The International Journal of Psychosocial Rehabilitation
Cultural competence and models in mental health:
Working with Asian Service Users  

 


Shoba Nayar
Doctoral Candidate
School of Occupational Therapy
Division of Rehabilitation and Occupation Studies
Faculty of Health and Environmental Sciences
AUT University

 

Dr Samson Tse
Director of the Centre for Asian health Research and Evaluation
School of Population Health
Tamaki Campus
The University of Auckland

 

 Citation:
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.

 

Correspondence:
Dr Samson Tse
Centre for Asian health Research and Evaluation
School of Population Health, Tamaki Campus
The University of Auckland
Private Bay 92 019
Auckland ,New Zealand
Email: s.tse@auckland.ac.nz
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Abstract
The Asian population is one of the fastest growing ethnic groups in New Zealand and this raises questions regarding the ability of the mental health service workforce to respond appropriately to the needs of New Zealand Asian population. This paper provides an overview of key findings from the international and New Zealand literature on the concept of cultural competence and delivery within mental health settings. From this systematic review of literature, the authors present an outline of a ten week education programme seeking to improve the cultural competence of the mental health workforce providing services to the Asian population are summarised.   <>  <>
Keywords: Cultural competence, mental health, workforce development

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Introduction
As the New Zealand population becomes more diverse, the need for the delivery of culturally competent and appropriate health care services is becoming paramount (Ho et al, 2002; Nursing Council of New Zealand, 2002; Ministry of Health, 2004). Moreover, one of the key recommendations from the literature review on mental health issues for Asians in New Zealand suggests, “It is essential that the formal mental health care systems become more responsive to the needs of the Asian communities. Health care providers can deal with their clients more competently if they are knowledgeable of their clients’ cultural beliefs, their interpretation of mental illness and mental well-being, their help seeking patterns, and choice of traditional alternative health practices” (Ho et al, 2002, p. 51).

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.

Literature Review Findings
Literature reviewed for this paper included national and international sources with the purpose of establishing a comprehensive understanding of professional practice and organisational requirements for a culturally capable workforce. Documents dating between 1990 and 2004 were located using computer searches and entering key phrases, ‘cultural competence models’, ‘workforce development’ and ‘mental health’. Additional material was identified through professional networking and key expertise.

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.

Cultural Competence
This section groups reviewed literature under three headings, Theoretical work; Policy document; and Mental health settings and training packages.

Theoretical Work
As a starting ground for cultural competence, international literature endorses the need for professionals working with culturally diverse populations to develop cultural awareness as a pre-requisite to developing collaborative relationships (Green, 1982; Papadopoulous et al, 2001; Harry, 2003). Cultural awareness is a beginning step towards understanding that there is a difference. Paralleling cultural awareness is cultural sensitivity which is the need to be aware of what one does not really know and the implications of this for clinical practice (Bhui and Bhugra, 1997). Both these concepts are considered critical in the build up to gaining cultural competence.

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 Bhopal (2004) who conclude that one of the barriers on accumulation of reliable and valid information on ethnic minorities is the measurement error that results from inadequate translation procedures, inappropriate content, insensitivity of items and the failure of researchers to make themselves familiar with cultural norms and beliefs. Bhui et al (2003), also discuss issues of translation and validation as measures of mental health for use in a number of languages and cultural contexts.

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.

Policy Document
In 2002, the World Health Organizationcalled attention to the need for improving the performance of health care workers worldwide, challenging workers to continuously change their practice behaviour to keep abreast of new developments in the health care field. A year later the National Institute for Mental Health (NIMH) in England (2003) published the first national approach aimed at reducing and eliminating ethnic inequalities in service experience and outcome. This document represented a landmark in health care in the United Kingdom, providing a cultural capability framework aimed at tackling institutional discrimination while educating the workforce to improve clinical practice with diverse cultural groups. This report was followed by the publication of a challenging government action plan to build a fairer and more inclusive society for people with mental health problems (NIMH, 2004). There is however, no mention of ethnicity of the groups in the report and while the Department of Health (2004) acknowledges ethnic monitoring their report Delivering Race Equality: A Framework for Action, the report fails to provide explicit guidance on how to improve clinical services.

In New Zealand, policy documents addressing cultural competence have primarily focussed on the development of the Maori Mental Health Workforce and the direction for Maori health (Ministry of Health, 2002a; 2002b; 2003) with minimal discussion of the Asian community. However in 2004, the Ministry of Health published the report Improving Mental Health: The Second National Mental Health and Addiction Plan. This is a promising document by the New Zealand Government to initiate action to develop resources and assist in making mental health services culturally competent.

