Umberta Telfener
Clinical psychologist, teaches at the Post-Graduate School of Health Psychology of Roma La Sapienza
University, teacher of the Milan Centre of Family Therapy
This article addresses the question of the possible conditions required for mutual understanding between different cultures: how we know what we think we know about our clients, their culture, their relationship with us during the process of counselling; how the meeting of different minds hearts and sensibilities takes place within a shared context. Operating in the territory of the other entails not taking our professional identity for granted but building and rebuilding it in the space of the meeting. Creating health means taking social, psychological, political, cultural, anthropological and spiritual factors into consideration and co-constructing action that is agreed upon with the clients themselves – action that emerges from careful analysis of the request, that brings out strengths and creates participative and processual situations.
Keywords: intercultural clinical practice, ethics, analysis of the request, reflexivity, blind spots
“You can never know who you are if you do not step outside yourself.”
José Saramago, The Tale of the Unknown Island, 1998
Introduction
Immigration is a fairly recent phenomenon in Italy, where people from other parts of the world have been arriving for about 15 years now. Previously a land of internal migration from the south and emigration to northern Europe and America, Italy too has now become a goal for immigrants. While France, Germany and Britain can be considered multiethnic countries, the process is still in the early stages here. Immigrants initialy presented us only with their physical ailments. Those from countries with no psychological tradition somatized all their problems and their grief in a sick and suffering body. In situations where the problems were mental, they instead returned to their homeland, as though unwilling to entrust their systems of morals and values to a culture so different and often so unfriendly.
They have only recently started placing both their physical and their mental problems in our care, but the way in which these are addressed is often unduly pathologizing, based as it is on the universalistic ethics of a Western culture (Fruggeri 2008) and on a rigid nosography derived from official psychiatry, which does not favour the social construction of problems and does not seek out the potential resources available.
Immigrants present us with problems of integration, coexistence and dialogue: mixed marriages, non-EU citizens on their own or with families, with illnesses in need of medicines, children “stripped” of their identity through adoption, mixed classes at school with problems of fitting in, and so on. These are situations that involve everyday practice, collective representation, value systems and institutional response in the organization of services. These foreigners have forced us to rethink our praxis by inventing new pathways, fostering multiplicity, and reflecting on culture1, they have done the most to bring us face to face with the loss of certainties. Their arrival has obliged us to come to terms with complexity, not only in intellectual terms. It has provided an opportunity to place a West-centric monoculture in a definitive state of crisis. Let us start with a question. Why is it that so many italian health professionals are taking an interest in non-EU citizens?
I have met practitioners involved in putting forward and testing new projects, clinicians committed to reinventing their professional practice and interested in other people’s experiences. What is the origin of this enthusiastic and indeed almost urgent interest? It is unquestionably the result of an emergency, understood as an immediate need now devastatingly manifest as a result of immigration. Emotive and psychological drives of a subjective and collective nature can also be discerned in the attention focused on immigrants: challenging personal prejudices; curiosity; the desire for change and stimuli emerging from differences; the need to deconstruct our certainties; the fashionable appeal of the exotic as something remote and outside our experience. Working with them accentuates doubt, prompts us to become still more sensitive to differences, clinical responsibilities and ethical aspects; allows us to dream of revitalization and contact with new worlds, makes it possible to hone our forms of communication and cure ourselves of Western ethnocentrism, and offers the opportunity to partecipate in the production of a new understanding. Cultural polyphony represents the need for a psychology that gives space to multiplicity without demanding integration; it means the acceptance of other forms of unity, the coordination of numerous elements that come one by one into the spotlight. Multiplicity does not mean “anything” but many things; it means that the spirit has many sources from which to draw meaning, direction and value. Immigrants offer the opportunity to become flexible and to come into contact with multiplicity.
