Академический Документы
Профессиональный Документы
Культура Документы
Sanction/reward
Role
Social infuence
Billy:
thinks the confrontation was more to do
with Ahmed and his illness than with him
feelsfneanddoesnotrealisehow
damaging and unnacceptable his racist
language is
continues to use racist terms on the
ward to the distress of Ahmed and
several other patients
feels that other White patients agree
with him
Examples of how power and authority can be used positively
What type of power has Jon used? What type of authority has Jon used?
Personal
Emotional
Role
Knowledge
Informational
Sanction/reward
Billy:
initially angry at being confronted but
starts to engage as Jon talks to him in a
frm but fair and respectful way
expresses his anger and frustration at
being locked up on the ward
Jon acknowledges Billys feelings
but suggests he should fnd more
appropriate ways to express them.
Makes some suggestions and offers to
spend time with Billy to work with this
some more
feels acknowledged but also realises
that racist language will not be tolerated
and knows that if he uses it in the future
he will be challenged
Summary - 2
REMEMBER that power
is not inevitably negative
can be shared by both people in a relationship without detracting anything from either
person
can work and infuence in both directions between service users and staff
is not limited; if other person has power you do no lose yours but you may have to
re-assess how you use it
can be used positively as well as negatively
there is always a choice! You have tremendous opportunities to use your power and
authority to help, empower and support others
Dealing with racial harassment
Almost three quarters of the units visited in National Visit 2 had no policies for dealing with
racial harassment directed at patients by staff or other patients and 11% of the patients
whose case notes were examined had reported incidents of racial harassment. The fol-
lowup exercise found a continuing lack of policies relevant to racial harassment perpetrated
against patients in mental health units and it is this topic about which the most respondents
asked for assistance in effectively addressing the issue.
(University of Central Lancashire (Centre for Ethnicity & Health )/Mental Health Act Commis-
sion/NIMHE, 2003)
Interpreters
Family members, acquaintances and untrained staff should not be asked to act
as interpreters at clinically signifcant events.
In the case of an emergency, untrained interpreters should be used only to com-
municate the minimum information necessary until a trained interpreter can be
found.
Children under the age of 16 years should never be asked to interpret on behalf
of family members.
References
University of Central Lancashire (Centre for Ethnicity & Health )/Mental Health Act Commis-
sion/NIMHE (2003), Engaging and Changing: Developing effective policy for the care and
treatment of Black and minority ethnic detained patients
Personal Refection
In what ways are your assessment and planning systems service-led?
RECC - ESC Advanced Module
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RECC - ESC Advanced Module
Interviews with destitute asylum-seekers suggest that:
There are high levels of mental health needs amongst destitute asylum-seekers.
Whilst some of this was precipitated by their experiences before coming to the UK,
much of it has been exacerbated by destitution.
Morethan90%fearedreturningtotheircountryoforigin.
Mostarebeingaccommodatedbyfriendsoracquaintances(64%)orcharitable
organisations(8%).
Nearlytwothirds(65%)felttheirproblemswerecausedbytheirinabilitytosupport
themselves and wanted to be able to work.
Morethanhalf(55%)saidthattheywerereceivingmedicationfordepression,indicat-
ingthatasignifcantnumberwereabletoaccesshealthcare.
However,asignifcantnumberalsotalkedaboutthediffcultiesinfndingaGPwho
would accept them.
Many of them talked about the heavy burden of fear that they were living under. This
was caused by the fear of being sent back, of being challenged by their GP to show
proof of eligibility to health care and of sleeping rough.
A question was also asked about their physical and mental health since coming to the
UK.Nearlyall(96%)feltthattheirhealthhaddeterioratedsincecomingtotheUK.A
third(33%)describedtheirhealthasseverelydeteriorated.
(Dumper, 2006)
Themes of Equality
Just as there are Themes of Institutional Discrimination, the model suggests there are
Themes of Equality which can work against and prevent the negative processes outlined
above.
Theme 1 ~ Valuing Cultural Diversity
Valuing cultural diversity would begin with reinforcing the cultural identity of individual service
users and taking the issue of cultural background seriously in practice. The iceberg model
would suggest that understanding where a person is coming from in terms of their cultural
identity involves enabling BME service users to feel comfortable in sharing their cultural
beliefs and values with practitioners. It means that the service user and their families and
carers should be viewed as the experts in their own cultural identities. Hence, BME service
user participation is essential for culturally appropriate practice.
On a wider front, services should be made more culturally appropriate for BME individuals
and communities. Culturally appropriate services are not just about having the right posters
on the wall or having the right kind of food available to service users. The iceberg model
shows us that the real challenge is to develop mental health services that are inclusive of
peoples beliefs and values as well.
Session 8
Review Practice Checkpoint 7: Working in an empowering way
(30 minutes)
Group Activity 8.1 The role of family/carers (30 minutes)
Group Activity 8.2 A model of family/carer empowerment (45 min-
utes)
Reminder of Work Task: Empowering BME families
Page l04 Tralners Manual : Sesslon 8 - worklng wlth famllles and carers
RECC - ESC Advanced Module
Group Activity 8.2 A Model of Family/Carer Empowerment (45 mins)
Overview:
The exercise applies the model of family empowerment to a realistic situation involving a
BME service user. The family system depicted here adds to the complexity of service provi-
sion to the service user and her family but also needs to demonstrate how families can be
partners and assets and the trainer should ensure that these positive messages emerge
from the feedback.
