The ‘Group-Analytic Stance’ in Training of Psychiatrists: Race,Cultural Differences and the Case Based Discussion Group

Abstract

Britain is a multicultural society with psychiatrists and their patients coming from many different countries. It is therefore important that psychiatric trainees learn to understand their own cultural determinants and how these influence understanding patients who come from different cultures, other than their own, while operating within a third and different culture.

When conducted with the group analytic stance, the Case Based Discussion (CBD) group, which is a mandatory component of psychiatric training, can be a rich medium for enabling trainees to see both themselves and their patients in their cultural context.

Keywords

Case Based Discussion (CBD) group training culture race psychiatry

Case Based Discussion (CBD) Group

The CBD group is used in psychiatric training with mandatory attendance of at least 30 sessions over two years by the training body, the Royal College of Psychiatrists in the UK. The goals of the CBD group are to develop the trainees’ ability to formulate the patients’ problems psychologically and to begin to understand the concepts of transference and countertransference.

This form of work was originally introduced by Balint when working with GPs who found support and increased understanding of their patients through the experience of group discussion with an expert who could encourage the group to consider the psychodynamics of the doctor patient relationship. The original Balint group approach concentrated on analysing the doctor–patient relationship from the case material presented using the resonance of other group members to the material presented as an additional resource. It did not in any other way use the group process or explore the interaction in the group or acknowledge the social (unconscious) context that inevitably appears.

Nowadays CBD groups are run differently from the traditional Balint approach (Riordan, 2008), as a result of the experience of many consultant medical trainers of junior psychiatrists who have been influenced by group-analytic theory and practice. By taking on a group-analytic stance, the social and cultural determinants of here-and-now group can be considered.

A major component of core psychiatric training is a requirement to understand the socio-cultural determinants of psychiatric illnesses or diseases. All areas of the curriculum stress the impact of racial and cultural aspects. Employing organizations also have mandatory ‘diversity’ training for their staff. As an addition to academic teaching programmes, Case Based Discussion groups are ideal places for encouraging increased awareness of the cultural determinants of trainees’ and patients’ interactions across racial difference.

Currently, the assessment of the CBD Group training includes an item on whether the trainee is aware of the impact of their own and their patients’ gendered, cultural or age related pre-suppositions on the clinical situation. If the group employs a group analytic frame, it realizes its full potential to enable the delineation and putting into words the socially unconscious, racial, cultural (classed and gendered) determinants of our interactions, and thus be a rich experiential learning context.

The National, Regional and Local Contexts

London has the greatest ethnic and racial mix of all European cities and a report from the Greater London Authority in 2009 (Hollis, 2009) shows that nearly 40% of Londoners are of ethnic minority origin. Within this highly cosmopolitan setting it is vitally important that the cultural differences between doctors and patients, including among doctors themselves, are understood. The Royal College of Psychiatrists reports that 59% of college members, fellows and affiliates are white, whereas 25% are Asian, 4% black, 1% Chinese, 1% mixed and 4% are other in origin (Royal College of Psychiatrists, 2012).

Cox (1980) reported that 50% of trainee psychiatrists in Britain have had their undergraduate training overseas and described a ‘culture shock’ among these trainees as a result of coming to the UK and many present with anxiety, irritability and depression, similar to a bereavement response that follows a ‘loss’ life event. Fazel and Ebmeier (2009) showed that in the UK, psychiatry is the least popular specialty choice for junior doctors who are UK graduates and more so for doctors trained abroad. In our experience in a large South West London psychiatric training scheme, UK born and trained trainees are a minority and often the case based discussion groups are constituted by doctors ‘who all come from somewhere else’.

Kehoe et al. (1994), indicate that one third of trainees feel discriminated against within their psychiatric training. So it is essential to understand the impact of racism on our work not only because our patients present with a complex profile of health, social and spiritual needs, but also to facilitate the well being of doctors.

There has been a lot of work focussed on overcoming racial discrimination in the UK over the last 10 to 15 years in all national institutions. However, as Bhugra and Bhui argue ‘supervision and training issues have been neglected’ (2001 p. 96). They talk of the importance of the development and evaluation of one’s cultural identity in the psychological growth process. Unfortunately, the importance of each trainee’s understanding of the cultural determinants that influence their treatment of patients from a different culture from their own, while operating within a third different culture, has not been a topic of much study.

