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The Ten Essential Shared Capabilities


ESC Advanced Module
Race Equality and Cultural
Capability
Trainers Manual
by Peter Ferns
Other Contributors:
Premila Trivedi
Suman Fernando
Dominic Makuvachuma Walker
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Contents
Introduction to RECC Trainers Manual ................................................... 3
Outline of the RECC programme............................................................. 4
Principles & values of the RECC programme.......................................... 8
Some fundamental concepts in RECC training ....................................... 9
The challenge for RECC trainers........................................................... 10
Delivering the RECC programme ...........................................................11
Ground-rules for RECC groupwork ....................................................... 12
SESSION 1- REFLECTING ON CULTURE .......................................... 13
SESSION 2 - REFLECTING ON BELIEFS ........................................... 27
SESSION 3 ASSUMPTIONS IN PRACTICE ...................................... 40
SESSION 4 REFLECTING ON COMMUNICATION .......................... 48
SESSION 5 WORKING ACROSS DIFFERENT CULTURES ............. 63
SESSION 6 UNDERSTANDING RACE EQUALITY IN MENTAL
HEALTH SERVICES ............................................................................. 76
SESSION 7 WORKING IN AN EMPOWERING WAY ........................ 89
SESSION 8 WORKING WITH BME FAMILIES & CARERS ............. 111
SESSION 9 UNDERSTANDING DISCRIMINATORY
SITUATIONS ........................................................................................114
SESSION 10 IDENTIFYING NEEDS IN A HOLISTIC WAY ............. 124
SESSION 11 HOLISTIC APPROACH TO PLANNING ..................... 133
SESSION 12 ANTI-DISCRIMINATORY RISK WORK ....................... 151
Appendix RECC Report to Senior Managers ................................... 156
Acknowledgements
Firstly, I would like to thank my wife Celia for her patience and support in getting these
materials produced over the last two years. Thanks also to my colleagues and friends
Premila Trivedi, Dominic Walker, Dr. Suman Fernando who have actively helped to develop
all of the materials and Thurstine Bassett and Professor Hilary Brown at Kent University for
acting as critical readers and very wise advisers.
I would particularly like to thank Premila and Suman for their detailed and generous
comments and invaluable additions to the materials.
I would also like to thank all those people who took part in the RECC pilots for their time and
efforts in helping us to refne the materials. Including the RECC Trainers Workshops, with
special thanks to Ranjit Senghera (West Midlands, Race Equality Lead) in organising this
event and for her constant support and encouragement.
Finally, thanks to Ian Macgonagle at CCAWI for his sterling project management and Anisa
Mustafa at CCAWI for her hard work in laying out the documents and putting them into elec-
tronic format. Also, thanks to members of the BME Education and Training sub-group under
the leadership of Roslyn Hope and John Allcock who have worked skilfully and diligently over
the last two years to get these materials produced, distributed and implemented.
Peter Ferns
Tralners Manual
RECC - ESC Advanced Module
Page 2
Tralners Manual - |ntroductlon
RECC - ESC Advanced Module
Page 3
Introduction to RECC Trainers Manual
Welcome to all Trainers who are about to deliver the Race Equality and Cultural Capability
(RECC) training programme. The most important attribute a RECC trainer should have is
self-awareness, in other words knowing where you are coming from in relation to race and
culture issues in mental health. Of course, it helps to be enthusiastic and committed about
the issues as this energy needs to be communicated to participants if they are to be moti-
vated to use their learning in practice and improve services for BME people. Knowledge and
experience can be gained by working collaboratively with capable trainers, trying things out
and learning from your mistakes. Qualifcations are of secondary importance compared to
the drive, determination and passion you bring to training around these issues.
RECC training can be complex and trainers need to be prepared for challenges and resis-
tance to some of the content of the programme. It is vital that RECC trainers prepare them-
selves well and feel confdent in dealing constructively with such challenges as they can be
valuable opportunities for learning. We have listed some common challenging responses
from participants involved in RECC training.
Its all very well telling me about this stuff but its my manager you want to talk to!
Our managers dont listen to us.
We did this kind of training years ago and nothing has really changed.
We just dont have the time to do it like that - they expect us to take on more and
more work.
There arent the resources for us to develop anything new at present.
We do all this anyway.
Im part of a Health dominated team now so we cant do things in this way as we
operate with a very medicalised approach.
It feels like you are attacking me for all of this there is nothing I can do about it.
The comments above from participants on race equality training courses act as a reality
check on the challenges ahead for all trainers in this type of training, whether they are practi-
tioner-based or service user/survivor trainers.
In this introduction we will give you an outline of the RECC materials and some ideas about
how the programme could be delivered. We will clarify the underpinning principles and val-
ues for the RECC materials and defne two fundamental concepts in the programme.

Purpose of the RECC programme
To provide learning and development opportunities for all mental health practitioners to
improve their practice in working with BME people who may need services due to mental
distress.

Page 4 Tralners Manual - Outllne of the programme
Outline of the RECC programme
The RECC programme consists of 12 one and a half to two hour training Sessions with
twelve workplace tasks attached (one for each Session). The materials provided include:
Trainers Manual Instructions for all RECC groupwork exercises, slides for all
presentations in the teaching session and handouts for participants to support the
exercises.
Participants Reader - A set of optional pre-course reading materials.
Practice Development Workbook - A series of work task templates that help
participants to undertake the tasks, get supervision from their line-managers and
gather data that contributes to an overall report to senior managers.
Senior Management Report A set of templates to compile a short report of key
points arising from the work tasks undertaken by participants.
The twelve teaching Sessions are summarised in the table below with their contents.
Session 1 Refecting on culture
Defning culture more clearly and appreciating its complexity.
Introducing a useful model of culture to help understand it at different levels.
Making links between culture, power and oppression.
Session 2 Refecting on beliefs
Analysing the nature of cultural change in mental health services.
Understanding the social and cultural context of diagnosis in mental health.
Raising awareness of the impact of personal beliefs and values of practitioners on
their practice.
Session 3 Assumptions in practice
Encouraging refective mental health practice in relation to ones own beliefs and
values.
Appreciating the power of hidden assumptions to shape practice in mental health
work.
Understanding how circles of fear develop between BME service users and
mental health practitioners.
Session 4 Refecting on communication
Identifying ways of breaking circles of fear with BME service users.
Appreciating the importance of good communication between service users and
practitioners for the quality of mental health services provided.
Understanding the use of power and authority through communication in service
settings.
Session 5 Working across different cultures
Identifying the barriers to good communication with BME service users in mental
health settings.
Understanding cultural differences through a model that avoids cultural
stereotyping and values diversity and inclusivity.
RECC - ESC Advanced Module
Page 5 Tralners Manual - Outllne of the programme
Refecting on ones own differences in cultural beliefs and values.
Session 6 Race equality in mental health services
Analysing the impacts of individual cultural differences in teams and in services as
a whole.
Understanding of and being able to recognise the processes involved in
institutional racism.
A clearer understanding of what promoting race equality means in mental health
services.
Session 7 Working in an empowering way
An analysis of how well local mental health services promote race equality.
A deeper understanding of the consequences of powerlessness and internalised
oppression for BME service users.
Introduction to a model of individual empowerment of service users.
Session 8 Working with BME families and carers
Formulation of a strategy to empower BME service users in local services.
Understanding what is involved in BME family/carer empowerment.
An appreciation of BME community empowerment and the role of Community
development Workers.
Session 9 Understanding discriminatory situations
Looking at ways of empowering BME families and carers in local mental health
services.
Understanding the importance of accurate analysis of situations involving possible
racial discrimination for successful interventions.
Using a whole systems approach to gathering information in complex situations
with BME people.
Session 10 Identifying needs in a holistic way
Analysis of a complex situation involving a BME service user in local mental
health services.
Understanding the fundamental principles of a holistic approach to mental health
assessment.
Critical analysis of assessment processes in local mental health services using
the principles of a holistic approach.
Session 11 Holistic approach to planning
The Five Service Accomplishments to help defne the desired lifestyle of BME
service users
A holistic and anti-discriminatory process of person-centred planning with BME
people
Identifying the desirable lifestyles of BME service users.
Session 12 Anti-discriminatory risk work
A critical analysis of the local assessment and individual planning processes in
relation to cultural appropriateness and person-centred practice.
Awareness of how race and culture issues can infuence risk assessment and
RECC - ESC Advanced Module
Page 6 Tralners Manual - Outllne of the programme
management.
An understanding of the principles and process of anti-discriminatory risk work.
The Sessions described above can be delivered in the form of one Session per week or
fortnight or at regular intervals, alternatively the programme could be arranged into one-day
workshops with time for work tasks in between each workshop. If the RECC programme is
delivered as a series of three one-day workshops it could follow the following pattern to allow
for time to undertake the work tasks as participants progress through the programme:
Workshop 1 Sessions 1 to 4
First follow up half-day session - report back about work tasks about four weeks
later to allow for four work tasks to be completed
Workshop 2 Sessions 5 to 8 (this could be held the day after the follow-up
session outlined above if people were travelling longer distances to attend
Second follow up half-day session report back about work tasks completed four
week later
Workshop 3 Sessions 9 to 12 (again this could be the day after the second
half-day session above)
Third follow up half-day session report back about fnal four work-tasks.
Although it is recommended that participants undertake the pre-course reading for each Ses-
sion prior to the training to get the maximum beneft - it is not essential. Essential reading for
the Session is incorporated in the Learners Notes as a handout. The optional material for
each Session in the Participants Reader consists of:
three learning outcomes which can be used for evaluation of learning by
participants
a list of key words for the Session these defnitions outline the way in which
the words and phrases are used in the text and are not meant to be dictionary
defnitions
teaching material in the main body of the text
quotes and research fndings in boxes
interesting related facts under the points of interest boxes
refection points for readers to stop and consider some deeper questions about
the text
references for sources of information quoted in the Session.
The material for each Session in the Trainers Notes consists of:
a very brief overview of the Session timetable
a statement of purpose for each exercise
instructions on how to run the exercise
a list of resources required to assist trainers in preparing for each exercise it is
assumed that fipchart paper, pens and a digital projector or overhead projector
will be made available for every Session
a suggested timing which trainers should use as a guideline bearing in mind that
each training group may approach an exercise in a different way.
There are several stories about BME service users throughout the materials and it is impor-
RECC - ESC Advanced Module
Page 7 Tralners Manual - Outllne of the programme
tant for trainers to make it clear that these are not just case studies in the usual sense in
training materials but are meant to be illustrations of models or concepts that are offered in
the teaching sessions. Many of the stories are rich and based on true stories however they
are included to serve a purpose and trainers must ensure that the purpose of the exercise
and its learning outcomes are fulflled through the use of such stories.
Suman Fernando puts it in this way:
I think it important that histories when presented are not taken just as cases to be dis-
cussed in depth but as illustrations of something (such as) how events and observations
are interpreted to produce symptoms which by and large represent the attitudes (towards
race, immigrants, etc.) that we hold.
RECC - ESC Advanced Module
Page 8 Tralners Manual - Prlnclples and values
Principles & values of the RECC programme
1. Dealing with inequality and not just cultural difference
~ Valuing cultural difference without dealing with inequality and racism in mental health
services will not work. Cultural capability without a strategy to address institutional and indi-
vidual racism based on an analysis of power dynamics and structural inequalities will have a
limited impact on discrimination in services.
2. Having a deeper understanding of culture
~ A superfcial analysis of culture can lead to tokenism and cultural stereotyping a simple
understanding of culture leads to simply wrong judgements.
3. RECC is an ordinary part good practice
~ Race equality and cultural capability are not special or different approaches; they are es-
sentially about good practice and improve mental health services for everyone.
4. Services will improve only through a whole systems approach
~ There must be a coherent strategy for change based on a whole systems approach to
achieve sustained and continuous improvement in services.
5. Greater BME service user participation leads to greater appropriateness of services
~ Genuine participation and involvement of BME service users, their families and commu-
nities is the most effective and rapid way to achieve mental health services that are more
appropriate and accessible to BME people.
6. Miscommunication often leads to unnecessary conficts
~ Everyone needs to share a common understanding of the fundamental concepts in equal-
ity and diversity work if we are to establish a constructive dialogue about diffcult issues
between the different groups involved in BME mental health.
7. We need to recognise institutional discrimination as a problem before we can begin
to tackle it properly
~ Institutional discrimination is often covert and complex, mental health practitioners need
help in recognising when and how it operates in their services.
8. Know yourself frst before trying to understand others
~ You can only understand where other people are coming from in terms of culture only if
you understand where you are coming from frst.
9. Unacknowledged prejudices grow in power and infuence
~ If you dont face up to the prejudices and stereotypes you hold they will become even more
powerful in shaping your practice.
10. Values are central to mental health practice
~ Value judgements come into all decisions we make in mental health service as we are
dealing with people and trying to improve the quality of their lives.
RECC - ESC Advanced Module
Page 9 Page 9 Tralners Manual - Some fundamental concepts ln PLCC Tralnlng
RECC - ESC Advanced Module
Some fundamental concepts in RECC training
Culture
In RECC training, a superfcial analysis of culture can lead to tokenism or cultural stereotyp-
ing. The materials that have been developed emphasise the complexity of culture, offer a
multi-layered model of culture and provide a structured approach to working with cultural
differences that does not fall into the trap of cultural stereotyping of specifc ethnic groups.
Culture is viewed as a dynamic and fuid social concept where individuals and groups
interact with each other and develop within a cultural framework that they actively shape
as well as being actively infuenced by it. It cannot be over-emphasised that training about
cultural capability without a strategy to address individual and institutional racism based on
a thorough analysis of power dynamics and structural inequalities will have a limited impact
on discrimination in services. Race equality and cultural capability approaches are integral
to good practice - they are not special or different approaches to practice. In other words a
race equality and cultural capability approach improves mental health services for everyone
and is an ordinary part of good practice.
The challenges of Race Equality & Cultural Capability training, Peter Ferns in Fernando S.
& Keating F. (due 2007), Mental health in a multi-ethnic society (second edition), Routledge

A whole systems approach to training
The challenges of Race Equality & Cultural Capability training, Peter Ferns
in Fernando S. (due 2007), Mental health in a multi-ethnic society
Page l0 Tralners Manual - The challenge for PLCC programme
RECC - ESC Advanced Module
The challenge for RECC trainers
Getting to grips with the RECC materials
Ensure that you read the participants pre-course reading before each session to refresh
your memory of it. The trainers notes are quite detailed for each exercise and you may wish
to do some further reading around the issues covered in each exercise. This is usually a
good idea as there are often awkward questions asked in training sessions about race and
culture. You will be expected to give some advice about how to apply the models taught in
each session in local practice.
Taking on local issues
The RECC materials have to be adapted by trainers to ensure that they are relevant to the
local issues that practitioners raise in training sessions. Allow time for discussion about local
concerns and be prepared for variations such as rural versus urban contexts, varying sizes
of BME populations, varying migration patterns and different experiences of disadvantage
and discrimination. Although there are case studies put forward in the materials, it would be
best for RECC trainers to create their own case studies based on local issues and experi-
ences of BME service users. The materials can serve as illustrations of how the theoretical
models are refected in practice.
Involving BME service users and families
One of the most important features of the RECC training materials is their design to incorpo-
rate the inputs from BME service user / survivor trainers. Training for trainers in the RECC
programme should cover issues of co-training between BME service user/survivor trainers,
carer trainers and other mental health trainers. We have found the participation of a wide
range of trainers to be very benefcial for practitioners as will a being an effective way of
constructively challenging local practice.
Dealing with culturally strong teams
Although training whole teams can potentially lead to greater changes in practice and service
development, there is also an increased risk that teams with strong cultures may not be so
open to change. Dealing such teams may be very diffcult for trainers as long-standing alli-
ances and cliques will tend to emerge if team members are challenged about discriminatory
practice. Traditional ways of doing things may feel right even though they are discriminatory
if they have remained unchallenged they will become part of the unwritten rules teams oper-
ate by. If you are a local trainer you could fnd out more about the teams you are training and
may be even attend one of their team meetings prior to training to fnd out more about how
they operate and get on together.
Multi-agency working
Multi-agency working is a crucial issue for many BME service users and their families. It is
still a developing way of working in several areas and differences and even rivalries between
professional cultures can sometimes take over the training agenda and defect exercises
away from a focus on services to BME people. It is best to tackle these kinds of issues up-
front and encourage people to forget their differences, temporarily at least, for the purpose of
improving services for BME communities.
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RECC - ESC Advanced Module
Delivering the RECC programme
The extensive pre-course readings for participants, if undertaken, will help to reduce the
pressure of learning during the training sessions and allows time for people to deepen their
learning through practical exercises and discussion of views about practice in light of the
theories and models presented in the materials. As part of a whole systems approach to
training, several of the exercises have been designed to generate a lot of useful data and
evidence of practice for managers. The purpose of feeding through such data to leaders is to
enable them to make better judgements about policy and procedures and ultimately design
better systems and structures to support and deliver anti-discriminatory practice. Following
each session there are workplace tasks designed to link learning in that session to practice
and some key points from these tasks are gathered through the workplace task templates
for senior managers. Line-managers are also fully involved in the workplace tasks through
the use of a template for a supervision session around the task prior to participants reporting
back to the RECC training group at the next Session or at a follow up half-day.
The DRE Action Plan recommended that:
A more active role for BME communities and BME service users in the training of profes-
sionals, in the development of mental health policy, and in the planning and provision of
services; and..all who work in mental health services should receive training in cultural
awareness and sensitivity all managers and clinical staff, however senior or junior,
should receive mandatory training in all aspects of cultural competency, awareness and
sensitivity. This should include training to tackle overt and covert racism and institutional
racism
(DoH, 2005)
One of the most innovatory aspects of the training is that it has been designed to be de-
livered in partnership with BME service user/survivor trainers. This elicits a whole host of
issues for commissioners, trainers and participants. We have found the involvement of BME
service user/survivor trainers to be invaluable in delivering RECC training. Issues of power,
institutional discrimination, BME service user experience and cultural appropriateness have
been discussed and dealt with very effectively. Co-training between BME service user/survi-
vor trainers and other mental health trainers adds more complexity to the implementation of
RECC training but it is essential in achieving its fundamental goals. This is why it is our strat-
egy to press for training for trainers as part of the implementation process along with the
establishment of a pool of BME service user/survivor trainers in every CSIP/NIMHE Region
in partnership with Ferns Associates.
Although the RECC materials are pitched at around foundation level training, it is likely
higher levels of RECC materials will be developed. A second level of RECC is being devel-
oped by Ferns Associates to focus on RECC skills development in specifc areas of practice
such as assessment and person-centred planning, working with interpreters in interviews
and in service areas such as Children and Adolescent Mental Health Services, forensic
services, drug and alcohol services and elders. A third level of training has begun to be
developed for team leaders on managing diverse teams and taking on a leadership role in
promoting RECC. Finally, a fourth level is being planned for senior managers and service
planners which will focus on systemic approaches to RECC, changing organisational cul-
tures, designing systems to promote RECC and creating sustainable service improvements
Page l2 Tralners Manual - Dellverlng the PLCC programme
for BME communities.
Detailed information about the RECC materials and the additional levels of RECC available
on the website: http://www.fernsassociates.co.uk.
Or contact us on 0208-641-9358
Delivering the RECC materials will be challenging as well as personally rewarding and
people involved in delivery on a regional basis will require support, coaching and practice
development. Ongoing monitoring of quality of training delivery will be important and the
establishment of a regional training support group in relation to RECC may provide many
of these functions. The potential impact on the dynamics around mental health training in
a region through this initiative could be fundamental and it would be fascinating to set up a
longer-term evaluative study.
Ground-rules for RECC groupwork
We have found that the more diverse the group of participants is, the greater the potential for
learning particularly where voluntary sector organisations, BME service users and family/car-
ers are involved with practitioners in statutory services. Qualifed staff can beneft as much
as unqualifed from the workshops and the materials will complement most forms of profes-
sional training in mental health. Greater diversity in the participant group does require more
careful handling of the group dynamics and it is useful to set a clear learning agreement with
ground-rules for the group at the start of the frst Session and at every workshop.
We have found the following checklist useful in negotiating learning agreements:
Confdentiality to allow people to share openly what is going on for them at work
and in their practice.
Respect for each other even though people may disagree with the each others
opinions.
Engaging in constructive challenge to make sure that people open up issues for
debate rather than close them down through personal confict.
Listening to each other and giving people space to express their views to avoid
miscommunication as much as possible.
Making assumptions and beliefs more explicit to allow people to refect on their
own views as well as understand other peoples views more accurately.
Offering data and evidence for personal views to allow a clearer discussion to
take place and increase learning.
References
DH (2003), Delivering Race Equality: A Framework for Action, DH, October 2003