Purpose:
To practise using a model of empowerment with BME families and carers.
Instructions:
- Remind people of the model of empowerment introduced in the last Session using Slide 7.1
if necessary.
- Present the model of family empowerment using Slide 8.2.
- Give people Handout 8.2 Gita and Dilips story (part 2 ) and ask them to read it.
- Now ask people to stay in the same groups as for the previous exercise and address the
following task:
Use the model of family empowerment to fnd ways of empowering Dilip and the family
involved in providing support for Gita.
Resources:
Slides 7.1 and 8.2; Handout 8.2.
Time:
45 minutes
(10 minutes trainer presentation,15 minutes in groups, 20 minutes feedback in large group)
Note: At the end of this Session, the trainer should remind people that it is strongly recom-
mended that people do the pre-course reading for Session 9.
Session 8 - Practice Development Tips
Remember that families can be very effective partners in providing culturally appro-
priate services to BME service users and an invaluable resource in understanding a
service users cultural context.
Use the model of BME family empowerment as a checklist with any BME families you
are working with at present.
A focus on families would be the most culturally appropriate way of service provision
in many BME communities.
Page l05 Tralners Manual : Sesslon 8 - worklng wlth famllles and carers
Slide 7.1
RECC - ESC Advanced Module
Page l06 Tralners Manual : Sesslon 8 - worklng wlth famllles and carers
Slide 8.1
A model of Family & Community Empowerment
RECC - ESC Advanced Module
Page l07 Tralners Manual : Sesslon 8 - worklng wlth famllles and carers
Handout 8.1
Gita & Dilips Story
Gita is a 36 year old Indian woman who has been living with her older brother Dilip in a
comfortable fat for the past year, there is no-one else living with them. Gita is the youngest
of 4 children and the only girl. Gita has three brothers who all live locally and have families of
their own apart from Dilip. Gita has been using mental health services since she was in her
early twenties. Her father died when Gita was three and her mother died two years ago when
Gita herself was in the local psychiatric hospital.
Gita has been given a diagnosis of schizophrenia and is currently on tablets but she used to
be on depot injections until a year ago. She was managed on 2-weekly injections of Depixol
and oral Procyclidine, but two months ago (at the request of her brother Dilip) her medica-
tion was changed to oral Clozapine. She is being supported by the local community mental
health team as Gita has a history of going into crisis quite suddenly and going back into hos-
pital. However, she has managed to stay out of hospital for over 18 months with the support
of her brother Dilip.
Gita came to live with Dilip over a year ago after she had been living with her other brother
Sanjay and his family. Gita says that she really loved living there as she used to get on so
well with Sanjays young children and she often used to baby-sit for them when they were
younger. Previously, she had lived for several years with her eldest brother Sanjay, but the
arrangement broke down about 18months ago when Gita fell asleep with a cigarette in her
hand and started a fairly serious fre in her bedroom. Distraught and overcome with guilt,
Gita took a signifcant but not life-threatening overdose and was admitted to the local psy-
chiatric ward as an informal patient. Sanjay made it clear it would not be possible for Gita to
return to his house when she was discharged because of the threat she might pose to his
family. At this stage Dilip (the only unmarried brother and one who had always been an ad-
vocate for Gita) volunteered to take Gita, mindful that it was going to be important to ensure
that the relationships between Gita and Sanjays family (and the rest of the extended family)
were repaired and maintained.
Gita now says that she wants to stay with Dilip because he is my brother and he really
understands me. She also says that she really loves having her family around her especially
the young ones. Initially, Gita seemed to settle at Dilips, quickly taking on the role of look-
ing after Dilip (who works in a pressurized job in the city), tidying the fat and cooking the
occasional ready meal. Dilip in his turn worked hard to ensure that Gita remained engaged
with the wider family and recently the relationship between Gita and Sanjays family has
started to improve.
She says the good thing about living at Dilips is that hes out all day and she can do what
she wants, such as stay in bed all day or go to the park and meet up with the people who
congregate there. Dilip does not approve of these people and has tried to discourage Gita
from meeting them. Overall, Gita and Dilip seem to get on well together, although there are
times when the relationship becomes strained because of Gitas dependency on and clingy-
ness towards Dilip, and his frustration at her passive acceptance of her illness, marked sub-
servience to her psychiatrist and her general lack of drive and motivation. He has also taken
control of Gitas fnances as he knows she tends to spend her money erratically on gifts for
RECC - ESC Advanced Module
Page l08 Tralners Manual : Sesslon 8 - worklng wlth famllles and carers
friends, and feels she is vulnerable to others preying on her.
Gita says that she often goes to the temple late at night or in the early morning because she
feels at peace there just having people around at the temple who understand your beliefs
makes you feel a part of your community. When upset or anxious she often recites Hindu
prayers and has told her CPN that this helps her to accept her fate and recognize she is
only a very tiny fragment in a huge universe and whatever happens to her is in the hands of
higher forces. So its like every so often things go out of balance and I seem to lose myself
and my bad spirit takes over. I believe I need to improve my spirit - then my mind and body
will get better. But to improve my spirit I must learn to accept my fate and pray. I have to
believe in our gods. We are all just a small part of the wider universe.
