reading of my findings and analysis.

2.1 Governing at a distance, translation, technologies of government and discipline

Central to my theoretical framework is Rose’s (1999: 49) notion on ‘governing at a distance’, which he suggests for the analysis of liberal forms of governing. His perspective on government is situated within Foucault’s larger conceptualisation of governmentality, which has been described as “the government over people in their social and cultural conduct” (Samuelsen & Steffen 2010: 9), and “the disciplining and regulation of the population without direct or oppressive intervention” (Flynn 2002: 163). In this theoretical approach, power is not considered to be located within a central state apparatus, but rather “embedded in social relations, discourses and practices” (Flynn 2002: 163). Foucault (Milanzi 2001: 19) argued that governmentality constitutes a combination of technologies of power and technologies of the self, and I aim at employing ‘governing at a distance’ to focus more on technologies of power in liberal approaches to government (Rose 1999: 49):

Political forces instrumentalise forms of authority other than those of ‘the state’ in order to ‘govern at a distance’ in both constitutional and spatial senses – distanced constitutionally, in that they operate through the decisions and endeavours of non-political modes of authority; distanced spatially, in that

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these technologies of government link a multitude of experts in distant sites to the calculations of those at a centre – hence government operates through opening lines of force across a territory spanning space and time.

Governing is thus not only located within a ‘central government’ and its institutions, but furthermore dispersed over non-political authorities, exercising power over the microsocial conduct of others far-off from centralised calculations, programmes and policies. Rose (1999: 48) argues that centralised and distant authorities are linked through processes of ‘translation’:

The forging of alignments between the objectives of authorities wishing to govern and the personal projects of those organisations, groups and individuals who are the subjects of government.

General aims of, for instance, economic, legal, or medical authorities are thus aligned and connected with the specific ambitions and goals of individuals, corporations, non-governmental organisations etc. through processes of translation. With regards to how translations are operationalised, Rose (1999: 50) elaborates:

Actors have come to understand their situation according to a similar language and logic, to construe their goals and their fate as in some way inextricable, they are assembled into mobile and loosely affiliated networks. Shared interests are constructed in and through political discourses, persuasions, negotiations and bargains.

Flynn (2002: 163) continues that translation works in a manner “so that actors come to perceive problems in similar ways and accept a responsibility to seek ways of transforming their position themselves”, and enables government at a distance. In case translation would be an undisrupted process, Rose (1999: 50) argues that the autonomy of individuals, families, non-political authorities etc. could be harmonised with the objectives of governmental authorities. However, he further adds that oftentimes translation is an imperfect process entailing contestations and fragility.

This approach is of specific relevance to (neo)liberal forms of government, because the adopted political narratives what Rose (1999: 48) refers to as ‘political rationalities’, aim on the one hand at limiting political influence in certain fields through respecting autonomy, while also shaping the social and cultural conduct in ways that correspond to specific conceptualisations of individual and collective well-being. In governing at a distance social and cultural conduct are not directly interfered with by political authorities, but the latter nonetheless aim at indirectly shaping conduct from a distance.

Neoliberal strategies became more dominant in the UK and Europe from the 1970s onwards, and introduced an ideal of the ‘enabling’ state, with an inherent economic rationale and the pursuit of ‘enterprise’ as the golden standard. As a reaction against the ‘social’ state, those strategies aimed at fundamental reconfigurations based on a business- and competition-ethic, grounded in logics of the market. The advent of ‘new public management’ as an international trend, turned public service into private management (Rose 1999). Among other, healthcare settings turned into ‘businesses’ whereby performance and delivery are managed based on accountability, and organisational activities became issues of ‘incomes’, ‘costs’, ‘allocations’, ‘savings’, ‘profit’... Marketisation and privatisation of knowledge-intensive industries –

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healthcare as one of them – furthermore introduced new techniques of control, not informed by professional expertise but rather by accounting and management. Rose (1999: 52) refers to Foucault’s notion on technologies of power, by conceptualising technologies of government:

Technologies of government are technologies imbued with aspirations for the shaping of conduct in the hope of producing certain desired effects and averting certain undesired events… A technology of government is an assemblage of forms of practical knowledge, with modes of perception, practices of calculation, vocabularies, types of authority, forms of judgement, architectural forms, human capacities, non-human objects and devices, inscription techniques and so forth, traversed and transected by aspirations to achieve certain outcomes in terms of the conduct of the governed. Organisations are rendered into ‘accountable’ and ‘calculable’ spaces, wherein professional activities are expressed in financial jargon. Rose (1999) refers to calculative technologies as powerful technologies for government at a distance and continues that through an accounting discourse, experts are subjectified into ‘objects of calculations’ and ‘relays for calculations’ (ibid.: 152):

As object, calculations from a central point can be made of workers, managers, doctors, or teachers in attempts to assess their performance in relation to a specified standard. And as relay… individuals can be encouraged or required to evaluate their own activities and those of others through the calculative routines of accountancy.

Rose further points out that audit practices have occupied a pivotal role among technologies for governing at a distance, and how it transforms the professional practices that are to be audited (ibid.: 154):

Government by audit transforms that which is to be governed. Rendering something auditable shapes the process that is to be audited: setting objectives, proliferating standardized forms, generating new systems of recordkeeping and accounting, governing paper trails. The logics and technical requirements of audit displace the internal logics of expertise.

Auditing and accounting techniques further disclose the questioning of professional expertise, and reflect a lack of trust in professional practices and decision-making capabilities. In order to be accountable and auditable, professionals in knowledge-intensive industries are furthermore subjected into managers of their own disciplines – besides exercising their actual discipline – in producing information for government purposes. Power (2000: 113) conceptualises audit as the ‘control of control’, and Rose (1999: 154) continues that “its power derives from its capacity to act upon systems of control themselves”. In line with government at a distance, I also consider Foucault’s conceptualisation of discipline (Rose 1999: 22):

Disciplinary techniques may be embodied in an external regime of structured times, spaces, gazes, and hierarchies. But discipline seeks to reshape the ways in which each individual, at some future point, will conduct him- or herself in a space of regulated freedom.