Further questions arise. What should our attitude be towards non-EU citizens? What sort of lenses should we adopt in order to work with them? Probing the cultural traditions of the person before us (foreign or otherwise) does not protect us from involvement in the social and political dynamics that determine the quality of life both for us and for others. We must therefore be on guard against the risk of taking an interest in others with the tacit intention of reasserting our Western identity, of breaking down the very concept of the intercultural clinical practice that we have espoused.
Intercultural clinical practice
The ways to approach others are legion and involve operative choices; for years they were based on the possibility of establishing dialogue between the representatives of various disciplines, such as trans-cultural psychiatry, ethnology, anthropology and ethno-psychiatry.
In my opinion INTERCULTURAL CLINICAL PRACTICE does’nt need any more anthropology as an aid, since the focus of treatment is no longer different cultures but rather the encounter which is analyzed in the here and now of the place of meeting (italian health care centers) through an analisys of the request. It is impossible to know every culture from within, we must become comfortable with the stance of knowing we don’t know and with the thought that we don’t know that we don’t know.
The culture I propose to address specifically regards the symbols and meanings that emerge in the relationship, in the here and now of the definition of the context, the problem and the possible solutions. The practice I am describing regards negotiation on the terms of the relationship as the focal point of the encounter. Attention is not focused on the patient’s original culture: access to this is problematic because it is an invisible, tacit and often idealized. It is focused instead on the representations shared in the clinical context. It is focused on the problem for which help is requested, on the shared context in which interaction will take place, and on the relationship between those who request and offer assistance. How does the other read the request for help and how do I read it? What does the other understand of the context we are in and what explanations do I offer? What is the other asking for when he/she asks me for help and what do I understand by it? What type of relationship does the other expect and what type of relationship am I accustomed to? The questions to be explicitly stated, set on the table and addressed always regard the relationship and the expectations on both sides, the definition of the relationship and the problem in the consulting room. The issues that emerge cannot be divorced from the resources now available
and the new ones to be identified. Culture becomes an operative construct that emerges from the encounter and is played out in the relationship of those temporarily sharing the same context. Who I am as a clinician, whether I am male or female, my religious beliefs, my personal and professional history, my values, race and social class: all of these aspects come into play in the encounter with the other, who in turn has a gender, a religion, a group he/she belongs to, and so much else besides. From the first handshake, from the very first meeting, some of these things are in danger of being taken for granted (above all in Italy, where the colour of the clinicians’ skin is nearly always white and their religion nearly always Catholic). It is instead imperative that they should be brought out into the open rather than taken for granted and left unsaid.
The second important aspect, aside of the stance one chooses to take, is the necessity to recognize the inevitability of one’s ignorance, which means resigning oneself to knowing that one does’nt know, understanding that one does’nt understand. The difference between a normative and an evolutionary approach rests on the extent to which the practitioners get involved in the process and take themselves into consideration as active participants; how far they then succeed in differentiating between action aimed at change versus an effort not to block a situation that is inherently “processual”. I am talking about the difference between “intervening” from a knowing position and avoiding collusion, being alert to the danger of chronicity2 being constantly on guard against blocking the natural tendency of the system to evolve, making an already difficult situation static; monitoring the possibility of blind spots, inevitable prejudices, the culturally determined grids through which to read events; paying constant attention to the danger of iatrogenic risk, to all the assumptions and events that can block the process and – because of how they are managed – create pathology and stasis rather than evolution (Bianciardi, Telfener 1995).
Do we recognize the narratives in which we are involved and regard ourselves in any case as simultaneously part of the process underway and outside the sphere of observation (in order to reflect on the grids we use)? In other words, do we keep check on our position as participating observers? Taking cognizance of this means taking responsibility for the descriptions put forward, adopting an ethical attitude of awareness of our awareness, of reflection on our reflections and responsibility for the inevitable blind spots. (I apologize for the semantic repetitions but cannot avoid them. I firmly believe that clinical praxis rests on second-order operations, i.e. operations on operations. The repetitions reflect a epistemolo= gical stance to which I attach great importance.)
