The
International Journal of Psychosocial Rehabilitation
Cultural competence
and models in mental health:
Working with Asian Service Users
Nayar, S., & Tse,
S. (2006).Cultural competence and models in mental health: Working with
Asian Service Users.
International Journal
of Psychosocial
Rehabilitation. 10 (2), 79-87.
Cultural competence of the
workforce
is vital to ensure equity in access to appropriate and high quality
care.
Furthermore the literature indicates a growing need to develop
resources on
cultural competence to assist health service providers to address the
needs of
people from diverse backgrounds. For the purposes of this paper,
cultural
competence is defined as “the ability of individuals and systems to
respond
respectfully and effectively to members of all cultures, races, classes
and
ethnic backgrounds and religions in a manner that recognises, affirms,
and
values the cultural similarities and differences and their worth” (Tse
et al,
2005, p. 23).
The aim of this article is to
review
the literature on cultural competence, leading to seven critical
success
factors in developing effective training programmes and present the
beginnings
of a ten week education programme.
In the first instance, literature
reviewed focused on investigating cultural competence, workforce
cultural
responsiveness and principles of culturally safe practice. Secondly,
literature
pertaining to models and programmes used when training in cultural
competence
was reviewed.
Bhui et al (2004) contend that
cultural
competence further demands the promotion of education and skill within
the
health workforce. One such skill is communication. Words that Harm,
Words that
Heal (Bedell et al, 2004) discusses the power of language by physicians
in
harming or healing their patients. Given the intertwined nature of
language and
culture, this article challenges the use of appropriate language as an
important skill in learning to provide appropriate health care services
that
are culturally sensitive to patients from diverse cultures and
languages, a
stance supported by Huang (1997) and Lin and Cheung (1999). The need
for this
skill is also discussed by Hunt and
Development of education and skill can be accessed through training and supervision which Bhui and Bhugra (1998) acknowledge as an integral component in the development of multicultural effective health services. However, development of cultural competence is not immediate nor a one off lesson, rather cultural competence is an ongoing process (Campinha-Bocte, 1994). As a way of assessing cultural competence within the workplace, Chin (2002) recommends ongoing training and staff development for working with culturally diverse groups.
Within New Zealand, the Mental Health Issues for Asians in New Zealand: A Literature Review (Ho et al, 2002) emerged in response to New Zealand’s fastest growing ethnic group and reflects some of the findings of international literature. It highlights the difficulties, problems and barriers, faced by Asian immigrants and clearly supports the urgent need to cultivate responsiveness, such as use of interpreters for enhanced communication as a way of improving mental health services to Asian people.
In
Literature included in this review
suggests clearly cultural competence in individual health service
practitioners
requires resources, training, organisational support in order to be
accessible,
safe and effective. In 2001, the Mental Health Commission of New
Zealand
launched the Recovery Competencies Training Resource Kit. This is a
helpful
starter kit for training as well as a useful resource and tool. Because
of its
generic approach to all cultures it can be easily applicable and
modified to
suit any cultural group.
The term ‘cultural safety’ was developed in the 1980s in New Zealand in response to the indigenous Maori people’s discontent with nursing care and in 1990, the Nursing Council of New Zealand amended its standards to incorporate cultural safety into its curriculum assessment processes and guidelines. The concept of cultural safety, which can be described as “a manner, which affirms, respects and fosters the cultural expression of the recipient” (New Zealand Nurses Organisation, 1995). is achieved in a gradual, progressive fashion, starting with cultural awareness, progressing to cultural sensitivity and finally cultural safety – an outcome that enables safe service to be defined by those who receive the service.
Similar to this model in that
cultural competence is achieved in an ongoing manner is a programme
designed by
the
The second of three objectives
outlined in “Inside Outside: Improving mental health services for Black
and
minority ethnic communities in
Within
As with the QTMHC programmes, Purnell’s model of cultural competence (Purnell and Paulanka, 2003) was selected for its comprehensiveness and application to many disciplines, both within and outside of health care. The framework for data collection consists of areas such as communications, family roles and organisation, health care practices, and spirituality. Primarily, Purnell’s model is a guideline to understand service users from culturally diverse backgrounds. It is easily accessible and provides learning opportunities for professionals without affecting productivity in workplace.
Based on the literature review, critical success factors that make training on cultural competence effective and successful include:
1) Organisational support and commitment - When health practitioners are encouraged and challenged to develop skills and increase knowledge of cultural competence by their organisations, their motivation and learning ability tends to increase and is sustained over a longer period.
2) Guidelines and standards of cultural competence – Trainees need to know what they need to attain and develop in terms of providing culturally competent health care services.
3) Variety of mode of delivery – It is vital to use a combination of didactic methods as well as other styles of training such as a problem based learning method. Trainees learn both content and critical thinking skills better if the processes are based on actual problems (Barrows, 1985; Stepien and Gallagher, 1993).