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Power can thus be exercised through disciplinary practices, either imposed or through one’s own conduct. In that regard, Foucault’s elaboration on the Panopticon as a conceptualisation of disciplinary techniques for surveillance, inspired by Jeremy Bentham’s prison, is of specific interest to me (Rose 1999: 187):

The Panopticon was the diagram of a political technology, one that was individualising, normalising, based on perpetual surveillance, classification, a kind of uninterrupted and continuous judgement enabling the government of multiplicities, reducing the resistant powers of human bodies at the same time as it maximised their economic and social utility.

Eckerman (1997: 157) continues that “the Panopticon’s potential for surveillance nurtures self-discipling - causing individuals to ‘gaze upon themselves’ - which replaces torture as the ‘paradigmatic’ method of social control”.

2.2 Category fallacy

As part of a larger medical-anthropological discussion on diagnostic categories (Beneduce & Martelli 2005), Kleinman (1987: 452) introduced the notion of ‘category fallacy’ in order to denote:

The reification of nosological categories, that are developed for a particular cultural group, and then applied to members of another culture for whom it lacks coherence and its validity has not been established.

He argues against the superimposition of culturally specific illness categories onto people in different cultural settings, because this would reflect the underlying assumption that such categories are value- and culture-free (Kleinman 1977: 7). Such fallacies, he continues, are also related to an underlying presumption of diseases – biological or psychological – being universal and ‘discrete entities’ out there, which are enclosed by cultural layers and in need for ‘discovery’. In contrast with that, Kleinman (1977: 4) claims that culture shapes the explanation and furthermore the very conception of illness.

Besides ontological disputes, there are also epistemological questions underpinning Kleinman’s concept of category fallacies. With regards to mental illnesses and ‘evidence-based practice’, psychiatric categories in the Diagnostic and Statistical Manual of Mental Disorders 3_{(American Psychiatric Association} 2013) are constructed in the local context of the United States, and in that sense to be considered culture-specific. Applying those categories to people within a different cultural context would thus lack cross-cultural validity (Kleinman 1977: 4). In line with that, Kirmayer (2012b: 251) points out that psychological research is mostly based on ‘Western’, middle class, educated young people, and hence does not represent ethnocultural minorities in the United States and Western Europe – which I consider as the ‘West’. As a consequence, diagnostic categories, measurements on outcomes, and psychological interventions could be questioned concerning their validity when applied to a cross-cultural context. Furthermore, Kirmayer (2012b) argues that randomised controlled trials are often based on populations with single psychiatric diagnoses, and tend to disregard physical or psychological comorbidities. Such research results might

3_{Diagnostic and Statistical Manual for Mental disorders: is a standard classification system of mental disorders used by mental health} professionals, and developed by the American Psychiatric Association

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therefore not reflect actual patient populations. Lindert (2008) also contests the value of psychological research data on ethnocultural minorities, because the wielded psychometric instruments are based on ‘Western’ psychiatric categorisations and symptoms, applied to ‘non-Western’ individuals. Those issues altogether might contribute to “to spurious findings of treatment ineffectiveness because heterogeneous problems are being addressed” (Kirmayer 2012b: 251), and present for example problems when treatment outcome measures are employed for comparative purposes between different clinical settings (see 5.2.2). This furthermore contests the validity and practical use of DSM based diagnostic categories and treatments, when imposed on ethnocultural minorities in a ‘Western’ clinical setting.

Of important notice is that I do not want to disregard nor minimise the reality of people’s experiences and emotional distress, neither is my goal to argue that mental suffering is fundamentally different within various cultural contexts. Rather, through employing Kleinman’s notion on category fallacies, I adopt a critical realist approach (Warner 2009), and aim at emphasising the social context surrounding diagnostic categories and how this might influence the treatment processes.

2.3 Strategic categorisation

On top of Kleinman’s (1977) critique on the validity of biomedical categorisations for patients with a migration background, Summerfield (1999) highlights how refugees might be more likely to prioritise economic and social factors over psychological treatment when they are asked. He thus emphasises the importance of considering the broader socio-economic and political contexts of migrant patients into the treatment process. It also shows how psychology – often being a distinct discipline from social care – may not always be equipped for addressing the patient’s needs in a helpful manner when treating migrant patients (Watters 2001).

Taking this into account, Watters (2001: 1710) points out that caretakers are sometimes pressured into reframing their patients’ story according to a biomedical context, and introduces ‘psychiatric diagnosis as a strategic categorisation’:

Biomedical taxonomies are not merely scientific labels but are mechanisms whereby resources, be they professional help or financial support, can be directed in accordance with established norms of clinical need. Agencies concerned with the social welfare of refugees may have to identify the problems in the context of clinical categories.

He argues that sometimes diagnostic categories are strategically employed by caretakers, in order to mobilise resources for helping people in need. And due to a “felt responsibility to act” (ibid.: 1710):

The agency may feel an overwhelming sense of responsibility to act and may eschew critical analysis in favour of a pragmatism that proliferates, and adds credence, to bio-medical taxonomies.

So when caretakers feel obligated to assist their patients with regards to whatever problems they might present, there is the necessity of fitting the patient’s experiences into a predefined biomedical framework consisting of diagnostic categories. In that sense, caretakers translate their patients’ stories into symptoms and psychiatric disorders. This not only has the risk of ‘de-culturalising or de-politicising’ the story of the

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patient into an individualised mental disorder (Watters 2001: 1712), but it also reflects what Ong (1995: 1248) refers to as therapists and patients being “caught up in webs of power”, wherein the regulatory effect of biomedicine becomes clear through its dominance over other narratives. In short, such labelling practices of patients tend to be reproduced in order to mobilise social support.

2.4 Matching procedures

Kirmayer (2012a) points out to ethnocultural and linguistic matching as common therapeutic practices in intercultural psychiatry. On a therapeutic level, this constitutes a procedure that links both therapists and patients based on similar ethnocultural backgrounds or linguistic skills. This is purported to make the treatment process less complicated and more time-efficient compared to working with cultural mediators or translators (Van Dijk & Ghane 2013).