Clinical work cannot therefore be divorced from cultural aspects and from the choice of an epistemological stance, both implicit. Both must be made explicit in praxis. In other words, we must be cautious in our position as involved observers. What do we think of behaviour that is unusual for us? Most practitioners address the problem of the other and the elsewhere, with respect and intelligence, to avoid our Western habit of absorbing others through a process of grinding down and homogenization.
Working with the problem determined system
Cultural plurality can be expressed in clothing, food, accent, lifestyle, experience and habits. Sensitivity, family structure, the meaning attached to the past, present and future, the everyday use of time, the importance attached to traditional values, varying commitment toward members of the original and extended family, intuitive or rational ways of decoding and addressing problems, diversity in performing roles, are all aspects that change with changes in geography and original culture. They even change between inhabitants of the same city and the same district. Many clients prove culturally distant from us already as regards the level of reflexivity (personal relationship with the processes of understanding) to which they are accustomed. It becomes important to be aware of the danger of differences being interpreted as intrinsic characteristics of the client rather than reflections of the cultural context and the history of the problem, as well as the clinical encounter.
Working with people means eliminating none of the cultures present, coexisting with differences, and presenting your culture in explicitly stated form. I am against pre-packaged prescriptions, specific approaches with non-EU citizens, and especially against the proposal of new models. I prefer to address the question from another angle: readiness to reflect on whether the means in our possession are sufficient to enter into contact with the other and
what specific aspects this otherness involves.
Etienne was “streetwalking” on the pavement when two men got out of a car (driven by a woman), beat her up, poured petrol over her, and set her on fire. The burns left her previously smooth body like a volcanic landscape. She was hospitalized for a long time and contacted the San Gallicano clinic in Rome after her discharge. She was sent to me by the director of the structure on the grounds that it “would do her good to feel taken care of after the trauma”. Aged 20, she was living with other young Nigerian women in accommodation provided by a woman of the same nationality, to whom she owed €40,000. She told me that her mother thought she was doing a course in Italy to become a hairdresser, that she had been recruited by a woman who promised her an “honest” job and then took her to a flat in Rome, where she lived until the incident. She suspected that her mother might know about her “real” life but had in any case never contradicted the family’s official version. She was now living with nuns (women again, often treacherous) and sad that she could no longer be “on the game”, which she described as “better”: easier, more fun and more remunerative than her present reality, which made her feel “dead” and alone.
What to do with Etienne, deaf to her inner needs and concerned solely with her body and the possibility of regaining its previous smoothness, beauty and appeal to men? She displayed none of the emotions connected with the trauma suffered and seemed to have no interest in going over her previous life, which she felt to be very remote, extraneous to her present reality and the serious problem afflicting her. First of all, what is her problem? What is the problem to address? How to tackle it? Does it make sense to speak of post-traumatic stress syndrome? She has certainly undergone major trauma, to say the least. Does it make sense to speak of alexithymia (the state in which the subject cannot name his/her feelings), since immigrants tend to express their emotions non verbally and not necessarily as we do? It certainly makes no sense to develop a Western diagnosis and, in my view, it may be necessary to do without definite maps and clear indicators. I undertake to ABANDON A PRIORI DIAGNOSTIC CATEGORIES in favour of a more participative subjectivity, trying not to separate the symptom from the person, the subject from her universe, her from me. I try to enter her universe and to seek and co-construct coherence (wherever possible) between the maps in play. No one is more right than anyone else. The aim is to interweave opinions and conjectures in order to find a superordinate viewpoint encompassing the maps of everyone involved.