RECC - ESC Advanced Module
Page l3 Tralners Manual : Sesslon l - Penectlng on culture
RECC - ESC Advanced Module
TRAINERS NOTES
SESSION 1- REFLECTING ON CULTURE
Group Activity 1.1 Defning Culture (30 minutes)
Overview:
This exercise encourages people to think more deeply about the concept of culture as it is
such a familiar term to people that most people assume that that everyone agrees about the
meaning of the term. The exercise should draw out the variations in the meaning of culture
and how complex it is as a concept prior to offering a model of culture.
Purpose:
To help participants appreciate the variety and complexity of culture.
Instructions:
Write the following question up on a fipchart beforehand:
What is culture?
Ask people in the large group to have a quick-think session about this question and facilitate
discussion.
Trainer presents What is culture using Slide 1.1.
Resources:
Slide 1.1, Handout 1.4 -Learners Notes.
Time:
Total approximately 30 minutes
15 minutes in large group discussion and 15 minutes presentation by trainer.
Group Activity 1.2 (a) Cultural Assumptions
Overview:
This two-stage exercise initially helps people to take a critical look at their own views about
other cultures that are often marginalised in our society. The material leads people through
a process of challenge to common assumptions held about minority cultures as well as rein-
forcing the view of culture as a multi-layered concept. Finally, a very useful model of culture
is introduced in this session which informs several other models used later in the RECC
materials.
Purpose:
To help participants to refect on the nature of cultural assumptions about others.
Group Activity 1.1 Defning Culture 30 minutes
Group Activity 1.2 Cultural Assumptions 1 hour
Reminder for Workplace Task 1: Culture change in your organisation
Page l4 Tralners Manual : Sesslon l - Penectlng on culture
Instructions:
Look at the picture of the young women wearing the hijab (Slide 1.2), a traditional Mus-
lim form of dress, on a London march.
Ask the following question:
What is it about these young womens culture that causes them to choose to dress this
way in Britain today?
Ask people to write down their thoughts in a couple of paragraphs and keep their written
notes for later in the Session.
- Now refer participants to Handout 1.4 - Learners Notes for Activity 1.2(a) to read the
paragraph about this particular activity.
Now, draw up a fipchart into two columns with one headed Values and the other left
blank. Introduce the concepts of values, beliefs and assumptions by asking people in
the large group to come up with some common values in our society. Then choose one
value and ask people why this value is important in our society. By asking why the
trainer should draw out the fact that values are founded on a set of beliefs and assump-
tions that the value is good for society and therefore functional for the cultural group.
Write the heading of the blank column as Core beliefs and assumptions and then go on
to say that culture is a layered concept.
Finally, present the iceberg model of culture using Slide 1.3.
Resources:
Slides 1.2 & 1.3, Handout 1.4 - Learners Notes.
Time:
Total 20 minutes
5 minutes personal refection and writing notes and 15 minutes for the discussion and pre-
sentation by the trainer.
Group Activity 1.2 (b) Cultural Assumptions (contd)
Purpose:
To help participants to refect on the nature and effects of cultural assumptions about others.
Instructions:
Read the extract from an article in The Michigan Daily newspaper in Handout 1.4,
Learners Notes for Activity 1.2(b).
Ask people to work in pairs.
Give people a copy of Handout 1.2 and ask them to use the iceberg model to identify
examples of each of the layers of culture from this newspaper story in the blank dia-
gram provided.
When they have fnished ask them to look at the example provided in Handout 1.3.
Now get them to refer back to their personal notes from Individual Activity 1(a) and go
through the same process for their own written piece.
Ask each pair to discuss:
Were there any surprises for you? Did you learn something new in doing this
exercise?
Take feedback in large group

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Page l5 Tralners Manual : Sesslon l - Penectlng on culture
Task Output:
An iceberg model flled in for the example about the hijab based on the newspaper story
provided.
Resources:
Handouts 1.2, 1.3, & 1.4 (Learners Notes).
Time:
Total 40 minutes
5 minutes individual reading, 10 minutes in pairs with Handout 2, 10 minutes in pairs on own
notes, 15 minutes feedback.
RECC - ESC Advanced Module
Page l6 Tralners Manual : Sesslon l - Penectlng on culture
Slide 1.1
Culture is
made up of a number of factors such as values, language, traditions, religion,
rituals, symbols, food, clothes and fashion
part of a living environment where individuals grow and develop; it infuences
them but does not totally defne them as people
chosen or rejected by individuals and often results in parts of cultures being
brought together by people leading to a constant mixing of cultures
always changing with time and with different groups of people in society
not easy to defne clearly as it is not just a collection of facts that can be learned
or passed on to people who are new to that culture
rich and varied, with a range of different values within each culture
not value free for example in a racist society in which Black peoples cultures
will tend to be seen as inferior to White peoples cultures; lesbian and gay cul-
ture will be seen as inferior to heterosexual culture; deaf culture will be seen as
inferior to hearing culture etc

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Page l7 Tralners Manual : Sesslon l - Penectlng on culture
Slide 1.2
International Hijab Solidarity Day in London, 2004


RECC - ESC Advanced Module
Page l8 Tralners Manual : Sesslon l - Penectlng on culture
Slide 1.3
The Iceberg Model of Culture
Products, food, clothes,
symbols, rituals, buildings etc.
Decisions and behaviours
Norms and values
Core beliefs and assumptions
RECC - ESC Advanced Module
Page l9 Tralners Manual : Sesslon l - Penectlng on culture
HANDOUT 1.1
Culture is
made up of a number of factors such as values, language, traditions, religion,
rituals, symbols, food, clothes and fashion
part of a living environment where individuals grow and develop; it infuences
them but does not totally defne them as people
chosen or rejected by individuals and often results in parts of cultures being
brought together by people leading to a constant mixing of cultures
always changing with time and with different groups of people in society
not easy to defne clearly as it is not just a collection of facts that can be learned
or passed on to people who are new to that culture
rich and varied, with a range of different values within each culture
not value free for example in a racist society in which Black peoples cultures
will tend to be seen as inferior to White peoples cultures; lesbian and gay cul-
ture will be seen as inferior to heterosexual culture; deaf culture will be seen as
inferior to hearing culture etc

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Page 20 Tralners Manual : Sesslon l - Penectlng on culture
Handout 1.2
Products, food, clothes,
symbols, rituals, buildings etc.
Decisions and behaviours
Norms and values
Core beliefs and assumptions
RECC - ESC Advanced Module
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Handout 1.3
An Example of the Iceberg for the hijab article
Products, food, clothes,
symbols, rituals, buildings etc.
Decisions and behaviours
Norms and values
Core beliefs and assumptions
Wearing a hijab
Being modest in public appearance
Showing you are a Muslim

Deciding to dress differently from


others in the majority culture
To follow religious teachings around female
dress
Determination to wear the hijab despite
hosility to Muslims

Being appreciated for intelligence rather than


physical appearance
Valuing the fullmment of religious duty
Not being able to stand up for your beliefs
and rights
Thinking for yourself

More likely to be seen as a person rst not


an object
Doing what God has instructed.
Its easier to discriminate against Muslim
women

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Handout 1.4
LEARNERS NOTES
SESSION 1- REFLECTING ON CULTURE
Learning Outcomes
Participants will be able to:
have a clearer understanding of the variation and complexity of the concept of
culture
describe a useful model of culture
explain how cultural assumptions can infuence the values and behaviours of
practitioners.
Defning culture
First try this activity:

Group Activity 1.1 Defning Culture
It is essential to recognise that culture is very complex and it is always changing over time.
The constant mixing and blending of cultures over time means there has never been and
never will be a pure culture for an ethnic group of people. The large groupings we use to
describe a persons ethnicity disguise this complexity, terms like Asian or African or Carib-
bean incorporate a number of cultural variations within these broad ethnic descriptions. The
picture is further complicated by the fact that many BME people who come to this country of-
ten take on aspects of the majority culture and subtly but signifcantly alter their own cultural
heritage. BME people who have been in the UK for many years often fnd that when they
return to their country of origin they are viewed as being different from the indigenous popu-
lation and perhaps being seen as just British. This process is referred to in the research as
acculturation. However, if coercion or pressure is involved in people taking on the majority
culture and power dynamics create a dominant culture the process is more like assimilation
(see glossary in the Participants Reader for this session).
all cultures are involved with one another; none is single and pure, all are hybrid, het-
erogeneous, extraordinarily differentiated, and unmonolithic. (Said, 1994)
Participants should insert Handout 1.1 after this page
Now try the following activity:

Individual Activity 1.2 (a) Cultural Assumptions
Learners Notes for Activity 1.2 (a): What may frst strike you about these young women
is how differently they dress from most young women of their age in this country. They are
also appear to be happy and confdent which may feel incongruent as the wearing of hijab

BME service user quote


When a woman cries there are tears in her eyes. When a man cries his
tears stay in his heart they dont come out.
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in Western European countries usually carries a lot of negative connotations, particularly
about the religious suppression of womens rights. Why do these women look different?
Are they forced to dress like this? Do they actually choose to dress like this? What does
it mean to them as young people to appear in public dressed in this way in Britain today?
What messages do they want to send to others in our society? To unpack these questions
and try to answer some of these questions one has to understand the cultural context of the
young women from their perspective. Their personal appearance is an important statement
about themselves as it is for any young person. If it is a conscious decision they are taking,
it demonstrates choices and behaviours that are important for them. It also signifes certain
values they hold about the role of women in society. In turn, these values are underpinned by
assumptions and beliefs about what constitutes a good or bad woman in society. This is a
glimpse of the layered nature of culture which is explored more in the next section.
An iceberg model of culture
Peoples cultural values, or what they think is most important to protect in a situation pre-
sented, infuence what they would do in that situation leading to actions and outcomes.
These are clues about the nature of culture and how it can be seen as a series of layers that
interact with each other. You have, no doubt, also noticed how varied peoples cultures and
values can be. If you look deeper, you fnd that values are based on certain beliefs and as-
sumptions that give meaning to why something is important in other words beliefs give rise
to values.
Products, food, clothes,
symbols, rituals, buildings etc.
Decisions and behaviours
Norms and values
Core beliefs and assumptions
The idea of an iceberg representing different layers is a useful one because a large part
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of culture is below the surface the line of consciousness, or subliminal. It also suggests
that it is dangerous to ignore what is below the surface. At the deepest level of culture, core
beliefs and assumptions exist as the unspoken rules of a cultural group or are viewed by the
group as common sense. Core beliefs and assumptions develop over a long period of time
as they are shaped by responses to familiar problems that continually have to be solved by
a cultural group in order that it can survive in its physical, social and economic environment.
The solutions for survival become more and more familiar, to the extent that they become
unspoken ways of relating to the environment. They become embedded in a cultural group
and passed from one generation to the next through such things as rituals, taboos, traditions
and religious beliefs.
Core beliefs and assumptions underpin values and norms in a cultural group. Values are
more publicly stated than assumptions and beliefs and are refected in the laws of society,
in the policy and procedures of organisations and in political thinking about important social
issues. Values essentially represent what people in the cultural group fnd most important in
their lives.
Complex concepts like values can be thought of as being in some ways like extended
families. Values, though complex, are not chaotic, but coherent in the way that an
extended family made up of many different members is coherent. (Woodbridge & Fulford,
2004)
Values are coherent because they are underpinned by core beliefs and assumptions that are
functional for the cultural group who holds them and enables that group to survive as stated
earlier. Moreover, many values are common to all cultures, perhaps with varying degrees
of importance, but there are many more similarities of values between cultures than differ-
ences. This is an important point to remember when discussing cultural differences.
Values also drive particular behaviours and judgements, although other factors such as
personality and situational factors can also be very infuential, people generally behave to
protect what they value. Not all behaviours and judgements of people are easily understood,
because most communication in any society is non-verbal in nature and open to interpreta-
tion.
The most visible layer of culture is that of its products such as its art, rituals, symbols, build-
ings, clothes and food. This layer is often what we mean when we talk about culture, but it
must be remembered that there are several other layers of culture. For culturally appropriate
services, therefore, the real challenge in the future is not just to have the right food, literature,
music and posters on the wall, but to develop services that are truly inclusive of the different
values, beliefs and assumptions of the diverse communities they serve.
Core beliefs, assumptions and values are infuenced by many complex factors in any culture
apart from ethnicity and religion. Issues of gender, class, sexuality, disability and age are just
a few other powerful infuences in shaping the creation of the deeper levels of culture.
Personal Refection
Can you think of one key impact of gender on core assumptions and beliefs in Britain
today? Discuss your suggestion with a colleague.
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Now try the following activity:
Individual Activity 1.2 (b) - Cultural Assumptions (contd)
The Muslim faith has fve pillars:
1) Shahada is the profession of faith: There is none worthy of worship except God and Mu-
hammad is the messenger of God;
2) Salat are the prayers that are performed fve times per day by all Muslims over the age of
10. Prayers are required before sunrise, and at noon, midday, sundown, and night. Prayers
are preceded by a ritual ablution, wudu, washing face, neck, arms and ankles. The practice
of praying includes the recitation of Quranic verses and prostration toward Mecca;
3) Zakat or charitable giving, is compulsory for all devout Muslims For most purposes this
involves the payment each year of two and a half percent of ones capital.;
An extract from Wrapped in Modesty - Muslim Women Dispel Stereo-
types about Islamic Dress By Christina Hildreth, Daily Staff Reporter,
March 31, 2005
For both Grewal and Jukaku, the decision to wear hijab is deeply rooted in their faith.
I think that its my religious duty to wear it, said Grewal, adding that the vast majority of
interpretations of the Quran, the Islamic holy book, dictate that women wear hijab.
Jukaku agreed. I want to follow what God has told me to do, she said, adding that wear-
ing hijab also has practical benefts, as her modesty allows her to be appreciated for her
intelligence rather than her physical appearance.
Grewal said she feels wearing hijab is actually an empowerment.
A lot of times women are judged frst on how they look and then how they think, she
said, adding that hijab makes me a person before it makes me an object.
Like any religious practice, Grewal said wearing hijab is easy at times and hard at others.
Around Sept. 11 it was extremely diffcult (to wear hijab) because there was so much
negative association with Muslims and especially with women who wear hijab, she said,
adding that it is easier for people to discriminate against Muslim women than anyone
else, because the second they see me they know Im Muslim
While wearing hijab may present some obstacles for Grewal and Jukaku, they still
choose to make it a part of their life, and reject the falsehood that it is a decision made for
them. Its kind of disheartening that there is an image of Muslim women not being able
to think for themselves, Grewal said. Why cant I be the one making the decision, why
does it have to be someone else?
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4) Sawm is religious fasting from food, drink, and sexual activity from dawn until dusk and is
followed during the month of Ramadan, the 9th month of the lunar calendar. Fasting is prac-
ticed to obtain physical and spiritual purity;
5) Hajj is a pilgrimage to Mecca, which is a goal of every Muslim if physically and economi-
cally able, at least once during his or her lifetime.
Participants should insert Handout 1.2 and 1.3 after this page

BME service user quote
If I talked about spirituality to the doctor he would increase my medication.
Session 1 - Practice Development Tips
Dont expect people to know about their own core assumptions and beliefs remem-
ber that most of culture is below the line of consciousness or subliminal.
A good approach to identifying core assumptions and beliefs is to examine the
persons behaviours and decisions by asking what she or he would prefer doing in the
situation. This will uncover what is important to the person (their values) and asking
why it is important will identify their core assumptions and beliefs.
Find out more about the major BME groups in your local area also fnd out about
religious organisations operating in your local community.