Mental health settings and training packages
Research on cultural competence in mental health settings contain mixed results. Phelps and Johnson (2004) positively demonstrate how a health department rose to the challenge of assisting their health workforce to develop culturally sensitive and appropriate health services to a rapidly increasing population of Haitian immigrants. However, other literature questions the cultural competence of the health workforce. For instance, Kirmayer (2002) challenges clinicians to learn to decode the meaning of somatic and dissociative symptoms that are not simply indices of disease or disorder but part of a language of distress with inter-personal and wider social meanings. In addition, Tucker et al (2003) raise the need for mental health settings to provide culturally sensitive health care incorporating people skills, individualised treatment, effective communication and technical competence.

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.


Training in Cultural Competence – Models and Programmes
Several models and workforce development programmes have emerged to meet the challenges of various multicultural health care systems. Some of these models include the “ethnic-sensitive practice” (Devore and Schlesinger, 1981), “ethnic-competence” (Green, 1982), “ethnic minority practice” (Lum, 1986) and “cultural specific care” (Leininger, 1967). Within this study, six training models or programmes used in the training of cultural competence by various organisations were examined.

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 Research Center for Transcultural Studies in Health at Middlesex University. Designed to deliver a team-based, practice-focused model of education and training to promote cultural competence in a small number of teams, cultural competence is taught through four key stages, starting with cultural awareness, moving through the second and third stages being cultural knowledge – understanding service users and their experiences of mental health; and cultural sensitivity respectively. The fourth stage, cultural competence is the synthesis and application of the previously gained awareness, knowledge and sensitivity (Papadopoulous et al, 2001).

The second of three objectives outlined in “Inside Outside: Improving mental health services for Black and minority ethnic communities in England” (NIMH, 2003) advocates the development of the workforce. It sets out two key approaches in ensuring a culturally competent and capable workforce. These include, mandatory training in cultural awareness and recruitment of multicultural workforce so that the workforce in mental health reflects the people it serves. It suggests that training needs to occur at three levels, organisational, community and individual.

Within Australia, the Queensland Transcultural Mental Health Centre (QTMHC) provides flexible educational programmes through lectures, seminars, workshops and Train-the-Trainer programmes for all professional disciplines working in the field of mental health. The training programmes employ adult learning principles, provide follow up support and encourage training participants to make contact with the service providers at any time. This is a relatively well established programme in Australia with a strong emphasis on active participation in learning and application to practice.

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.

Finally, Campinha-Bacote (1994) proposes the ‘cultural competence model of care’ which views cultural awareness, cultural knowledge, cultural skills and cultural encounter as components of cultural competence. A key feature of this model is that it represents a process in which health practitioners see themselves always in the process of becoming culturally competent rather than being culturally competent. In addition the model has clear awareness, knowledge and skills and provides the health practitioner with a sound framework for delivering culturally competent health care.

Learnings from the Literature
To gain the knowledge, attitudes and skills needed to effectively work with Asian people affected by mental illness, mental health workers must receive appropriate education and training. However, while it has been recognised that training staff to acquire the competencies to work effectively within a multicultural community is necessary, there is no consensus on the content, style or delivery of such training. Nevertheless, recent work in this area has begun to specify the core competencies, skills, values and knowledge base which would be fundamental in training.

            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.

Still, no cultural competence workshop can make an individual culturally competent. Cultural competence is a journey, not a destination. It is a state of having a demonstrated ability to incorporate cultural concepts and data into care and is an ever-evolving process (Harris, 2004). Thus, health practitioners must anticipate variations and differences in the level of cultural competence that can be attained (Kirmayer, 2001; Ballenger, 2001). 

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 New Zealand

·         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 Zealand?”

·         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

 

 

 


It is suggested that the programme includes both practical and theoretical content. The latter providing an important framework and in-depth analysis of the practical material. Each session starts with outlining the aims, objectives and session content, followed by teaching and learning exercises to facilitate participants’ development in the session topics. The next stage is to proceed to trial of the proposed education programme in the main cities in
New Zealand. Authors welcome enquires from readers should they wish to find out more about this training programme and its trial outcomes.

Summary
The Asian population is one of the fastest growing ethnic groups in New Zealand and other western countries like the United States and United Kingdom. There is now acknowledgement from the New Zealand government of the need for mental health services to be able to cater for people from diverse cultural backgrounds.

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 New Zealand.
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References

Ballenger, J. C., Davidson, J. R., & Lecrubier, Y., et al., (2001) Consensus statements on transcultural issues in depression and anxiety from the international consensus group on depression and anxiety. Journal of Clinical Psychology, 62,47-55.

Barrows, H. (1985) Designing a problem-based curriculum for the pre-clinical years. Springer Publishing Company, New York.

Bedell, S. E., Graboys, T. B., Bedell, E., et al (2004) Words that harm, words that heal. Archives for Internal Medicine, 164(13), 1365-1368.

Bhui, K., & Bhugra, D. (1997) Cross-cultural competencies in the psychiatric assessment. British Journal of Hospital Medicine, 57(10), 492-496.

