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
competence further demands the promotion of education and skill within
health workforce. One such skill is communication. Words that Harm,
Heal (Bedell et al, 2004) discusses the power of language by physicians
harming or healing their patients. Given the intertwined nature of
culture, this article challenges the use of appropriate language as an
important skill in learning to provide appropriate health care services
are culturally sensitive to patients from diverse cultures and
stance supported by Huang (1997) and Lin and Cheung (1999). The need
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.
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
The second of three objectives
outlined in “Inside Outside: Improving mental health services for Black
minority ethnic communities in
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
(Campinha-Bacote, 1994) to be covered in a ten week education programme
at providing New Zealand mental health workers with the necessary
Table 1. Overview of Education Programme Session Topics and key contents utilizing the Cultural Competent Model of Care (Campinha-Bacote, 94)
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
programme for implementation has been proposed. The authors suggest
that the most
pressing research from this study is to now test the effectiveness of
training methods in a variety of contexts and with different
groups that reflect the diverse mental health workforce in