Watters (2001: 4) continues that this treatment strategy is situated under the guise of cultural sensitivity, and refers to how the World Health Organisation argues that it would result in more effective and meaningful treatments for migrant patients, and aid in overcoming ‘barriers’ during the therapeutic relationship. I consider the adoption of notions such as treatment ‘barriers’ problematic – especially when it is not clarified what a barrier entails – because I assume it can result in problematising patients, and thus ultimately complicate therapeutic alliances 4_{. With regards to effectiveness of matching practices, this is} contested by Van Dijk and Ghane (2013) because of a lack of clear data. They also point out that such studies oftentimes struggle with the methodological operationalisations of concepts such as culture, ethnicity, and matching (ibid.: 23). Ong (1995) further argues against effectiveness of this strategy, by referring to her qualitative study wherein linguistically matched caretakers aided in the translation of patient stories into a biomedical narrative based on DSM diagnostic categories, and individualise the patient by disregarding the broader context.

Van Dijk and Ghane (2013) further criticise that matching could contribute to societal processes of segregation, and be counterproductive in incentivising non-intercultural mental health institutions to increase their organisational and therapeutic cultural sensitivity. It furthermore entails the risk of homogenising migrant patients by overlooking their diversity, and that matching furthermore potentially contribute to processes of intra-ethnic (counter)transference – e.g. increased emotional involvement of therapists or patient expectations about therapists, in case of similar ethnocultural backgrounds (Comas-Diaz & Jacobson 1991).

When considering the broader societal context with regards to ethnocultural or linguistic matching, this is situated within what Gemmeke (2015) refers to as ‘ethnic entrepreneurship’, rooted in the neoliberal reform of the Dutch healthcare system in 2004-2006. This neoliberal political decision-making enabled the growth of local health care initiatives with a specific focus on migrants, and were a response to ‘interculturalisation projects’ (Meershoek & Krumeich 2008). The intercultural psychiatric clinic where I did my research is exemplary of ethnic entrepreneurship, and targets patients with a migration background for the provision of care. Van Dijk & Ghane (2013: 27) further suggest that overemphasising the importance

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Therapeutic alliance: refers to the interpersonal processes that occur in relationships between a therapists and patients, and are considered an important factor for therapeutic success. For more information see Smith et al (2010).

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of matching procedures might contribute to distorted perceptions of the intercultural psychiatric clinic as an “allochtonen-GGZ” (migrant-GGZ), resulting in possible patient referrals to the clinic, based on language or ethnicity.

2.5 Culture, culturalistic discourse and culturalisation

Meershoek and Krumeich (2008: 174) refer to the “cultural and lifestyle explanatory paradigm” as a dominant rationale in the Netherlands for explaining the apparent health disparities among ethnocultural minorities. They continue by arguing that such dominance is due to the paradigm’s influence on many ‘interculturalisation projects’ and professional trainings. Those came about in the aftermath of the “Dutch Council for Health Care’s recommendations on intercultural management, education, expertise-centres and counselling” (ibid. 174) in 1999, as a response to the increasing diversity of the Dutch population. This paradigm assumes health disparities to be the result of lifestyle decisions, which on their turn would be based on culturally determined norms, values and beliefs. Contemporary anthropological critique has pointed out how this reflects a static and essentialised conceptualisation of culture as a “homogeneous and sharply bounded entity that is transmitted from generation to generation with very little change” (ibid. 174). It is referred to as the “culturalistic fallacy”, and is part of a broader “culturalistic discourse” (ibid.: 174):

Culturalistic discourse presents a culture as existing more or less independently of everyday reality, as something following its own laws of development. It reifies culture, portraying it as a thing or approaching it as an organism or a collective individual.

Meershoek and Krumeich (2008: 175) continue that such essentialised notions of culture are problematic since they may lead to stereotypes and generalisations of migrant patients in healthcare. An example of that is the presumption that migrants’ illness behaviour is culturally determined, e.g. stigma concerning mental illnesses would make migrants prone to somatise. This stereotype would then receive the status of a cultural phenomenon or cultural trait, and constitute a ‘barrier’ to successful treatment since it would prevent caretakers from exploring their individual patients in order to get a better understanding of the issue at hand. In their research, Meershoek and Krumeich (2008: 193) found that doctors tend to “use cultural explanations to explain the behaviour of migrant clients that deviate from the expected norms”. They refer to this as culturalisation, as in that culture becomes an “all-encompassing explanation for behaviour that is seen as a barrier to treatment” (ibid.: 193) during the intercultural clinical encounter.

As opposed to the culturalistic discourse, anthropology suggests a more dynamic approach in conceptualising culture:

It involves the ongoing process of transmitting and using knowledge that depends on dynamics both within communities and at the interface between ethnocultural communities and institutions of the larger society… cultures are often hybrid, mixed, and undergoing constant flux and change.

(Kirmayer 2012a: 155) It is an outcome of interaction… constantly redefined and changed by interaction processes… refers to repertoires of action in which norms and values are enacted.

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(Meershoek and Krumeich 2008: 196-197) Such a postmodern approach to culture (Clarke 2003) has constituted a fundamental starting point throughout my thesis project.

3. Research question

Returning back to the central aim of investigating multiple interaction points between the context and content of the intercultural clinical encounter leads me to my main research question:

What broader social structures and discourses are reflected by professional practices of mental healthcare workers at a Dutch intercultural psychiatric clinic, and in what manner do those practices contribute to the provision of care at this clinic?

I divide this main question further into two sub-questions:

- Which professional practices at the intercultural psychiatric clinic reflect broader social structures and discourses?

- How do those practices contribute to the micro- and meso-level of care at this clinic? In the following I elaborate on how I approached this question concerning methods and analysis.

4. Research methodology and data analysis

In my attempt to answer such research questions I employed qualitative research methods for the gathering of data during a fieldwork period of ten weeks. I furthermore approached the collected data by using Charmaz’s constructivist grounded theoretical perspective as a framework (Charmaz & McMullen 2011). In what follows I touch upon the data-collection methods, data-analysis, some ethical aspects and limitations to the study.

