Personal narrative
Ah Seng was a frequent visitor around our neighbourhood, and he would often be found asking for money or small jobs to do in return for some financial reward. I was 6 years old when I became aware of his visits, and I was intrigued by who he was and where he came from. I discovered that my father knew him. This took place in a housing estate of British colonial homes in Singapore in the 1970s. My father was the chief pharmacist at the psychiatric institution in Singapore, Wood-bridge Hospital, near where we lived. Ah Seng was a patient in a long-term rehabilitation ward; as he was not considered to be a risk to others, he enjoyed the freedom to roam the surrounding area.
This triggered my interest in him and the other patients, and led me during my school holidays to spend time with my father at the hospital. The seeds were sown of my journey into mental health and my subsequent career as an occupational therapist. I recalled observing the industrial therapy, social and creative groups that the patients engaged in. I noticed that they demonstrated a real sense of industry in these activities, appearing to derive satisfaction from their involvement. I did not realise then that it was occupational therapy.
My journey began in 1989 at the London School of Occupational Therapy (now Brunel University) in the UK. I vividly remember my first weeks in the UK, where I was struck by the distinct socio-cultural differences and perspectives. Certain patterns of behaviour that in Singapore would be frowned upon were esteemed in this new environment. Questioning individuals in authority, such as lecturers, and articulating ideas instead of speaking only when you were spoken to were both new and unsettling. These differences highlighted the importance of appreciating the complexity of how individuals are shaped by their socio-cultural context and lived experience (Lim & Iwama, 2006).
My first occupational therapy post in 1992 was in a secure psychiatric unit in a large London mental hospital. This experience was daunting and intriguing. The clients were unwell and were detained as there was a high risk of violence. However, the containing nature of the ward and the skills and qualities of some staff appeared to minimise incidents and created a therapeutic milieu in this potentially hostile environment. What was notable was the disproportionate number of black young men on the ward – a phenomenon replicated throughout the hospital.
Cultural sensitivity, in this context, is my passion and research interest. This includes culturally sensitive practice, socio-cultural construction of occupational therapy and occupation, social inclusion and recovery of mental health service users and the Kawa ‘River’ Model.
Introduction
This chapter will clarify the key terms used and explore the evolving socio-cultural contexts. This will be followed by views of cross-cultural mental health and will conclude by exploring culturally sensitive practice and professional and personal imperatives. Although focused primarily on the UK, the issues raised and strategies suggested in addressing cultural sensitivity are relevant internationally.
Clarification of key terms
There is confusion around the concepts of culture, minority ethnic groups, cultural sensitivity and competency as these terms are defined and understood in a variety of ways (Dillard et al., 1992; Fitzgerald et al., 1997; Awaad, 2003). The terms client and service user will be used interchangeably.
Culture
Wells and Black (2000, p. 279) defined culture ‘as a set of values, beliefs, traditions, norms, artefacts and customs that is shared by a group or society’. Whilst Hasselkus (2002, p. 42) stated that culture consists of ‘patterns of values, beliefs, symbols, perceptions and learnt behaviours shared by members of a group and passed on from one generation to another’. What is significant and valuable to a particular cultural group may not be shared by the majority population or wider society (Lim, 2006a). Culture is evolving and dynamic, and therefore assumptions made about any cultural group, and their responses, may alter with time (Awaad, 2003; Chaing & Carlson, 2003).
Lim and Iwama (2006) proposed that a selection of ethnically diverse individuals who are socialised within a common community may subscribe to an agreed set of values and principles despite their racial differences. They warned of the dangers of racial assumptions and stereotypes that influence and bias interpretations. They suggested that information gained before interviewing and assessing clients, although valuable, must be verified and supplemented by the clients, as they provide the best reference point for their cultural beliefs, needs and preferences (Lim, 2001; Tribe, 2002). The provision of culturally sensitive care involves an appreciation of the socio-cultural context and cultural influences that shape individuals’ identity, perspective and lived experience (Keating, 2006). Acknowledging, affirming and valuing clients’ perspectives are important in validating their personal experiences (Hocking & Whiteford, 1995; Howarth & Jones, 1999; McGruder, 2003).
Minority ethnic communities
Wells and Black (2000, p. 282) define minority ethnic communities as ‘a group of persons who, because of their physical or cultural characteristics, are singled out from others in the society in which they live, for differential and unequal treatment and who regard themselves as objects of collective discrimination’. Bhugra and Bahl (1999) exclude national minorities such as the Scottish, Northern Irish and Welsh, who, despite their equal rights, have distinct cultural traditions and values, and argue that the current provision of services for them takes into account their specific needs. However, this view may not be shared by these respective communities who may feel that their cultural traditions and values are not sufficiently acknowledged (Leavey, 1999).
