Frameworks that inform cultural responsiveness principles & practices
Human rights legislation and conventions, in particular The Convention on the Rights of Persons with Disabilities, apply when providing mental health care.
Non-discrimination is central to the right to health. The cultural rights of service users and community members need to be respected. The right to freedom of expression obliges services to provide information in accessible and understandable ways.
The right to protection of the family obliges health services to recognize diverse family and kinship relations when providing health care.
Racism, sexism, homophobia and all other forms of discrimination have negative effects on individuals, families and communities. Experiences of discrimination can and do cause psychological harm. They affect the resilience of individuals and communities and their capacity to cope with external stressors (Victorian Equality Opportunities and Human Rights Commission, 2020).
SOCIAL & CULTURAL MODELS OF HEALTH
Social and cultural models of health focus on three main dimensions: how groups think about health, how health and illness are created in social contexts, and how health care services are used and organised. This not the same as adopting a ‘biopsychosocial approach’ when working with individuals and in order to explain their situation or develop care and treatment plans.
The meaning attributed to health, illness and distress reflect the culture, politics, and moral structures of individuals and groups. Terms, concepts and meanings vary within groups, across societies and change over time. We need to experience connections to culture, language, family and community for the sake of our physical, social and emotional wellbeing.
Health and illness are socially produced and distributed — some social groups have more health or illness than others. Variations in health status generally follow a gradient, with overall health tending to improve with improvements in socioeconomic position. More unequal societies are associated with poorer health outcomes across the society. Those who are most disadvantaged suffer the most (Wilkinson & Pickett, 2011). All social determinants of health are mediated by culture.
Health care is also socially organised.
In culturally diverse societies, the dominant culture, which is expressed through social institutions, including the health care system, regulates what sorts of problems are recognized and what kinds of social or cultural differences are viewed as worthy of attention (Kirmayer, 2012, p. 149).
Racialised communities — indigenous peoples, immigrants and refugees, as well as some long-established ethnic, linguistic, cultural and religious communities — experience substantial inequities in mental health. These groups are more likely to experience mental health problems, experience problems more often and have more difficulty accessing appropriate mental health care These disparities arise in the context of social disadvantage, including poverty, exposure to violence, racism and discrimination (Gee et al., 2014; Kirmayer & Jarvis, 2019).
People’s lives are multi-dimensional and complex. Race, ethnicity, age, gender, sex, sexual orientation and gender expression, ability, religion, faith and spirituality and so much more, can intersect in a single person or interaction.
People can experience multiple and unique forms of discrimination and oppression that cannot be conceptualised separately. People can also experience privilege and oppression simultaneously.
An intersectional approach invites participation for those who have been excluded and silenced. It involves thinking beyond individual identities and social factors, and focuses on people’s experiences of discrimination at the points of intersection (Crenshaw 1989; Hankivsky, 2014).
Crenshaw, K. (1993). Mapping the margins: Intersectionality, identity politics, and violence against women of colour. In K. Crenshaw, N. Gotanda, G. Peller, & K. Thomas (Eds.), Race theory: The key writings that formed the movement (pp. 357-383). New York, NY: New Press.
Gee, G., Dudgeon, P., Schultz, C., Hart, A., & Kelly, K. (2014). Aboriginal and Torres Strait Islander social and emotional wellbeing. In P. Dudgeon, H. Milroy, & R. Walker (Eds.), Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice (2nd Ed.) (pp. 55-68). Canberra, ACT: Australian Government Department of the Prime Minister and Cabinet.
Hankivsky, O. (2014). Intersectionality 101. Vancouver, BC: Research and Policy, Simon Fraser University.
Kirmayer, L. (2012). Rethinking cultural competence. Transcultural Psychiatry, 49(2), 149-164.
Kirmayer, L. & Jarvis, E. (2019). Culturally responsive services as a path to equity in mental healthcare. Healthcare Papers, 18(2) 11-23.
Victorian Equality Opportunities and Human Rights Commission. (2020). [Website]. humanrightscommission.vic.gov.au
Wilkinson, R. & Pickett, K. (2009). The spirit level: Why more equal societies almost always do better. London, UK: Allen Lane.
Cultural responsiveness principles & practices
MENTAL HEALTH ACROSS CULTURES
‘Culture’ is shaped by many intersecting socio-political factors including age, physical abilities, ethnicity, sexual and gender diversity, religion, spirituality, class, economic status, power, and life experience.
Culture is not something to simply appreciate or study. It is a critical site of social action and intervention, where power relations between people are created and potentially disrupted (Procter, 2004).
Culture plays a significant role in how people experience mental health issues. Culture also informs mental health practice and how services are structured and organised.
THE NEED FOR CROSS CULTURAL PERSPECTIVES IN MENTAL HEALTH & ILLNESS
Population-level differences in access to health care and individual service user characteristics do not fully explain inequalities in mental health care. A more holistic interpretation of this disparity acknowledges the inherently complex social, psychological, emotional, and cultural interactions that occur between people, professionals and health care institutions.
Mental illness experiences, including distress, are by no means universal. While commonly used diagnostic manuals use predetermined categories to explain and describe mental illnesses and symptoms, these too are culturally determined.