Gita had abandoned her Hinduism when she frst became ill after an elderly aunt had told
her that she obviously had bad karma. However, since moving in with Dilip, Gita has been
remembering some of the prayers her mother had taught her as a small child and has also
started going to the local Hindu temple where she says she feels safe and can be with mum
again. Recently Gita has become more involved at the temple and sometimes helps to pre-
pare the daily meal for the priests. She also assists the teacher with the youngest children at
the Hindu Sunday school, and has shown herself to be reliable and popular with the children.
On the whole Gita seems to have been managing adequately with the current arrangement
of visits every two weeks from her Community Psychiatric Nurse and appointments every
two months with her psychiatrist. Dilip has been told to contact the team if there is any cause
for concern.
RECC - ESC Advanced Module
Page l09 Tralners Manual : Sesslon 8 - worklng wlth famllles and carers
Handout 8.1
Gita & Dilips Story (Part 2)
Gitas Care Manager and Community Psychiatric Nurse have been contacted by Dilip with
a request for Gita to have a trial in a local group home as he cannot cope anymore. The
Care Manager and the CPN have agreed to try to get Gita into the group home to increase
her independence. Dilip says that he doesnt want to force Gita to live somewhere else and
he would be happy to carry on living with her but he doesnt know what will happen next.
She stays at home all day often in bed, goes out late at night without telling him and seems
to be getting worse recently. The Care Managers notes state that Gita is lacking self-care,
aggressive when challenged and very clingy towards Dilip. Gita has been taking money from
Dilips wallet according to him and recently fell asleep with a lighted cigarette in her hand.
Dilip is worried that she will set the fat on fre and he says I just dont know whether I will
come home one day to some catastrophe I just cant stop worrying about her at work and
its affecting my career prospects. Dilip works as an accountant for a large company and
has been very successful up until now. When asked about taking money from Dilip she says
I needed it for my cigarettes anyway its not stealing, he is my brother. Dilip has taken
control of Gitas fnances as he says she has been prone to spend money erratically in the
past on gifts for friends.
Gita is adamant that she doesnt want to live in the group home even though when they vis-
ited it recently she seemed to get on well with the staff some of whom were Indian and she
seemed reasonably happy with the other tenants. Dilip had been quite resourceful in fnding
out about the group home on his own. The group home takes both men and women from a
wide catchment area. Gita says that she values her independence with Dilip as no-one tells
her what to do and she wants to live with her family. However, Dilip is getting increasingly
stressed by Gitas clingyness, withdrawal and lack of self-care and personal hygiene. Dilip
says I cant even go out on my own I have to take her everywhere I just dont seem to
have a life of my own I cant even meet girlfriends the way things are at present. Dilip has
always encouraged Gita to stay in touch with the rest of the family even at times of some
tensions due to the fre incident. Dilip always makes sure that she is included in family get-
togethers and special occasions like weddings. Dilip says that he wants Gita to move into
the group home but does not want her relationship with him or the rest of the family to be
threatened. He feels quite ambivalent about Gita moving out as he would miss her greatly
but he can see no alternatives.
Gita had attended a day centre nearby a year ago where there were very few Black service
users and there were mainly men at the centre. The staff at the centre reported to the Care
Manager that Gita was diffcult to motivate to do anything and she seemed bored to them
despite their efforts to provide her with activities in the groups they run. Gita reports that she
had been racially abused by another service user at the centre and she did not feel safe
there with some of the men. She did not go to the centre for very long and preferred to go to
the local park where she regularly meets up with her friends and where she likes watching
the children play. Gita has recently admitted to Dilip that she sometimes sells her tablets to
her friends in the park. Dilip does not like the people she mixes with down at the park as they
are seen to drink in public. He has spoken to the Care Manager saying that he cannot afford
trouble with the police if Gita is dealing drugs. Gita says that it helps her with getting more
money.
RECC - ESC Advanced Module
Page ll0 Tralners Manual : Sesslon 8 - worklng wlth famllles and carers
Gita would like to do some work again as she used to help out at Sanjays business doing
offce work but what she really wants to do is to work with children. Gita secretly would like
work with children properly, but feels that she will never get the chance because her psy-
chiatrist has told her it would be impossible with her psychiatric record. She would like to
undertake a child-care qualifcation and do some work in a nursery. Dilip feels that Gita has
a very good way with young children and was always trusted with family baby-sitting until
the fre incident. Gita also enjoys doing voluntary work at the temple where she also likes
to discuss religious issues. He would like to see Gita using her potential much more and is
pleased she is at least having some contact with children at the temple. Dilip is also very
concerned that Gita tends to go to the temple very late at night or early in the morning, and
he is worried about her safety. A group home place is now going to become available in one
months time.
RECC - ESC Advanced Module
Page lll Tralners Manual : Sesslon 8 - worklng wlth famllles and carers
RECC - ESC Advanced Module
LEARNERS NOTES
SESSION 8 WORKING WITH BME FAMILIES & CARERS
Learning Outcomes
Participants will be able to:
understand the experiences and support needs of BME families in mental health
services
understand the importance of BME family and carer participation in mental
health service delivery
apply a model of empowerment for BME families and communities.