Bhui, K., & Bhugra, D. (1998) Training and supervision in effective cross-cultural mental health services. Hospital  Medicine, 59(11), 861-865.

Bhui, K., McKenzie, K., & Gill, P. (2004) Delivering mental health services for a diverse society.  British Medical Journal,  329(7462), 363-364.

Bhui, K., Mohamud, S., Warfa, N., et al (2003) Cultural adaptation of mental health measures: Improving the quality of clinical practice and research. British  Journal of  Psychiatry, 183, 184-186.

Chin, J. L. (2002) Assessment of cultural competence in mental health systems of care for Asian Americans. In: K. S. Kurasaki, S. Okazaki, & S. Sumi, (Eds.). Asian American mental health: Assessment theories. Kluwer Academic/Plenum Publishers, New York.

Campinha-Bacote, J. (1994) Cultural competence in psychiatric mental health nursing: A conceptual model. Mental Health Nursing, 29(1), 1-8.

Devore, W., & Schlesinger, F. G. (1981) Ethnic-sensitive social work practice. CV Mosby, St. Louis.

Green, J. W. (1982) Cultural awareness in the human services. Prentice-Hall, New Jersey.

Harry, B. (2003) Developing cultural self-awareness. Retrieved February 21, 2005, from http://www.casanet.org/library/culture/culture-aware.htm

Ho, E., Au, S., Bedford, C., et al (2002) Mental Issues for Asians in New Zealand: A literature review. Wellington: Mental Health Commission.

Huang, G. (1997) Beyond culture: Communicating with Asian American children and families. Retrieved February 21, 2005, from http://www.casanet.org/library/culture/communicate-asian.htm

Hunt, S. M., & Bhopal, R. (2004) Self report in clinical and epidemiological studies with non-English speakers: The challenge of language and culture. Journal of Epidemiology and Community Health, 58 (7), 618-622.

Kirmayer, L. J. (2002) Cultural variations in the clinical presentation of depression and anxiety: Implications for diagnosis and treatment. Journal of  Clinical  Psychology, 62, 22-28.

Kirmayer, L. J., & Minas, H. (2000) The future of cultural psychiatry: An international perspective. Canadian Journal of Psychiatry, 45(5), 438-446.

Leininger, M. (1967) The culture concept and its relevance to nursing. Journal of  Nursing Education, 6(2), 27.

Mental Health Commission (2001) Recovery competencies teaching resource kit. Wellington: Author.

Ministry of Health (2002a) He Korowai Oranga: Māori health strategy. Wellington: Author.

Ministry of Health (2002b) Whakatataka: Māori Health Action Plan 2002-2005. Wellington: Author.

Ministry of Health (2003) Building on Strengths: A new approach to promoting mental health in New Zealand/Aotearoa. Wellington: Author.

Ministry of Health (2004) Improving mental health: The second national mental health and addiction plan 2005-2015: consultation document. Wellington: Author.

New Zealand Nurses Organisation (1995) Cultural Safety in Nursing Education. In Policy and Standards on Nursing Education. Wellington: Author..

Nursing Council of New Zealand (2002) Guidelines for cultural safety, the Treaty of Waitangi and Māori health in nursing and midwifery education and practice. Wellington: Author.

National Institute for Mental Health in England (2003) Inside Outside:  Improving mental health services for black and minority ethnic communities in England. Leeds: Department of Health.

National Institute for Mental Health in England (2004) From here to equality: A strategic plan to tackle stigma and discrimination on mental health grounds 2004-2009. Leeds: Department of Health.

Papadopoulos, I., Tilki, M., & Lees, S. (2001) Cultural competence in care. Open Mind, 110, 20-21.

Phelps, L. D., & Johnson, K. E. (2004) Developing local public health capacity in cultural competency: A case study with Haitians in a rural community. Journal of Community Health Nursing, 21(4), 203-215.

Purnell, L. D., Paulanka, B. J. (2003) Purnell’s model for cultural competence. In: L. D. Purnell, B. J. Paulanka (Eds.). Transcultural health care: A culturally competent approach. Philadelphia: F.A. Davis Company.

Queensland Transcultural Mental Health Centre (2002) Education and Development Handbook. Woolloongabba: Queensland Health.

Stepien, W., & Gallagher, S. (1993) Problem-based learning for traditional and interdisciplinary classrooms.  Journal for the Education of the Gifted, 16, 338-357.

Tse, S., Bhui, K., Thapliyal, A., et al (2005) Asian Mental Health Workforce Development Feasibility Project. Auckland: Health Research Council of New Zealand.

Tucker, C. M., Herman, K. C., Pedersen, T. R., et al (2003) Cultural sensitivity in physician-patient relationships: Perspectives of an ethically diverse sample of low-income primary care patients. Medical Care, 41(7), 859-870.

World Health Organization(2000) Improving provider skills: Discussion paper No. 1. Geneva: World Health Organization

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