Transition is then required from a prescriptive technique (the meeting aimed at causing change) to LISTENING, understood as the ability to recognize and appreciate the importance of the narrative presented: interactive participation and empathy. It is the construction of a possible world that I am prompted to propose, feeling “confronted” by a girl recently arrived in the Western world, greatly in awe of the potential for conspicuous consumption, and not versed in psychological categories (misused and prejudicial though these often are). I seek out and make the most of the (admittedly few) “GIFTS3” that she has in store for herself and for me, the resources she can bring into play, the expectations she set off with and still cherishes. I also take an interest in the good things she has received from Italy, from the few people who have become “special” (a man she went with, a prostitute friend) and enabled her to maintain a little hope. We make a list together of the “owners”4 that possess her and organize her behaviour and mental states for good and for bad.
I investigate, I ask questions, I expect a narrative regarding her life. Etienne says very little very reluctantly, in “her” French, which is difficult to decode. Does she want me to talk? She gets distracted immediately if I do. What she wants is for me to magically heal her skin. Frustrated by the “little” we succeed in putting together and the difficulty of an “impoverished” relationship, I believe it is necessary to “CONTAMINATE” THE SETTING, to abandon a dual and exclusively verbal encounter. I suggest broadening the operative context and making it more complex through the inclusion of significant figures brought to the sessions by her and recruited also in the structure where we are based. I think that a group of reference will ensure the respect of traditional norms and the possibility of amplifying and decoding – sometimes translating – emotive experiences specific to the culture to which she belongs. I therefore invite some people to meetings: mediators of the healthcare service, a friend who is still “on the game” (she attaches importance to maintaining contacts, and this is a resource), a nun she feels to be more of an ally then the others. A Nigerian female mediator helps in particular by manifesting great anger on her behalf: screaming, yelling, waving her arms, modelling a possible reaction of anguish, getting emotional in her place and “curing” her of her anger through her own, which continues with great sincerity for more than one session. I find myself having to manage the mediator’s anger too but realize that by so doing I am communicating with Etienne.
The fifth aspect (after the abandonment of diagnosis, adoption of active listening, search of resources and “contamination” of the setting) on which I choose to focus attention is the NETWORK OF PRACTITIONERS: the unavoidable coordination between professionals and the connections between groups and institutions. Hence the need to go with her and talk to her physician in order to recapitulate together the stages of the process of “bodily restoration”. I also invite the social worker from the cooperative responsible for her to attend meetings together with her in order to organize a common plan. Collaboration between a number of professionals (inside and outside the Service) and the joint construction of hypotheses seem to offer the only possibility of integrated intervention fully cognizant of the complexity of the situation. The avoidance of all operative fragmentation seems the only way to respect the social complexity present in her condition of abuse and respond to her need with a suitable and equally significant degree of joint strategy building. Networking becomes a key tool of intervention in the attempt to cross the boundaries of the professions and social services responsible for Etienne. I endeavour not to endorse an order imposed from the top and to construct a shared strategy and vision through prearranged meetings at which we are all present. The purpose is to pool the differences, state them explicitly, and resist the collusive mentality in order to construct evolutionary plans together and “futurize” the stages of a possible process. In other words, I work with the system determined by the problem of which I too am a part.
I engaged in a non-linear and non-rigid project organized over a number of pathways, equipped with possible alternatives, and firmly connected to the social dimension. Driven by the need for a precise strategy, this project involved words and actions, meetings arranged solely to give her a new cream for her body or to hear about the umpteenth problem in her relationship with the nuns, meetings with her and with all of the system rotating around her. The healthcare structure proved useful in providing a physical space also to meet with other women and propose “social” alternatives to the meetings with me. I proposed a reference group of her own culture and tried to put her in contact with the church of her religion, both of which were rejected. I was instead able to introduce her to an authoritative person of her own community (a guardian angel who took her under his wing) and to suggest a group of mutual self-help operating within the healthcare service itself (and hence social links with new people). The attempt was to make the service curative in itself by getting various figures of reference to look after the client and get her involved in a variety of activities and proposals.