Empowering BME Families and communities
Empowering BME families must begin with respecting and strengthening their cultural heri-
tage and value base. This does not mean that there may be things that are undesirable or
unhelpful in a familys culture this would be true of all cultures. However, services should
actively seek to engage families on their terms to offer help in a culturally sensitive manner.
A family approach will enable practitioners to be more fexible and creative in putting together
packages of assistance further on in the process of intervention.
The problem of under-reaction or over-reaction by service to BME people has been high-
lighted in Session 6 as one of the themes of institutional discrimination. In terms of empower-
ing BME families it is important to establish the right level of assistance to the service user
and their family to avoid unnecessarily intrusive interventions in family situations while ensur-
ing that enough assistance is offered to lessen the damaging effects of mental distress on
family relationships. Practitioners should seek to build on the strengths of BME families and
increase the protective factors in the service users social networks to achieve a preventa-
tive approach; a theme of equality outlined in Session 6.
BME families may well beneft from some independent advice or advocacy from a Carer
Support group or community organisation, especially if there are language barriers for the
family in their dealings with services. It can be quite daunting for BME families coming into
their frst encounter with mental health services and it could be culturally diffcult for them to
challenge professionals who in their culture would not normally be questioned or criticised.
It is essential to get a clear articulation of the familys viewpoint if they are directly involved in
providing care to a service user as any plan of assistance is likely to fail unless all signifcant
family members are supportive of it.
If BME families are to express their viewpoint clearly and be fully involved in service delivery
and important decisions, where appropriate, they should be fully informed about the relevant
practice or clinical issues impacting on their loved-one and of the services or help available.
Thought needs to be given about the most effective way of getting across information in dif-
ferent languages and formats allowing for literacy problems and/or sensory impairments.
Once BME families are involved in the process of assessment and service delivery there
needs to be transparency in the decisions being made and explanations given to families
if their views and wishes are not followed by services. Communication by services is often
slow or poor with BME families, resulting in a feeling of disrespect and tokenism thereby re-
Page ll2 Tralners Manual : Sesslon 8 - worklng wlth famllles and carers
ducing their level of engagement and increasing risks for service users. Practitioners should
ensure that accurate and up-to-date information is passed to the family as a high priority in
partnership working.
Engaging BME families in a meaningful way does not mean that all the familys wishes
should be accepted without question. It is possible that families that have been left to cope
unsupported by services or even by their own communities have developed unhelpful or
counter-productive ways of dealing with their family members mental distress. Families may
well need help in identifying their needs and wishes in the same way that a service user
may need this type of assistance. It can be quite liberating for a practitioner to challenge a
family around unhelpful strategies or responses to mental distress and to name unspoken
fears or feelings. Often the most creative, culturally appropriate solutions can arise from such
constructive and respectful challenges.
One area of constructive challenge could be to encourage the family to think ahead to their
future together and how they may support their family member to avoid future crises. A fam-
ily element of an advance directive may be helpful as often when their distressed family
member goes into crisis many of the other family members also may fnd it diffcult to focus
on what is most effective in dealing with the situation. Having a contingency plan can begin
to reduce the stress at a time of crisis for the family and develop a more proactive approach
in managing their family members episodes of distress.
Finally, aligned with the theme of equality in safeguarding rights the family should be fully
informed of what they can do if they are not happy with the assistance they receive from
services. The Carers Assessment provides a useful review document to go over what has
or has not happened as planned or promised. It is very effective to involve BME families
and carers as well as service users in the evaluation of service quality or audit work to look
at service improvement. Practitioners should plan ahead for review meetings to ensure that
supports are in place for family members to be involved as much as possible in reviews.
Empowering BME communities will require changes in individual practice and in some
cases changes in organisational culture compared to traditional approaches in mental health
services. Delivering Race Equality, the national strategy to improve mental health services
for BME people, includes the creation of 500 Community Development Worker (CDW) posts
over the next few years (their roles are outlined in Key Document 4 at the beginning of this
Participants Reader). These new workers will be an invaluable resource for mental health
practitioners in their efforts to empower BME communities in their local areas.
Every community and every culture has challenges in dealing with the stigma attached to
mental distress. Mental health promotion campaigns, training and education opportunities
and promoting positive images of BME service users and families are all ways that practi-
tioners can be directly involved with BME communities as well as supporting the efforts of
CDWs in their key role of capacity builder. Working specifcally with infuential individuals
and groups in BME communities can be effective in creating more socially inclusive BME
communities and lead to the development of more culturally appropriate self-help and com-
munity-led groups.
Enabling BME communities to express their views about services and consulting them about
plans to develop services can help to quickly identify gaps and problems in service delivery
RECC - ESC Advanced Module
Page ll3 Tralners Manual : Sesslon 8 - worklng wlth famllles and carers
RECC - ESC Advanced Module
to these communities. Advocacy is a key issue for many BME service users in the mental
health system and establishing a dialogue and strengthening channels of communication
with BME communities can generate interest and enthusiasm amongst BME individuals to
become advocates for service users.