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TRAINERS NOTES
SESSION 2a - REFLECTING ON BELIEFS
Group Activity 2.1 Diagnosis & social context 1 hour
Overview:
The exercise touches on some more complex issues around diagnosis in mental health but
does not attempt to go into the technical arguments about diagnosis. The important point to
get across here is to emphasise the importance of value judgements in the process of diag-
nosis in mental health. The example further emphasises the importance of social and politi-
cal factors in shaping the way that mental health is dealt with in any society. These points are
a precursor for the introduction of a holistic approach to assessment as the wider social and
political factors must be taken into account in for effective service delivery to BME people in
distress.
Purpose:
To help participants to understand how social context infuences the diagnostic process in
mental health.
Instructions:
Present the Social context of mental health work diagram by Suman Fernando using
Slide 2.1.
Split people up into small discussion groups.
Ask people to look at the Learners Notes to fnd the two historical accounts of how the
mental health of Black African slaves was studied in the middle of the 19th Century.
Get each group to appoint a note-taker and use Suman Fernandos diagram to answer
the following questions.
First in relation to Suman Fernandos diagram you may ask the group:
What was the political context at this time and how did it affect the issue of slavery?
What were the social pressures on people in the South to defend slavery and why were
they so strong?
What cultural factors in the South maintained slavery?
How did the factors of common sense, racial stereotyping and cultural assumption af-
fect the individuals involved including psychiatrists at the time?
Finally ask people to address the following questions and bring some answers to the
large group.
What do these accounts tell you about the diagnostic process being followed at that
time?
How is the process of diagnosis today different from what happened then in mental
health services?
Ask people to take a look at the analysis provided in Handout 2.1.

Review Work Task 1: Culture Change 30 mins


Group Activity 2.1 - Diagnosis & social context 60 mins
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Now take feedback in the large group on the fnal two questions asked above.
Task Output:
To produce notes about peoples views on social and political key factors involved in slavery
in the 19th Century.
Resources:
Slide 2.1, Handouts 2.1 & 2.2 - Learners Notes.
Time: Total 1 hour
5 minutes trainer presentation, 5 minutes reading time for participants, 20 minutes for small
group work, 20 minutes feedback in large group and 10 minutes to review analysis in text.

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Slide 2.1



(By Suman Fernando)
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Handout 2.1
Using Suman Fernandos diagram we give an example below of the analysis of infuences
on the diagnostic process at that time:
Social Factors
Political expediency Slavery at that time was a highly contentious political issue
that was fuelling a civil war and there were strong vested interests on both sides
of the argument for and against slavery. To show that slavery was a natural
condition for Black people would help to justify its existence as being an inevitable
fact of a natural process.
Social pressures Many people were implicated in the practice of slavery and
there were strong economic incentives to defend slavery in the Southern States
of America. Runaway slaves were extremely uneconomical as it was expensive
to track and bring them back to the plantation. Many of the inhuman punishments
severely reduced the slaves value to owners or, of course, people were
sometimes murdered to serve as a lesson for others and exert social control
through fear.
Traditions The culture in the American South had been steeped in the slave
trade and a great deal of wealth in the local economy in the South had been
generated in the past through plantations and the traffcking of slaves. Slavery
was felt to be an inherent part of the Souths culture and so any attack on slavery
was an attack on the Souths culture.
Individual Factors
Common sense It was generally thought that Black people brought to America
as slaves were better off than those remaining in their countries of birth as they
were being civilised. White people at that time, including psychiatrists, were
convinced that Black people were very different from White people and that they
were certainly inferior.
Racial stereotyping It was felt that Black people were less intelligent and less
civilised than White people. It was even suggested that they did not feel pain as
much and could stand long days working hard in the sun without damage to their
health. Interestingly, similar views were held about people in mental distress in the
early asylums where inhumane treatments were justifed on the grounds that
people in distress could not feel physical discomfort or pain. It was held that Black
people would not experience the same forms of mental distress as White people
as their brains were fundamentally different.
Cultural assumptions It was so strongly believed that slavery was right and
natural that White people from the South thought that even Black people would
see the sense and benefts of it. Black people who escaped were seen as acting
irrationally and thus mentally ill. Towards the end of the Civil War it was even
suggested that Black slaves may fght for the South to defend plantation life and
culture, paradoxically in return for their freedom.
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RECC - ESC Advanced Module
TRAINERS NOTES
SESSION 2b - REFLECTING ON BELIEFS

Activity 2.2 - Shades of Grey
Overview:
The exercise is carefully structured to provide some groundrules and parameters to discuss
what could be diffcult and risky differences within a team or group of participants. It allows
people to discuss these issues without entering into a personal confict and models how
these kinds of practice dilemmas should be discussed in the workplace. There are often
taboo issues in teams that rarely get discussed for fear of confict but many of these issues
may be very pertinent to the quality of service that people vulnerable to oppression may re-
ceive. It can be a powerful activity for some teams who are not used to talking about issues
around equality and diversity in an open way. It is useful for people to remember the basic
groundrules for the learning session, particularly listening carefully to each other, showing
respect for each other and challenging other people in a constructive way.
Purpose:
This activity is about encouraging people to clarify where they are coming from in relation to
their personal values and identifying how these values infuence their practice. It also mod-
els how diffcult and contentious practice issues can be safely discussed in teams without
personal confrontation or risk to team relationships. It can be a powerful activity for some
teams who are not used to talking about issues around equality and diversity in an open way.
It is useful for people to remember the basic groundrules for the learning session, particularly
listening carefully to each other, showing respect for each other and challenging other people
in a constructive way.
Instructions:
Split people up into groups of six or seven people around a table.
The statements listed below should be made bigger and put onto slips of paper to
create a deck of statement cards to be used in a group.
The statements should remain face down in the middle of the group throughout
the activity and viewed only one at a time.
Two larger labels with Acceptable and Unacceptable should be laid out on the
table opposite each other to form a spectrum of acceptability for the exercise.
Instruct people that they are commenting on the acceptability or unacceptability
of the behaviour or decision of the underlined person or group on each card from
their perspective as a service user, carer or practitioner. They should place their
card in the spectrum of acceptability on the table.
If a card is touching the label it is completely acceptable or unacceptable,
points in-between represent varying degrees of these more extreme positions.
The middle point really represents a dont know area and groups should be
encouraged to avoid this area as it is a bit of a cop out.
Group Activity 2.2 Shades of Grey 1 hour 20 minutes
Reminder for Work Task 2: Examining you own beliefs & assump-
tions
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Ensure that people do not deal out the cards as this only leads to people reading
and thinking about their card rather than the whole group focusing on one card at
a time.
The frst person should pick up a card, read it out, place it on the spectrum and
say why they have placed it in the position chosen. This takes place with no
discussion in the group to allow the person to express their view.
The person can add a condition or proviso to the situation outlined on the card to
help place it which should be accepted by the group without criticism.
Once the card is placed the rest of the group can discuss the issue and suggest
other positions for the card. Only the person who has placed the card can move it
though.
After hearing the discussion the person who placed the card initially should review
their decision and move the card if she or he wishes.
The group can only move onto the next card if everyone can live with where the
card is at. In other words there must be a strong disagreement before the card
can be taken out as an unplaced card otherwise the card remains where it is.
The next person in the group now picks up a card reads it out and goes through
the same procedure until all of the cards are exhausted.
Remember that this activity requires the trainer to maintain a safe environment for sharing
views, have a positive debate not personal confict and to conduct an effective debrief.
Task Output:
A ranking of individuals refections on their values about important practice issues and con-
structive challenge from peers on their views.
Resources:
It is best to do this activity on a large table for each group. A set of cards for each group with
the Shades of Grey statements.
Time:
Total 1 hour 20 minutes
10 minutes to receive instructions for the activity, 1 hour in small group discussion,
10 minutes debrief in large group.

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Shades of Grey Statements
Participants are making judgements about the decisions and behaviours of the underlined
actors in the situations.
1. A colleague in your team refuses to work alongside a male team
member who continually makes sexist comments.

2. You report a colleagues racist comments to your line-manager.
3. During an assessment of a refugee you encourage her to exaggerate
her needs as you feel that she is vulnerable but she does not quite
meet the criteria to receive a service.
4. A colleague in your team asks you to undertake some work with a gay,
young man. You agree after he explains that he is very religious and
cannot deal with homosexuality on moral grounds.
5. Putting pressure on a young mother with learning disabilities to use
contraception, because you feel that she could not cope with another child.
6. A young Asian woman who has a history of manic episodes and has been
a devout Moslem, starts to dress in Western skirts and acting
provocatively towards young men. Her family say that she needs to have
treatment in hospital as she does not think that she is mentally ill.
The social worker disagrees with the family because she feels that this is
normal behaviour for a young Asian person taking on Western values.
7. A Jewish patient on the ward who is going through a psychotic episode
asks for bacon and is given it. The family are angry about this and complain
to ward staff who dismiss the familys objections as the patient has a right
to eat what he wants.
8. A young West African woman who has experienced sexual abuse in the
past and is increasingly self-harming has recently been referred to mental
health services. Her family are currently taking her to a spiritual healer
who is exorcising her demons as she is evil and possessed. The young
woman believes that the exorcisms are helping her so the Mental Health
Team do not challenge the family as they are engaging in culturally
appropriate therapeutic actions.
9. During a Child Protection meeting the Chairperson states that in her view a
person with a diagnosis of schizophrenia is likely to be a poor parent.
10. A young Rastafarian man attending a mental health resource centre shows you
a small piece of cannabis that he has on him but he says that he will not
smoke it on the premises, so you let him keep it.
11. You arrange for the services of an interpreter for a young female Bangladeshi
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patient being voluntarily admitted to psychiatric hospital but when he arrives
the parents object because the interpreter knows the family. It is late on a
Fridayafternoonanditwouldbediffculttogetareplacementsoyouinsiston
using the interpreter.
12. Not allowing a service user to attend a therapeutic group that she has chosen
becauseyoufeelthatitwouldnotbenefther.

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HANDOUT 2.2


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RECC - ESC Advanced Module
Handout 2.3
LEARNERS NOTES
SESSIONS 2a & 2b - REFLECTING ON BELIEFS
Diagnosis & social context
Our personal values and the values of society will always play a part in determining the
judgements that are made during the diagnostic process in mental health. The diagram be-
low is adapted from Suman Fernando (2002) and summarises the wider process of diagno-
sis.
The issues surrounding personal values of practitioners are focused around the individual
factors box in the diagram. Practitioners will be strongly infuenced by their sense of what
feels natural to them or what feels like common sense when faced with making judgements
about social situations. Underlying these natural preferences are the practitioners own
cultural assumptions gained from a variety of sources, including their ethnic background and
the cultural norms of the society and/or professional group within which she or he operates.
Racial stereotypes are liable to infuence a societys cultural norms and so perceptions of
Black people tend to be negative in the context of a discriminatory society.
Learning Outcomes
Participants will be able to
understand how culture infuences the process of diagnosis in mental health
work
recognise the impact of social, political and personal factors on practice with
service users in the mental health system
explain how culture, power, privilege and oppression are inter-related within
society.

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RECC - ESC Advanced Module
In the social factors box the political agenda will also have a big impact on the diagnostic
process. For example, if there is a public panic about a specifc group of people such as
those with a diagnostic label of personality disorder there will be pressure on authorities to
do something about that group and the perceived threat they present to the public. This
group effectively constitutes an out-group in society which is discussed later in this session.
The impact on diagnosis may then be to have a greater focus on dangerousness and the is-
sue of treatability and the persons best interests may then be side-lined. Traditional views
of mental distress will also infuence the purpose, process and outcomes of diagnosis as it is
essentially a value-based process.
First try the following activity:
Group Activity 2.1 Diagnosis & social context
1851 Dr Samuel Cartwright Mental health problems of slaves
(from My Southern Home by William Wells Brown, 1815-1884)
This work is the property of the University of North Carolina at Chapel Hill. It may be used freely by
individuals for research, teaching and personal use as long as this statement of availability is included
in the text.
Dr. Samuel A. Cartwright was a prominent Louisiana physician in 1851 and one of the lead-
ing authorities at the time on the medical care of Negroes. Dr. Cartwright claimed to have
discovered two mental diseases peculiar to Black people. These were called drapetomania
and dysaesthesia aethiopica.
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RECC - ESC Advanced Module
The frst term came from drapetes, running away from home, and mania, meaning mad or
insane. Cartwright claimed that this disease caused Black slaves to have an uncontrollable
urge to run away from their home (the plantation) and their masters.
Dysaesthesia aethiopica supposedly affected both mind and body. He described it as heb-
etude (dullness of mind) a disease peculiar to Negroes called by overseers rascality.
The diagnosable signs included disobedience, answering disrespectfully, refusing to work
and deliberate damage to equipment and tools. The treatment was to put the person to
some kind of hard labour which apparently sent vitalised blood to the brain to give liberty to
the mind or alternatively being whipped.
(Participants should insert Handout 2.1 after this page)
1895 Dr. T.O. Powell Slaves are mentally healthier
Dr. Cartwright also stated that The disease is the natural offspring of Negro liberty the
liberty to be idle, to wallow in flth, and to
indulge in improper food and drinks. This
theme was later developed and scientifcally
proved in 1895 by Dr. T. Powell, Superin-
tendent of the Georgia Lunatic Asylum. He
compared the census records between 1860
and 1890 and showed that insanity among
Negroes had increased from one in 10,584
to one in 943. Dr. Powell believed the stable,
secure and structured lives led by slaves
served as protective factors against mental
illnesses. Dr. Powell stated: Freedom, how-
ever, removed all hygienic restraints, and
they were no longer obedient to the
inexorable laws of health, plunging into all
sorts of excesses and vices; leading irregu-
lar lives and having apparently little or no
control over
Statute celebrating emancipation of slaves
Points of interest
By the middle of the eighteenth century, in London alone, there were 18,000
Black slaves, forming nearly three per cent of an estimated population of
650,000. The infuence of slavery and colonisation has left an indelible mark on
African-Caribbean people by familiarising them with many aspects of British life
and institutions.
(The Parekh Report, 2002)
by 1860 ten of the richest men in America lived not just in the South but in the Nat-
chez district of Mississippi alone. In 1810, the cotton crop had been worth $12,495,000;
by 1860, it was valued at $248,757,000. Overall, 26 percent of Southern white families
owned slaves.
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RECC - ESC Advanced Module
Sometimes I aint so sho whos got ere a right to say when a man is crazy and when he
aint. Sometimes I think it aint none of us pure crazy and aint none of us pure sane until
the balance of us talks him that-a-way. Its like it aint so much what a fellow does, but its
the way the majority of folks is looking at him when he does it.
William Faulkner (1930)
References
The Parekh Report (2002) The Future of Multi-ethnic Britain, London: Profle Books.
Rosenhan (1973)
Engs R.F.(2002), The Confederacy , Macmillan Information Now Encyclopedia
Session 2 - Practice Development Tips
Remember, diagnosis in mental health is not purely a scientifc or technical process
- it always involves value judgements by practitioners.
Whenever there is a major change in legislation or policy affecting BME people ask
why it is happening to uncover the underlying values being promoted. Make a judge-
ment about what is good or bad about the change to uncover your own values and
where you stand.

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TRAINERS NOTES
SESSION 3 ASSUMPTIONS IN PRACTICE

Review Workplace Task 2: Examining you own beliefs & assumptions
(30 minutes)
Split people up into small review groups (three or four per group).
Each participant should use Work task sheet 2.3 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 3.1 The power of assumptions (30 mins)
Overview:
This exercise is a short but powerful reminder of how assumptions infuence practice in
fundamental ways. The statement made is very familiar in many parts of the country but the
revelation at the end that the statement is taken from an inquiry in the death of a Black man
reminds people of how far-reaching such assumptions can be. The iceberg model is again
illustrated by this exercise and used to unpack the statement in a structured way. It is best for
trainers to have a quick review of the David Bennett report to answer any questions raised
by the exercise.
Purpose:
To understand the importance, power and impact of personal assumptions on the quality of
practice of practitioners.
Instructions:
(NB/. You may choose to give out Handout 3.3 - Learners Notes after this activity so as not
to infuence peoples thinking on seeing the quote used.)
- Talk to people in large group.
- Look at the following quote from a mental health practitioner illustrating their belief on Slide
3.1.
- Use the blank diagram of the Iceberg Model on Handout 3.1 to think of what is seen as
most important by the practitioner. In other words - What values may fow from this stated
belief or assumption in providing appropriate services for Black people?
- What kind of behaviours or decisions might fow from these values in the local mental
health services concerned?
- Take feedback from the group and put the main points onto a fipchart under the headings
beliefs, values and practice.

Review Workplace Task 2:


Examining you own beliefs & assumptions 30 minutes
Group Activity 3.1 The power of assumptions 30 minutes
Group Activity 3.2 The circles of fear 30 minutes
Reminder for Workplace Task 3: Breaking the circles of fear
Page 4l Tralners Manual : Sesslon 3 - Assumptlons ln practlce
RECC - ESC Advanced Module
Resources:
Slide 3.1, Handouts 3.1 & 3.3.
Time: Total 30 minutes

Group Activity 3.2 Circles of fear (30 minutes)
Overview:
The diagram represents a BME service user viewpoint of mental health services and so may
feel like a one-sided and negative view of services but the intention of the diagram is to ex-
plain that the fear exists for both practitioners as well as Black service users. It is important
to discuss the ways of breaking the circles of fear through good practice and the work task
links this to participants own practice.
Purpose:
To enable participants to refect on the impact of common stereotypes of BME people on
communication between service users and practitioners.
Instructions:
- Trainer presents the Circles of Fear diagram from pre-course reading using Slide 3.2
which illustrates some of the challenges for Black men in accessing mental health services.
- Ask people in the large group to think of the effects of having such common stereotypes in
our society, that Black men in mental distress are dangerous, physical, unemotional, non-
communicative, unpredictable or other negative stereotypes that they have come across.
Note some ideas down on a fipchart.
- Lead a large group discussion on the following questions:
What impact do stereotypes have on communication between service users and practitio-
ners involved in mental health?
How would this example relate to the iceberg model in Session 1?
- Refer people to Handout 3.2 after the discussion.
Resources:
Slide 3.2 & 3.3, Handout 3.2 and Handout 3.3 - Learners Notes.
Time: Total approximately 30 minutes
Page 42 Tralners Manual : Sesslon 3 - Assumptlons ln practlce
Slide 3.1
There is a risk that, in places like
XXX, people may never develop the
awareness and skills to deal with
Black people because there are so
few of them.
RECC - ESC Advanced Module
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RECC - ESC Advanced Module
Slide 3.2
Circles Of Fear
Inappropriate
Service response due to
inaccurate assessments of
risk & needs.
Harm to self
Harm to others
Dangerous
Service Users
Harmful
Services
Staff Service Users
Stereotypical view
. of Black People
Racism
Cultural ignorance
Stigma of mental
distress
No Contact
Non compliance
Crisis Escalates
Illustrated by Dominic M. Walker
Reinforced
prejudices
provoke more
coercive responses
(By Dominic Makuvachuma Walker)
Page 44 Tralners Manual : Sesslon 3 - Assumptlons ln practlce
Handout 3.1
Products, food, clothes,
symbols, rituals, buildings etc.
Decisions and behaviours
Norms and values
Core beliefs and assumptions
RECC - ESC Advanced Module
Page 45 Tralners Manual : Sesslon 3 - Assumptlons ln practlce
Handout 3.2
An example of discussion points for the trainer
BME SERVICE USERS MH PRACTITIONERS
Images and appearances
of BME service users
Negative media images of
Black men being aggressive
& dangerous, especially in
mental health services can
damage their self-esteem.
Public expectations of prac-
titioners in relation to Black
men in distress can lead to
more fear, unwillingness to
understand them and coer-
cive or forceful interventions
to ensure protection of the
public & avoidance of public
censure.
Behaviours and decisions
in relation to each other
The negative social roles
created for Black men as be-
ing violent, criminal, unintelli-
gent & unemotional by racist
stereotypes in society can
lead to stress & pressure for
Black men. Less likely to be
trusting towards practitioners
and share their true feelings.
Practitioners may be infu-
enced in their judgements
of risk & dangerousness
leading to more defensive
practice & greater social
control of Black men. Lack
of understanding of Black
mens thoughts & feelings
can lead to reliance on
physical treatments.
Values and norms that
people hold about each
other
Black men feel that they are
being treated differently and
unfairly by mental health
services leading to anger,
frustration and distrust. Black
men may develop skills that
help them survive in the hos-
tile environment of service
settings but are not useful in
the wider community.
Practitioners interact with
Black men on superfcial
levels & are less likely build
trusting relationships. Black
men are not given the op-
portunity to address underly-
ing causes of distress, as
concern for control of un-
predictable behaviour leads
to more symptoms & higher
dosages of medication.
Beliefs & assumptions
about each other
Black men may develop a
culture of distrust of men-
tal health services as their
beliefs are shaped by an
experience of negative ex-
pectations of physical harm,
discrimination and social
control by practitioners.
Practitioners may initially
look for evidence to confrm
their negative expectations
and actually elicit negative
behaviours from Black men
thereby confrming their
prejudicial beliefs.