All parties to a mental health clinical encounter bear culture in some way; consumers and practitioners. Aspects of local and broader social contexts influence whether and how someone will seek help.
We are each part of the same social fabric. Working together and accommodating each other’s differences will create a more equitable and socially just mental health care system. We need to listen to communities, acknowledge disparities and injustices, find broad agreement on issues and identify priorities. Work to improve the mental health and wellbeing of people who have been systematically excluded and devalued needs to be driven by structural reform. Pursuing universal goals, such as zero deaths from suicide, should entail targeted strategies and programs (powell et al., 2019).
Cultural safety involves acknowledging how power operates in mental health service systems and in consumer-practitioner relationships. It also includes taking steps to avoid imposing one’s own cultural values on others. Threats to a consumer’s cultural safety when receiving mental health care include: not being able to communicate with practitioners, not being listened to, not being respected and not being able to involve trusted family or friends.
We are working in an increasingly diverse and complex service environment. Power operates in health service delivery and can be the source of lasting harm and distress. The assumptions that professionals and services wittingly and unwittingly hold can have serious consequences for individuals, families and communities. When professionals and organisations examine their assumptions and understand the historical and social contexts in which they operate, the quality of care that they provide improves.
Practising cultural safety in mental health care provision demands that we critique and transform how power is embedded within knowledge paradigms, professional practices, institutional structures, policy directives and funding priorities.
‘Each of us comes with our own histories, stories, heritage and points of view’ (Chavez, 2012). Cultural humility is a willingness and ability to listen and learn from people about their lived experience.
We need to move beyond concepts of cultural sensitivity and cultural competence, toward understanding power imbalances, and institutional discrimination as they apply to health care. Practising cultural humility entails making a lifelong commitment to self-reflection and self-critique, recognising and challenging power imbalances in service user and professional dynamics, and developing partnerships with communities that are mutually beneficial and non-paternalistic (Tervalon & Murray-Garcia, 1998).
RECOVERY AND CULTURAL RESPONSIVENESS
Culture shapes the expression of mental health problems, how they are experienced, modes of coping, pathways to care and the effectiveness of treatment and prevention, as well as the processes of resilience and recovery (Kirmayer & Jarvis, 2019).
Personal recovery means ‘being able to create and live a meaningful and contributing life in a community of choice’ (Commonwealth of Australia, 2013, p.11). Developing an organisational culture and language that makes people ‘feel valued, important, welcome and safe’, and promotes hope and optimism — these practices are ‘central’ to recovery-oriented service delivery (p.4).
It is important to notice that ‘recovery’ goals and ‘recovery-oriented practices’ are also cultural concepts and practices; they are not equally meaningful to all consumers, families and professionals. Recovery-oriented practice in the context of culturally responsive practice needs to be based on finding ways to work with people in the context of their life-worlds.
Improving the cultural responsiveness of a mental health service requires commitment, planning, sustained effort and adequate resources. Culturally responsive services are respectful of the health beliefs, practices, culture, language and faith of diverse populations. They are also regarded by service users as ‘accessible’, that is, approachable, acceptable, accommodating, affordable, and appropriate (Levesque et al., 2013).
Chavez, V. (2012). Cultural humility [Video]. youtube.com/watch?v=SaSHLbS1V4w
Commonwealth of Australia. (2013). A national framework for recovery-oriented mental health services: Guide for practitioners and providers. Canberra, ACT: Department of Health and Ageing.
Kirmayer, L., & Jarvis, E. (2019). Culturally responsive services as a path to equity in mental healthcare. Healthcare Papers, 18(2) 11-23.
Levesque, J-F., Harris, M., & Russell, G. (2013). Patient-centred access to health care: Conceptualising access at the interface of health systems and populations. International Journal for Equity in Health, 12(18), 1-9.
powell, J., Menendian, S. & Ake, W. (2019). Targeted universalism: Policy and practice. Berkeley, CAL: Haas Institute for a Fair and Inclusive Society. haasinstitute.berkeley.edu/targeteduniversalism
Procter, J. (2004). Stuart Hall. London: Routledge.
Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence. Journal of Health care for Poor and Underserved, 9(2), 117-125.
Domains where Victorian Transcultural Mental Health (VTMH) builds capacity for cultural responsiveness
Working with individuals, families and friends, collectives. Groups may be local, formed by organisations, or based on shared interests and informal ties. Includes supporting communities to talk about mental health and use services.
Working with service providers and government to improve mental health responses to diverse populations. Includes partnerships and projects, and offering advice and consultancy.
Connecting across systems, between communities and institutions, between and within groups. Includes leading and participating in meetings, networks and other forums that facilitate communication and understanding.
Providing opportunities to develop the knowledge, skills, and abilities of people working in range of areas and also improve their self-awareness and capacity for critical reflection. Includes offering online resources, workshops, supervision, and group-based reflective sessions.
Generating, synthesising, transferring and implementing different kinds of knowledge — experiential, practical & theoretical — that resides in lived experience, practices and discourses. Includes undertaking research studies, evaluations and implementing evidence-based practices.
— Strengthen the wellbeing of communities
— Create a more equitable and socially just service system
— Build bridges between people, groups and systems
— Develop a responsive, reflective mental health workforce
— Share experiences, stories and evidence