Going a step further than consultation and facilitating genuine participation of BME commu-
nities in the design and improvement of services would be the most effective way of devel-
oping innovative and more culturally appropriate services. Looking out for new initiatives
emerging in BME communities and nurturing BME-led projects that are valuable resources
for BME service users, sustains good practice and services become more responsive to
changing community needs. The overall impact of empowering BME communities is to
increase the accountability of mental health services to local BME communities. Supporting
CDWs in their key role as a change agent is a focus for practitioners in these aspects of
community empowerment.
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RECC - ESC Advanced Module
TRAINERS NOTES
SESSION 9 UNDERSTANDING DISCRIMINATORY
SITUATIONS
Review Work Task 8: Working with BME families (30 minutes)
Split people up into small review groups (three or four per group).
Each participant should use Work task sheet 8.4 in their Practice Development Work-
books to present their Work Task to colleagues.
In the large group, each review group should feedback their individual key messages
for senior managers (one for each participant) and this should be noted down or written
onto a fipchart.
Group Activity 9.1 Sadies Scenario
Overview:
This is a quick but very useful exercise in introducing the dangers of making quick judge-
ments based on superfcial evidence. The scenario lends itself to analysis on the four levels
of understanding introduced later in the session once the full story has been revealed. The
scenario also helps participants to refect upon their own assumptions when approaching
situation where they have only partial information and how we, as human beings, tend to fll
in the gaps almost automatically.
Purpose:
To help participants to appreciate how easy it is to jump to conclusions about situations
based on little evidence and superfcial analysis of a complex situation.
Instructions:
We will start with a short scenario to help illustrate the main topic we are covering here.
- Ask people to work in pairs in the activity.
- Give people Handout 9.1 and ask them to read it.
- What are the frst few questions you would ask to fnd out what is going on?
- Take feedback noting peoples questions in four sections on a fipchart representing the
Four Levels model (IPSA) but do not reveal the headings until presenting the IPSA model.
- Now refer people to Handout 9.2.
- Finally, present the IPSA model and refer people to their Learners notes.
Resources: Handouts 9.1 and 9.2.
Time: 20 minutes
5 minutes in pairs, 15 minutes feedback/pesentation in large group.
Session 9
Review Work Task 8: Working with BME families (30 minutes)
Group Activity 9.1 Sadies Story (20 minutes)
Group Activity 9.2 Huseyns Story (1 hour)
Reminder of Work Task: 9: Understanding discriminatory situations
Page ll5 Tralners Manual : Sesslon 9 - Understandlng dlscrlmlnatory sltuatlons
Group Activity 9.2 - Applying the Levels of Understanding model
Purpose:
This activity helps people to apply the 4-Levels of Understanding model in complex dis-
criminatory situations. Huseyns story is based on a real person with some details changed
to protect his identity. The idea behind using the 4-Levels of Understanding model is to get
people to think more deeply about situations involving people who may be vulnerable to dis-
crimination and oppression. It may feel diffcult and perhaps even uncomfortable for people
to use this process of thinking but it encourages people to structure their judgement about a
situation and collect information and evidence in a more systematic and careful way.
Instructions:
Review the 4-Levels of Understanding model in Handout 9.7 - Learners Notes.
Break into small working groups to discuss Huseyns story and share your personal
notes from the pre-course reading.
The task is to use the 4-Levels of Understanding model to examine Huseyns situation
(Handout 9.3) and untangle what is going on for him.
There is a proforma (Handout 9.5) that sets out the key problems that have emerged
from discussions with Huseyn and there is space to examine each problem in more
depth using the 4-Levels.
Get people to fll in the proforma using the information provided and any personal experi-
ence of working with refugees and asylum seekers.
It is useful to refer to the Themes of Institutional Discrimination (Handout 9.4) in Session
6 for the Level 3 analysis.
Then take feedback in the large group.
The facilitator can use the example proforma (Handout 9.6) that has been flled in as a
focus for discussion about what is going on for Huseyn.
Finally, emphasise that analysis of Huseyns situation on all four levels is much more
likely to lead to an effective whole systems approach to assisting him.
Task Output:
An analysis of some key problems for Huseyn using the 4-Levels of Understanding model.
Resources:
Handouts 9.3, 9.4, 9.5, 9.6 and 9.7.
Time:
1 hour
- 5 minutes review of model with trainer and instructions for activity, 25 minutes in small
group work, 30 minutes feedback/discussion in large group and reading example proforma.
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Page l2l Tralners Manual : Sesslon 9 - Understandlng dlscrlmlnatory sltuatlons
RECC - ESC Advanced Module
Handout: 9.6 - Understanding Huseyns current situation (an example)
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Page l22 Tralners Manual : Sesslon 9 - Understandlng dlscrlmlnatory sltuatlons
RECC - ESC Advanced Module
Handout: 9.7
LEARNERS NOTES
SESSION 9 UNDERSTANDING DISCRIMINATORY SITUATIONS
Learning Outcomes
Participants will be able to:
describe the dangers of superfcial analyses and short-term solutions in complex
situations in mental health
use a whole systems model for examining complex discriminatory mental health
situations involving BME people
take a deeper look at discriminatory situations involving BME service users in
their own services and consider if more effective responses are possible.