A study of occupational therapy students at Brunel University explored issues of ethnicity, race, culture, health and well-being. The majority of white (English) students felt uncomfortable and struggled to identify their own ethnicity: they had never thought about themselves in these terms and found the task difficult. In contrast, students from minority ethnic groups had no such difficulties – identifying issues relating to their ethnicity, race and being different were frequently reinforced within their daily lives, through experiences of discrimination and prejudice (Reynolds & Lim, 2005).
Cultural sensitivity and competence
The key to cultural sensitivity and competence involves the willingness of practitioners to explore the meaning of culture and to acquire knowledge about cultural issues, including their personal bias (Dillard et al., 1992; Wells & Black, 2000; Reynolds & Lim, 2005). Cultural competence cannot be achieved by completing a course of study. Wells and Black (2000) suggest that it requires self-awareness, a cultural knowledge base, an ability to access relevant information, learning to interact with others with sensitivity and respect, developing appropriate practice and an ability to evaluate personal performance and outcomes.
The evolving socio-cultural context
Increased globalisation has fostered the freedom to travel, work and live abroad and has promoted the consequential cross-cultural exchange of narratives, knowledge and experiences. The Office for National Statistics (2001) indicated that 5.29 million people, representing 8.9 % of the UK population, are from minority ethnic groups. The increased diversity is found throughout the country, although minority ethnic groups make up a significant proportion of populations in Leicester, Manchester, Glasgow and Bradford (Office for National Statistics, 2001). In London, 29% of the population is from minority ethnic groups, and in some communities, this figure rises to over 50% (King’s Fund, 2003).
The recent expansion of the EU has also increased the population diversity within the UK. A view that the UK is overpopulated and overwhelmed by immigrants is perpetuated by inaccurate and provocative reports in the media (Trivedi, 2002). These negative views extend to refugees and people seeking asylum and have the potential to prejudice perceptions of both these groups, with some believing that those seeking refuge in the UK are economic migrants rather than genuine refugees. This has an adverse effect on refugees trying to settle and integrate into the UK. However, such myths are discredited when the Office for National Statistics (2005) indicates that over a thousand British citizens are migrating from the UK daily.
Assimilation and integration into mainstream society requires that migrants and refugees go beyond existing; they must be able to live, work and contribute and have the freedom to be, belong and become without fear, exclusion or discrimination (Reynolds & Lim, 2005). This is impossible when migrants and refugees are segregated in deprived areas with other social excluded members of society (Lim, 2005; Smith, 2005). Conflict and jealousy arise when the majority population perceive that their already limited resources are being siphoned away by migrant groups. Issues of social and occupational injustice, loss of opportunity, intolerance and prejudice can lead to further discrimination and even greater social exclusion (Whiteford, 2000; Wilcock, 2006).
With prejudice and injustice, social inclusion and integration are unlikely to occur. This situation can be compounded by mental illness. The Social Exclusion Unit (Office of the Deputy Prime Minister, 2004) indicates that refugees and minority ethnic groups with a mental illness are the most excluded people in the UK. Thus, the promotion of social inclusion in enabling individuals to participate fully in society, enjoying the same opportunities and engaging in daily activities of their choice, becomes an impossible dream. This is reinforced by Smith (2005), who highlights the shortage of social capital, opportunities and resources required to support the educational, health and social needs of these groups.
National recognition of discrimination, racism, inequality and lack of cultural safety led to policies and standards to address these issues within health and social care (DH, 1999; DH, 2000; Office of the Deputy Prime Minister, 2004) and particularly in Delivering Race Equality in Mental Health Consultation Document (DH, 2003), which all reflect the importance of eliminating the problems of cultural insensitivity and promoting access, choice, opportunity and equality.
High-profile inquiries conducted by, MacPherson (1999) and Blofeld (2003) highlighted the poor levels of care and discriminatory treatment received by black and minority ethnic (BME) service users, and led to the Delivering Race Equality in Mental Health (DRE) Action Plan (DH, 2005a). This 5-year plan aims to achieve equality and to tackle discrimination in mental health services by outlining objectives, initiatives and targets for mental health services. To support the plan, a national steering group has been commissioned to ensure that current and future mental health practitioners are equipped with relevant cultural knowledge and skills to work competently with a diverse range of clients in equitable and culturally sensitive ways.