In this article, after a review of relevant definitions, literature and an overview of theories with which to understand racism, our experience of working with these issues in a London Psychiatric Specialty Training Scheme with trainees using the Case Based Discussion group is described.

Race, Ethnicity and Culture Definitions

Anthropologists have long argued that race from a genetic perspective is not very clear. Eriksen (2002) mentioned interbreeding between ‘races’ and the difficulty of establishing which physical traits are passed on. Sanjek (1998) added that the physical traits upon which race classifications are founded merge into each other. Classification of ‘races’ in the past has been the legacy of ethnocentric European scientists, who set out to prove that white ‘races’ were intellectually and culturally superior to other ‘races’. Dalal wrote

that in moments the ideas of race, culture and ethnicity have the look of a hard reality, that appear objective enough to drive huge swathes of human history. At these times they clearly have a critical emotional significance. But yet when one approaches these entities closely, they turn into chimeras evaporate before one’s very eyes. They have an emotional reality, which does not calibrate very easily with objective reality like DNA or even skin colour. (2002: 30)

Nevertheless, race as a socio-cultural construct is a reality and with it comes racism and racial discrimination. Anthropologists have in recent decades turned to the term ‘ethnicity’, which gives more emphasis to ‘aspects of relations between groups who consider themselves, and are regarded by others, as being culturally distinctive’ (Eriksen, 2002: 4). Keesing and Strathern (1998) describe culture as ‘systems of shared ideas, systems of concepts and rules and meanings that underlie and are expressed in the ways that humans live. Culture, so defined, refers to what humans learn, not what they do and make’ (Keesing and Strathern, 1998: 16). The advantage of this definition is that it emphasizes learned behaviour. People store vast amounts of information unconsciously about their culture, verbal or non-verbal. As a result, emotions can be expressed overtly or covertly and this difference can impact on diagnosis. Studies have shown that overtly expressed emotions are more likely to cause a patient to be wrongly labelled as neurotic or over-emotional (Helman, 1990).

It is also important to note that class differences within a culture complicate behaviour as classes have their own culture. Bourdieu (1984) for instance, shows that class and taste in food, music and art are closely linked. In the group analytic discourse Blackwell (2002) writes about classes having their own culture and the importance of acknowledging that psychotherapy, and indeed group analysis, are middle class cultural forms. Thus we are well advised to take heed of the professional cultures we inhabit and in this context to take heed of the culture of the psychiatric system in the UK.

Understanding Racism

We are all embedded in our cultures and we repeat our conditioning without being aware of it. In other words, we are formed and shaped by our culture unconsciously but at the same time we reproduce our culture, also unconsciously. Our cultural conditioning includes prejudices about other cultures and our internal racisms have been with us from very young. Carpenter (2008) shows that associations of racial bias are laid down neurologically before we are old enough to consider them rationally (before age six). The world from then on is viewed through this, mostly unconscious, filter that has largely been transmitted via the family and the culture around us.

We have prejudices across all cultures. Whenever we see a difference we have the impulse to keep it separate and project the unwanted aspect of ourselves into others, for example violence into the black youth. Splitting and projection are the mechanisms used to understand racism according to psychoanalytic theory.

Dalal (Dalal, 1993; Dalal, 2002) writes that power relationships created by human groups are organized to distribute essential resources. Racial categories are created rather than exist a priori. This is Dalal’s concept of racialization. We create the categories first and then pay attention to physical characteristics in order to identify and then to stigmatize that group. This was the case with Jewish physical attributes and now is so with African and Moslem attributes. A white person with African attributes may still be perceived as black even if the skin colour is quite white. Sometimes for political reasons the stigma is taken on by the group themselves in order to define the difference such as women wearing the Moslem headscarf or not shaving in Moslem men.

Dalal summarizes,

The resulting theory of racism is an integration of insights from three domains—the cognitive, the emotional and the sociological. Thus, racism can no longer be thought of as primarily a result of splitting and projection, but a complex psycho-social phenomenon that is driven by the pragmatics of the power relations in the world. Whilst psychological mechanisms play a critical role in this process, they are not elevated as causal agencies. (Dalal, 2002: 227)

Racism therefore requires a diverse range of theories to explain it. Initially psychoanalytic concepts of splitting and projection can explain how the unwanted aspects of oneself are projected into the other. At the next level, the group systemic concept of how a subgroup can hold a difference for the whole group, as exemplified in scapegoating, shows we can project into a visually different subgroup. Study of history and politics helps us to understand power relationships that humans create. The group analytic concept of ‘the social unconscious’ brings these together as the internalized social cultural conditioning, including historical traumas between races and nations, histories of slavery, colonization, oppression and genocide. As long as they are unprocessed, unmourned and unacknowledged, they continue to be enacted in our lives today, both personally and in tragic national wars (Volkan, 2001). The ‘social unconscious’ as a concept is elaborated in a recent book edited by Hopper and Weinberg (2011). We can say very briefly here, the concept refers to the unconscious cultural determinants of the ‘here and now’ experience.