RECC - ESC Advanced Module
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RECC - ESC Advanced Module
Handout 3.3
LEARNERS NOTES
SESSION 3 ASSUMPTIONS IN PRACTICE
Learning Outcomes
Participants will be able to
understand the importance and power of personal assumptions for a practitio-
ners quality of practice
describe the impact of common stereotypes of BME people on communication
between service users and practitioners
identify ways of positively engaging with BME people in mental distress.
The following diagram has been created by one of the BME service users involved in the
SCMH research project.
Circles Of Fear
Inappropriate
Service response due to
inaccurate assessments of
risk & needs.
Harm to self
Harm to others
Dangerous
Service Users
Harmful
Services
Staff Service Users
Stereotypical view
. of Black People
Racism
Cultural ignorance
Stigma of mental
distress
No Contact
Non compliance
Crisis Escalates
Illustrated by Dominic M. Walker
Reinforced
prejudices
provoke more
coercive responses
The four key drivers in the idea of Breaking the Circles of Fear diagram are the stereotypi-
cal views a practitioner may hold about Black people; complete or partial ignorance to the
BME service users culture, fuelled in part also by the stigma attached to mental distress, as
well as racism within mental health services. These drivers then fuel inappropriate respons-
es from service providers as a result of inaccurate assessments of the service users need
and level of risk in the situation. The combination of poor assessment and the four key driv-
ers invariably result in the escalation of a crisis, because not only is the service user likely
to have little or no contact with the inappropriate service on offer but, even where contact is
made, the service user is unlikely to comply with an inappropriate intervention plan that often
ensues. This ultimately provokes a more coercive response driven by prejudices that are ap-
parently reinforced by real events.

Page 47 Tralners Manual : Sesslon 3 - Assumptlons ln practlce


On the one side, staff have a perception of a dangerous service user while BME service us-
ers perceive the service to be dangerous to them and never the twain shall meet! Breaking
the Circles of Fear (Keating et al, 2003) raises issues about breaking the pattern of these
key drivers and challenging the practice that follows in mental health services through listen-
ing to both sides, BME service users and practitioners.
(by Dominic Makuvachuma Walker BME survivor trainer, based on work done by the
Sainsbury Centre for Mental Health, 2002)
Activity 3.1 The power of assumptions
Assumptions such as this may seem rather innocuous and commonplace but they can have
very serious consequences - the quote in the activity was made by a consultant psychiatrist
at the Norvic Clinic in Norfolk where David Rocky Bennett, a young African Caribbean man,
who died while being restrained. The psychiatrist had made the statement in response to
questions from the Panel of Inquiry about racial issues at the Clinic (Independent Inquiry
into the Death of David Bennett - December, 2003).
Session 3 - Practice Development Tips
Remember that beliefs, assumptions and values (including prejudices stereotypes)
will infuence your practice. The most powerful infuences will be prejudices and ste-
reotypes that you are not aware of and remain unacknowledged.
If you are worried or feel challenged about working with a BME service user do not
caught in the trap of keeping it to yourself for fear of being thought of as racist it will
only increase stress for you and will be a disservice to the service user.

RECC - ESC Advanced Module


Page 48 Tralners Manual : Sesslon 4 - Penectlng on communlcatlon
RECC - ESC Advanced Module
TRAINERS NOTES
SESSION 4 REFLECTING ON COMMUNICATION
Review Workplace Task 3 - Breaking the circles of fear (30 minutes)
Split people up into small review groups (three or four per group).
Each participant should use Work task sheet 3.3 in their Practice Development
Workbooks 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 4.2 Communication, power and authority (1 hour)
Overview:
The use of a model of different types of power and authority in a realistic situation involving
racial discrimination enables groups to come up with ways in which such incidents can be
dealt with positively or negatively by staff. The familiar situation of racial abuse and harass-
ment in ward situations is used to get practitioners to be more aware of their power and
authority in such situations and it also mirrors what happened in the David Bennett story
mentioned in a previous session.
Purpose:
To use a model for analysing power and authority used in communication between service
users and staff in mental health settings.
Instructions:
- Trainer introduces Slide 4.1 (Summary of good communication practice in clinical set-
tings).
- Trainer introduces the basic scenario written on a fipchart:
Situation: A forensic unit:
Ahmed (a BME patient) complains to Jon (a staff nurse) that another White pa-
tient, Billy, has been repeatedly addressing him using racist names.
How could Jon respond - in a negative or positive way?
- Break into an even number of small working groups and ask each group to come up with
examples of how Jon could respond positively or negatively in the scenario given and record
this on fipchart for the small group to work on later.
- After a short period get people back into the large group, trainer introduces factors that
need to be considered in looking at communication and power issues using Slide 4.2 and the
types of power and authority using Slides 4.3 and 4.4.
- Ask them to analyse a few of their examples of Jons responses on their fipchart using
Handouts 4.1, 4.2 and the information about power and authority presented in Handout 4.5
Learners Notes.

Review Workplace Task 3 - Breaking the circles of fear 30


minutes
Group Activity 4.2 Communication, power & authority 1 hour
Reminder of Workplace Task 4: Breaking barriers to communication
Page 49 Tralners Manual : Sesslon 4 - Penectlng on communlcatlon
- Take feedback in the large group.
- Discuss the examples given in Handouts 4.3 and 4.4 in the large group.
Resources:
Slides 4.1, 4.2, 4.3 & 4.4, Handouts 4.1, 4.2, 4.3, 4.4 & Handout 4.5 - Learners Notes.
Time:
Total approximately 1 hour - 5 minutes for trainer to present Slide 4.1; 10 minutes to come up
with Jons possible responses to the scenario; 10 minutes for trainer to present Slides 4.2,
4.3 and 4.4; 15 minutes in small groups and 15 minutes feedback and 5 minutes for partici-
pants to read examples.
RECC - ESC Advanced Module
Page 50 Tralners Manual : Sesslon 4 - Penectlng on communlcatlon
Slide 4.1
Summary of good communication practice in clinical settings from a BME
service user perspective

Important factors when communicating with
service users in clinical settings
listen &
acknowledge
patients
knowledge of
themselves
build rapport
and convey
respect
communicate
acceptance
communicate
empathy
identify common
ground
facilitate
autonomy and
enable
participation
provide
information
build trust
maintain
rights
good
practitioner/service user
interpersonal skills
RECC - ESC Advanced Module
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RECC - ESC Advanced Module
Slide 4.2

Page 52 Tralners Manual : Sesslon 4 - Penectlng on communlcatlon
Slide 4.3
Types of Power

People have power in relation to others for a variety of reasons, e.g. because of
who they are in society
Personal Characteristics
because of your position in society, e.g. because of your
class, race, gender, age..
Personality
because of your personal qualities, charisma,
attractiveness etc..
Emotional
because you can make others feel better or worse
according to the way you are and your own mood
Social infuence
because you may have informal connections with
signifcant others who can infuence patients situation
Physical
because you can physically threaten and intimidate
others
RECC - ESC Advanced Module
Page 53 Tralners Manual : Sesslon 4 - Penectlng on communlcatlon
Slide 4.4
Types of authority
People have power in relation to others for a variety of reasons, e.g. because of
their position at work
Job Role
because of your position as a staff member in the
service organisation
Knowledge
because you have knowledge/expertise that service
users generally dont have
Informational
because you have access to information that service
users do not
Sanction/Reward
because you can reward or punish service users within
agreed rules


RECC - ESC Advanced Module
Page 54 Tralners Manual : Sesslon 4 - Penectlng on communlcatlon
Handout 4.1
Examples of how power and authority can be used negatively
Write some of your examples here

Examples of how power and authority can be used negatively
Write one example here
What type of power has Jon used? What type of authority has Jon used?
What will the outcome be for Ahmed and Billy?
Ahmed: Billy:
RECC - ESC Advanced Module
Page 55 Tralners Manual : Sesslon 4 - Penectlng on communlcatlon
RECC - ESC Advanced Module
Handout 4.2
Examples of how power and authority can be used positively
Write some of your examples here

Page 56 Tralners Manual : Sesslon 4 - Penectlng on communlcatlon
Handout 4.4
Examples of how power and authority can be used positively
Write one example here
What type of power has Jon used? What type of authority has Jon used?
What will the outcome be for Ahmed and Billy?
Ahmed: Billy:

RECC - ESC Advanced Module
Page 57 Tralners Manual : Sesslon 4 - Penectlng on communlcatlon
Handout 4.3
Examples of how power and authority can be used negatively
Write some of your examples here
Jon tells both Billy and Ahmed to stop winding each other up, and instructs
them to keep out of each others way. Adds that the ward is very busy today and
he hasnt got time to waste with them
Jon tells Ahmed to go to his room and Billy to go to the smoking room.
Jon makes sure both do as theyre told by asking other staff to monitor the
situationandthengoesbacktooffcetofnishthepaperworkhewasdoing.

Examples of how power and authority can be used negatively
What type of power has Jon used? What type of authority has Jon used?
Personal characteristics
Emotional characteristics

Sanction/reward
Role
Social infuence

What will the outcome be for Ahmed and Billy?


Ahmed:
feels angry and resentful that his
concerns and the effect on him have not
been taken seriously by Jon
fears he will get further abuse from Billy
and other White patients
hears voices which become more and
more pervasive and threatening
becomes increasingly paranoid from
staff perspective
feels that he is a problem because he is
different

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

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Page 58 Tralners Manual : Sesslon 4 - Penectlng on communlcatlon
Handout 4.4
Examples of how power and authority can be used positively
Write some of your examples here
Jon acknowledges Ahmeds disterss and spends time talking to him about how he is
feeling. He states clearly that racist language is unacceptable on the ward and not in
accordance with the services policy on anti-discriminatory behaviour. He says that he
will talk to Billy immediately about the situation and do everything he can to make sure
the same thing doesnt happen in the future. He says he will ensure all patients are
aware of unacceptable and oppressive language.
Jon ensures Ahmed feels reassured and is engaged in activity and then goes to talk to
Billy, telling Ahmed he will return.
Jon tells Billy how upset Ahmed is, and reminds Billy how upset he was when he was
abused by another patient.
Jon ensures he gives Billy an opportunity to explain why he uses such language or
why he is trying to wind Ahmed up, but also reminds Billy of the services policy on
discriminatory behavour that no matter what, racist language is completely forbidden
in the hospital and he must fnd more acceptable ways to express his emotions and
address his personal issues.
Jon offers to spend some time with Billy to do this, reminding him it is his (i.e. Jons)
responsiblity to ensure everyone on the ward feels safe.
Jon offers Ahmed a chance to talk to an independent advocate if he wishes.


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

What will the outcome be for Ahmed and Billy?


Ahmed:
feels heard and respected
has had a chance to express his
distress and confrm that some action is
going to be taken
now making some tea, and beginning to
respond as another patient who talks to
him in a supportive way

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

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Page 59 Tralners Manual : Sesslon 4 - Penectlng on communlcatlon
Handout 4.5
LEARNERS NOTES
SESSION 4 REFLECTING ON COMMUNICATION
Learning Outcomes
Participants will be able to
understand the differences between the use of power and authority
describe the importance of communication within mental health services and
gain an appreciation of how poor communication can contribute to unnecessary
misunderstandings and conficts
describe the types of power and authority that operate through communication in
services.

Group Activity 4.1
The effects of stereotyping on communication
Communication & power
The model presented here helps staff to look at the way they are using their power in any
situation. It focuses on the types of power people use, the process of power that takes place
in the situation and the outcome. The diagrams that follow set out the model and an exercise
to help you use the model in practice.

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Page 60 Tralners Manual : Sesslon 4 - Penectlng on communlcatlon
Differences between power and authority
Power could be defned as the capability or potential through force, manipulation or
instruction to infuence behaviours of others and get things done in a particular way.
Power operates outside of any legal or policy limits or authorities that have been agreed
in a formal way. It may go far beyond (or even work against) the legal and organisational
defnition of a practitioners role.
Authority, on the other hand, operates within agreed limits set by employing
organisations, policies and legal frameworks.
Power may be manifested in the mental health system through diagnoses, assessments
and guidance.
The use of power is riskier because there are less ethical or legal controls to guide its
use.
Power can be used to coerce, control or oppress service users or it can be used to chal-
lenge discriminatory systems or individuals.
Because authority is more clearly defned in a formal sense it is possible to challenge the
decisions and practice of professionals if there are ways of doing this in mental health
services.
Types of Power

People have power in relation to others for a variety of reasons, e.g. because of
who they are in society
Personal Characteristics
because of your position in society, e.g. because of your
class, race, gender, age..
Personality
because of your personal qualities, charisma,
attractiveness etc..
Emotional
because you can make others feel better or worse
according to the way you are and your own mood
Social infuence
because you may have informal connections with
signifcant others who can infuence patients situation
Physical
because you can physically threaten and intimidate
others
Types of authority
People have power in relation to others for a variety of reasons, e.g. because of
their position at work
Job Role
because of your position as a staff member in the
service organisation
Knowledge
because you have knowledge/expertise that service
users generally dont have
Informational
because you have access to information that service
users do not
Sanction/Reward
because you can reward or punish service users within
agreed rules

RECC - ESC Advanced Module


Page 6l Tralners Manual : Sesslon 4 - Penectlng on communlcatlon
Now try the next group activity:
Group Activity 4.2 Communication and power
Summary - 1
Power dynamics are present in all relationships between service users and staff.
Examining these power dynamics may help mental health professionals to clarify and
own the types of power and authority they possess and remind them that their powers
can be used in positive as well as negative ways.
Similarly, examining power dynamics between service users and staff can help
service users to recognise the power they may possess and enable them to make
informed choices about how they use their own power, especially as part of their
recovery process.


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.

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Page 62 Tralners Manual : Sesslon 4 - Penectlng on communlcatlon
Policies should recognise that although a patient may speak English, at times of
distress the patient may have reduced understanding or ability to express them-
selves that language and interpreting provision should be made.
Policies should emphasise a minimum standard of when interpreters should be
these standards should include use on admission, at assessment, during the
formulation and delivery of care plans, at clinically signifcant meetings and at
the introduction new interventions.
Interpreters should be made available to explain treatment and care to carers
where English is not the carers preferred language.
(University of Central Lancashire (Centre for Ethnicity & Health)/Mental Health Act Commis-
sion/NIMHE, 2003)
Session 4 - Practice Development Tips
Make sure you understand and can explain to service users the policies and proce-
dures for racial and sexual harassment in your service.

Be clear about what authorities you have in your job and communicate this to your
BME service users. If you are unsure about your authorities check this out with your
line manager.

Remember that there are more safeguards for BME service users in the use of au-
thority rather than power as they can legitimately challenge unfair authority. However,
sometimes in a discriminatory service the positive use of power may be the only way
of achieving fair treatment.

When you are going to conduct a challenging or diffcult interview with a BME service
user dont just think about your approach also think about the possible consequences
and outcomes of your approach. Decide what degree of power and authority you are
going to use.