Try the following group activity before reading the section below:
Group Activity 9.1 - Sadies Scenario
Why do we misjudge situations so easily? It is often because of a superfcial analysis of a
complex situation leading to a partial view and resulting in a partial response or ineffective
short-term solution. Any short-term solution can and often does lead to longer-term prob-
lems, so practitioners have to be wary of making quick judgements about situations involving
possible discrimination as they are often very complex.
The Four-Levels of Understanding IPSA Model
The model proposed here has been adapted and developed from the work of Peter Senge
(1994) and his colleagues in the feld of learning organisations. It provides a useful frame-
work that helps us to make a deeper, whole systems analysis of what is going on in com-
plex discriminatory situations.
Level 1 Understanding
(I) Individual behaviours and events
At this level collection of evidence is focused on individual discriminatory events that
have occurred or specifc behaviours of practitioners, the person or others around them.
Understanding at this level leads to a reactive response to immediate events.
Level 2 Understanding
(P) Patterns of discrimination
Patterns of discriminatory behaviours or events provide a higher level of understand-
ing here as the response can become more proactive in other words it helps you to
predict discriminatory behaviours with a better understanding of longer-term and broader
factors operating in a complex service situation.
Personal Refection
Have you ever been involved in team where a superfcial analysis of the situation resulted
in wrong judgements being made about a team member or manager? What were the
consequences?
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Level 3 Understanding
(S) Systems that shape individual and institutional discrimination
The data gathered at this level focuses on all of the important systems that impact on
the quality of life individuals, including their experiences of services. This level of percep-
tion yields a much more in-depth understanding of the wider social and environmental
factors that are impacting upon the persons experience of discrimination. A response
as a result of this level of understanding increases the possibilities of comprehensive
change as new patterns of discriminatory behaviour and institutional practices can be
shaped or be more generative by changing the systems operating in the situation.
Level 4 Understanding
(A) Assumptions and beliefs that shape systems of institutional discrimination
Gaining an understanding of the beliefs underpinning the design of service systems and
structures as well as the core beliefs and assumptions of the service user and others
who signifcantly interact with the person, such as the prejudices and stereotypes that
social groups may be subjected to. It is not straightforward to analyse this level such as
the prejudices and stereotypes that social groups may be subjected to but it can lead
to the most far-reaching change. The responses that can result from this analysis are
more transformative in nature where changes in thinking can lead to radical shifts in
the way the service works with the person (as predicted by the iceberg model of culture
discussed in Session 1). Signifcant change can take place in relation to the individual
service users approach to her or his life or the way in which managers and practitioners
create and use service systems to either promote equality or oppress.
References
Kendell, R. and Jablensky, A. (2003) Distinguishing between the validity and utility of psychi-
atric diagnoses, American Journal of Psychiatry, 160, 4-12.
Senge P., Kleiner A. , Roberts C. et al (1994) The Fifth Discipline Fieldbook, Doubleday,
New York
Points of interest
Thoughtful clinicians have long been aware that diagnostic categories are
simply concepts, justifed only by whether they provide a useful framework
for organising and explaining the complexity of clinical experience in order
to derive inferences about outcome and to guide decisions about treatment.
Unfortunately, once a diagnostic concept such as schizophrenia or Gulf War
syndrome has come into general use, it tends to become reifed. That is,
people too easily assume that it is an entity of some kind that can be invoked
to explain the patients symptoms and whose validity need not be questioned.
(Kendell & Jablensky, 2003 - Dr. Robert Kendell was a past president of the
Royal College of Psychiatrists)
Session 9 - Practice Development Tips
Stop yourself from jumping to quick solutions in dealing with BME service users.
Use the IPSA model as a tool for analysis in complex situations before going on to
assess the BME persons needs or risks
Session 10
Review Work Task 9: Understanding discriminatory situations
(30 minutes)
Group Activity 10 The principles of a holistic approach to assess-
ment (1 hour)
Reminder of Work Task 10: Improving holistic assessments
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Resources: Handout 10.1 & 10.2.
Time: 1 hour
- 5 minutes to review holistic principles, 25 minutes for small group work and 30 minutes
feedback in large group.
RECC - ESC Advanced Module
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Handout 10.1
Evaluating your assessment system
Holistic Principle Strengths Weaknesses
1. Holistic assessment
2. Challenging stereotypes
3. Reinforcing cultural
heritage
4. Culturally appropriate
services
5. Overcoming
communication barriers
6. Outreach and preventative
work
7. Focus on discriminatory
barriers
8. Appropriate intervention
9. Family/carer support
10. Range of therapeautic
options
11. Empowerment and
advocacy
12. Safeguarding rights
What are the three most important areas of development for your service to improve assess-
ments involving BME service users?
1.
2.
3.
RECC - ESC Advanced Module
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RECC - ESC Advanced Module
Slide: 10. 1 A Holistic Assessment Process
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RECC - ESC Advanced Module
Handout 10.2
LEARNERS NOTES
SESSION 10 IDENTIFYING NEEDS IN A HOLISTIC WAY
Learning Outcomes
Participants will be able to:
describe the key principles of a holistic approach to BME mental health service provision
use the principles of a holistic approach to evaluate the assessment system in local
mental health services for BME people
describe a holistic and anti-discriminatory process of assessment with BME people.