The structure of the encounter
To what extent, as human beings and as practitioners, do we allow ourselves pauses for reflection capable of leading to suspension of the customary spatio-temporal categories and cultural concepts so as to open up the possibility of new ways of thinking/feeling/acting5 and responsiveness to some of the transformations that meeting with the other can trigger? I believe that no choice can shield us from responsibility for its consequences. As regards the structure of the encounter, I wish to mention some specific points about work with immigrants. First, the times of meetings (frequency and duration) cannot be taken for granted. They can be spread out or bunched together. The weekly appointments typical of the Western setting prove impracticable. Going back into ancestral time can prove useful but not always necessary. (In our case, Etienne was reluctant to speak about the family that she thought had “betrayed” her by allowing her to leave even though they “suspected” the nature of the work involved.) What is important is the here and now of everyday life. It is impossible to think about the future, which is far too unstable even to be imagined. As regards interlocutors, both real and mental, importance attaches to some distant, absent and imaginary figures (the mental interlocutor who consented to the departure, in her case a maternal uncle who “blessed” her and “would come and save her if he knew”). Importance also attaches to the figures of reference in the present context, who may not exist, in which case they must be made present in the mind and hence invited to take part in the encounters.
Finally, attachments to language, places, divinities, ancestors, forms of action and social situations are all important too. In the same way, the canonical spaces no longer apply (it became therapeutic to go with Etienne to see the dermatologist or in a store for dermatological creams) and it is necessary to emerge from the antiseptic setting of your consultation room. This involves greater attention to what is done in a session than to what is said (an aspect whose importance is often underestimated). With Etienne and with immigrants in general, words do not seem powerful enough to cause perturbation. They seem to have no permanence, to lose meaning and be discarded as soon as they are uttered. “Transitional” objects (the tea drunk together, the discussion of a hairstyle, the sharing of food when she made the effort to cook couscous) instead become actions that co-construct an emotive climate, a way of approaching one another. I learned with her how necessary it is to invent new codes of encounter, to construct confidence that is not one-way but developed out of mutual exchange. The non-verbal, irrationality, empathy, doubt and the heart all proved useful in the search for moments of sharing. It was important for me to consider both the potential resources that emerged in talks and the limits that Etienne liked to expatiate on, and to make myself a witness of possible moment of respite from anxiety and paralysis.
Requests made by third parties
Requests regarding immigrants come from individuals (themselves or others) but also from external social clients (schools, courts, hospitals and the social sphere in general). The request is made sometimes to address a specific problem where coexistence is at risk due to certain behaviors. How is this to be done? As outlined above, by means of a contaminated and complex setting, with time-based projects, the involvement of networks… I shall now present another clinical case, reminding readers that it is the context that transforms problems into possibilities:
The directors of two middle schools in a medium-sized town in central Italy ask the local branch of Caritas6 to set up an after-school structure for children of immigrants who are creating problems in class because 1) they do not study, 2) do not attend regularly, 3) do not take their educational commitments seriously, 4) their record is poor as regards both conduct and progress. Caritas responds to the request normatively and opens an afternoon centre with educators whose job is to get the children to do their homework. (Caritas later involves other schools so as to have an “interesting” number of pupils.) As soon as attendance at the centre decreases, Caritas asks the local mental health centre (CSM) to contact the families of the immigrant children and get them to ensure attendance. The CSM personnel performs this task, they then asked for supervision having realized the degree of collusion established and not wishing to act as “doctor homeostat” (Hoffman 2002).
The questions are, as usual, many: who is the client of the personnel of the CSM? How do their needs differ from those of the schools and Caritas? What is the correct course of action for the new arrivals?
1) The school directors do not shoulder the problem but send children elsewhere and delegate responsibility to the Caritas in the belief that they are using a resource of the local administration. They do this without giving any explicit rationalization of aims and purposes to the children involved, to their families. Caritas educators content themselves with the fact that a new initiative is being launched and set to work straight away. We therefore have delegation of responsibility to a religious structure (Catholic, unlike the children involved) and the risk of this, if not realized, constituting an element of confusion and coercion. (The suspicion of an indirect attempt at conversion inevitably arises).