The group analytic frame of reference, as well as enriching the theoretical understanding of the human problem of racism and discrimination, by having the group as the arena of experiential interaction, also powerfully provides the means of intervening, challenging prejudices and attitudes, thus aiding the further development of professionals.

The Use of the CBD Group as a Training Tool for Cultural Understanding

In a group where trainees feel safe enough to share their vulnerabilities, there is the possibility to discuss one’s own prejudices or experiences of racism and intercultural differences. It is important for the leader of such a group (usually a consultant medical psychotherapist) to be open to the possibility of discussing the impact of cultural differences on the clinical situation. Thus the CBD group during psychiatric training can help trainees to see both themselves and their patients in their ‘cultural’ context in the broader sense including the wider prejudicial categories in our diverse society. The group interactions together with the group analytic stance of the facilitator, allow the possibility of aspects of the ‘social unconscious’ to emerge, to be appreciated and made conscious. In so doing not only are these young psychiatric trainees more emotionally contained in their experiences during their training, the everyday racism they endure, but also they develop an understanding of their patients’ dynamics related to the social and cultural differences they experience. The trainees become better, more aware doctors. The group, although not a therapy group but held with sensitivity to the psychiatric trainees’ predicament, becomes the context for containment and understanding of their work relationships.

The challenge for all of us remains to continue to communicate across the language, culture and gender differences, so we may understand each other within our culture bound practice of western medicine.

Issues in Clinical Psychiatric Practice

The culture of psychiatry incorporates the medical and developmental model that expects a patient to take an active part in their healing. Thus there may be a cultural clash with a patient from a paternalistic culture with different expectations where the doctor takes care of everything. If one is not aware that even our medical practice exists within a cultural context then there is the danger of unconsciously imposing values from medical practice culture on the patient’s view of life. If psychiatrists find it hard to accept that there can be a different view of the world and different ways of doing things, and with the added impact of the power difference, it may be difficult for patients to bring up different expectations based on their cultural origins.

Case Example One

(Personal details of patients and doctors have been altered for reasons of protecting confidentiality).

During one CBD group an Indian doctor was able to discuss her experience of diagnosing a 19-year-old Korean female patient with an Emotionally Unstable Personality Disorder; the patient seemed to meet the diagnostic criteria of this condition. The female doctor explained to the group that the patient had presented with low mood and mood instability as well as turbulent social and personal relationships. During the psychiatric examination she thought that patient was ‘overtly emotional’, had an exaggerated expression of her distress and anger and was also very self-critical. At the end the doctor had made the diagnosis despite feeling unsure and uncomfortable by putting this label on the patient. In the discussion that followed we wondered what the accepted way of expressing emotion was in this patient’s family and her culture and whether she was within those norms. What were the stresses on her, her family having experienced dislocation from her country and usual support systems, and now living within a different cultural context? So the understanding deepened and this patient could be seen within her original and new cultural context.

We could also comprehend the problems of using our diagnostic systems, developed in western contexts, for patients from different cultures who have different learned ways of communicating emotions. We then had the opportunity to acknowledge that the trainees in this CBD group had grown up in a number of different cultures, had experienced different ways of expressing emotion, and that they, via the training in psychiatry within the British medical culture, had learnt yet another language to diagnose and work with psychiatric conditions. Discussion followed on the cultural influences on the diagnostic systems. At the end of the group, there was an increased understanding of the complexity of the clinical situation with this patient. She was appreciated with her own family history, her family in the context of the culture they are part of and with the added significant impact and trauma of migration and dislocation in another culture, at a time of adolescent anxieties and separation issues to deal with. The doctors could speak about the cultural differences between themselves and also between them and the host British culture. It was possible then to speak of some of their patients’ prejudiced reactions to them as ‘foreign’ doctors and their ways of dealing with the racism.