Principles for a holistic approach to mental health services
The summary of research discussed in the Participants Reader - Session 6 has highlighted
several problematic issues in mental health services for BME service users. The holistic
model outlined here directly addresses these experiences of institutional discrimination
for BME people. The holistic model used acknowledges the important role of good clinical
practice. However, it also recognises that mental health needs have to be understood in their
wider social context and not subjected to a narrow medical approach.
1. Holistic assessment
Several sources in research studies have suggested that misdiagnosis of BME people in
the psychiatric system is a great concern. A holistic model of mental health would not attach
undue importance to a persons medical diagnosis but would view their health needs within a
wider socio-economic context and, in relation to BME people, this would include the context
of institutional racism in services. People with similar diagnoses will often have very different
personal needs and require different forms of assistance to support community living.
2. Challenging stereotypes
BME people often have to deal with powerful stereotypes arising from a legacy of racism
that has been handed down to them through a history of slavery and colonialism. Racist
stereotypes have infltrated several areas of professional practice in public services, particu-
larly the theoretical frameworks used by professionals in their work. Practitioners have to be
constantly vigilant to guard against the infuence of stereotypes in their practice, particularly
in areas where racial discrimination has been proven to exist (such as in decisions about
dangerousness and problems associated with cultural stereotyping and misunderstanding
in assessments). A holistic model avoids making assumptions about individual needs based
on any categorisation or ascribed characteristics of the individual concerned. Stereotypes in
practice are exposed and challenged through a process of critical self-refection, informed
questioning and constructive challenging by peers.
3. Reinforcing cultural heritage
Cultural misunderstanding by practitioners has led to poor assessment and treatment in
mental health services. In a holistic model, greater importance is attached to individual cul-
tural heritage and ways are sought to support cultural identity through service provision. Ho-
listic assessment includes the identifcation of the cultural and spiritual needs of the person
and clarifes their desired lifestyle with a view to maintaining and developing their lifestyle in
Session 11
Review Work Task 10: Improving holistic assessments (30 minutes)
Group Activity 11.1 Annettes Story (1 hour)
Reminder of Work Task 11: Improving assessment & planning
processes
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Slide: 11. 1 Holistic Assessment & Planning Process
RECC - ESC Advanced Module
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Slide 11.2
The Five Service Accomplishments
(by OBrien, 1989)
RECC - ESC Advanced Module
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Handout: 11.1
Annettes Story
Annette is a 22 year old African-Caribbean woman, who has a baby son aged nearly one
year. Her medical notes indicate that she has been diagnosed as having depression and
possibly a bipolar illness, she also has a condition of cerebral palsy. She is able to get about
fairly well although she gets tired easily especially since she has developed diabetes soon
after the birth of her son, Michael. Annette has not been in a psychiatric hospital for mental
distress for over two years now and is determined never to go back into hospital. Annette
says that she does not get on with her current psychiatrist who has noted in her records that
Annette does not always comply with medication and can act aggressively on occasions
when challenged. Annette has said that she has been worried about taking her medication
while breast-feeding even though everyone has assured her that the medication she is on
would not affect her baby.
Annette became mentally distressed when she was still at school after an intense period of
bullying. Her mother still blames the school for not doing enough to protect Annette when the
bullying frst came to light. At frst Annette developed a phobia about going out of her house
and at the time of her distress she believed that she could speak in tongues with a secret
language hidden in her Bible. During this time her family had attempted to get help from
mental health services but with no real success. She then started self-harming and eventu-
ally she made suicide attempt with an overdose eventually being taken into hospital on an
emergency basis. Since that time Annette has had some ups and downs but she has kept
relatively well when she starts to feel unwell she tends to stop eating, neglect her appear-
ance and personal hygiene, and becomes very withdrawn and uncommunicative often stay-
ing locked in her room for days reading and chanting to herself.
There has been evidence of abuse of Annette from some of Dereks (Michaels father)
friends in the past including sexual abuse as well as fnancial exploitation e.g. eating An-
nettes food, using her phone and extracting money from her. There is currently an injunc-
tion against Derek preventing contact with Annette. She was strongly advised by her social
worker to take out this injunction but Annette secretly would like to re-establish contact with
Derek as she feels that he has changed and she misses his company a great deal. Her son
Michael is currently doing well and has had no major illnesses or injuries.
Annette had been getting 12 hours of personal assistance in her own Housing Association
fat before the baby was born but is now getting only 6 hours. She has 24-hour support for
the baby, Michael, since his birth. The child care support staff, from the Children and Fam-
ily Outreach Team, help out with all aspects of baby care, cooking of food, domestic tasks
and shopping, while a separate agency provides support workers for Annette to see to her
personal care and provide any other assistance to her. Her son, Michael goes to stay with
Annettes mother on the weekends and Annette can have space for herself at this time. Her
mother lives nearby with her two teenage sons, the boys get on well with their young
nephew.