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

RECC - ESC Advanced Module


Page 63 Tralners Manual : Sesslon 5 - worklng across dlnerent cultures
RECC - ESC Advanced Module
TRAINERS NOTES
SESSION 5 WORKING ACROSS DIFFERENT CULTURES

Review Work Task 4: Barriers to communication (30 minutes)
Split people up into small review groups (three or four per group).
Each participant should use Work task sheet 4.3 in their Practice Development
Workbooks 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 5.1 Where do you stand? (1 hour 20 minutes)
Overview:
This exercise helps people to refect upon their own cultural beliefs and assumptions in rela-
tion to the seven dimensions or cultural spectra that are common in every culture. It helps
people to build up a picture of their own cultural profle. It also shows how unique our re-
sponses are to our cultural heritage and environment. It also helps people to appreciate that
although there may be cultural differences between individuals it is not necessary to feel that
one cultural approach is necessarily better than another as there are strengths and weak-
nesses in every culture. Cultural assumptions and beliefs are functional for the social group
who hold them they work to help that group to survive in their environment. However, if
their environment is rapidly changing it is possible for these beliefs to become dysfunctional
and cause stress which in turn requires changes in assumptions and beliefs or changes in
environment.
Purpose:
To make our own cultural beliefs and assumptions more explicit and make us more aware of
our own culture.
Instructions:
The trainer should note that this exercise can be challenging as it encourages you to think
more deeply about what feels most natural to you rather than actually how you behave now
in your social situation. There is often a confict between what feels natural and how a per-
son actually lives their life in terms of home and work life. This confict can be the source of
tension, stress and sometimes mental distress in peoples lives.
- Five labels should be prepared for this exercise and placed at fve gathering points around
a large room. The labels should read two with Agree, two with Agree with reservations
and one with Sitting on the fence. There should also be labels indicating a left-hand end
of the room and a right-hand end of the room that correspond to the statements below and

Review Work Task 4: Breaking barriers to communication (30 min-


utes)
Group Activity 5.1 Where do you stand? (1 hour 20 minutes)
Reminder of Workplace Task 5: Team & Organisational Culture
Page 64 Tralners Manual : Sesslon 5 - worklng across dlnerent cultures
represent different viewpoints along each of the cultural spectra.
- Ensure that everyone has Handout 5.1 - proforma for a Cultural Profle.
- The trainer should read out the statements on Slides 5.1 and 5.2. one at a time (ideally
each of the seven pairs of statements should be on separate slides or use paper to cover
part of the slide).
- Give people a few seconds to make up their minds about where they stand and go to the
label that most closely represents their view on each of the statements. Emphasise that
people should go with what feels most natural to them. This is not even necessarily what
they actually do currently in their lives.
- People should speak for a few minutes to one other person standing next to them about
why they are standing at that point.
- The facilitator should then ask people to fnd another person to talk to who is standing at a
very different point in the room.
- Afterwards everyone should go back to their seats and fll in the Cultural Profle (Handout
5.1) form before going on to the next statement (1 would represent an agreement with the
left-hand side of the spectrum, 3 would be the sitting on the fence position and 5 would
be agreement with the right-hand side of the spectrum). People should keep this form to
refer to later in Work Task 5.
- Work through all seven colours of the rainbow and if you are running short of time you
could ask people to stay in their seats for some dimensions and fll in their rating frst and
think of why they have chosen this rating. People should then talk to the person sitting next
to them and explain why they have rated themselves in this way.
- Finally, give people Handout 5.4 Learners Notes.
- At the end of this Session you could give participants Handouts 5.2 and 5.3 which is a quiz
on the rainbow model to act as a reminder of the model.
- Finally, remind people that there is good and bad in every culture and creating an inclusive
culture is about bring the good bits of every culture together taking the best of both worlds
in each colour of the rainbow and bringing them together into an inclusive culture.
Resources:
Slide 5.1 and 5.2, Handouts 5.1, 5.2, 5.3 & 5.4.
Time:
Total approximately 1hour 20 minutes
Trainer Note:
Once the basic model has been understood by participants they are asked to undertake
a Work Task to in the Practice Development Workbook to illustrate how the best of both
worlds can be brought together in every dimension they are given the following grid to help
them better understand how this can be done in practice.
RECC - ESC Advanced Module
Page 65 Tralners Manual : Sesslon 5 - worklng across dlnerent cultures
RECC - ESC Advanced Module
INCLUSIVE CULTURE GRID
FEELINGS - Expressive INCLUSIVE CULTURE FEELINGS - Reserved
You need to help people show
those around them how they
feel so that others know when
problems are occurring and
can adjust their behaviour
and respond to maintain
relationships
Enabling people to function
effectively in their lives and
get practical things done but
taking peoples feelings into
account and maintaining good
relationships.
You need to help people to
cope with strong emotions to
enable them to function and get
on with their lives.
RULES - Flexible INCLUSIVE CULTURE RULES - Standardised
You need to make sure that
rules and regulations are
applied fairly according to
individual circumstances
of service users, allowing
practitioners to use their
discretion.
Applying rules and regulations
in a consistent but fair way that
takes into account peoples
individual circumstances
and allow for practitioners
discretion.
You need to apply service rules
and regulations consistently
according to the agreed
protocols.
INDIVIDUALITY - Group INCLUSIVE CULTURE INDIVIDUALITY - Individual
You must ensure that peoples
social networks are functioning
well in order for them to be
adequately supported.
Encouraging individual
autonomy, growth and
responsibility within a
supportive and well-functioning
social environment.
You must ensure that
individuals have a sense
of autonomy and provide
opportunities for personal
growth and development.
PROBLEMS - Intuitive INCLUSIVE CULTURE PROBLEMS - Analytical
You need to step back from
a situation to get a better
view of the patterns and
connections between the key
factors involved and how they
relate to the overall situation to
enable people to have better
understanding in making a
decision.
Analysing complex problems
and situations by getting
accurate data about key factors
but ensuring you take a more
holistic view of the persons
situation.
You need to get a better
analysis of a complex situation
by breaking things down into
key factors and getting more
accurate data
STATUS - Ascribed INCLUSIVE CULTURE STATUS - Achieved
You need to show respect and
appreciation for people who
have experience and past
accomplishments and play a
valuable and important role
in service organisations or
communities.
Respecting and recognising
people for their performance as
well as their social and cultural
value and the experience
they bring to stabilise service
environments.
You wish to recognise and
give credit to professional
colleagues based on their
current performance in role and
their recent accomplishments.
ENVIRONMENT - Accept INCLUSIVE CULTURE ENVIRONMENT - Control
People need to understand
the impact of their behaviours
and decisions on their
living environment and the
constraints that are operating.
If they can achieve harmony
with their environment by
adapting what they are doing
they are more likely to succeed
Taking action to change and
infuence what people are able
to in their situation through a
better understanding of their
environment and designing
strategies that maintain
harmony within it.
People need to engage in
direct actions to infuence and
change their situations. If they
carefully analyse the situation
and take determined action
they are likely to succeed
TIME - Past-present INCLUSIVE CULTURE TIME - Present-future
People need to look back to
ensure that they have learned
the lessons of the past and
gain a sense of continuity by
appreciating their own and
others achievements. This will
help them to be clearer about
present and face the future with
greater confdence.
Planning creatively for the
future based on a thorough
understanding of the present
situation and having learned
the lessons of the past.
People need to look ahead
and construct plans that will
prepare them for the future
and help them to capitalise on
opportunities now.
Page 66 Tralners Manual : Sesslon 5 - worklng across dlnerent cultures
Handout 5.1
CULTURAL PROFILE
1. FEELINGS
Expressive 1 2 3 4 5 Reserved
2. RULES
Flexible 1 2 3 4 5 Standardised
3. INDIVIDUALITY
Group 1 2 3 4 5 Individual
4. PROBLEMS
Intuitive 1 2 3 4 5 Analytical
5. STATUS
Ascribed 1 2 3 4 5 Achieved
6. ENVIRONMENT
Acceptance 1 2 3 4 5 Control
7. TIME
Past-
Present
1 2 3 4 5 Present-
Future

RECC - ESC Advanced Module
Page 67 Tralners Manual : Sesslon 5 - worklng across dlnerent cultures
RECC - ESC Advanced Module
Slide 5.1
1. Feelings (Red)
(LEFT-HAND) It is perfectly alright to show what you are feeling in public sometimes even
when it is with people you dont know very well.
(RIGHT-HAND) It is always best to contain your emotions when you are in public otherwise
people will feel that you are melodramatic or excitable.
2. Rules (Orange)
(LEFT-HAND) Rules and regulations in organisations are all very well but you cant take
them literally. You have to take into account the person and their situation when applying
them and be prepared to bend them where you feel it is necessary. Fairness is about being
fexible.
(RIGHT-HAND) Rules and regulations in organisations must be applied to everyone in
exactly the same way if they are going to be seen as fair exceptions must be kept to a
minimum.
3. Individuality (Yellow)
(LEFT-HAND) It is better for individuals to see themselves frst as part of a family, commu-
nity or work team even when it is not in their personal interests. In this way these groups
will help them in future when they require it and they will get their needs met.
(RIGHT-HAND) Looking after your immediate family and yourself is defnitely the high-
est priority, other wider social group interests would be of secondary importance. A good
community or group is where individuals have the most personal freedom, take their own
decisions and have opportunities for personal development and individual prosperity.
4. Problems (Green)
(LEFT-HAND) The best way to approach a complex problem or situation is to frst step
back from the detail and take a bigger picture view to get a feel of what is happening by
looking for patterns and relationships between the different elements of the situation and
then get more accurate information.
(RIGHT-HAND) The best way to approach a complex problem or situation is to frst break
things down frst into the most important elements and get some accurate information
about each element so when you put it all together again you will have a better under-
standing of what is going on in the bigger picture.
Page 68 Tralners Manual : Sesslon 5 - worklng across dlnerent cultures
RECC - ESC Advanced Module
Slide 5.2
5. Status (Blue)
Everyone has a right to a basic level of respect but we often give extra respect and reward
to some people in society.
(LEFT-HAND) It is better for people to be valued and rewarded in society on the basis of
their importance and reputation in their family, community and work rather than just going
on recent performance in their social roles or job-related roles. This brings stability and
continuity to society and organisations.
(RIGHT-HAND) It is important for people to be valued and rewarded in society on the
basis of how they perform in their roles and what they actually accomplish at present rather
than who they are in the community, their past reputation or their job title.
6. Environment (Indigo)
(LEFT-HAND) We are far from being able to control our situation and what may happen to
us in the future. We need to focus on being in harmony with our environment and within
ourselves and calmly accept things that we cannot change and actively work for inner
peace of mind.
(RIGHT-HAND) We are quite capable of taking charge of our own destinies and shaping
what happens to us. We need to focus on changing things by analysing our situations and
engaging in determined action. We should never sit back and accept things.
7. Time (Violet)
(LEFT-HAND) We cannot understand the present or go into the future unless we look back
to understand, value and celebrate our past. It is fne to spend time and resources doing
this.
(RIGHT-HAND) We should not dwell on the past and waste resources celebrating the past
but look ahead to what we want in the future. We should look for and take up potential op-
portunities in the present and make plans for that desirable future.

Page 69 Tralners Manual : Sesslon 5 - worklng across dlnerent cultures
Handout 5.2
Post-Course Quiz on Rainbow Model
Look at each of these statements from BME service users and write down which
dimensions(s) and which end of the spectrum they give you evidence about.
1. I suppose you just got to gather yourself and keep going. There isnt any point of wish-
ing things were different because they arent going to be are they?
(Pakistani woman)
Dimension(s):
2. You need to be a strong person with a positive mind and a strong attitude to life. If you
are not a positive person you will sink deeper, you will fail. (Black Caribbean man)
Dimension(s):
3. Having a goal makes you work for it, makes a path for you to follow [makes you]
keep moving forward, thinking about the future. (Indian woman)
Dimension(s):
4. I dont really think of the future, never have. Im happy to take things one step at a time.
I dont like thinking too far ahead. Dont know what will happen what will be.
(Pakistani woman)
Dimension(s):
5. When I wonder how I will cope I refect back and know that I coped with a thousand
worse things before so you know you can do it. (Indian woman)
Dimension(s):
6. Every problem has a solution I dont believe in that nothing can be solved in this
country every corner you can fnd help by sleeping you cant solve any problem. By
moving and sorting things out you can solve the problem.
(Pakistani woman)
Dimension(s):
7. If I feel upset I try not to cry in front of people, I try and avoid that situation and not talk
about it. (Pakistani woman)
Dimension(s):
8. If youve got kids depending on you, you cant afford to take that road, cant let them
down. (Pakistani man)
Dimension(s):
9. I just suppressed it and didnt have any feelings at all, I just wanted mum to get bet-
ter I didnt think about me because this wasnt about me at the time and I just had to be
strong for my mum. (Black Caribbean man)
Dimension(s):
RECC - ESC Advanced Module
Page 70 Tralners Manual : Sesslon 5 - worklng across dlnerent cultures
10. And our people still, especially people who come from villages, they think doctor
know better, just like some people from villages, some people believe more on GP, they
think what a GP is saying, she or he is saying right, thats the way they are People are
brought up in a different way. Back home, most of the old people, Asian old people came
from back home, the tradition back home is different than here and they believe that OK,
doctor know it all, thats why they ask doctor (Indian woman)
Dimension(s):
(adapted from OConnor W. & Nazroo J. [eds.], 2002)

RECC - ESC Advanced Module
Page 7l Tralners Manual : Sesslon 5 - worklng across dlnerent cultures
RECC - ESC Advanced Module
Handout 5.3
Post-Course Quiz on Rainbow Model (ANSWERS)
These are some suggested answers.
1. I suppose you just got to gather yourself and keep going. There isnt any point of wish-
ing things were different because they arent going to be are they?
(Pakistani woman)
Dimension(s): ENVIRONMENT - Acceptance
2. You need to be a strong person with a positive mind and a strong attitude to life. If you
are not a positive person you will sink deeper, you will fail. (Black Caribbean man)
Dimension(s): ENVIRONMENT - Control
3. Having a goal makes you work for it, makes a path for you to follow [makes you]
keep moving forward, thinking about the future. (Indian woman)
Dimension(s): TIME Present-Future
ENVIRONMENT - Control
4. I dont really think of the future, never have. Im happy to take things one step at a time.
I dont like thinking too far ahead. Dont know what will happen what will be.
(Pakistani woman)
Dimension(s): TIME Present
ENVIRONMENT - Acceptance
5. When I wonder how I will cope I refect back and know that I coped with a thousand
worse things before so you know you can do it. (Indian woman)
Dimension(s): TIME Past-Present
6. Every problem has a solution I dont believe in that nothing can be solved in this
country every corner you can fnd help by sleeping you cant solve any problem. By
moving and sorting things out you can solve the problem.
(Pakistani woman)
Dimension(s): ENVIRONMENT Control
PROBLEMS - Analytical
7. If I feel upset I try not to cry in front of people, I try and avoid that situation and not talk
about it. (Pakistani woman)
Dimension(s): FEELINGS - Reserved
8. If youve got kids depending on you, you cant afford to take that road, cant let them
down. (Pakistani man)
Dimension(s): INDIVIDUALITY - Group
Page 72 Tralners Manual : Sesslon 5 - worklng across dlnerent cultures
RECC - ESC Advanced Module
9. I just suppressed it and didnt have any feelings at all, I just wanted mum to get bet-
ter I didnt think about me because this wasnt about me at the time and I just had to be
strong for my mum. (Black Caribbean man)
Dimension(s): FEELINGS Reserved
INDIVIDUALITY Group
10. And our people still, especially people who come from villages, they think doctor
know better, just like some people from villages, some people believe more on GP, they
think what a GP is saying, she or he is saying right, thats the way they are People are
brought up in a different way. Back home, most of the old people, Asian old people came
from back home, the tradition back home is different than here and they believe that OK,
doctor know it all, thats why they ask doctor (Indian woman)
Dimension(s): STATUS - Ascribed
(adapted from OConnor W. & Nazroo J. [eds.], 2002)


Page 73 Tralners Manual : Sesslon 5 - worklng across dlnerent cultures
Handout 5.4
LEARNERS NOTES
SESSION 5 WORKING ACROSS DIFFERENT CULTURES
Learning Outcomes
Participants will be able to
have a clearer understanding of their own assumptions and beliefs that underpin
their values in practice
deal with cultural differences in a more structured way and work towards cultural
inclusivity
critically analyse cultural differences between personal, team and organisational
cultures which may be the source of tensions within services.
The cultural rainbow
The iceberg model introduced in Session 1 represented culture as a series of layers and the
deepest level of any culture consists of its unwritten rules or core beliefs and assumptions.
These core beliefs and assumptions are like a social glue that holds a cultural group togeth-
er and enables people in the group to see the world in similar ways as well as communicate
more easily as they share many hidden cultural meanings that usually remain unspoken. As
stated in Session 1, core beliefs and assumptions develop over a long period of time and
are shaped by responses to familiar problems that continually have to be solved by a cultural
group in order to survive in its physical, social and economic environment. The solutions for
survival become more and more familiar to the extent that they become unspoken ways of

BME service user quote


When a woman cries there are tears in her eyes. When a man cries his
tears stay in his heart they dont come out.
RECC - ESC Advanced Module
Feelings
Rules
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Page 74 Tralners Manual : Sesslon 5 - worklng across dlnerent cultures
relating to the environment. They eventually become embedded in the cultures traditions,
spiritual beliefs, rituals and symbols. The seven dimensions of culture, represented here
by the seven colours of the rainbow, are fundamental problems of living that are common
to all cultures and thus offer a useful framework for looking at cultural differences in a more
structured way. The model has been adapted from the work of Trompenaars and Hampden-
Turner (1997).
In reality culture is a lot more complex than represented here in the rainbow diagram. There
are an infnite number of colours and tones created in any culture as the process of mixing
and merging of cultures has been going on since human beings began living together in
larger social groups. One need only take English culture as an example. How do we defne
English culture? How far back do we go? Romans came to Britain in 49 AD and brought
a wide variety of cultural infuences with them including North African troops stationed at
Hadrians Wall in northern England. We could go further back to Celtic tribes who spanned
the whole of Europe right through to the Black Sea. Many Celtic gods were Eastern gods in
origin. The Phoenicians, an Eastern Mediterranean people (around modern day Lebanon),
were trading saffron for tin with Celtic people in Cornwall long before the Romans came
here (saffron cake is still a local speciality in Cornwall and an indication of the endurance
of culture). Subsequent to the Romans we had Germanic tribes such as Angles, Saxons
and Jutes, Scandinavian infuences through the Vikings and French infuences through the
Normans. So, even a culture as familiar as English culture is extremely diffcult to defne as
there has been a constant mixing and blending of cultures since the dawn of history.
Group Activity 5.1 Where do you stand?
It is important for practitioners to understand how a persons culture infuences their ex-
pression and representation of feelings and states of mind, as well as their view of mental
distress and how this is expressed. If this is not properly understood there is an increased
danger of misdiagnosis and poor interventions in the situation. A large part of culture is
about the expression and representation of feelings and states of mind and so practitioners
must have some understanding of the persons cultural viewpoint to be able to provide effec-
tive assistance. As we have seen it is dangerous to assume that the person you are dealing
has the same mainstream values in the seven dimensions of culture as the majority of the
cultural group that they identify with. In order for practitioners to learn about an individuals
culture, it is important that they are open and able to learn from the BME service user them-
RECC - ESC Advanced Module
Personal Refection
Do you feel that you have to adapt at home or at work in relation to any of these cul-
tural dimensions?
What kind of conficts does it create for you?
Are there things you can do about these conficts in your life to reduce stress?

BME service user quote


I enjoy the voices sometimes - they can be very funny but they can also be
very abusive and violent.
Page 75 Tralners Manual : Sesslon 5 - worklng across dlnerent cultures
selves and from their family and carers. Enabling meaningful participation of BME service
users and their families/carers within their own package of assistance and within the devel-
opment of services is the only real way of gaining a true picture of a persons cultural needs
and avoiding cultural stereotyping.

In addition to the potential for cultural misunderstanding the existence of institutional racism
can further add to the barriers to BME service users receiving effective assistance when they
need it.