4.1 Research methods

Although my research focus shifted during the fieldwork period, no major modifications were made to data collection methods. However, informal conversations and participant observations gained in importance along with this shift of scope and processual adjustments were made to the content of interviews.

4.1.1 Diary

All observations, reflections, interpretations, analyses and subjective experiences during the fieldwork were kept in a research diary. In line with Green and Thorogood’s (2004) suggestion to keep empirical observations separate from analyses as a good data management strategy, it facilitated a more

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structured data analysis in how you treat your data as a researcher. Although initially a separate script seemed to interrupt a natural flow of writing and thinking, as in automatically linking interpretations with observations, I considered it a good exercise to keep a structure in the diary which facilitated an initial analysis from the start.

4.1.2 Interviews

I conducted 15 semi-structured interviews with therapists at the psychiatric clinic. These had the original aim of exploring the interactional nature of the intercultural clinical encounter and focused for example on different illness explanatory models 5_{(Kleinman et al 1978) between therapist and patient, and} how those are dealt with during treatment. However, as my fieldwork progressed, the content shifted towards investigating therapists’ experiences about the clinic within a broader corporation and mental health system. Interviewing professionals reflected what Green and Thorogood (2004: 93) refer to as “elite interviewing”, because interviewees occupied a more powerful social position at the clinic than myself, a student-intern. This oftentimes resulted in interviews being restricted in terms of time due to busy professional schedules (ibid.: 94) or to additional ethical considerations (see 4.3). For that reason, I organised follow-up interviews when it seemed feasible for interviewees and relevant to my topic.

In the second half of my fieldwork, I further conducted semi-structured interviews with three patients, a member of the local management and an employee of the larger corporation affiliated with the department of intercultural psychiatry. Interviewees that were different from therapists, enabled the triangulation of multiple perspectives on various aspects of intercultural care (Ritchie & Lewis 2003).

During patient and therapist interviews, the setting and context were of specific relevance since they were held in consultation rooms. This was for practical reasons in order to have more privacy and limited acoustic interferences for the voice-recording process. The interior of these clinical rooms was standardised, and consisted of a desk with a personal computer and designated seats for both patient and therapist. In relation to the allocation of seats, I would like to emphasise the symbolic importance of where one sits, and my assumption that this contributes to possible associations with therapeutic power dynamics during the interview (see 4.3).

All interviews lasted between 20 and 75 minutes, were recorded with a Phillips voice recorder and transcribed ad verbatim. Both audio and transcriptions were stored on a personal computer. Interview languages were Dutch, English and Turkish. In the latter, I had help from a Turkish friend who acted as a translator during the interview, and helped me with transcribing. It was interesting to experience interview dynamics that were different from dyadic interviews. For example, having a Turkish translator helped a lot in terms of building rapport and creating an open intercultural space for interviewing. Translations further gave me more time to formulate my questions, while at the same time I considered those to have less depth since translations were often a summary of the interviewee’s account.

5_{Explanatory models of illnesses are the narratives people adopt for explaining: the cause of an illness (aetiology); when and how an} illness began (onset); how this illness manifests itself within the body (pathophysiology), how the treatment should look like; course of the illness (chronic-acute, severity…). For more information see Kleinman et al 1978.

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On top of formal interviews, informal conversations were held with various members of staff and patients during multidisciplinary meetings and open studio sessions (see 4.1.3). As previously mentioned, informal conversations gained in importance throughout the fieldwork period, because people tended to disclose more on personal experiences, which gave me a better impression of the context of the clinic. Informal conversations furthermore were often a source of inspiration for interviews.

4.1.3 Participant observations

Regarding my original focus on cultural competencies as an interactional process, I considered observational methods as a valuable complementary tool to semi-structured interviews. Later on in the fieldwork, this approach turned out to be important for learning about personal experiences and normative ideas – aspects that might have gone unnoticed during interviews (Green & Thorogood 2004: 132).

I conducted participant observations during art therapy ‘walk-in open studios’ on a weekly basis. Those were free sessions at the clinic wherein patients could come and go for practicing visual arts – e.g. painting, drawing, sculpturing – and this constituted a free and safe space wherein the exploration and articulation of one’s own artistry is facilitated. Participation was on a voluntary basis and took place every week in order to offer “continuity” to participants (Deshaldian & Wasmann 2015: 267). Such participant observations provided me with opportunities to get acquainted with patients and art therapists, and build rapport. What soon seemed to be an initial challenge was my rather vague status as a ‘research-intern’, making it difficult to position myself towards patients and staff since I did not have a clearly defined role. In order to create some clarity in that regard, I handed out flyers with information about myself and my research (see 4.3).

Further exploring the art therapy department, I participated in a body movement session wherein movement was used to therapeutic ends. Besides it being a fun participation and furthering my understanding of the variety of practices at the clinic, the minimal role for language during movement therapy did not present me the language issues I often encountered during open studios.

I additionally performed participant observations during multidisciplinary meetings, in which various disciplinary perspectives contributed to the translation of patients’ stories into psychiatric narratives. Those meetings were also intended for deciding on future treatment policies. Such observations presented me opportunities to explore how various disciplines contribute with their own specialty to the provision of intercultural care, and furthermore gave me insights in professional jargon and hierarchies at play. These meetings also informed me on normative ideas on work experiences, referral practices of patients, as well as aspects of the mental health care system in the Netherlands. Those all contributed to an increasing interest of mine in the broader organisational structures wherein the clinic was embedded.

In the context of my original focus on the interactional nature of cultural competencies, I aimed at observing intake sessions of new patients. However, intakes in Dutch and English were scarce during my fieldwork – most were in Turkish or Arabic – and I was only able to attend one intake session, rendering language a limitation to my research.

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Further participant observations included joining public art exhibitions organised by patients themselves, a group visit with patients and therapists to a local museum, joining an educational session for therapist organised at the clinic, and a farewell lunch.

