A Cross Cultural Model of Service Delivery in Mental Health
...eople from non English speaking background communities. Minas et al (1993) have highlighted nine specific deficiencies in the current environment that impinge on non English speaking background mental health issues: · Inadequate mental health legislation and failure to implement existing policies · Poor quality of services currently available · Lack of involvement of non English speaking background communities in the design and evaluation of services · Inadequate access to information by non English speaking background communities · Failure to adequately study stigma and to develop approaches for its diminution · Inadequate education of mental health professionals · Inadequate research in the area of mental illness in non English speaking background communities · Inadequate information about mental health status and mental health service needs of non English speaking background communities · Inadequate information about the pattern of service utilisation by non English speaking background communities The cultural diversity of Australia's community should be reflected in the development and operations of mental health services. It is the responsibility of organisations to develop policies to ensure that mental health services are designed and implemented to meet the needs of people of non English speaking background communities. According to Gaunlett et al: In our multicultural society there is a need for services to be accessible to all people with mental health problems. It is crucial for services to reach and more importantly keep in contact with such people regardless of their colour, culture and gender. (1995: 36) The beliefs, values and attitudes of an organisation's management and staff are reflected in the development of the organisation's culture. However according to Cox (1989), organisations are not necessarily reflective of the wider community. The establishment of organisations tend to be based on the needs of a particular community which is usually the dominant culture. This is certainly reflected in Australia's health system and more specifically in the mental health system. According to Cox In countries like Australia, where early life was dominated by a particular culture (in Australia's case Anglo-Celtic), the country's organisational life reflected that culture. (1989: 185) Organisations are responsible to cater for needs of communities they are servicing This incudes addressing issues of culture, communication, religion, isolation, stigma, traditions and beliefs, and participation to name a few. Often the organisations' culture and structure create barriers for non English speaking background communities' access to services. It is important for an organisation to know its environment well, including its demographics, to ensure that it is responsive to the needs of the community it services. Demographic profiles change constantly. Organisations need to take into account ageing populations, different community groups and social class. According to Patrickson et al (1995) organisations must respond to the increasing pressures to provide quality services for all clients. They need to be increasingly flexible in their service delivery to respond to specific needs of their socially and culturally diverse clientele. These issues are also relevant for today's changing mental health service system. If mental health services are not reflective of the community it services then people may not use the service. Cox states ...utilisation patterns are... an important indication of how acceptable and appropriate potential client groups regard a particular service. (1989: 187) According to Cox (1989), there are six main issues which influence the use of health organisations. These are: identification of needs; program development; staff recruitment and development; client utilisation; culture; and organisational structure. D'Aloia states (1994: 12) "people with a disability encounter barriers and disadvantages in a society that struggles to respond positively to human diversity". People from non English speaking background communities who have a mental illness may be disadvantaged in accessing mental health services if the organisational culture and structure of many of these services are not responsive to their particular needs. Some mental health services have attempted to improve access to services for non English speaking background communities, yet despite their good will their strategies have often been rather ad hoc. There is certainly room for improvement. Action on Disability within Ethnic Communities Inc (ADEC), has developed the Access Model which further develops Cox's theory. According to Fitch et al "the Model aims to impact on organisational culture by providing opportunities for management and staff to review their organisation's policies and practices". (1992: 15) ADEC believes that an organisation's culture will eventually reflect society's cultural diversity if certain policies and organisational factors are taken into consideration in the planning of services. These changes need to consider service location and contact; needs assessment; access to information; internal information systems; culturally relevant programs; appropriate staff and work practices; and non English speaking background consumer participation. ADEC developed the Access Model to assist mainstream services respond to the needs and demands of people with a disability from non-English speaking backgrounds. It tackles the issue of access and equity and emphasises that organisations should be reflective of the needs of people from non English speaking background communities and increase access to services (Papanicolaou 1994). Participation in decision making for non English speaking background communities has an important place in service design and implementation. D'Aloia (1994) states that participation means one's involvement in the decision making process and changing of power relationships. All Australians have the right and responsibility to participate in shaping services. According to Minas et al non English speaking background communities are rarely engaged in formulation of policies, design and management of services or evaluation of such services. (1993: 17) As a result services structures and practices do not cater appropriately for the needs of non English speaking background communities. Various strategies must be implemented by organisations to ensure that participation by non English speaking background communities occurs in a manner that is inclusive of these communities needs. It is the organisations responsibility to explore and develop with people of non English speaking background communities what the right strategies are (D'Aloia 1996). Participation can be seen as a partnership concept where both organisations and non English speaking background communities work together to address relevant issues at an organisational and individual level. It is believed by some organisations that consultation is a sufficient means of participation. This however is only one form of participation and in many cases consultations are not designed effectively to be inclusive of non English speaking background communities. According to Minas et al The lack of adequate structures and processes for genuine participation by non English speaking background communities in decision making processes is a fundamental deficiency in the current situation of developing mental health services. (1993: 17) Many authors ( Nguyen 1984; Lorenzo et al 1984; Jayrauriya 1986 ; Burdekin 1993; Pauwels 1991; Gaunlett et al 1995) argue that mental health services are underutilised by non English speaking background communities due to services not taking into account their cultural beliefs. Cauchi (1991) highlights the point that people from non English speaking background communities who have a mental illness have specific religious, cultural and language needs which must be addressed by services to ensure appropriate treatment. Hoang and Erikson (1985) further state that the difference in perceptions creates a gap between service providers and patients. There are a number of problems experienced by non English speaking background communities accessing mental health services which include the stigma