For example, if a patient in hospital is judged to be in need of control because the rea-
sons for his/her anger cannot be understood, a repressive or controlling treatment such
as seclusion or tranquillisers at a high dosage may be perceived as being required, while,
on the other hand, if the anger is recognised as emanating from psychological or social
problems,psychotherapyorsociotherapy(waysofinfuencingbehaviourbymanipulating
the environment) may be seen as the patients need. (Fernando, 2002)
It is sobering to think how serious cultural misunderstanding can be in a context of institution-
al racism in mental health services. What we have argued for in this Session is the creation
of a more inclusive culture within services - this is the only way forward if we are to develop
appropriate services for BME people.
Session 5 - Practice Development Tips
It is important to be aware of where you stand in relation to the cultural rainbow. From
time to time, refect on your decisions and behaviour in relation to feelings; rules; individu-
ality; problems; status; environment and time (FRIPSET).
Whenever there is a situation involving tension, stress or confict with a BME service user
use the rainbow model to identify specifc cultural differences that may heighten prob-
lems and work out a strategy to create a more culturally inclusive way forward.
References
Fernando, Suman (2002) Mental Health, Race and Culture Second Edition.
OConnor W. and Nazroo J. [eds.] (2002), Ethnic Differences in the Context and Experience
of Psychiatric Illness: A Qualitative Study, The Stationery Offce
BME service user quote
My grandmother in India hears voices and has hallucinations but she is ac-
cepted by the local community and they go to her for advice because she is
in touch with the spirits.
RECC - ESC Advanced Module
Page 76 Tralners Manual : Sesslon 6 - Pace equallty ln mental health servlces
RECC - ESC Advanced Module
TRAINERS NOTES
SESSION 6 UNDERSTANDING RACE EQUALITY IN
MENTAL HEALTH SERVICES
Review Workplace Task 5: Team & Organisational Culture (30 minutes)
- Split people up into small review groups (three or four per group).
- Each participant should use Work task sheet 5.4 in their Practice Development Workbooks
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 6.1 Identifying themes of discrimination & equality
(1 hour 15 mins)
Overview:
This is a design exercise where the trainer should encourage the participants to be creative
in their design alternative ways of running this exercise can involve the use of objects
rather than just using pens and fipchart. The idea of this exercise is to identify the underly-
ing processes that result in racial discrimination in mental health services for BME people. In
doing this, the exercise helps to build up a framework that could be applied to any group of
people who are vulnerable to oppression and in any public service setting. It is a useful re-
minder that when we are talking about race equality we are really talking about good practice
which will be relevant to and a beneft for everyone using services.
Purpose:
To highlight the broader patterns of institutional discrimination in mental health services and
go on to defne more clearly what is meant by race equality in services.
Instructions:
- Break into two or four small groups and assign one of the following tasks (Task 1 or Task 2)
to each of the small groups:
Task 1
Design a mental health service of your choice to be covertly or subtly racist in the way it
operates (acknowledging that it would not feel subtle to people on the receiving end of such
a service). In other words do not be too obvious in the way that discrimination occurs in the
service you design. Encourage be people to be creative in the ideas they come up with.
For example:
Review Workplace Task 5: Team & Organisational Culture
30 minutes
Group Activity 6.1 Identifying themes of discrimination & equality
1 hour 15 minutes
Reminder of Workplace Task 6: Promoting Race Equality
Page 77 Tralners Manual : Sesslon 6 - Pace equallty ln mental health servlces
Having the necessary numbers of BME staff to meet targets in your organisation but
restricting them to less senior levels.
Having a complaints procedure available to everyone that it is very paper based and
requires a high degree of written and verbal profciency in English.
Having no BME advocates in the local Independent Advocacy service.
Using a Family Therapy services available to BME communities that only operates on
Western European models of families.
Drug and Alcohol services operating in diverse communities without tackling the barrier
of stigma and shame within local BME communities.
Put your design onto a fipchart to enable you to present it to the large group. Be as creative
as you can.
Or
Task 2 Design a mental health service of your choice that promotes race equality in the
way that it operates. Put your design onto a fipchart to enable you to present it to the large
group. Be as creative as you can.
- Take feedback in the form of presentations from each group and draw out the common
themes that seem to be emerging from each of these two approaches to service design
sorted into two sets of characteristics.
- Now people should ask themselves which list of characteristics most closely resembles
their own service and say why.
- After the discussion, give people Handout 6.1 and everyone should look at the Themes of
Institutional Discrimination followed by the Themes of Equality or there could be a presenta-
tion by the trainer using Slides 6.1, 6.2, 6.3 and 6.4. See Handout 6.1 - Learners Notes for
full presentation information.
Resources:
Slides 6.1, 6.2, 6.3 and 6.4; Handout 6.1.
Time:
Total 1 hour 15 minutes
5 minutes introduction, 20 minutes in small groups, 30 minutes presentations/feedback in
large group, 20 minutes trainer presentation of Themes.

RECC - ESC Advanced Module


Page 78 Tralners Manual : Sesslon 6 - Pace equallty ln mental health servlces
Slide 6.1
Themes of Institutional Discrimination
1. Assimilation
Forcing people to ft into a dominant culture.
2. Under-reaction or Over-reaction
Ignoring serious problems or intervening in a punitive way with minor problems.
3. Disempowerment & Stereotyping
Taking away personal autonomy, reducing infuence over ones own life opportu-
nities and making negative assumptions about groups of people.
4. Service-led Approaches
Assessing and meeting peoples needs with the priorities of the service or
organisation put frst with little or no regard for anyone elses priorities.
5. Poor Access to Services
Bureaucratic procedures, diffcult locations and poor publicity about goods or
services.
6. Erosion of Rights
Denial of basic human rights and/or civil rights of people.

RECC - ESC Advanced Module


Page 79 Tralners Manual : Sesslon 6 - Pace equallty ln mental health servlces
RECC - ESC Advanced Module
Slide 6.2
Themes of Equality
1. Valuing Cultural Diversity
Reinforcing cultural identity of individuals.
Providing positive images and symbols of different cultures.
Culturally appropriate services and work environments.
2. Preventative Approaches
Supportive services available to all within services or organisations.
Timely interventions in problematic situations.
Providing opportunities for the growth & development of people.
3. Autonomy & Advocacy
Assistance for individuals to express their point of view.
Access to independent advocates.
Groups for building solidarity between people, promoting positive self-image and
building self-confdence.
4. Holistic Approach
Model of assessment and planning that takes into account wider social and com-
munity issues.
Building on personal strengths & interests of individuals.
Helping to defne & create desirable personal futures for people.
5. Participation & Information
Enabling meaningful participation of service users & communities in service
developments.
Accessible information & publicity about services.
Positive efforts to involve communities in the management & provision of public
services.
6. Safeguarding Rights
Policies & procedures to maintain & promote equality and diversity.
Ensuring that decision-making is linked to clearly defned values.
Monitoring service quality & having accessible complaints procedures.

Page 80 Tralners Manual : Sesslon 6 - Pace equallty ln mental health servlces


RECC - ESC Advanced Module
Slide 6.3
Slide 6.4
Page 8l Tralners Manual : Sesslon 6 - Pace equallty ln mental health servlces
RECC - ESC Advanced Module
Handout 6.1
LEARNERS NOTES
SESSION 6 UNDERSTANDING RACE EQUALITY IN
MENTAL HEALTH SERVICES
Learning Outcomes
Participants will be able to:
describe some of the main ways in which institutional discrimination impacts on
service delivery
describe the key elements of a race equality approach in mental health services
at different levels
identify some ways in which local mental health services can better promote
race equality.
Group Activity 6.1 - Identifying themes of discrimination & equality
Themes of Institutional Discrimination & Equality
Themes of Institutional Discrimination
Theme 1 ~ Assimilation
Assimilation means that people from a different cultural group to the dominant group are
put under some degree of pressure to ft in with the dominant culture. This may seem like
a good way of reducing tensions between different ethnic groups but there are some real
diffculties with this approach. We have seen in Session 1 how complicated culture is to
defne - so who decides if someone is ftting in? Is this desirable anyway? We have seen
that culture can be a very important part of a persons sense of identity - so does it make
sense to effectively say to people they should forget about their culture and join in with the
dominant culture? At the heart of the problem with this approach is that it is essentially just a
form of cultural arrogance in assuming that we have nothing to learn from other cultures and
that our culture is better. This position does not refect the reality of how all cultures have
developed in the past with their constant interaction and mixing.
Cultural arrogance shows itself in a variety of ways. It is inherent in the assumptions within
the disciplines that underpin mental health services, namely psychiatry, psychology and
social work. It shows itself in hidden ways through environment and dcor, the sorts of facili-
ties and activities available, the assumptions of staff, even in their body language, and in the
general set up of services. All of this results in people from a different cultural background
not feeling comfortable in a setting or organisation as a service user or an employee. For
example, lesbian and gay culture in the workplace may be subtly but powerfully devalued by
the colleagues who assume that everyone is in a heterosexual relationship. This may result
in a gay or lesbian person feeling that colleagues think of them as odd or different and
may even lead to people feeling that they must hide their sexuality for fear of discrimination
increasing their levels of stress and anxiety at work.

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Theme 2 ~ Under-reaction or Over-reaction
The issue of under-reaction and over-reaction to BME people in mental distress is a long-
standing problem, originally a term coined by a Black psychiatrist called Aggrey Burke in the
1980s. Several inquiries into cases involving BME service users (usually Black men) have il-
lustrated the impact of this discriminatory approach from Randolph Ince, who suffered physi-
cally from high doses of medication in the 1980s, Orville Blackwood, who died in seclusion
in 1991, Christopher Clunis, whose problems were not taken seriously enough in the 1990s,
and David Rocky Bennett who died as a result of being held face down by several nurses
in 2003. Under-reaction refers to when services fail to respond to a signifcant and growing
problem resulting in an avoidable crisis occurring. Whereas over-reaction refers to when
services intervene in a punitive and controlling way where there are BME (or other groups
vulnerable to oppression) resulting in coercive action that jeopardises the basic human rights
of the person involved. In both cases there is an inappropriate level of response to a mental
health situation which increases the likelihood of discriminatory practice and poor outcomes.
BME women remain marginalised within current policy debates. They are often viewed
exclusively,instereotypedethnicimagesforinstance,asloudanddiffculttomanagein
the case of African-Caribbean women, or in the case of Asian women, as having problems
thatarerootedexclusivelyinculturalconfictorpracticewithinthefamily.Thisresultsin
their needs as women being ignored and overlooked.
(Keating, Robertson & Kotecha, 2003)
Theme 3 ~ Disempowerment & Stereotyping
BME people and other people vulnerable to oppression are often subjected to stereotyping
and institutional discrimination as outlined in Session 1. The effect on the individual is to treat
the person as a member of an out-group in society and thereby take away their individuality
and sense of being in control of their own future. It becomes diffcult for people to know when
they are being discriminated against or whether there is genuinely another reason for they
way they are being treated by others, particularly those with authority and power in soci-
ety. The skills and talents of the individual are effectively ignored and service organisations
engage in block treatment of human beings as if they are all the same or worse still as
commercial commodities to be traded by service organisations in some unpalatable market
of human misery. The overall impact upon the person serves to create a powerful feeling of
being out of control of ones destiny, making the person feel less powerful than they actually
are. This process of disempowerment along with prejudice, stereotyping and institutional dis-
crimination can then fuel a longer-lasting and more serious problem of internalised oppres-
sion which is looked at in more detail in Session 6.
Stereotyping also happens in services in hidden ways through the language being used
about service users, the appearance of buildings where services are provided (bars on win-
dows denoting dangerousness) and the labels that are put onto people. Stereotyping means
that assumptions are made about an individuals personal qualities, skills and even personal-
BME service user quote
One consultant said that I would never get better and that I wouldnt get a
job he undermined my recovery.
RECC - ESC Advanced Module
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ity because they happen to belong to a particular social group. Essentially stereotyping takes
away a persons individuality and results in people being treated in a block way, as mem-
bers of a devalued group.
Theme 4 ~ Service-led Approaches
Service-led approaches are damaging for all service users because services tend to view
their priorities as an organisation as being of equal and sometimes greater importance than
the individuals needs. BME people are often seen as being more diffcult and complex in
terms of meeting individual needs and so are particularly prone to this type of approach from
services.
(Dutt & Ferns, 1998)
The service ends up:
slotting BME people into existing services rather than creating new and more
appropriate services
doing assessments that focus narrowly on determining whether people are eli-
gible to use services rather than helping people to identify their needs
providing services that are based on stereotypical professional views of what
peoples need are rather than their real needs
creating block services that are not very well designed for the individuals using
them
having a focus on flling existing inappropriate services rather than identifying the
gaps where services need to be developed for BME communities
blaming individuals as being the problem rather than questioning the appropri-
ateness of their provision when needs are not adequately met.

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Page 84 Tralners Manual : Sesslon 6 - Pace equallty ln mental health servlces
Theme 5 ~ Poor Access to Services
Barriers to access for BME people include:
diffcult bureaucratic procedures in getting referred to existing services in the frst
place
information about services not being in languages and formats that are useful for
local BME population bearing in the mind the changing natures of many commu-
nities, for example with refugee and asylum seeker communities
suitable services being located in the wrong areas for BME people requiring
long journeys or hazardous trips into areas that may feel hostile for some ethnic
groups
a lack of representation of BME staff within the workforce as this gives BME
communities more confdence that the service is anti-discriminatory and may
have the capability to deliver a culturally appropriate service.
Refugees and asylum seekers face particular barriers to accessing and using mental
health services. As well as experiencing the issues associated with the BME groups to
which they belong, refugees have often been exposed to severe physical and psycho-
logical trauma as a result of war, imprisonment, torture or oppression. In their new host
countrytheycanthenexperiencesocialisolation,homelessness,languagediffculties,
hostility and racism, all of which are strong predictors of poor mental health.
(DoH, 2003, p51)
Chinese groups tend to access their GP only after long delays and the GP is
thefrstcontactpersonforlessthan40%ofallindividuals.Manyindividuals
from minority ethnic groups encounter barriers when seeking help including
language, the discrepancy between the patients and doctors views as to the
nature of the presenting symptoms, cultural barriers to assessment produced
by the reliance on a narrow biomedical approach, lack of knowledge about
statutory services, and lack of access to bilingual health professionals.
(Li and Logan,1999 & 1999a)
Theme 6 ~ Erosion of Rights
A strong feature of mental health services for BME communities is the fear that services will
not uphold the basic human rights of Black people in the system. This is partly due to media
coverage but is also because of some high profle and very poor bits of practice resulting in
people being over-medicated, denied competent and sensitive treatment, being exposed to
racist abuse and in extreme cases being injured or even killed within the mental health sys-
tem. There is a fundamental lack of trust in many BME communities that members of their
communities will get a good quality mental health service at times when people are at their
most vulnerable. Despite examples of good practice in parts of the country, good practice
with BME people is still not common enough to change perceptions yet for the majority of
them.

Personal Refection
In what ways are your assessment and planning systems service-led?
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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.

BME service user quote


Someone told me when I was homeless that if I pretend to be mentally ill I
will get accommodation. I pretended and they gave me a strong drug and
locked my jaw.
Page 86 Tralners Manual : Sesslon 6 - Pace equallty ln mental health servlces
RECC - ESC Advanced Module
Theme 2 ~ Preventative Approaches
Preventative approaches require services to ensure its priorities are to provide support and
early interventions to everyone who may need mental health services. Under-reaction and
over-reaction is not only damaging to people it also results in long-term and costly problems
further down the line. It requires services to intervene in a timely fashion when problems are
detected rather than wait until a crisis occurs, so a responsive service is crucial for a truly
preventative approach. Preventative services must also increase opportunities for people to
grow and develop and build resilience and endurance in relation to mental distress.
Theme 3 ~ Autonomy & Advocacy
There will be times when people will be unable or unwilling to express their own point of view
and interests in services. It would be necessary to provide assistance to people to advocate
for themselves at these points. Independent advocacy is required for advocates to be able to
truly represent the service users viewpoint and interests. The ultimate goal of any advocacy
should be to enable and empower service users to speak for themselves and take more con-
trol of the important decisions being made in their lives. For BME service users it would be
best to have someone advocating that understands the experience of racism and surviving
the psychiatric system. Ideally BME people should have access to a group of BME service
users/survivors so that they can generate a sense of solidarity as well as gaining exposure to
positive role models leading to greater self-confdence.
Theme 4 ~ Holistic Approach
A holistic approach requires services to view service users not just as individuals but as
members of families and communities and take into account wider social and community
factors in assessing individual needs. Assessments have to be balanced with consideration
given to the personal strengths and interests of the person and a wider view of their needs
not just a narrow focus on symptoms of mental distress or problems in the persons life.
Page 87 Tralners Manual : Sesslon 6 - Pace equallty ln mental health servlces
Many mental health services focus on just the basic needs of people for everyday survival
but services need to move beyond this goal to really improve the quality of life for service
users. Services must help people to identify a desirable personal future and achieve the
kind of lifestyle people would want. There are often discriminatory barriers preventing people
from achieving their goals for happiness and fulflment and services must focus on assisting
people to remove these barriers. We will look at identifying needs in a holistic way in Session
9.
Theme 5 ~ Participation & Information
Mental health services have to be more proactive around equality issues and reach out to
groups who have been poorly served or excluded in the past. The lack of credibility created
by a legacy of poor services in the past will be a serious barrier to progress unless service
providers work actively to establish credibility with BME communities. One of the most ef-
fective strategies for gaining credibility is to enable the genuine participation of BME service
users and their communities in the design and improvement of services. A good frst step
for services is to provide accessible and accurate information to BME people about what is
available in the locality. Participation has to be meaningful for the people involved and so
having a carefully thought out strategy is essential with resources set aside to implement
improvements that are needed. There are now an increasing number of examples of BME
service user-led audit and service improvement initiatives to draw examples of good practice
in participation.
Theme 6 ~ Safeguarding Rights
Mental health services have the potential to infringe peoples rights so there must be safe-
guards to ensure that people are protected from abuse and exploitation. Compulsory ad-
mission to hospital and forced medication are all unique to mental health and so robust
safeguards are required. Policy and procedures to promote equality and diversity have to be
implemented and monitored to be of any real value. Systems such as monitoring the quality
of services are best undertaken in partnership with BME service users, families and carers to
guarantee that judgements about service quality are based on criteria that are important for
BME people. Complaints procedures should be fully accessible to BME service users with
the necessary supports. Leaders must ensure that they model and promote good practice in
BME service user quote
I want more information Ive been in this country for 2 years and Ive just
found out about Meals-on-Wheels.
RECC - ESC Advanced Module
BME service user quote
An abused child doesnt make much of a fuss when she is little but when
she grows up she causes problems and gets labelled as mentally ill.
Personal Refection
In what ways are your assessment and planning systems needs-led?
Page 88 Tralners Manual : Sesslon 6 - Pace equallty ln mental health servlces
their decision-making and ensure that they support BME service user participation. Partici-
pation is vital for safeguarding rights as it acts as a check and balance against practitioner
power increasing the likelihood of culturally appropriate practice. Finally, practitioners have
to start taking individual accountability for promoting race equality in their own practice and
within their teams. It includes training such as this where learning gained must be put into
practice if we are to ever really change the culture of mental health services.
References
Department of Health (2005) Delivering race equality in mental health care - An Action Plan
for reform inside and outside services; and the Governments response to the
independent inquiry into the death of David Bennett, Department of Health
Department of Health (2003) Caring for Dispersed Asylum Seekers A Resource Pack, DoH,
June 2003
Dumper H., Malfait R. & Scott-Flynn N., Mental Health, Destitution & Asylum-Seekers: A
study of destitute asylum-seekers in the dispersal areas of the South East of England, Care
Services Improvement Partnership (CSIP) and South of England Refugee & Asylum Seeker
Consortium (SERA).
Dutt R. and Ferns P. (1999), Letting Through Light a training pack on black people and
mental health, Department of Health & REU
Keating F., Robertson D. & Kotecha N. (2003), Ethnic Diversity and
Mental Health in London Recent developments; Kings Fund 2003
Li P. and Logan S.,(1999) The mental health needs of Chinese people living in England: A
report of a national survey London, Chinese National Healthy Living Centre
Li, P. L., S. Logan, et al. (1999a) Barriers to meeting the mental health needs of the Chinese
community Journal of Public Health Medicine 21(1): 74-80
Nazroo J., Ethnicity and Mental Health : PSI 1997,