4.2 Data analysis

In my approach to data, grounded theory seemed suitable to the exploratory aim of my research. More specifically, I considered Charmaz’s constructivist approach to grounded theory as a framework for the data analysis. This approach’s value to me lies in its “treatment of earlier grounded theory strategies as flexible guidelines rather than rigid rules” (Charmaz & McMullen 2011: 168). In that regard, it takes a pragmatic methodological stance between Strauss & Corbin’s approach on the one hand, with its convenient and explicit descriptions on techniques for ‘doing grounded theory’ – helpful for researchers being new to grounded theory – and Glaser’s approach on the other, which is less prescribed methodologically and thus offers more space for imagination and creativity through constant comparison and sensitizing concepts (Charmaz & McMullen 2011; Green & Thorogood 2004). Besides methodological pragmatism, I also adopt its epistemological orientation in seeking interpretative understanding and taking the research situation into account through considering the mutual construction of data by the researcher and researched (Charmaz & McMullen 2011). I do not necessarily consider my findings to be transferrable to other settings – also because of a limited number of respondents – but rather aim at further sophisticating ongoing debates within intercultural care and mental health in general.

I used Atlas.ti as a data analysis software for fracturing the data into open codes, and create subsequent axial and selective codes in later stages of the analysis (Green & Thorogood 2004). Because of a limited timespan for fieldwork and the following writing process, I consider my research not to have reached empirical nor theoretical saturation. However, this does not seem problematic to me because of the exploratory nature of my research in finding relevant themes for further investigations. At the same time, I also tried to go beyond a mere representation of ‘emic’ respondent summaries – characteristic of thematic analysis – through looking at relationships between categories and finding meaningful links with existing theory (Green & Thorogood 2004).

4.3 Ethics

During interviews with therapists and patients, I encountered various issues in need of ethical reflections. First of all, it oftentimes occurred that busy professional schedules limited my interviewing time. Therapists were occupied by administrative work, or even spent lunchtime or private time on interviews. In anticipation of such issues I organised follow up interviews when feasible for respondents, or decided to keep interviews short so that they would not intrude too much on time budgets of interviewees. Another struggle was when one interviewee asked me to use her interview on the condition that she could review and modify the transcription herself. This presented me with issues of balancing research interests – using the original version – with the protection of respondents’ integrity. This led to questions as how one approaches data that is manufactured, how this feeds back to the way I approached informed consent, or

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how clear the information was to my respondent before the start of the interview. I ultimately decided not to include the interview for the analysis. As for patient interviews, I considered it challenging when respondents disclosed personal psychiatric histories. The content of such data – although deviating from my research questions – was in need of continuous ethical reflexivity from my side in carefully selecting what topics to explore and when to disengage.

All participants were verbally informed on my research, and gave consent before the start of the interview. However, interviews remained a continuous challenge of navigating research goals in the face of issues such as professional time management, sensitive information concerning patient histories or mental illnesses etc.

Another aspect that displayed ethical struggles was the symbolic meanings attached to the interview setting. Since all patient and therapist interviews took place in treatment rooms with standardised interiors (see 4.1.2), I want to argue that the allocation of seats was possibly associated with power dynamics inherent to the therapeutic relationship. In case of therapist interviews, I always sat in the patient chair, which one could interpret as a symbolic reinforcement of Green and Thorogood’s (2004: 93) concept of ‘elite interviewing’. However, at the same time I believe that me sitting in the patient chair contributed to establishing rapport since this was a ‘natural’ and comfortable seat allocation for therapists. It would also make the interview awkward if I were sitting in ‘their’ chair. When interviewing patients, I offered them the choice where he or she would like to sit before we started, in the attempt of minimising potential associations with therapeutic power dynamics during the interview. This option of choosing one’s chair was received with enthusiasm by patient-interviewees.

Returning back to the issue of handing out research flyers in Dutch to participants of open studios (see 4.1.3) I soon realised how not everyone understood Dutch. I further thought those flyers installed a formality that was in conflict with the studio’s aim of being a free and open space. Moreover, I believe that those flyers presented me as an ‘elitist university student’ who was doing research on mental health patients. Adding to that, open studios did not consist of a fixed group of participants making it complicated to inform everyone about my research without needing to hand out flyers on more than one occasion. Taking into consideration the potential disruptive effect on the open and relaxed open studio sessions, I stopped handing them out. Instead, I participated in those studios and only engaged with participants when they were interested and open to it.

Regarding the representation of data – besides keeping anonymity of all respondents – I encountered an ethical balancing whether or not to anonymise the clinic and the larger mental healthcare corporation as a whole. Since my positionality increasingly shifted, according to a changing research scope, towards the adoption of a more critical outsider view on the topic, I decided to keep the name and location anonymous to avoid repercussions for the participants and research setting as a whole. With regards to sensitive and personal details, some aspects needed to be left out or modified in order to keep anonymity of participants or the research setting.

Concerning confidentiality, I aim at only sharing my findings with the psychiatric clinic, supervisor and second reader of the university. Sharing those results with the research setting will also constitute an ethical challenge in how to translate and present my findings from a theoretical and rather abstract

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discussion into more useful and practical information. I realise how the ethical process will remain a continuous balancing act when informing on my results.

4.4 Limitations

What I consider a limitation in terms of data analysis is the employment of grounded theory when looking at the actual research findings and conclusions. However, at the time of starting my analysis I considered this approach as a valuable option for the exploration of intercultural mental healthcare – and I still do. Nevertheless, when reflecting back on the results I would rather consider critical theory, discourse analysis or the analytics of government (Ritchie & Lewis 2003; Rose 1999). This is a suggestion for further research on this topic.

Another limitation with regards to data collection is my language proficiency in Dutch, French and English. Many patients at the intercultural psychiatric clinic were not proficient in any of those languages, making the organisation of interviews difficult and informal conversations superficial at times. It furthermore rendered participant observations during clinical intakes sessions nearly impossible, since most were conducted in other languages (4.1.3).

