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.