UK mental health ethnicity statistics
Wilson and Francis (1997) noted that African, African-Caribbean and Irish people were over-represented in psychiatric hospitals and Irish people were overrepresented in alcohol services in the UK. Browne (1997) further found that African and African-Caribbean people were more likely to be detained under the Mental Health Act. The Sainsbury Centre for Mental Health (SCMH) (2000) and a systematic review by Bhui et al. (2003) noted that the lack of cultural sensitivity and appropriateness of existing assessments may contribute to misdiagnosis and disparities in treatment options available to BME service users. More recently, the Healthcare Commission Census (DH, 2005b) reported that BME service users encountered greater involvement of the police in their referrals and higher rates of physical restraint than other patient groups. Central to these inequalities was the failure of staff to appreciate the individuals’ lived experience (Lim, 2001; Trivedi, 2002). Mind (2002) reported that, although black men represent 1% of the UK population, they are ten times more likely to be diagnosed with a mental health problem. They are more likely to receive physical treatments, be given atypical medication and are less likely to be referred for talking therapies; additionally they make up 16% of those detained in one high-security hospital.
In contrast, such groups as Chinese and South Asians (including Sikhs) are under-represented in mental health services (Bhui et al., 2003). This may be due to genetics or increased resilience to mental health problems or, conversely, that they experience greater difficulty in accessing help or avoid mental health services (Lim, 2001). Additional efforts must be made to understand this phenomenon to ensure that people from these groups are not disadvantaged
Providing culturally appropriate food, having information in different languages and interpretation services are a start, but are not enough to address intolerance of religious beliefs and customs, discrimination and inflexibility in making adjustments to respect the values and needs of individuals (Lim, 2001).
The death of Stephen Lawrence, a black teenager in East London in 1993, led to a public inquiry that concluded that institutional racism, defined as ‘a collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origins’, existed within public services in UK society (MacPherson, 1999, p. 4262-i). Such discrimination can be overt or covert and is detected within the attitudes, behaviours and processes of an organisation. Although unintentional, it may be demonstrated through unwitting prejudice, thoughtlessness and racist stereotyping, which disadvantages minority ethnic people. Reflecting these findings, Greenwood et al. (2000) and Secker and Harding (2002) explored the in-patient experiences of service users from Asian, African and African-Caribbean backgrounds who reported a loss of control, experience of overt and implicit racism, unhelpful relationships with some staff and a lack of therapeutic groups and activities during their admission.
The independent inquiry into the death of David Bennett (Blofeld, 2003) stressed the failure of the National Health Service (NHS) to tackle institutional racism and the excessive use of physical restraints and recommended that all staff receive cultural awareness and sensitivity training. As it is difficult to separate the attitudes and practices of employees from their organisation that influences their actions (SCMH, 2002), occupational therapists need to examine the professional philosophies and principles within their practice (Lim, 2005) to ensure inclusive, cultural by sensitive and non-discriminatory services to clients.
Inequalities in power
Central to the process of involvement is the power to influence decisions affecting one’s treatment, health and social requirements. However, despite national initiatives to promote greater service user involvement, collaboration is often superficial (Trivedi, 1999; Keating, 2006). Trivedi (2002) proposed that staff are vested with more power than clients and this inequality is more than even the most confident, skilled and empowered client could overcome. To lessen this inequality, staff need to ensure that clients are enabled to influence their own goals and treatment (Hinkin & Schresheim, 1994; Lim, 2005).
At a societal level, the negative impact of mental health services, as experienced by certain communities, perpetuates the belief that these services are part of a larger system that subjugates and restricts freedom of choice and lifestyle (Mintzberg, 1983; Trivedi, 2002). These minority ethnic groups may perceive that the mental health system fulfils a more sinister role of social control, enforcement and exclusion (Keating, 2006). The following example captures this view.
Cross-cultural mental health perspectives
The cross-cultural interpretation of mental illness may be different from Western conceptualisation that frames individual’s experience into categories of ill health. Diagnosis is important, as treatment is centred on identifying and counteracting the problem (Masi, 1992; Lim, 2001). This contrasts with the non-Western perspective, where mental ill health may be attributed to a failure to maintain life balance or a consequence of witchcraft or incurring a curse (Helman, 2000). This view negates the importance of adhering to a medication regime, and a visit to a healer or maintaining a balance through traditional remedies may be reasoned to be more effective.