Case Example Two

The next example highlights the discrimination we may enact with doctors trained outside the UK, perhaps without being aware of it, under the guise of ‘training to be a good psychiatrist’. This example was brought up when discussing cultural differences, including that of the culture of the established psychiatric practice, in a CBD group. A doctor trained in Egypt was told when she arrived in Holland to forget everything she had previously learnt in her medical training in Egypt. She was now going to learn to do it ‘properly’. When she later moved from Holland to the UK she was told that she had to forget about the ‘Dutch way of mental state examination’ even though exactly the same psychiatric examination book is being used in both countries. This clearly shows how psychiatric societies in different countries reject each other’s ways, even though they share the same books and systems. Moving between different countries and working in different cultures usually gives one the ability to have a wider perspective. The CBD group work gives the opportunity for trainees from different cultural backgrounds to gain the necessary skills to be able to use this experience in their practice. This skill is gained through the possibility to talk about these issues. The group analytic stance of the facilitator gives permission for such conversations. As such, even though the CBD group is not used for therapeutic purposes, it may still have therapeutic value for the trainees.

The Trainees’ Experience of the CBD Group

In our London based CBD group, trainees who worked with different facilitators over a period of two years noticed a remarkable difference in approaches in leaders of CBD groups. Some facilitators focussed mainly on the patient, while the trainees’ experiences with regards to the cultural aspects were more difficult to bring in. Other facilitators were more open to bringing one’s personal experiences, and subsequently the trainees managed to carry the work to a different level, feeling encouraged to disclose their personal issues without the fear of being criticized. In addition, trainees seem to have different experiences according to their own cultural backgrounds. For example, a trainee from western Europe admitted to feeling uncomfortable with disclosing emotions, whereas another trainee from a non-western background felt relieved about being able to talk about their emotional experience openly.

The openness in the CBD group that facilitates discussion of cultural issues enables other experiences to be brought in. Fundamental to this openness is having a safe environment created by the facilitator. In our groups, trainees have talked about being racially abused by their patients, patients refusing to see them because of their ethnicity and the prejudice and even discrimination experienced from colleagues. The more they felt safe, the better they could express themselves, which led to a shared understanding of their difficulties. This way the CBD group enabled deep emotional work that hopefully prevented these issues being carried around without being resolved. With group membership of trainees, and their facilitator, who all come from ‘somewhere else’, it is possible for these experiences to be processed so that there can be increased understanding of our humanity, our histories and our in-humanities to one another. So despite all the differences, there is a shared universal understanding of emotions, and although expressed differently, it allows us to form cross-cultural relations and build new avenues for exploration.

Conclusion

The British psychiatric system operates within the western medical context and we experience clear problems when we forget that we are operating from this particular culture. Moving from one place to another, however, gives one the ability to observe cultures from different perspectives. Through open discussions, which can be facilitated in CBD groups, trainees can become aware of the different contexts from which their patients or colleagues may be coming.

The CBD Group is a rich context for increased understanding of the impact of race and culture on clinical practice. One of the junior psychiatrists’ assessment criteria focuses on the understanding of diversity and being self reflective enough to acknowledge one’s own cultural assumptions. With trainees from the four corners of the world, rich training in the area of racial and cultural reflection can take place, especially when a non-judgemental and safe environment is provided. The facilitator of the CBD group only needs to be open to the ideas of using this context for this purpose and to be prepared to consider the explication of our social behaviour that we may not always be conscious of.

Footnotes

Acknowledgements

We thank Mr. Harold Herrewegh, PhD Student at Brunel University, London, UK for sharing his anthropological insights as well as the anonymous reviewers of Group Analysis for their feedback and orienting comments.

Jale Cilasun is consultant psychiatrist, medical psychotherapist and trainer of junior psychiatrists at South West London and St. George’s NHS Trust, London, UK since 2001. She is also a group analyst, with training responsibilities at the Institute of Group Analysis in London. Address: Wandsworth Complex Needs Service, Springfield University Hospital, South West London and St. George’s Mental Health Trust, 61 Glenburnie Road, London SW17 7DJ, UK. Email: j.cilasun@doctors.org.uk

Muge Herrewegh graduated from Hacettepe University Medical Faculty in Turkey. She moved to the UK in 2005 and completed her core psychiatric training in 2010. Currently she is doing her higher specialist training in child and adolescent psychiatry at the Institute of Psychiatry. Address: Croydon CAMHS, 113 High Street, Croydon CR0 1QG, UK. Email: mugetrak@yahoo.com

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