2) The school directors think that the problem has nothing to do with teaching, with the teachers or with the policy and “ethos” of the school, and delegate responsibility rather than propose internal discussion.
3) Only the children most in need of help are sent to the newly-created after-school centre, thus creating another division between the “bright” and the “dim” and broadening the gap between residents and foreigners still further.
4) When absences become obvious also at the centre, i.e. when the children “naturally” continue to behave as they always have at school (since nothing has changed for them, they have just received more than usual in a context that is the same as the previous one), Caritas turns to the CSM and asks its personnel to contact the families and develop motivation for attendance. Rather than analyzing and redefining the request, rather than wondering why the children are not motivated at school and how the assumptions of the school itself can change, the personnel rush headlong into the task of contacting all the immigrant families in the area, only to discover that this pursuit leads to an increase in suspicion and absences. As a large proportion of immigrants are from countries where the figure of the psychologist is nonexistent, they have never had socio-psychological assistance and suspect that it involves judgment rather than support. Moreover, the teacher is a naturally authoritative figure in many non-Western countries, and parents would never dream of going and interfering with the work of the institution to which they have entrusted their children’s education.
5) The network built up between CSM and Caritas operators excludes the school teachers, who have delegated all responsibility for the problem and never questioned their own educational practices. It also excludes the families of the children, who are not involved in the planning and the problem but only called upon to accept coercion, which increases their feeling that they are being judged.
6) The client is the school. It would be a mistake to assume that the requests made by the school and the families are the same (tacit presupposition on the part of the staff), even though it would be interesting to see all the families (including those whose children are making good progress and are not sent to the Caritas centre): what would they like to have from the social structure, if they were informed of their right to make requests? Why would they want some things and not others? If we then discover that what the school and the families want is the same thing, i.e. for the children to study and be successful, why not ask the families for direct help in order to reach a common goal, why not involve them rather than “investigate” and suspect them? Why not work on the assumptions of the people involved so as to state them explicitly and try to identify points of contact as well as the practices that accentuate the mechanism of exclusion?
7) Are we sure that the way to make school a positive experience is by giving the children more of the same thing, more of what they already dislike? Why not also consider the possibility of organizing spaces devoted solely to play and sport, gratifying experiences, places of excellence where “donkeys7” can excel in something else rather than continuing to be frustrated by something we know they cannot do?
The analysis of the request
At this juncture, the case is placed in my hands and necessarily have to start again by defining the problems, the alliances, the games underway and the possible collusion. I could very easily get caught up in a self-perpetuating game that has already blazed a very clear trail to follow, this if I don’t start from the request by the clinicians and if I don’t place myself within the picture. In supervision, we therefore examine the difference between DELEGATION and PLANNING and the need to be clear as regards both operations. Caritas has accepted the responsibility delegated by the school and taken its place with a view to motivating the children involved. It has, however, organized no precise planning at the group level and regards every case received as the same. No specificity can be discerned in the pathway and the activities proposed. The contract is vague, no specific results are expected, no liaison is required between the different organizations, and minimal control is involved (doing becomes more important that thinking). We reflect on the premises that keep the process going and creates a paradoxical stance: if the after-school centre worked, the families would be at risk of appearing in a bad light, of having failed where others have succeeded. Can children be successful at school if their families are judged and shown in a bad light? If an uprooted child is forced to choose between family and school, because the two are not allies, which will they opt for? The teachers may also find themselves in an awkward situation if young educators succeed where they have failed. Moreover, the after-school centre runs the “risk of success” above all if it succeeds, in synergy with the school, in identifying the minors with the most serious problems. The vicious circle is evident. The more the services do, the more the families tend to delegate responsibility, for fear of being criticized and judged. The less the families are involved, the more the children are left to their own devices. The more the children feel that this is a priority of the school and not of the family, the more they find themselves caught in the middle between these two social organizations, the greater the risk that they will play one off against the other in a self-perpetuating circuit and the worse their behaviour will become. The pathology is worsened by the very attempts to find a solution.