Looking at the context of interviews, I assume there were generational aspects – as in how long someone is working at the psychiatric clinic – affecting the content of interviews. For example, in how far the status quo of the clinic was normalised or naturalised by interviewees, and thus having a longer career would enable comparison of the present with previous experiences at the clinic. However, a limited number of respondents due to the limited timespan of fieldwork made it difficult to further pursue that assumption. Besides a limited number of respondents, the interviews did not transcend perspectives that were directly connected to the clinic. In that sense, I risked a ‘black-boxing’ and essentialising of broader social structures and discourses. Further exploration therefore, could look into perspectives beyond the locality of (intercultural) mental health clinics in order to deepen an understanding of the intricacies and complexities inherent to surrounding social structures and discourses.

5. Research findings and data analysis

The first part on research findings elaborates on the clinical ‘complexities’ the intercultural psychiatric clinic is faced with, and how this might be related to matching practices. In the second part I continue by exploring how those complexities need to be translated into diagnostic categories and the consequences this has for therapeutic practices, while the latter are also being assessed based on a certain set of assessment norms. In the last part I investigate the work pressure on therapists and consider possible consequences this might have for the provision of care.

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When people think of transcultural, they think that you really have to do things completely differently. However, it is first and foremost to dwell on your own situation and assumptions. Your own cultural background and beliefs. To make that bridge to someone with a different cultural background, and bringing this into the room over and over again… And always paying attention to migration aspects, religious aspects, language is also something like that. Everything a person includes, it is actually being very broad-minded.

(Int. 12, therapist, 9 years of experience at the centre) Because yes, what is cultural care? Well, in my view it is just that you take into account the culture of the other in the treatment. That you try to connect as much as possible. And that, yes, look I think the advantage that we have is of course the language. You have a much better connection with that.

(Int. 7, therapist, 12 years of experience at the centre) The intercultural psychiatric clinic, where I conducted research, is part of a larger specialist mental healthcare provider within the Dutch GGZ-landscape. The clinic focuses on psychiatric treatments of patients with a migration background, and consists of different therapeutic teams that accommodate multiple mental health disciplines. Those disciplines meet on a weekly basis during multidisciplinary meetings in order to discuss patient cases, intake procedures and treatment policies. The clinic further incorporates an art therapy team wherein various artistic expressions – e.g. dancing, painting, music – are incorporated into the therapeutic process, with a minimal role for language (see 4.1.3). What is specific about this clinic is that it employs ethnocultural and linguistic matching as a strategy for improving relationships between therapist and patient. This implies that a lot of therapists working at this clinic have a migration background themselves and are proficient in various languages other than Dutch, e.g. Turkish, various dialects in Arabic, French, Chinese etc. In the following, I will first elaborate on the presentation of ‘clinical complexities’ at the clinic, and further continue with exploring matching practices.

5.1.1 ‘Complex’ clinical cases

Therapists at the clinic often argued how they encounter patients presenting ‘complex clinical cases’. They articulated complex as “layered”, “multi-problem” or having “co-morbidities”. By highlighting this aspect of the clinic, it is not within my aim to stereotype patients with a migration background as ‘problematic’ or ‘complex’. Nor do I want to suggest that complex clinical cases are more likely to be patients with migration backgrounds. What I do intend by this is investigating what is considered as ‘clinically complex’, and explore the possible mechanisms contributing to this phenomenon. First of all, patients often tend to present socio-economic problems:

R: When I talk to therapists, I often hear about social problems, that this is an important reason for seeking help. Then it's about a residence permit, or housing, or papers that need to prove that they are sick, you know.

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I: There is much more to it?

R: Yes, and of course those are not really the things that we can solve for patients, we don't do that because that is within social care.

(Int. 17, management level) This is in line with Summerfield’s (1999) argumentation that patients with migration backgrounds oftentimes prioritise socio-economic issues over the reception of psychological care, and how as a result psychology might not always have the disciplinary capabilities to cover for the patient’s needs. This is problematic since these cases are nonetheless referred to the clinic, and therapists need to find a way to navigate their psychotherapeutic practices regarding such issues.

Another ‘layer’ that is perceived to contribute to clinical complexities is the chronicity of patients’ mental suffering:

I have a lot of people who have had help for 20 years in white institutions, let's say white institutions where they are not treated by people with their own cultural background or language. Then they have actually been there for years. We have taken over many chronic patients. Actually, very little has been done because of the language barrier and cultural misunderstanding. So often they receive medication, limited talking therapy, and even if they received any, they did not get much out of it. They do not understand what has been discussed at all in all those years, nor can they recall it. So that is peculiar. This does not mean that those institutions have not always done their best, but that the connection is just missing somewhere. And, what we often see is that their explanation [regarding illness cause] is there, but they never dared to tell it because, “that Dutch person will never understand me”. That's what they say in my room, “they don't understand me anyway, they're going to make me crazy, because they don't believe in it themselves”… And they come here and then you have to, yes, it will be difficult to always be able to help them properly because there is already so much going on… They have been through so much, it has existed for so long…Their moral thinking has been affected a little: "to what extent can I get better?". I find it very poignant to see that people like that could actually have been helped easily if they had just invested a little more time in them.

(Int. 7, therapist, 12 years of experience at the centre) This account reflects mechanisms contributing to the chronicity of clinical presentations at the clinic, since such patients received years of ‘insufficient’ care from ‘white’ institutions. Leaving the generalisations and stereotypes regarding ‘white’ institutions aside, this account demonstrates how a lot of patients with a migration background have been ‘wandering around’ for a long time in the mental healthcare system, without being cared for in a ‘proper’ manner. The argument is that it is due to missing a necessary connection because of linguistic or ethnocultural differences between therapists and patients. Since matching is one of the major strategies within the intercultural psychiatric clinic, it allegedly offers a practical solution to those patients that have become ‘chronically ill’ throughout years of ‘insufficient’ care. Although this is a rather blunt statement concerning treatment quality within other institutions, the result is that the clinic often receives patients who might be difficult to motivate or treat, because they have developed chronic illnesses throughout the years.