Non-Western perspectives of health and well-being
Effective practice in a multi-cultural context requires an appreciation of how individuals understand their world, their philosophy and what they perceive as meaningful. In the UK, Western perspectives and priorities are dominant. Although cultural and philosophical differences may not be an issue when working with individuals from a similar background, they may be potential hurdles when working cross-culturally. Diverse individuals and communities require occupational therapists to examine alternative views and experiences (Iwama, 2003; Lim, 2004a). Although these perspectives are not totally exclusive to each group or shared by all its members, they are generally shared by individuals within Western and non-Western societies. These differences are identified in Table 3.1.
The Western perspective of health and well-being purports a reductionist and scientific view; in contrast, the non-Western, holistic perspective focuses on interrelated factors contributing to the difficulties experienced. Health and well-being are not the absence of illness, but equilibrium is achieved through all aspects of the individual’s life (Lim & Iwama, 2006). It is a cyclical process with inter-related components connected to a larger whole. Acceptance and contemplation are natural and necessary for recovery and the maintenance of health is dependent on balance and harmony between the inter-related components (Henley & Schott, 1999; Servan-Schreiber, 2004). So, health and well-being are not achieved through discovering and eradicating a single identifiable problem but through the individual’s ability to be in rhythm with societal and natural forces and maintaining a body, mind, soul and spiritual cohesion (Iwama, 2003).
In Western societies, where personal autonomy and independence are highly esteemed, the individual is important. The non-Western view is on collective interest and agreement, visualising the self as a component of a larger collective whole (Henley & Schott, 1999; Lim & Iwama, 2006). Maintaining harmony and unity are priorities in cultures where personal autonomy, independence and choice are not accorded the same status (Helman, 2000). The minority ethnic client, perceived as unassertive or indecisive, may be delaying a decision until family or community can be consulted (Lim, 2001). The Western world is characterised by pressures that require people to be doing, whereas the Eastern view expounds the virtues of contemplation, stillness and being, which are more important than doing; achievement is attained through contemplation rather than engagement (Lim & Iwama, 2006). The client who perceives illness as a consequence of an imbalance may seek alternative solutions beyond the medical model. As the UK and other Western countries have become multi-cultural societies, occupational therapists must be sensitive to the cultural interpretations of health and illness and consider their clients on many levels (Lim, 2001; Lim & Iwama, 2006).
Table 3.1 Western and non-Western perspectives of health and well-being.
Source: From Lim and Iwama (2006). With permission.
| Western perspectives | Non-Western perspectives |
| Reductionist | Holist |
| Individualism and personal autonomy | Collectivism and harmony |
| Scientific analysis and problem solving | Awareness and contemplation |
| Control and doing | Acceptance and being |
| Domination | Balance |
Culturally sensitive practice: professional imperatives and personal strategies
Communication is the first step in the interaction between client and therapist, but this can be difficult if people do not speak the same language. Interpreters must speak the correct dialect as not all individuals from a particular ethnic background, cultural group or country use the same one. Not all health terms can be translated into the client’s language, and phrasing questions accurately to elicit information can be problematic. If the word stress does not have a clear translation, it may be easier to ask about the symptoms of stress. Within some cultures, somatic symptoms may be a more culturally acceptable way of communicating psychological distress (Lim, 2001).
Central to occupational therapy is client-centred practice (COT, 2005). This requires the ability to examine personal, cultural and ethnic influences and their impact on values, beliefs and prejudices towards those encountered in practice (Wells & Black, 2000; McGruder, 2003; Lim, 2004a; Reynolds & Lim, 2005). Levy et al. (1998) warned against stereotyping, where one piece of information about an individual such as age, gender or race may generate inferences about all other aspects of that person. Gross (2001) states that personal/social values influence relationships but should not be imposed on clients and their carers. The consequence of presuming that occupational therapists know what is most beneficial for clients becomes apparent when they are labelled non-compliant, demotivated, disgruntled or simply absent from treatment (Wetherell, 1996; Lim, 2001). There may be different reasons for their behaviour. A lack of skill or awareness on the part of the professional, in imposing inappropriate or culturally insensitive practices, may elicit the undesired response. Sensitivity to the cultural dimensions of each client is needed to form a therapeutic partnership (McGruder, 2003).
The World Federation of Occupational Therapists’ Position Statement on Human Rights (2006, p. 1) states that ‘people have the right to participate in a range of occupations that enable them to flourish, fulfil their potential and experience satisfaction in a way consistent with their culture and beliefs’.