Annettes fat has a constant fow of workers going through it and there have been several
staff changes over the past year or so. Annette says that she wants to do things for herself
but the support workers do not listen to her and often do things for her and her baby, ignoring
her objections. She feels that she has no privacy with her baby and that she is missing out in
RECC - ESC Advanced Module
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caring for her child in many ways. She has not been allowed to bathe the baby without staff
present as it is felt that the child would be at risk of injury. She says that she needs help but
she wants support to do things herself not for others to take over. On several occasions An-
nette has lost her temper with the Support Workers and sworn at them on one occasion she
threw a saucepan at one of the workers in her kitchen. There are now some staff she has
refused to speak to. The constant scrutiny has resulted in a lot of stress for Annette recently
according to her mother. The support workers believe that Annette has always had unrealis-
tic expectations of trying to cope on her own and needs more support than she realises.
Annette is terrifed that Social Services will take her baby away and is willing to do anything
that they say to prevent this happening. She is quite assertive though and well able to speak
up for herself but she is beginning to be ground down and is becoming more dependent on
others. Her confdence seems to have been gradually undermined.
Annette expresses her needs with the baby as requiring help to change his nappy and cook
food for him. She feels that she is good at playing with him and talking to him. It is obvious
she is a very loving mother in many ways but under a lot of stress. Annette speaks about
having a recurrent nightmare where her child is being taken away.
She says that when she goes out with staff people think that the baby belongs to the staff
and they do not believe that Michael is her baby. This makes her very angry. Annettes dia-
betes has affected her in terms of nausea, tiredness, and high blood pressure. Annette does
not know much about her diet and diabetes in general. Annette has been advised by the
child care workers that she must take the baby out at least once a day for some fresh air
but she fnds it physically diffcult to push the buggy for any distance. She also has diffculty
lifting any weight if the surface is at the wrong height for her.
Annette is very interested in developing herself in terms of further education. She is particu-
larly interested in learning more about child care and child development and working with
people. Annette would be interested in fnding part-time work in the future but this depends
on the needs of her child. Annette says that she is feeling down at present and fed up with
all these people around her all the time. She would like to go out more as well. In the past
she had enjoyed going to pubs, night-clubs, friends houses and a social club for people with
mental health problems. Annette says that she has a lot of friends in the local area.
Annette wants bigger accommodation on the ground foor with a garden for Michael to play
in with a slide and swings. Her current fat has steep stairs going down to it. Annette would
be interested in any way of owning her own place and not using social services accommoda-
tion.
The option of fostering or adoption was suddenly raised by the Children and Family Team at
an early stage in Annettes pregnancy which came as a great shock to Annette and her moth-
er. The Social Care Services would want Annettes mother to take primary care of the child
as this would reduce the cost of support but she works full-time and is not keen on the idea.
This option does not seem to have gone away and a decision is currently being taken by the
Children and Family Team whether to take Michael into care and use long-term fostering for
Michael as the 24 hour package of assistance is proving too expensive to maintain. There
has been a recent report from one of the Children and Family support workers that Annette
had dropped the baby while trying to bathe him on her own.Handout: 11.2
RECC - ESC Advanced Module
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Annettes desired lifestyle
PRESENCE
PARTICIPATION
RELATIONSHIPS
CHOICES
VALUED ROLES
RECC - ESC Advanced Module
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RECC - ESC Advanced Module
Handout: 11.3
LEARNERS NOTES
SESSION 11 PROVIDING CULTURALLY APPROPRIATE ASSISTANCE
Learning Outcomes
Participants will be able to
have greater awareness of the dangers involved for BME service users in as-
sessing risk in mental health practice
understand how judgements about risk in complex situations involving BME peo-
ple are heavily infuenced by the depth of analysis that is made of the situation
critically evaluate risk work in local mental health services against a set of prin-
ciples for anti-discriminatory practice.
Holistic Planning
The holistic planning process begins with the formulation responses by services to help
meet the holistic needs of people and better achieve their desired lifestyle. It is important to
separate out the two stages of the process of assessment and planning to ensure that an ac-
curate picture of a persons situation and needs is built up before looking at meeting needs.
This approach avoids slotting people into existing services as described in a service-led
approach earlier in Session 6 as a Theme of Institutional Discrimination.
Generate creative options to address barriers to desired lifestyle.
Focusing on barriers to desired lifestyle ensures that services do not patholo-
gise or blame the individual for their situation and this is particularly important
in dealing with BME people who are vulnerable to institutional racism. It is more
likely that practitioners will be successful in engaging BME people in mental
health services if they address their concerns and interests rather than pursuing
a service-led agenda. The options generated may not be service options there
may also be suitable non-service options. It must be remembered that it is not
possible or even desirable that services meet all the needs of service users as
it is much better to strengthen and build the natural social networks of people
and enable them to meet their own needs as much as possible. This will avoid
long-term dependence on services and enable people to take more control over
their own lives. However, it is not a green light for services to opt out of provid-
ing adequate assistance and support for service users but a plea for services to
intervene in a more empowering and focused way.
Check cultural appropriateness of options and consider need for risk assessment.
Once possible options for BME service users have been identifed, they must be
evaluated for their cultural appropriateness. Trying to see the proposed interven-
tion from the BME service user perspective may help to make the package of
assistance more sensitive to peoples needs and stop the plan from breaking