4) Cultural awareness included in training programme – Cultivating awareness is vital because it provides a basis for accurate opinions, attitudes and assumptions.
5) Availability of resources, materials, information, follow up and assessment tools –given the understanding that acquiring cultural competence is an ongoing process, the availability of resources, materials and assessment tools is of utmost importance in assisting and supporting trainees outside of structured training sessions.
6) The importance of skills development – This is the ability to build on awareness and apply knowledge toward effective change in multicultural settings.
7) Communication skills and language support. Culture and language have considerable impact on how patients access and respond to health care services. Only through careful interaction and communication will it be possible to accurately identify problems, issues and work together to solve them in a cross cultural setting.
Education
Programme – An Overview
Table 1 provides an overview of
proposed session topics utilising the ‘cultural competent model of
care’
(Campinha-Bacote, 1994) to be covered in a ten week education programme
aimed
at providing New Zealand mental health workers with the necessary
training in
cultural competence.
Table 1. Overview of
Education Programme Session Topics and key
contents utilizing the Cultural Competent Model of Care
(Campinha-Bacote, 94)
|
Cultural Awareness |
Cultural Knowledge |
Cultural Skill |
Cultural Encounter |
|
Be aware of
one’s own cultural background ·
Define terms such as culture, ethnicity, race ·
Develop attitudes that will enhance empathetic and
empowering relationships with Asian clients ·
Be aware of cultural transference and
counter-transference or biases |
Immigration
and mental health ·
Understand history of Asian people’s migration in ·
Identify different stages of post-immigration settlement ·
Biculturalism and multi-culturalism ·
Identify gains and losses, new opportunities and
challenges ·
Concept of acculturation and the associated stress |
Work with
Asian clients in assessment and diagnosis ·
Understand the role of culture and language in assessment
and diagnosis ·
Be aware of cultural impact on psychiatric
manifestations, notion of normality and abnormality and culture-bound
symptoms ·
Increase skills to identify cultural bias ·
Use cross cultural and cultural fair assessment tools ·
Appreciate code of rights and gain skills to advocate for
Asian clients’ interest and welfare |
Effective
cross-cultural communications ·
Understand that there is a complex relationship between
sense of self and language abilities ·
Identify the extent to which judgments of clients can be
influenced by their second language proficiency ·
Use appropriate language around mental health problems
and subtleties of that ·
Gain skills for improving the deciphering of strong
accents ·
Practise on how to solicit and record culturally specific
information relevant to mental health assessment and treatment planning |
|
|
Asian
people’s culture and mental health ·
Discuss “who are Asians in Aotearoa New ·
Understand core nature of Asian culture ·
Realise intra-ethnic variations within the Asian
population ·
Shame and stigma associated with mental illness in Asian
communities |
Work with
Asian clients in planning and implementing interventions – individual
level ·
Understand individual versus family, collective decision
making ·
Understand challenges faced by family members/ care-givers ·
Identify issues and Asian people’s assumptions about
therapeutic and psychosocial interventions ·
Understand ethnic variations in physiological responses
to medications |
Work with
interpreters in mental health settings ·
Practise how to effectively work with interpreters ·
Consider how interpreters work as “cultural brokers” ·
Be aware of ethical issues that might arise for an
interpreter who is also a member of his/her own community ·
Understand existing interpretation services |
|
|
Work with
people from refugees background ·
Understand nature, course and impacts of torture ·
Physical and psychological sequelae of torture ·
Discuss the nature and early signs of complicated or
pathological grief |
Work with
Asian clients in planning and implementing interventions – individual
and organizational level ·
Develop skills or strategies for building trust and
therapeutic alliance with individual clients and family members/
care-givers ·
Gain practical knowledge of potential services for Asian
clients for example, employment, recreational services ·
Develop skills or strategies to minimise barriers in
accessing mental health services |
|
|
|
Asian culture
as a source for resilience and strengths ·
Understand Asian people’s concept of resilience,
strengths, and various forms of coping mechanism of mental health
problems ·
Understand individual, family and community as sources
for resilience and strengths (and barriers in some cases) ·
Gain basic understanding of principles of folk and
alternative approach to treatment |
|
|
A review of the literature was conducted to identify a range of cultural competence models and best practice in the mental health setting. Results of this indicated that cultural competency is a complex, multifaceted concept requiring practitioners to be on going learners, developing skills such as communication and self reflections while grappling with more abstract concepts of cultural awareness and cultural sensitivity.
From this review, a proposed
education
programme for implementation has been proposed. The authors suggest
that the most
pressing research from this study is to now test the effectiveness of
different
training methods in a variety of contexts and with different
professional
groups that reflect the diverse mental health workforce in
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References