The challenge for occupational therapists is to cross the cultural divide, establish contact and partnerships with individuals and communities that are marginalised, socially excluded or occupationally deprived, to enable opportunities for equal participation (Lim, 2005). Christie (2003) identified strategies to support culturally and socially inclusive service delivery. These include equipping clients through skills development and working with them to ensure their involvement and influence in all aspects of service delivery.
Whiteford (2000) proposed that occupational therapists should become agents of change, in adopting an occupational perspective that considers the occupational needs of individuals within society. Townsend (1999) and Wilcock (2006) challenge occupational therapists to invest time and energy in influencing social and institutional structures to review their policies and standards to support the specific needs of those who are deprived, excluded or discriminated against, and to confront negative attitudes and to promote social inclusion. Kronenberg et al. (2005) emphasised the importance of occupational therapists being engaged in political activities of daily living in supporting and influencing political, economic, environmental, social, cultural and systemic change. They acknowledged the power of professionals to advocate on behalf of clients and communities that are marginalised. Change begins with vision and passion to see minority ethnic clients and communities experiencing improvement in their treatment by health and social care services. There must be a collective effort and commitment to make a difference for all groups within society (Reynolds &Lim, 2005).
Ensuring cultural sensitivity, competence and equality in practice is enshrined in the profession’s code of ethics (COT, 2005; WFOT, 2006). It requires occupational therapists to account for the diverse needs, values and perspectives of clients, but this intent must be implemented and evaluated to move from rhetoric to action. Most frameworks and models of occupational therapy, which reflect a Western stance, influence this commitment. Although they facilitate understanding and work with individuals, their value is limited cross-culturally (Lim, 2004a). Competing worldviews challenge the adequacy of existing models and frameworks to explain occupational phenomena for all (Iwama, 2003; Chaing & Clarson, 2003).
The Kawa ‘River’ Model is the first occupational therapy model developed from the East and it provides a radical perspective of how occupation and individual self is conceptualised (see Table 3.2). It arose as a consequence of Japanese occupational therapists’ frustration with the utility of Western models and concepts that were not resonant with their personal or client’s socio-cultural experiences (Iwama, 2006). Importantly, the Kawa Model indicates a major change from Western concepts and ideas, promoting the importance of discourse and validation of alternative perspectives (Lim & Iwama, 2006). Distinctively, it is devoid of linear structures, line, boxes and technical jargon. It is infused with a naturalistic and holistic perspective of life, health and well-being, and adopts the metaphor of a river – Kawa means river in Japanese. Each individual is perceived as having a unique personal river, which symbolises his or her life journey – the upstream of the river represents the past and the downstream represents the future. Personal health and well-being is expressed by the free and unrestricted flow of the river, whilst life difficulties, problems, barriers, environmental, financial and social constraints are symbolised by rocks and the restrictive river bank (Lim & Iwama, 2006).
Table 3.2 Five key components of the Kawa ‘River’ Model.
| Water |
| Water represents the client’s life energy and health |
| Water is flexible and is shaped by its container (experience, circumstances) |
| The river can flow fully, dry up and change directions |
| Water can be clear or be in a muddy state |
| Riversides and bottom |
| Represent the client’s physical and social environment and human resources |
| Family, healthcare professionals, school, workplace, culture and society can shape one’s environment |
| Rocks |
| Represent the client’s life difficulties |
| They block and slow down the water flow |
| Disease, symptoms and daily life challenges are represented as rocks |
| Driftwood |
| Represents the client’s attributes, values, character and experiences that can work positively or negatively (assets and liabilities) |
| Driftwood can either further block the water flow or bump the rocks away enhancing the flow |
| Spaces |
| Represent the client’s natural healing power, potential and include abilities and positive points |
| Enhancing the client’s inner ability and maximising opportunities is one of the major aspects of occupational therapy |
Case Study 3.1 Application of the Kawa Model
Krishna is 34 years old and unmarried. He lives with his supportive family, who can be overconcerned at times. Krishna has been diagnosed with schizophrenia and has a 15-year history of mental illness and relapse. He has an intermittent work history but enjoys using computers and is currently keen to do some voluntary work. He is sociable with a strong and supportive network of friends and family. However, he has poor concentration and self-care skills. He receives long-term sickness benefit. He is currently compliant with his medication and regularly attends his appointments with his occupational therapists and community psychiatric nurse.
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