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Cultural humility as good practice

Dr Ahmed Hankir explains the concept of cultural humility
So cultural humility has been conceptualised as the ability to maintain an interpersonal stance that is other oriented, or open to the other. In relation to aspects of cultural identity that are most important to the person. Now, the way I personally approach this topic is to adopt an open heart and an open mind when interacting with others, especially in a clinical context. What I mean by this is not to have any preconceptions about someone, especially those from minority religious or race groups, and to formulate any opinion of an individual’s identity based on the information that you are able to obtain from them and their preferences.
Amanda Waters and Lisa Asbill, in an article published in a newsletter for the American Psychological Association, identify three factors that guide a sojourner toward cultural humility. The first aspect is a lifelong commitment to self-evaluation and self-critique. Waters and Asbill argue that underlying this piece is the knowledge that we are never finished. We never arrive at a point where we are done learning. Therefore, we must be humble and flexible and audacious enough to look at ourselves critically and desire to learn more. Indeed, I argue that we must be brutally honest with ourselves when considering the following, when we do not know something are we able to say that we do not know? Often the ego can interfere with this process.
I think this is really relevant to Muslim mental health. If, for example, a non-Muslim practitioner is providing care to a Muslim patient and they do not know much if anything about the Islamic faith, then they must be honest with themselves and acknowledge that they are out of their depth. For example, a Muslim patient may vocalise that they have been possessed by a malevolent spirit, and that is why they can hear voices. A non-Muslim practitioner may suspect this belief is delusional. However, we must revisit the definition of a delusion before we can come to this conclusion.
So a delusion is a fixed false belief held with absolute certainty, despite robust evidence to the contrary that is inconsistent with cultural or religious norms. So cultural humility involves the practitioner taking action by consulting with a colleague such as an imam in the hospital chaplaincy or a fellow mental health care professional from the same faith background as the patient. To establish if such a belief is consistent with that particular cultural or religious norm or not. The consultation would reveal that this belief is not delusional. I will share another example, which, although fictional, remains common in clinical practice.
So in the book, a Thousand Splendid Suns by Khalid Hosseini, the character Maryam, a young Afghan girl, witnesses as her mother having a tonic clonic seizure. Instead of attributing this to aberrant electrical activity of the brain, which is the case in epilepsy, she believes her mother is possessed by jinn or an evil spirit. Again, if the non-Muslim practitioner encounters such a scenario in clinical practice, which is not uncommon and is not sure if this belief is delusional or not, they should have the humility to acknowledge this and to consult a colleague from the same faith background to establish if this belief is consistent with religious norms or not.
The second feature of cultural humility is a desire to fix power imbalances where none ought to exist. Nowhere is this more apparent than in psychiatry. A psychiatrist has the power to take someone’s freedom away from them. We can detain patients under the Mental Health Act, and there are many patients who resent this. Indeed, they may feel that psychiatrists exploit their power, however, as Waters and Asbill point out, we must forever remember that when practitioners interview patients, the patient is the expert on his or her own life, symptoms and strengths. It is true, as Waters and Asbill state in that article that the practitioner holds a body of knowledge that the patient does not, so is an expert by professional experience.
However, the patient also has an understanding outside the scope of the practitioner, is an expert by personal experience. Both people must collaborate and learn from each other for the best outcomes. They must co-produce a treatment Plan, Waters and Asbill conclude that one holds power and scientific knowledge and the other holds power and personal history and preferences. The third factor of cultural humility includes aspiring to develop partnerships with people and groups who advocate for others. Waters and Asbill contend that though individuals can instigate positive change, communities and groups often have the most profound impact on systems.
Waters and Asbill argued, and I agree, that we cannot individually commit to self-evaluation and fixing power imbalances without advocating within the larger organisations in which we operate and participate. Waters and Asbill conclude that cultural humility, by definition, is larger than our individual selves and that we must advocate for it systemically. Now, my humble working definition of cultural humility includes eliminating any pedestals and ivory coasts in mental health care and talking with patients on the same level. I will share an anecdote to illustrate this point. I was the psychiatry of doctor on call. I was asked to assess a patient in seclusion in the psychiatric intensive care unit.
Upon my arrival, I noticed that he was carrying a copy of the Holy Quran in his right hand, and staff were preparing to administer rapid tranquilisation. I swear, I could hear someone behind me refer to the patient as a terrorist. I approached the man and I gently and respectfully introduced myself and explained the purpose of my visit. However, the patient refused to engage. I then said, Salaam, peace be upon you. And that was when we made eye contact. I said to the patient that I could see he was carrying a copy of the Holy Quran. And I asked him if reciting from the Quran was comforting for him. He nodded his head.
I then suggested if we recited Surat al Fateha [verse from Quran] it might make him feel better. And he agreed. So we decided Surat al Fateha out together in unison. And upon completion, he had a huge face, had a huge smile on his face, and the situation de-escalated, and there was no need for rapid tranquilisation. The staff who had been working with the patient for a long time reported they have never seen the patient so calm before.
So if a non-Muslim practitioner finds themselves in a similar scenario, they can always consider contacting a Muslim practitioner who, by virtue of having the same faith background as the patient, may find it easier to develop a verbal rapport and a therapeutic alliance with them. And this may help to avert the utilisation of rapid tranquilisation with which often occurs under restraint.

In this step, NHS Consultant Psychiatrist and expert by professional and lived experience, Dr Ahmed Hankir explains the concept of cultural humility.

Cultural humility is a concept that refers to a way of interacting with others that is open to recognising aspects of cultural identity that are most relevant to the person you are talking to. This includes acknowledging what you do not know or understand about cultural practices and beliefs. The approach also represents a commitment to learning more to improve your understanding, and to addressing inequalities and imbalances of power.

Dr Hankir summarises this as the ability to “adopt an open heart, and an open mind, when interacting with others”. He goes on to explain the approach in relation to mental health support practice, referring to the work of Waters and Asbill (2013).

Importantly under this approach, knowledge is power. While those who provide support may have greater professional, scientific, or religious knowledge, the patient is the expert on their own experiences, personal history, and preferences.

Working in partnership with organisations that represent and advocate for marginalised groups is a core feature of cultural humility. These groups can be influential in affecting change and addressing structural inequalities in society.

Cultural humility is an approach that can be undertaken by all practitioners who provide mental health support, including Muslim and non-Muslim practitioners, and across mental health and religious settings. The approach is particularly useful for practitioners who seek to work within a holistic, bio-psycho-social-spiritual framework for understanding and supporting mental health in Muslim communities.

At 09:12 in this video Dr Ahmed Hankir talks about reciting Surat al-Fatihah. Surat al-Fatihah, or “The Opening” is the first “Sura” or verse, of the Qur’an. It plays especially important role in Islamic worship, being an obligatory part of the daily prayer, repeated several times during the day.

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Understanding Mental Health in Muslim Communities

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