Cultural distance and forensic psychiatric services in UK

Пиял Сен

Консультант, судебный психиатр

Служба личностных расстройств

Служба безопасности монастыря

Милтон Кейнес, Великобритания

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Культурная дистанция имеет значительное воздействие на адаптацию экспатрианта. Эта адаптация имеет три измерения: a) адаптация на работе, б) приспособление к взаимодействию с жителями страны-хозяйки, в) приспособление к общей среде вне работы. В случае профессионала здоровья, работающего с психиатрическими пациентами, эти измерения накладываются друг на друга, особенно когда пациенты страдают личностным расстройством и нуждаются в лечении и реабилитации в исправительном учреждении.

Cultural distance has a considerable impact on expatriate adjustment. This adjustment has broadly three dimensions to it: a) adjustment to work, b) adjustment to interacting with host nationals, and c) adjustment to general non-work environment. In case of a health professional working with psychiatric patients, these three dimensions overlap considerably, particularly when the patients happen to suffer from personality disorder and need to undergo treatment and rehabilitation within a long-term forensic setting.

This paper seeks to explore how cultural distance between staff and patients can influence the quality of care in a forensic psychiatric service geared to treating patients suffering from personality disorder. It was case vignettes to illustrate some of the difficulties and suggest ways in which some of the difficulties could be overcome.

Chadwick Lodge is a 92-bedded medium secure forensic hospital in Milton Keynes, United Kingdom, which accepts patients from all over the country. It has a 10-bedded male personality disorder service. Average length of stay of a patient within this service is 5 years. Over the past 5 years, including the current cohort of patients, 20 patients have been admitted to this service, 14 of whom have been patients with a history of sexual offences. 13 patients have spent time in a maximum secure forensic hospital. All except one are of White British ethnicity.

Regarding the staffing, the ward has a full multidisciplinary team but there have been gaps in the

Тезисы докладов Международной конференции по психоонкологии «Культура, мозг, тело»

team. For a long time, the team has not had a permanent Occupational Therapist or a Social Worker. The nursing team is one of the key components of the multidisciplinary team, where the full complement is meant to be 23 staff, but there are 3 vacancies. Of the 20 permanent nursing staff, including the nurse therapist 17 are Non-White, including the Ward Manager and her two Deputies. Regarding other members of the clinical team, all except the Consultant are of White British ethnicity.

Over the past 5 years, there have been complaints from patient groups about being unable to communicate properly with the nursing staff. When frustrated, they have often subjected staff to racist abuse. There was a period of time when there were a number of media reports about patients on the wards, particularly those with a history of sexual offences and patients blamed the nursing staff for leaking the information. In this climate of mistrust, complaints escalated from patients about not being supported enough by staff. Staff, on the other hand, felt that not enough was done to deter patients who subjected staff to racist abuse even though the organization adopted a zero-tolerance policy towards racist behaviour. They also felt that they lacked adequate training to manage complex patients with personality disorder especially since medication only played a very limited role in management.

One patient with a history of 2 manslaughter offences came to Chadwick Lodge after spending more than 20 years in a high secure hospital. He became more and more physically unwell and had severe breathing problems. He was confined to an extremely sedentary lifestyle, even though he was in his 40-s, and turned his frustration on staff. If he perceived his needs not to be met immediately, he would hurl racist abuse at staff. Even when confronted with how unacceptable his behaviour was, he would refuse to apologize, saying that he had deliberately used those terms, as he wanted to hurt staff. As he knew that he was too physically unwell to move forward in his treatment and would effectively spend the rest of his life in Chadwick Lodge, it was difficult for the clinical team to negatively re-inforce this behaviour.

Another patient had been sexually abused by a family friend when he was in his teens, and also found it very difficult to acknowledge his own homosexuality as he had quite entrenched homophobic attitudes. This led to frequent complaints from him about male staff in the ward looking at his genitals, particularly targeting young black males. One possible reason for this was such staff often not maintaining eye-contact while talking to him, which was cultural practice for some of these staff members, but which fuelled his paranoia about them staring at his genitals. He seemed to do much better in nursing shifts where there were more white staff around, particularly white female staff. However, given the ethnic composition of the ward nursing team, this was often a rare event. There thus were no easy solutions to this issue.

A third patient had a paranoid illness in addition to a personality disorder. When he felt frustrated, his paranoid beliefs would be particularly focussed on staff, who he perceived to be holding him in hospital against his, will. This would manifest itself in the form of racist abuse of staff, for which he would later apologize when he was calmer but attribute it to his «up-bringing». However this led to a greater sense of alienation between him and the clinical team as he would often lose privileges like leave after an episode of racist abuse, which would only increase his anger and frustration, only worsening the therapeutic relationship further.

These cases illustrate some of the difficulties in a forensic psychiatric service geared towards treatment of personality disorder. The therapeutic relationship is one of the key treatment tools in the smooth running of such a service. Unfortunately, cultural distance can often come in the way of a good therapeutic relationship. In patients with a long-standing history of insecure attachments, the perceived foreignness of caregivers was another barrier to secure attachment formation. The caregivers, in their turn because of some of their difficulties in fully adjusting to the expatriate experiences often lack the confidence and skills to overcoming some of the cultural barriers. Extraneous events like media reports on patients can also interfere with the development of a trusting therapeutic relationship.

The best way to overcome these difficulties is to offer cultural awareness training for both staff and patients. There should also be specific training offered to both groups on personality disorder to increase self-awareness. Most importantly, regular individual and group clinical supervision for staff along with mentoring, preferably with a professional from a similar ethnic background, would go a long way towards alleviating some of the difficulties around cultural distance in a forensic psychiatric service.