There is one aspect that I wish to highlight, even though it has been mentioned repeatedly above. In cases where the symptoms are clearly manifested and considered urgent, there is a danger of professionals offering an immediate answer, taking over the problem, and “buying” the explanations of what is happening offered by the dominant culture. They thus skip ANALYSIS OF THE REQUEST, which is always in itself the psychological-clinical operation of choice. Every clinical relationship should be based on analysis of the request, the key tool for identification of the disorder. This fundamental initial process focuses on the relationship between event and context of signification. Nathan (1990) describes this as similar to the dissociation of symptom and person peculiar to “savage” culture and developed by attributing intentionality to the invisible. This analysis seeks to focus on the pathway leading up to the symptom and the consequent request for help. It is therefore a sort of microanalysis of the construction of inter-subjective relational processes and the interconnection of events; the search for meaning in which the professional practitioners are also involved in the role of co-protagonists. It is a question of attaining what Shotter (1993) calls “knowing from within”, the ability to make information emerge from the participative relationship. Analysis of the request makes it possible to pool differences, accept reciprocity in manifesting viewpoints, and avoid seeking either synthesis or agreement. It means inventing a new “processual” language to handle the emergence of the problem; the need to remain in the “in-between” space and time, respecting and doing full justice to differences, coexisting with them with no need for a unitary point of view. It is sometimes a matter of acknowledging reciprocal incommunicability. For all these reasons, this procedure is even more important in intercultural work, as it makes it possible to suspend a habitual way of thinking – organized by psychopathology – and fosters the construction of participative listening and narrative. Let us remember that the process of transformation is already set in motion on encountering the structure and its personnel through the joint work on the request, with no need to implement a specific therapeutic procedure.
What is missing in the case described above is exactly an explicit request, analysis of the needs of all the parties involved, and the drawing up of a shared contract. The delegation of responsibility should have been redefined and more active involvement should have been secured on the part of the school, the families and Caritas. It would have been useful, if not indispensable, to give a meaning to what happened, by gathering and analyzing the responses that emerged along the way. The question that we considered together after analysis of the collusion and the traps is this: what context must we co-construct so as to bring out a “processuality” that has the characteristics of sharing, that is evolutionary and participative, and that creates a virtuous circle, using all the forces in play?
The need for an ethical stance
What have I proposed in my work with immigrants?
· Work on observing systems and hence on the relationship between clinician and clients. A focus on the system that includes the observer and emerges from the pooling of differences within a shared space
· A close check on the assumptions in play regarding the idea of the problem, treatment, of intervention, of diversity …
· The use of analysis of the request to construct a dynamic and “processual” context allowing an interplay of narratives and re-narratives within a clear and sharply defined space/time on the part of all those involved
· Minute planning, which is important in that it enables the clinician’s to make him/herself a constant
· The need to restore competency to the participants: the operators are experts on change, the clients on their lives
· Participative listening that takes explicit shape through an attitude of respect
· Serious coordination, also between personnel of different agencies
· A dual stance of personnel: optimism as regards the resources present, realism as regards the ongoing situation
I have argued that working with RESPECT FOR DIFFERENCES means reciprocal explication (not negotiation) of the symbols of the organizational culture that form part of our baggage and emerge in the representations that are made by the clinical system (including the client, the practitioner, the client’s family and social group of reference, the group of colleagues, the personnel of the structure in which the meeting takes place and all the others involved). It means presenting one’s situation in the counselling session and explicating the way in which, in telling their stories, both the professionals and the clients stress some pieces of information and omit others, attributing significant roles and values to themselves, to the others and to the newly created clinical context. The perspective put forward here inevitably entails exploration of the elsewhere in order to regard it not as a place of fear and extraneousness but as a melting pot of new themes, possible stories, and different languages to decode and interact with. In this view, otherness becomes a possibility rather than a constraint, provided that the elsewhere is not taken as a static concept (and acting on the elsewhere taken as a static praxis) and we succeed in “processualizing” polyphony. Only in this way can the elsewhere emerge in the relationship, in the rapport between people, the meeting of groups. Is the operative practice I propose specific and different from the one adopted with people of our own nationality? Not necessarily. It absolutely rejects psychotherapy, however, on grounds I have no space to illustrate (Telfener 2010).