BME service user quote
Its not just about the numbers of Black staff but its about their attitudes. Its
more a people thing not just a Black and White issue.
Session 6 - Practice Development Tips
If you are involved in planning or developing a mental health service in your area consider
how it will impact on BME communities by using the Themes of Institutional Discrimination
and Equality as checklists.
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RECC - ESC Advanced Module
TRAINERS NOTES
SESSION 7 WORKING IN AN EMPOWERING WAY

Review Workplace Task 6: Promoting Race Equality (30 minutes)
Split people up into small review groups (three or four per group).
Each participant should use Work task sheet 6.4 in their Practice Development
Workbooks to present their Work Task to colleagues.
In the large group, each review group should feedback their individual key mes-
sages for senior managers (one for each participant) and this should be noted
down or written onto a fipchart.
Group Activity 7.1 The spiral of oppression 45 mins
Overview:
This activity links with the next group activity and aims to introduce participants to a service
user view of powerlessness. It starts from a service users personal experience of powerless-
ness and leads to a consideration of what can be an empowering approach.
Purpose:
To summarise a BME mental health service user perspective of the experience of oppression
in society.
Instructions:
Read out Premila Trivedis poem to the group (using Slide 7.1 if necessary it is usually
best to read out the poem as it is more effective for the audience).
Give people Handout 7.1 and ask people to think about the poem for a little while in
small groups, sharing their feelings and responses to it at frst.
Then people should focus on the following questions written up on a fipchart:
What do you think a process of internalised oppression means?
Why does it occur?
What are the forces in society that drive it?
After thinking about these questions, take feedback in the large group.
Afterwards, ask people to read the statement on Handout 7.2 written by the author of the
poem.
Present the spiral of oppression by Premila Trivedi using Slide 7.2 and refer to the ex-
planation of it by her that follows in the Learners Notes.

Review Workplace Task 6: Promoting Race Equality 30 minutes


Group Activity 7.1 The spiral of oppression 45 minutes
Group Activity 7.2 A model of empowerment 30 minutes
Reminder of Workplace Task: Working in an empowering way
Page 90 Tralners Manual : Sesslon 7 - worklng ln an empowerlng way
Task Output:
An explanation of internalised oppression with its causes and consequences in wider soci-
ety for people using mental health services.
Resources:
Slides 7.1 and 7.2, Handouts 7.1 and 7.2.
Time:
Total 45 minutes

Group Activity 7.2 A model of empowerment (30 mins)
Overview:
This model is derived from work done with Black people with learning disabilities and offers
a practical step-by-step process of empowerment which emphasises the fact that empower-
ment is a process that people need assistance to go through and not something that can be
forced to happen to a person. It is important for people to have a sense of who they are and
what they want and this is why the frst step is about building a positive self image.
Purpose:
To identify strategies for helping people to deal with powerlessness and the introduction of a
model of empowerment.
Instructions:
Ask people to get into pairs and discuss for a few minutes what could help people to
cope or deal with a situation of powerlessness.
People should then come back into the large group and share what helped. The facilita-
tor should note their ideas up onto a fipchart.
(Whole process could be done in large group to save time)
The facilitator should now introduce the model of empowerment using Slide 7.3 see
Handout 7.3 - Learners Notes for full presentation information.
Resources:
Slide 7.3 and Handout 7.3
Time:
30 minutes

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Page 9l Tralners Manual : Sesslon 7 - worklng ln an empowerlng way
Slide 7.1 & Handout 7.1
DISEMPOWERMENT
Sleepless nights, enveloping despair - guilt.
Guilt at being me - black, female, poor,
Part of a large family -
Part of an even larger society
Resounding with racism and rejection.
Tablets, psychiatrists, falling more into the abyss
Of white mans medicine.
Hospital, enforced activity, constant cajoling
Tofttheircategorizationofme,
All the time denying me my pain, my hurt, my confusion.
Reinforcing my badness at feeling these things.
Isolating me - alone - with my problems,
Unexpressed anger, increasing guilt,
The silence growing louder.
Largactil, locked doors, ECT, eventually stillness.
Sinking deeper and deeper into the sanctuary of insanity:
Beautiful - silent - still - feelingless - internal death;
Pushing back the screaming agony
Before I infect them with my poison -
The poison of my blackness, my culture, my very being;
All wrong, all contradicting the norms of their society,
All disrupting their ordered world.
And in the end I saw it their way, the guilt was mine.
So I tried - and battled - and pulled my self out of it -
And buried myself deeper, keeping me inside,
Smiling nicely, acting right, colluding with them,
Ensuring their equilibrium was maintained,
So I have the privilege of existing in their world -
Of experiencing their values, their beliefs,
Their prejudice, their power.
What does it matter that I died in the process?
What does it matter? One more black, crazy female,
One more drain on society, what does it matter?
To them nothing -
And ultimately to me it must mean nothing too,
Otherwise even existence becomes impossible
And internal death can only be mirrored in external reality.
by Premila Trivedi in Survivors Poetry - from dark to light - Survivors Press 1992)
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Page 92 Tralners Manual : Sesslon 7 - worklng ln an empowerlng way
Handout 7.2
I became disempowered by
Not being listened to
an over-emphasis on the fact that my illness is a medical phenomena, with little
account being taken of social stresses (in particular the impact of personal and
institutionalized racism) on my life an over-emphasis on drug treatment
an over-emphasis on conforming to European norms and values
the assumption that I could have no responsibility for my illness or my response
to it
a disregard for my own coping skills and mechanisms
being treated as if I had only ever been a psychiatric patient
the assumption that I will always be just a psychiatric patient
Over time:
I have become more empowered by
being listened to and having my views and opinions taken seriously
having recognized that social factors (including personal & institutionalized rac-
ism) also contribute signifcantly to my mental health crises
making me see that see that drugs are only one response and other things may
be of important complementary value
acknowledging and respecting my own cultural and social norms, and helping
me to see myself in those contexts
helping me understand that I could take some responsibility for my illness,
parrticularly recognising and doing something about signs at an early stage
an acknowledgement that I do have coping skills that I can use much more to
help me self-manage
the recognition that I have a past and skills and talents that dont just disappear
because Ive become a psychiatric patient
the recognition that I have a right to a hopeful and useful future

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Page 93 Tralners Manual : Sesslon 7 - worklng ln an empowerlng way
RECC - ESC Advanced Module
Slide 7.2
The spiral of oppression
( by Premila Trivedi, 2001)






Page 94 Tralners Manual : Sesslon 7 - worklng ln an empowerlng way
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Slide 7.3

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Handout 7.3
LEARNERS NOTES
SESSION 7 WORKING IN AN EMPOWERING WAY
Learning Outcomes
Participants will be able to:
understand a BME service user /survivor view of powerlessness and its wider
impacts for them in society
describe a model of empowerment that helps people to formulate strategies for
dealing with powerlessness
apply a model of empowerment with a current BME service user.
First try this group activity:

Group Activity 7.1 The spiral of oppression
The diagram below illustrates the spiral of oppression that is experienced by oppressed
groups in society once they come into contact with psychiatry and enter the mental health
system. Forms of oppressions in society, such as racism, sexism, classism, ageism and
homophobia, can affect an individuals mental health by initiating emotional distress or
compounding that which may already be present. Societys response to such distress is to
treat people through an essentially medical approach in a system of mental and social health
care that, rather than understanding and challenging oppressions which give rise to mental
distress and reinforces them with their own oppressive attitudes and practices. This results
in more distress, driving the person even further into the mental health system and into a
continuing the spiral of oppression. For those individuals who do improve and leave mental
health services and enter back into society, they now (in addition to the original oppressions)
also become subjected to the oppression of mentalism since society has such a negative
and pessimistic view of anyone who has a psychiatric diagnosis. Thus the spiral continues,
leaving service users of mental health services feeling trapped within a system which per-
petuates oppression and discrimination.

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The spiral of oppression
( by Premila Trivedi, 2001)
















(Participants should insert Handouts 7.1 and 7.2 after this page)

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Page 97 Tralners Manual : Sesslon 7 - worklng ln an empowerlng way
Now go on to this group activity before reading the next section:

Group Activity 7.2 - A model of empowerment
A model of personal empowerment
Empowerment is a process that you work on with a person not something that you do to
people. The process of empowerment varies from person to person and is infuenced by a
persons past experiences. It is vital to get the pace of empowerment right and to be sensi-
tive to a persons changing needs in terms of personal support and degree of autonomy.
There are times when a person wants someone else to make a decision and there are times
when the person wants to make the decision themselves. People who have been affected
by institutionalisation may need many years before they can fully take control over all of the
decision-making in their lives. However, it is important for any plan of assistance to be aiming
at the ultimate goal of people taking control of their everyday lives.
For BME service users, the process of empowerment must be culturally appropriate in terms
of the seven dimensions of culture introduced in Session 4. For example, it may mean that
the persons family will be very much involved in the process of empowerment as their sense
of individuality is very much towards the group end of the spectrum or decisions are made
to accept the situation rather than take control of what is happening. The model of empow-
erment outlined here was created through work with BME people with learning disabilities in
self-advocacy groups. It needs to be sensitively applied with BME service users as explained
above and should never be rigidly applied but used in a fexible way to generate possible
strategies for empowerment.
There are eight building blocks in this model of empowerment as follows:
1. Build a positive self image
It is impossible to ascertain peoples interests, needs and wishes if they have little sense of
who they are or feel bad about themselves. People may require help in re-discovering and
re-affrming their identity. Providing positive role models and building solidarity with others
who have similar experiences can be very useful in building a persons sense of cultural
identity and self confdence. People in mental distress usually ask fundamental questions
of themselves and BME people often fall back on their cultural heritage and spirituality as a
source of strength and recovery.
2. Increase control and responsibility over ones own life
People often become more dependent within mental health services and service providers
inadvertently take control of the persons life in all sorts of unnecessary ways. Practitioners
need to actively help people to increase service users control over their lives and not use
their power coercively to impose narrow and discriminatory approaches to dealing with
mental distress. Along with control over ones life comes responsibility not to put oneself
BME service user quote
I used to work in hospitals. It was a big blow to be on the other side very
depressing.
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or others in harms way and so issues of risk and safety have to be discussed openly and
honestly with service users. BME service users are particularly at risk of being poorly served
by services and so these risks also have to be looked at seriously (further issues around risk
are discussed in Session 12). People are bound to make mistakes along the way as this is
part of human nature but it is important to be supportive and help people to learn from their
mistakes and not to respond in a punitive way.
3. Supporting self-advocacy
People should always be supported to express their point of view even if it is in opposition
to service providers or families and carers. Points of difference and potential confict can
often form the basis of a plan of action to improve the situation and mediate conficts in the
persons life. There are always going to be times when people are unable to speak up for
themselves and there may be need of independent advocacy. Practitioners can advocate for
their service users to some extent but there will be limitations as conficts of interest arise
especially when service users are in dispute with service providers. Independent advocacy is
the best option in these situations where advocates can truly represent the voice and views
of the service user. BME service users will need advocates who can understand their point
of view and their experience of institutional racism and discrimination. There may well be
cultural and language skills needed by advocates to be fully effective. Care has to be taken
in selecting a suitable advocate for BME service users as simple ethnic matching may not
work due to differences in gender, class, religion, political reasons or just the skills of the
worker concerned.
4. Giving the person information
Knowledge is certainly power. BME service users and carers are often given inadequate
information about what is available to them in a locality especially if they are an out-group
such as refugees or asylum-seekers who are new to the country and do not know the mental
health system. Giving people information about medication seems to come up in many
surveys of BME service users views and also ties in with one of the other building blocks
regarding peoples rights. People need accurate and up-to-date information to enable them
to make well-informed decisions. On the other hand information overload may not be very
helpful for a person in extreme distress and so working with families, carers and advocates is
a useful alternative practitioners must use their judgement in an empowering way.
5. Enabling participation in service provision
We have already discussed how important it is to fully involve BME service users and their
families and carers in the process of service provision if we are to create truly culturally
appropriate services. However, there are many barriers to genuine participation in services
in the way that practitioners do things such as take referrals, assess peoples needs, plan
and review through activities such as ward rounds and case conferences. All of these
approaches do not lend themselves to be very accessible to BME service users. Service
BME service user quote
If I can take responsibility for my situation then I can fnd ways of dealing
with it.
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providers have to be more fexible and enter into a real partnership with BME service users,
families and communities if the quality of service is to improve. BME service users and fami-
lies also have to begin to trust practitioners who are genuinely trying to each out to them and
work more collaboratively. This may not always be easy if people have had very bad experi-
ences of services in the past but it is essential to meet practitioners half way or we will never
bridge the gap of credibility and distrust that currently exists for a lot of BME people. Work in
the feld of BME service user and community participation has shown that once we do over-
come the initial hurdle of trust, admittedly a big one in many areas, some excellent work can
be done and good progress made in improving service quality (see forthcoming publication
by the author Journey to Participation from Pavilion Publishing).
6. Helping the person to fnd creative options
People going through diffcult and stressful times often develop tunnel vision where they
see very few or no alternatives in their situation. Capable practitioners must help people to
explore their situation more thoroughly and think creatively about what is possible. However,
this is unlikely to happen if the person is feeling very fearful and anxious. The practitioner
must ensure that they are exploring the situation with the person and be there with them
through the process of exploration. Being there is again something that a lot of BME service
users have asked of service providers, it is a powerful statement of solidarity for people who
are not only feeling alone in a wider hostile society but are also being threatened with rejec-
tion within their own hitherto safe family and community. Having someone who is knowledge-
able and capable with them during this period can serve to allay some of a persons fear and
enable her or him to think more creatively.
7. Helping people to plan for the future
Much of mental health service provision focuses on survival in the present and very little is
done to help people to consider and plan for a desirable personal future. However, we all
need our hopes and dreams to keep striving for a better quality of life. If we do not enable
people to raise their eyes to the future horizon we do not give people any real motivation
to keep struggling to grow and develop as people. This results in a self-fulflling prophecy
BME service user quote
One member of staff went out of his way to take me down to Abbey National
to get some money out and help me to send some clothes and toys to my
daughter.
BME service user quote
Ive got a wife but I feel wife-less, Ive got a house but I feel homeless and
Ive got money but I feel poor.
Personal Refection
Can you think of a BME service user who has experienced this self-fulflling prophecy in
mental health services?
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where people enter a downward spiral of being stereotyped and oppressed, being denied
valuable life opportunities as a result, subjected to a restricted existence and a poor environ-
ment for growth and development, resulting in increased dependence and deskilling of the
person and fnally a confrmation of the original oppressive stereotype. The diagram below
summarises this process.
8. Safeguarding the persons rights
BME people have consistently been poorly treated within mental health services despite
some pockets of good practice, often in the Black voluntary sector. Concern has been voiced
by a range of practitioners about the threat to the fundamental human rights of BME people
within mental health services in terms of legal safeguards as well as straightforward health
and safety issues and freedom from racial and other forms of abuse. Issues of social control
through the Criminal Justice System and forensic services, misdiagnosis, the over-use of
drugs, the lack of preventative services, the exclusion of BME families and carers from inter-
ventions are all just a few of the diffcult and complex problems being faced by capable and
committed practitioners.
Some of the previous building blocks certainly do provide some safeguards such as the pro-
vision of robust independent advocacy and accessible information and these measures are
not diffcult to bring about. However, at the heart of the problem is a more intractable prob-
lem of a need for a cultural transformation in mental health services and this will be a much
longer-term goal requiring strategic and whole systems thinking.
We have stated in Session 1 that systems change can drive different behaviour from employ-
ees and a small start can be made by services looking at and changing some key systems
that safeguard peoples rights. Complaints procedures exist in all mental health services now
Page l0l Tralners Manual : Sesslon 7 - worklng ln an empowerlng way
RECC - ESC Advanced Module
and ensuring that this system is accessible to BME people and their families is a frst step
to providing real protection of rights. Some areas have introduced advocates and carers
advocates to help people to better access the system of complaints and go through the pro-
cess. Another important system that is more proactive than complaints is the evaluation of
service quality. BME service user-led audit has been a useful catalyst for change in a local-
ity by providing a clear and focused agenda for action that is based on a BME service user
and family perspective (again see Journey to Participation by the author). These kinds of
system changes will start to shift the organisational culture in the right direction to protect the
rights of all vulnerable groups using mental health services. Changes and legislative frame-
works and the policies of mental health organisations can further enhance and reinforce the
changes already beginning to happen.
The diagram below illustrates the model of empowerment being proposed in this Session.
References
Begum, Nasa. 1992. Something to Be Proud Ofthe Lives of Asian Disabled People and
Carers in Waltham Forest. London: Race Relations Unit and Disability Unit
Erikson. E. (1985) Childhood and society, New York: Norton.
Session 7 - Practice Development Tips
A process of empowerment may have to be undertaken with BME people in mental
distress before an accurate assessment of their needs is possible.
A focus on empowerment is the most effective approach to preventative work in any
intervention.