associated with mental illness; lack of understanding the mental health system; lack of information for accessing services; limited language and cultural skills of service providers; and lack of principles guiding planning, management and responsibilities for clinical services (Nguyen 1984; Kinzie 1985; Jayasuriya 1986; Ponterotto et al 1988; Pauwels 1991; Cauchi 1991; Giest 1994). According to Burdekin (1993) non English speaking background communities' underutilisation of services may relate to the lack of bilingual/bicultural workers within mainstream services. Many people of non English speaking background may not access mainstream services because they believe mainstream workers will not understand them. There is a danger that mainstream services may assume that because non English speaking background communities do not access their services they do not need them. Ruiz (1995) explored the underutilisation of mental health services by the Hispanic-American community. He states a number of factors that could have an impact on the psychiatric diagnosis made, treatment chosen and outcomes of the therapeutic intervention. These factors are cultural identity of the provider and patient; cultural perceptions of mental illness and its treatment; and psychological and socioeconomical environment. It is therefore imperative that mainstream services and providers consider clients' beliefs and traditions program development. Ignoring such issues may result in misdiagnosis. According to Alarcon (1995) misdiagnosis due to cultural perspective is common. He further states that culture affects human behaviour therefore diagnosis must be sensitive and specific within the context of the person's background. Kimayer et al (1995) found that behaviour displayed by people of non English speaking background communities who have a mental illness may be in fact culturally accepted rather than be seen as behaviour related to mental illness. Acknowledging cultural factors is important when working with non English speaking background people. At the same time it is just as important for mental health workers not to become focussed on cultural issues and neglect the purpose of their intervention, that is, the mental illness. This has been a concern raised by some mainstream workers who at times became focussed on one issue neglecting the other in their own practice. In order that McMHAP increases access to mental health services and other relevant services for participants it: · assisted mental health workers develop program plans that reflected the participants' · assisted participants to understand Western treatment People from non-English speaking backgrounds who have a mental illness can be doubly disadvantaged when their cultural beliefs and issues are at times not incorporated in the designed treatment. The differences in perception of the cause of mental illness are not always acknowledged in service delivery. A study conducted by Furnhman and Malik (1994) established that Asian middle aged women in comparison to British born Asian and Anglo women perceived mental illness differently. It was found that the Asian middle aged women did not recognise the symptoms related to mental illness as defined in Western terms. Due to the stigma associated with mental illness they did not want to accept they had an illness. They responded differently to illness because of their cultural background; and it was difficult for them to define their illness as in their language such terminology did not exist. Levine and Gaw (1995) conclude it is important for the therapist to be aware of non-Western explanation of mental illness symptoms as these are integral parts of the experience of illness which may affect patient care. Another study by Eisenburch (1983) also found that one client's perception of illness led to not understanding the treatment described for her depression. He concluded that every culture has its own perception of cause and treatment of depression (or any mental illness) and emphasised if the therapist does not acknowledge the differences then it will be difficult to provide appropriate care. Kinzie (1985) notes the importance for therapists to recognise cultural and value differences that exist between themselves and the patient hence respect the patient's perception of mental illness. Ponterotto and Bensech (1988); Morones and Mikawa (1992); Kimayer et al (1995) and Lien (1995) found that non English speaking background communities, in particular the Vietnamese and Mestizo communities, have different views on mental illness compared to Western concepts. These two communities believe that mental illness is related to the supernatural world. Individuals are possessed by evil spirits for wrong doings in their lives or that of ancestors (Lien, 1995). Spirituality plays an important role in the healing process. Often for those possessed by evil spirits traditional healers are called upon to do an exorcism (Morones et al, 1992; Patel et al, 1995). Religion, in general, plays a crucial role in the lives of many people from non-English speaking backgrounds and impacts greatly on their beliefs about life. Therefore their mental health status needs to be considered within the context of their faith. Morones and Mikawa found that within the traditional Metstizo view ....health (mental health) consists of maintaining a balance with God and the practices of the family and community; violating these norms may result in illness. (1992: 450) There are, for example, at least three theories of mental illness amongst the Indochinese communities (China, Cambodia, Vietnam). These are the Natural; the Supernatural; and the Metaphysical. The Indochinese workers of McMHAP have to date been presented with the Supernatural. Those who believe in the Supernatural world rely on spiritual healers and herbs for treatment and cure. A study conducted by Heigel (1984) found that traditional healers were very important in ensuring that Cambodian community members were being provided the best care. The traditional healers provided support to patients. They were also able to solve cultural conflicts which at times occurred between the community member and Western worker. Heigel also found that traditional healers were respected by mainstream service providers because ...they are often well equipped to give psychological support to patients and to help them solve their emotional conflicts, especially when these conflicts are expressed through cultural beliefs in spirits and possession. ( 1984: 30) Therefore developing a partnership working style ensures that non English speaking background communities' mental health needs may be met most effectively. Allowing community members who are seen to have status in the area of mental illness to practice their treatments may ensure that non English speaking background patients will be understood culturally and linguistically. Trapper et al (1995) found that services which respected non English speaking background communities' perceptions of treatment were better accessed. Communication is imperative in the treatment process. Corsellis and Critchon (1994) conclude that communication is the essence of psychiatric assessment and treatment. Without effective communication appropriate care for non English speaking background patients cannot be achieved, and it is a very important tool in establishing rapport between the service provider and non English speaking background patient. According to Mullavey-O'Byrne Interactions between people from different cultures are further complicated when people are not able to communicate across cultures. This is especially so when they have little knowledge and understanding of each other's culture and have not developed the intercultural skill of respect for differences. (1994: 179) The ability for a person of a non-English speaking background to communicate their need is crucial so they have the opportunity to access services and receive equitable outcomes. According to Giest (1994) language is an important factor that complicates relationships between the service provider and patient if the patient's English skills are limited. It is the responsibility of the service provider to ensure that communication is clear and comprehended; using interpreters or co-working with bilingual workers are strategies to assis...