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An additional mechanism contributing to complex cases is the referral of patients purely based on their ethnocultural background or linguistic skills. A first example is the presentation of geriatric patients: We come across everything. Sometimes we get people aged 70-75, a bit towards the 80, even those come in. Those really need a completely different type of care. We simply do not have that expertise. That's what you call geriatrics, so then you have a very different mental health institution that really focuses on the elderly. This exists, but these patients get referred to us simply because of the language. But then you do no justice to what the patient needs. Look, in some cases, if the language really is a problem, then we would want to work together, but in some cases that is simply impossible. These people really need expertise from an institution that works with it for years.

(Int. 7, therapist, 12 years of experience at the centre) This indicates how sometimes language has priority over for example age as a criterium for patient referrals to the psychiatric clinic. A similar scenario is experienced with referred patients having a wide variety of DSM-based diagnoses:

And we just get a Moroccan patient because that is our expertise. So we are submerged by everything. From very light eating problems or a mild depression, to dystonia and psychosis. For example borderline. So, therein, we are very vulnerable. We just get everything over ourselves, we just have to deal with it…

(Int. 15, therapist, 12 years of experience at the centre) It shows how one’s ethnicity or birthplace is naturalised and essentialised as ‘the expertise of the institution’, both by external partners and the therapist. Again, this illustrates how one criterium overshadows other factors regarding clinical content during referral practices to the clinic. In this case ethnicity is prioritised over various DSM based diagnoses, while the clinic might not have the capacity nor expertise to treat such patients 6_{. Both aforementioned accounts demonstrate how in some cases,} ethnocultural background and language tend to get the upper hand during decision-making processes on referral practices of patients with a migration background. This reflects a rather static conceptualisation of ‘culture’ (Meershoek & Krumeich 2008) and points out to essentialised referral practices. I will further explore this phenomenon in 5.1.2.

Another aspect contributing to the ‘multi-problem’ nature of patients is considered to be related to migration which often involves traumas, feelings of loss etc. These are issues that need to be incorporated in the treatment process, but nevertheless remain disregarded by diagnoses and ‘evidence-based’ treatment protocols:

[in the context of matching procedures related to waiting lists] Intensity, problems... Our patients are always multi-problem patients, there is more to it than just a very beautiful depression or just anxiety,

6_{Within the specialist GGZ health care providers are often customised to specific patient populations. For example with regards to age} (geriatrics), ‘culture’, specific diagnoses and subsequent care-pathways, e.g. personality disorders, addiction, intercultural aspects.

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no, there is so much more involved. So we always have… it's something more loaded than with the regular population.

I: So you mean that it is less simple to solve one individual case, than supposedly just a clear-cut depression?

R: Yes, because you do have that aspect of migration and culture.

(Int. 15, therapist, 12 years of experience) R: We also have very heavy cases, so that also differs between the intercultural psychiatric clinic, and other care institutions within the corporation, really very heavy.

I: Does this have a specific reason?

R: Of course it does, it has also to do with immigration… When immigrants get a depression, then it is not only due to 1 or 2 factors, but there are several factors. Because you get a person that might have been a refugee before, then they are drawn from their own culture, family, their own support system, and arrive here sometimes with two months on the road, through different channels. And he comes here, and for a while has to ask for asylum which is sometimes very heavy and very difficult. And then perhaps also suffers from physical complaints, and then a foreign language, a strange country, a strange culture. Everything is strange to him, and then no work, and perhaps he had a high social status in his country. And here, everything is lost. So what do you expect from such a person, you really have to dig at the beginning, how are you going to… it isn't easy, how do you activate that person? So a very long treatment process is needed. That's why I say heavy cases, and sometimes even trauma, they experienced a lot… are traumatised. Sometimes raped, sometimes very bad stories, you hear very bad stories here. So I think it is very, very heavy. It comes close to you. Everything is open when you speak your their language, they think: “oh my own language! And expect a solution right away”.

(Int. 19, therapist 12 years of experience at the centre) This account argues how migration-related cases could be difficult to treat, and affect the therapeutic process in various ways. For example, an overload of traumatic stories due to matching procedures, could entail the risk of indirectly traumatising therapists when linked with patients coming from an area with a history of (political) violence, e.g. Afghanistan. This is what Klarić et al (2013) refer to as secondary traumatisation 7_{which I will further elaborate on in 5.1.2 in the context of matching practices. An additional} issue is that cases might include multiple problems, which are not included in diagnostic categories that reflect single clear-cut illnesses. Migration histories, traumatic experiences etc. might also need to be incorporated in the treatment protocol on top of diagnosis-based symptoms. Therapeutic practices therefore, one could argue, takes more time than estimated by standardised evidence-based protocols. In that regard, a diagnosis might misrepresent the actual treatment process regarding time and complexity

7_{Secondary traumatisation: refers to a process wherein traumatised individuals transfer stress to their immediate surroundings, with} potential manifestations of distress among persons in direct contact to that traumatised person. For more information see Klarić et al 2013.

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(see 5.2.1). I do not want to purport that psychotherapeutic theory-practice discrepancies are limited to the context of this clinic and patients with migration histories. However, I want to point out that this seems to be particularly the case in this clinic and its patient population. It results in therapists’ being loaded with ‘heavy’ and ‘complex’ clinical cases, with aspects relevant to the illness experience, that are not covered by diagnoses.

What also appears to occur within the intercultural psychiatric clinic is that some patients have never heard of psychology before, or what psychotherapy might include:

Oftentimes people are sent, and then I do not want to generalise, but part of a target population do not know at all what a psychologist does or what therapy is.

(Int. 12, therapist, 9 years of experience at the centre) But the majority, of say the people I saw, that is aged between 40 and 60 years… Yes, actually my parents' generation. And they often came in and in most cases they have already been sent by the doctor, they also have no idea what we are doing… They also do not understand the whole principle of psychological treatment.

(Int. 7, therapist, 12 years of experience at the centre) R: It also has to do, for example, with the fact that a psychologist is not really a clear title in Moroccan. That does not exist, you are a doctor of the mind. You're a doctor, you understand? Psychologists do not exist in the Moroccan, Arabic, or Berber language.