As the title of my article indicates, my intention is to outline an ethical stance in praxis. This does not mean ethics in the Aristotelian sense, doing the right thing and reasoning rightly in order to live a good life, not “I/you must, I/you mustn’t”, not moral judgment. I have chosen to use the concept of ethics as understood by Wittgenstein in the Tractatus: “It is clear that ethics cannot be put into words” (6.421); “It is clear that ethics has nothing to do with punishment and reward” (6.422). The philosopher shows that people do not so much represent as embody ethics. Von Foerster (1990), the renowned epistemologist and my mentor, is also clear that it is impossible to talk about ethics without lapsing into moralism. He suggests that we should make the two “sisters” of ethics – who create a beautiful frame and allow her to remain hidden – speak in her place. These are metaphysics, understood as the epistemological choices we all make, the stand we choose, the lenses through which we choose to observe (“the need to choose between decisions that are in principle undecidable”), and dialectics, understood as the use made of language in the relationship with the other and with the community in speaking, also in writing. The clinician cannot but feel involved by the values contained in the explanations and cannot but be considered responsible for what happens in the meetings in that he/she is socially defined as an “expert” in change and paid as such. This shared and social role makes it all the more necessary in our work to highlight and broaden the discourse on ethics.
I would like to end this article by addressing the ethical question as regards the processes that foster or hinder the construction/creation of shared meanings. It becomes indispensable to consider how best to secure the emergence of a workable reality (a therapeutic reality on which action can be taken), how to avoid becoming a “doctor homeostat”, how to avoid iatrogenic risk, collusion with the process, the system or the individual, how to work without imposing one’s own values and avoiding chronicity.
The first question facing us regards response to the request for help: who to call in, how to redefine the problem presented and what pathway to offer. Working systemically with foreigners has made me aware of the plurality of actions, emotions, beliefs and convictions present in the therapeutic setting; the plurality of equally rich and important stories has obliged me to take cognizance of the clinical choices I make and to assume responsibility for the operations I put in motion. The clinical path therefore seems to develop along the dual channel of thought and action through practices that form its skeleton, interfaces of a single attitude: thinking globally and acting locally, thinking in terms of a “pluriverse” and acting on the universe.
1 I refer to Geertz’s definition of culture as “the complex system of signs and symbols that supply the context and the
meaning, without which concepts and behaviours cannot be intelligently described”. It must be borne in mind, however, that the term “culture” is never neutral – despite the attempts of many anthropologists to make it so.
2 Our concept of care is different from that of physicians. We think that people evolve constantly and have different levels of adaptive capacity (the ability of immigrants to adapt is quite out of the ordinary). Our objective is therefore not to interrupt their process of natural evolution.
3 Gifts are qualities and subjective characteristics of the person that can be highlighted.
4 “Owners” are what Tobie Nathan (1996) calls attachments to invisible forces (such as logics of belonging that organize life). He maintains that foreigners, to a greater extent than Westerners, are never alone and never simply human.
5 There are two major stances regarding pathology. One is universalistic: illnesses are the same all over the world and it is impossible and pointless to make geographical distinctions. The other is relativistic: each culture expresses itself in a different way and someone deeply versed in the specific culture is needed to act as an interpreter. I propose a third stance, outlined in the article, which I call intercultural practice.
6 Caritas is a religious organization, geographically present in the whole of Italy, that intervenes in social projects.
7 “Donkeys” is the Italian way to call those who are bad in school.
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