I: So then you really just have to explain the discipline to someone? Which can be very vague to them? R: Yes, yes. But again, it has really been decreasing in recent years, especially the first generation, a lot less.

(Int. 19, therapist 12 years of experience at the centre) So a first reflection is that people are often referred to the clinic, without necessarily choosing for it. In that sense they are subjected into a role of ‘the intercultural psychiatric patient’, which is in conflict with patients being considered ‘customers’ and ‘service users’ within a commodified approach to health (see 5.2.2).

Furthermore, when patients are unfamiliar with the concept of psychology, therapists need to spend time on psycho-education in order to explain the basic principles of psychology and psychotherapy. Unfamiliarity, however, should not be an argument for stereotyping migrant patients as ‘uneducated’ or ‘backwards’. It points out how psychology is not the universal approach to mental health, but rather a culture-specific disciplinary development. Another aspect regarding this unfamiliarity is how it seems to be time-sensitive and related to generational dimensions of migration. This is in line with a dynamic understanding of ‘culture’, being processual, hybrid and under constant flux (Kirmayer 2012a: 155). For example, it is possible that after the start-up of the intercultural psychiatric clinic, ‘psychology’ as such might have gained in familiarity in neighbourhood communities. In that regard, it shows how unfamiliarity changes over time, and is thus time-sensitive.

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Aside from the consideration why or how migrant patients might be unfamiliar with mental healthcare, therapeutic explanations on psychology need to be taken into account during the treatment process. I want to argue that this adds another ‘layer’ to the ‘complexity’ of clinical cases because psycho-education cannot be considered as a routine therapeutic practice but rather as a time-intensive practice:

What we come across with immigrant patients is that you have to give a lot of explanations. And explanations are not standard. So psycho-education is not standard. That disease, this and this, explain it and then it is ready. No, you have to connect it to the experience and culture of the patient.

(Int. 16, therapist, 19 years of experience at the company) So psycho-education requires an individualised approach, by investing time to explore the sociocultural context of the patient in order to find a meaningful connection to his or her lifeworld.

In what follows I elaborate on matching practices at the clinic, and how this affects the provision of care.

5.1.2 Linguistic and ethnocultural matching

Benefits of matching

At the clinic a common therapeutic strategy is the use of ethnocultural or linguistic matching. This consists of linking up patients and therapists based on a common ethnocultural background or language (Van Dijk & Ghane 2013) and it is applied at various stages within the treatment process. This technique is grounded on the operationalisation of two dominating criteria – ethnicity and language – in the assumption that those contribute to the establishment of a good therapeutic relationship:

It is difficult to do a treatment if you do not speak the language, that is just the way it is. One of the most important elements that works in therapy is the therapeutic relationship. And it must be good. Language does not have to be the only factor that determines that, but it can play a determining factor. Because a patient really feels understood, heard.

(Int. 7, therapist, 12 years of experience at the centre) Besides the argument of improving therapeutic relationships, language and ethnocultural background are also considered to facilitate a more in-depth exploration of the clinical content:

I do feel that patients do express themselves more, and they kind of go deeper in the core of the problem when they are speaking their mother tongue.

(Int. 5, therapist, one year and a half of experience at the centre) In that regard, patients also expressed the merit of having a linguistic or ethnocultural match during the treatment process. It would make treatments more focused:

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More time can be spent on the actual mental illness, instead of wasting time on exploring and explaining my cultural background. This was very much the case in a previous institution where they do not work with Turkish therapists.

(informal conversation with patient) Furthermore, matching is considered to decrease barriers in disclosing on for example alternative explanatory models regarding illness aetiologies (Kleinman et al 1978):

Of course, being in the same culture, having that open atmosphere, non-judgemental atmosphere creates less defensiveness of the patient. Assume that I am a Dutch therapist who is saying that your djinn [spirit in Islam] is your dysfunctional parent mode [negative inner voice], blaming you, or saying “this is not good for you”. There would be a little bit more friction with the therapeutic alliance.

(Int. 3, therapist, 6 years of experience at the centre) Aside from the issue that this account reflects a rather stereotypical image of a ‘Dutch therapist’, it argues how similar languages or ethnocultural backgrounds could contribute to processes of trust and enable the disclosure on for example alternative explanatory aetiologies – why someone thinks he or she is mentally suffering, e.g. in relation to religious orientation.

More than language and ethnicity

Although matching practices reflect a rather static and essentialised conceptualisation of culture (Meershoek & Krumeich 2008), I want to emphasise that the clinic includes more than merely ‘language and ethnicity’ in order to link patients with therapists. This has also been suggested by Van Dijk and Ghane (2013) who argue that within intercultural psychiatry in the Netherlands, ethnic and linguistic matching are being expanded with multiple factors in order to provide a more suitable match. At the clinic, criteria such as clinical content, gender, sexual orientation, availability of the therapist and preferences of the patient are also taken into account. On the latter, it is possible that patients prefer not to be treated by a matched therapist. This is at times the case with second or third generation migrant patients, because it would label them as ‘culturally different’. Another reason could be related to ethnocultural taboos:

Coming from a similar culture, speaking a similar language, I thought it may be helpful, although it can be an obstacle sometimes. Because when you come from a society that is either very tribal, or kind of family-oriented, family-based: ‘oh she might know my uncle, she might know my grandfather’... So there are pros and cons to be from a similar country or background, speaking the same language.

(Int. 5, therapist, one year and a half of experience at the centre) This also demonstrates how language and ethnocultural background are not necessarily considered as a prerequisite for a good therapeutic relationship. Another criterium that contributes to matching practices is gender. This is sometimes considered in family or relational therapy in order to balance out genders during therapy sessions, or when the patient expresses a specific gender preference regarding his or her therapist. When mental illnesses are assumed to be related to sexual orientation – in terms of cultural taboos or forms of exclusion within certain communities – they are often referred to the LGBTQ department

When only considering the microsocial level of care does not seem to be enough

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