Page l02 Tralners Manual : Sesslon 7 - worklng ln an empowerlng way


Grotberg, Edith. (1999). Countering depression with the fve building blocks of resilience.
Reaching Todays Youth 4(1, Fall): 66-72.
Marshall K. (1997) A Framework for Practice: Tapping Innate Resilience, Research/Practice,
Vol 5 No.1 Spring 1997, Center for Applied Research and Educational Improvement.
Nazroo, J., King M., 2002, Psychosis - symptoms and estimated rates, in Sproston, K., Naz-
roo, J., (ed) Ethnic Minority Psychiatric Illness Rates in the Community (Empiric), National
Centre for Social Research, TSO
Sayce, L. 1995, Breaking the link between homosexuality and mental illness: an unfnished
history, a Mind discussion document.
Seligman, M.E.P. (1998) Positive social science, APA Monitor, 29, 2, 5
Walls P. & Sashidharan S.P., (2003), Real Voices - Survey fndings from a series of com-
munity consultation events involving Black and Minority Ethnic groups in England Report
prepared for the Department of Health, September 2003


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RECC - ESC Advanced Module
TRAINERS NOTES
SESSION 8 WORKING WITH BME FAMILIES & CARERS
Review Practice Checkpoint 7: Working in an empowering way
(30 minutes)
Split people up into small review groups (three or four per group).
Each participant should use Work task sheet 7.4 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 8.1 The role of family / carers (30 mins)
Overview:
This exercise builds on the individual of empowerment and extends it to BME families and
communities. The importance of families and communities for BME service users in their
paths to recovery refers back to the work done on cultural differences and in particular the
dimension on Individuality. The Participants Reader gives some further research evidence
about the crucial role and contribution of families and carers in assisting BME service users.
Purpose:
To recognise and be able to analyse the pressures and needs involved in a caring role in
mental health.
Instructions:
Break into small working groups and read Gita and Dilips story in Handout 8.1.
Ask people to address the following question: Identify the key areas of potential stress
and pressure for the family and carers in this story.
Take feedback from each group in the large group.
Resources:
Handout 8.1
Time:
30 minutes
(15 minutes in groups, 15 minutes feedback/discussion in large group.)

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
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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

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Slide 8.1
A model of Family & Community Empowerment
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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
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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.

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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.
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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
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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
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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
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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.

RECC - ESC Advanced Module


Page ll6 Tralners Manual : Sesslon 9 - Understandlng dlscrlmlnatory sltuatlons
RECC - ESC Advanced Module
Handout: 9. 1
Sadies Scenario
Sadie is an older African-Caribbean woman with a background in nursing and community-
based mental health services who is a very experienced manager and has had a good repu-
tation in her locality. She has recently been appointed as the manager of a multidisciplinary
Mental Health Team in an ethnically diverse area of a large city. One of the senior White
workers in the team had also applied for the job but had failed and several team colleagues
had expressed their disappointment openly. Within a few months of Sadie taking over as
manager there has been a general disquiet in the team with her management style. She
appears to ignore people on occasions when they enter the room, during team meeting she
appears not be paying attention to what was said and she appears to be arrogant by talking
over people putting her point of view across frst. Some team members have commented
that they feel intimidated by her as she tends to stand too close them when she talks to
them and uses her size to get her point across. Sadie has taken time off work already since
coming into the post and people are beginning to lose patience with her seeming lack of
interest in the details of what is going on in the workplace for her team members. She has
become increasingly distracted and less communicative. There is now talk at work amongst
the team about putting in a formal complaint about her performance in the role so far.

Page ll7 Tralners Manual : Sesslon 9 - Understandlng dlscrlmlnatory sltuatlons
Handout: 9.2
Sadies Scenario An analysis
Of course, there are several explanations about what is going on in Sadies situation and
many of them will focus on her problematic behaviour and poor work performance or the
covert racism of some staff in her team. It is human nature to see problems that are pres-
ent in a situation as being caused by the person or group involved. We will discuss this and
other sources of bias in our perceptions at the end of this Session. The important clues are
as follows:
She appears to ignore people on occasions when they enter the room.
During team meeting she appears not be paying attention to what was said.
She appears to be arrogant by talking over people putting her point of view
across frst.
She tends to stand too close to them (team members) when she talks to them.
Sadie has taken time off work already since coming into the post
She has become increasingly distracted and less communicative.
What is actually going on is that Sadie has recently been diagnosed with a serious hearing
impairment that has got rapidly worse in the past few months. She is fnding it hard to accept
the situation and is fnding it diffcult to adapt to the sudden loss of her hearing.

RECC - ESC Advanced Module


Page ll8 Tralners Manual : Sesslon 9 - Understandlng dlscrlmlnatory sltuatlons
Handout 9.3
Huseyns story
Huseyn, a Turkish man in his early twenties, is a refugee. He had left Turkey when he was
about ten when his family fed because of fear of the authorities, near relatives having been
imprisoned and tortured. He arrived in UK seven years later. After about two years he left
his parental home because of overcrowding to live in a hostel for the homeless. He began to
learn English, worked in a restaurant and got himself a rented room. He met a White woman,
Sybil, and she moved in with him but she left him a few months later when she got a coun-
cil fat. Sybil wanted Huseyn to marry her but he did not want to get married and then Sybil
asked him not to see her. When he persisted in trying to continue the relationship; she called
the police and he was sent to prison for four months on a charge of stalking. After release,
he happened to see Sybil in the street and she invited him to visit her again. But when he did
so, Sybil abused him, broke a glass pane in her front door and called the police. He was then
held in custody until his transfer to hospital under Section 37 of the Mental Health Act as suf-
fering from paranoid schizophrenia. The symptoms were identifed as paranoid delusions
and thought disorder on the basis that Huseyn thought that Sybil had been spying on him
and interfering with his body.
After one year in hospital, Huseyn appealed against his detention. He told the independent
psychiatrist who visited him that he had felt under stress when remanded in prison and was
glad to have been taken to hospital. He believed that his enemies in Turkey had paid Sybil
to spy on him, interfere with him, try to remove his kidneys and get him sent to prison to be
tortured. But all this was now in the past, he wanted to leave hospital in order to get married
to someone in Holland and lead a normal life.
The assessment by the Responsible Medical Offcer (RMO) was that Huseyn remained
deluded and had unrealistic plans for the future which were probably based on delusional
thinking. Also Huseyn was isolating himself by not participating in ward activities. He was
thought unft for discharge and to still presented a danger to the victim of his index offence.
It was felt that his illness required further treatment with medication possibly for an indefnite
period.
In the view of the independent psychiatrist (who took a transcultural view), Huseyn had suf-
fered a transitory psychotic state as a result of being in prison. His psychosis should be
understood in terms of his background. The fear of torture with electricity and having kidneys
removed was a reality for Huseyn. It was known that kidney removal for sale was practiced
in parts of Turkey and a real fear among some people there. Huseyn had isolated himself on
the ward because he had no interest in the type of Occupational Therapy activities available
and his English was not good enough for him to follow what was discussed at group meet-
ings. Since he had relatives in Holland, his plan to go there seemed realistic. At the Tribunal,
Huseyns mother asked whether X-rays had been done to make sure Huseyns kidneys were
intact because she believed Sybil was a malicious woman. She divulged the information that
the family was arranging a marriage for him with a cousin in Holland. The RMOs view was
accepted by the Tribunal and Huseyn was not discharged.
(Story by Dr. Suman Fernando)

RECC - ESC Advanced Module
Page ll9 Tralners Manual : Sesslon 9 - Understandlng dlscrlmlnatory sltuatlons
Handout: 9.4
Themes of Institutional Discrimination
1. Assimilation
Forcing people to ft into a dominant culture.
2. Under-reaction or Over-reaction
Ignoring serious problems or intervening in a punitive way with minor problems.
3. Disempowerment & Stereotyping
Taking away personal autonomy, reducing infuence over ones own life opportu-
nities and making negative assumptions about them.
4. Service -led Approaches
Asesssing and meeting peoples needs with the priorities of the service or
organisation put frst with little or no regard for anyone elses priorities.
5. Poor Access to Services
Bureaucratic procedures, diffcult locations and poor publicity about goods or
services.
6. Erosion of Rights
Denial of basic human rights and/or citizen rights of people.

RECC - ESC Advanced Module


Page l20 Tralners Manual : Sesslon 9 - Understandlng dlscrlmlnatory sltuatlons
Handout: 9.5 - Understanding Huseyns current situation
RECC - ESC Advanced Module
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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?
Page l23 Tralners Manual : Sesslon 9 - Understandlng dlscrlmlnatory sltuatlons
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

RECC - ESC Advanced Module


Page l24 Tralners Manual : Sesslon l0 - |dentlfylng needs ln a hollstlc way
RECC - ESC Advanced Module
TRAINERS NOTES
SESSION 10 IDENTIFYING NEEDS IN A HOLISTIC WAY

Review Work Task 9: Understanding discriminatory situations
(30 minutes)
Split people up into small review groups (three or four per group).
Each participant should use Work task sheet 9.4 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 10 The principles of a holistic approach to assessment
(1 hour)
Overview:
The twelve principles of a holistic approach in mental health were frst introduced in the
Ten Essential Shared Capabilities learning pack in Module 5 Race Equality and Cultural
Capability. The principles have been formulated to directly address and counteract the key
features of institutional discrimination in mental health services for BME people as described
in the Participants Reading for Session 6. They provide a useful framework for taking a criti-
cal look at systems for assessment and individual planning. The idea of this exercise is to get
practitioners to identify the strengths and weaknesses of their current assessment systems
against this set of principles and so get some ideas for change and improvement locally.
Purpose:
To critically evaluate the assessment system in local mental health services.
Instructions:
- Trainer should review the twelve principles of a holistic approach in the
Pre-course Reading with the group.
- Split people up into small working groups, preferably in the same services.
- Use the twelve principles of a holistic approach in the blank grid below (Handout 10.1) to
evaluate your services assessment system.
- What are the strengths and weaknesses of your services assessment approach under the
heading of each principle?
- Share your fndings in the large group.
- Finally, introduce a holistic process of assessment using Slide10.1 focusing on the assess-
ment stage and explain that the person-centred planning stage will be covered in the next
session.

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
Page l25 Tralners Manual : Sesslon l0 - |dentlfylng needs ln a hollstlc way
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
Page l26 Tralners Manual : Sesslon l0 - |dentlfylng needs ln a hollstlc way
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
Page l27 Tralners Manual : Sesslon l0 - |dentlfylng needs ln a hollstlc way
RECC - ESC Advanced Module
Slide: 10. 1 A Holistic Assessment Process

Page l28 Tralners Manual : Sesslon l0 - |dentlfylng needs ln a hollstlc way
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

Page l29 Tralners Manual : Sesslon l0 - |dentlfylng needs ln a hollstlc way


the future. It is essential to understand the cultural heritage of a service user if a good-quality
service is to be provided, one which offers opportunities for personal growth and develop-
ment, transmits a positive self-identity and increases self-confdence.
4. Culturally appropriate services
Evidence suggests that many BME people do not use mental health services because they
fnd that they are often culturally inappropriate. The provision of culturally appropriate ser-
vices is central to a holistic model. Remember the iceberg model in Session 1? Culturally
appropriate here means all levels of culture not just having the right food and posters on
the wall but being inclusive of peoples core beliefs, assumptions and values.
5. Overcoming communication barriers
Language barriers are a major contributory factor to the low take-up of services by BME peo-
ple from non-English speaking backgrounds. A holistic model improves access to services by
ensuring that information and publicity about services is available in different languages and
in different formats. People whose frst language is not English need access to interpreter
and translation services. The ideal option, of course, would be to have an ethnically repre-
sentative workforce in mental health services where practitioners would have the necessary
language skills to work with their BME service users directly.
6. Outreach and preventative work
BME communities may often need better information about services, but they also need
education about mental health in general. The stigma attached to mental illness is a prob-
lem in all communities and more outreach work has to be undertaken by services to all BME
communities. Communication strategies and mental health promotion initiatives would help
to increase knowledge about mental health as well as breaking down the stigma attached to
using mental health services.
There is some evidence from transcultural studies that the western medical model of mental
illness exacerbates stigma (see chapter Psychiatric stigma and racism in the book Cultural
Diversity, Mental Health and Psychiatry. The struggle against racism by Suman Fernando,
2003). Hence emphasis on a holistic approach to mental health problems, rather than the
strict diagnostic approach, should reduce stigma. Better communication, mental health pro-
motion and encouraging discussion of mental health issues could all help in breaking down
stigma. Individual mental health practitioners who take a health education approach to their
work can make a signifcant contribution to community education. A holistic model empha-
sises a preventative approach rather than a crisis-oriented one. The development of a range
of community support services would be essential for a preventative approach.
7. Focus on discriminatory barriers
What happens sometimes through institutional racism or the tendency to blame the victim is
that BME service users or their families are blamed when services do not seem to be helping
them. They may then be seen as diffcult or even aggressive. To counteract these negative
processes, the holistic model focuses on the social processes of discrimination and devalu-
ation that create unfair barriers for people, and refects this in assessment and planning to
meet the needs of individuals.
8. Appropriate intervention
There has been a consistent pattern of over-reaction or under-reaction to the needs of
RECC - ESC Advanced Module
Page l30 Tralners Manual : Sesslon l0 - |dentlfylng needs ln a hollstlc way
BME people by mental health services. Over-reaction has been characterised by crisis-ori-
ented responses, which are often punitive or controlling in nature. Under-reaction has led to
services ignoring what can be serious problems until these have reached a crisis point. At
this stage, services have become involved, but too late to prevent serious harm occurring to
BME individuals and their families. A holistic model requires timely and appropriate service
responses, which neither discriminate in practice nor lead to inaction arising from a fear of
being accused of being racist. This style of intervention also has to be culturally appropriate
for BME service users, and outcomes have to be in line with their personal preferences and
concerns.
9. Family/carer support
Lack of support for BME families and carers is part of the wider problem of lack of access
to mental health support services for BME communities. A model of good practice requires
proper assessment of family/carer needs and the development of a range of fexible and
readily available support services for families/carers.
10. Range of therapeutic options
The over-use of drugs and physical treatments with BME service users in the mental health
system is well documented. A holistic approach encourages the use of alternative thera-
pies from different cultural traditions of healing. The main aim of good practice should be to
increase the treatment options available to BME service users. The increased use of talking
therapies with BME users would provide less restrictive treatment programmes and would
also challenge the racist stereotypes of BME service users as being unintellectual and non-
verbal.
11. Empowerment and advocacy
Statutory authorities have often excluded BME service users from participation initiatives.
BME service users usually lack representation when decisions are made about the planning
and delivery of mental health services. Good practice requires a process of empowerment
for BME service users, to increase self-confdence and foster assertiveness. The develop-
ment of independent advocacy and self-advocacy schemes is urgently needed, for
BME service users to achieve proper representation and to speak up for themselves more
effectively. Holistic services would promote advocacy actively and incorporate BME service
user participation and advocacy in their procedures.
12. Safeguarding rights
The disproportionate use of compulsory sections of the Mental Health Act and the links
between mental health and the criminal justice system suggests that the basic rights of many
BME service users are under threat in the mental health system. A holistic model empha-
sises basic human rights and requires great caution in the use of statutory powers in men-
tal health services. BME service users rights are safeguarded through anti-discriminatory
procedures, accessible appeals and complaints systems and accurate monitoring of service
quality. Safeguards include quality assurance systems which are based on service users
views with indicators of service outcomes that refect improvements in the quality of life of
BME service users.
RECC - ESC Advanced Module
Page l3l Tralners Manual : Sesslon l0 - |dentlfylng needs ln a hollstlc way
Try this group activity frst:
Activity 10.1 Principles of a holistic approach
A Holistic assessment process
Get to know the person and their culture.
Practitioners have to build a relationship of trust and establish a dialogue with the
person if they hope to identify their real needs. Practitioners should be able to put
themselves in the shoes of the service user to appreciate their point of view and this
means they must understand the cultural background of the person. Compiling a
Cultural Profle using the rainbow model of cultural difference introduced in Ses-
sion 5 is useful at this stage.
Help to clarify the persons desired lifestyle.
People may need some help in thinking through what kind of lifestyle they would
really like to have and what they are aiming to achieve in the future. Most mental
health services focus on survival in the present and do not encourage and assist
people to plan for the future and strive for their hopes and dreams. The quality of
peoples lives will not improve appreciably unless people learn from the past, under-
stand and deal with the present as well as plan for their future. We will introduce a
useful model for looking at desired lifestyle later in the next section called the Five
Service Accomplishments.
Find out what the person thinks about their mental distress.
Looking at the meaning of mental distress for the person is an important step in pro-
viding a culturally appropriate service. The meaning of distress and how it impacts
on the persons quality of life will help the practitioner to assist the person in a sensi-
tive way.
Identify the barriers to the persons desired lifestyle.
By focusing on the barriers to desired lifestyle it is less likely that the service user will
be blamed for their situation either openly or in a covert way. It is also more likely
that BME service users will engage with services that are focused on helping them to
achieve what is important for them in terms of quality of life. Focusing on discrimina-
tory barriers gives mental health services a sharper focus and often leads to a more
effective use of resources.
NB/. The elements of a holistic assessment process outlined here lead to a holistic
planning process which is examined more fully in the Session 11. You can look at
Handout 11.1 in Session 11 to see the full process of holistic assessment and
planning.

Session 10 - Practice Development Tips


Ensure that your assessment and planning forms take a holistic view of a BME
persons situation and always records the views of BME service users and family/car-
ers about the kind of help they want.
Check that training for practitioners around assessment promotes a holistic process
as outlined in this Session.

RECC - ESC Advanced Module


Page l32 Tralners Manual : Sesslon l0 - |dentlfylng needs ln a hollstlc way
RECC - ESC Advanced Module
References
John OBrien (1989) Whats Worth Working For? - Leadership for Better Quality Human
Services; Responsive Systems Associates, Georgia: USA
John OBrien & Connie Lyle (1987) Framework for Accomplishment; Responsive Systems
Associates, Georgia: USA
Kleinman, A. (1988) Rethinking Psychiatry: from Cultural Category to Personal Experience.
New York: Free Press.
Further reading
Useful videos
Interesting websites

Page l33 Tralners Manual : Sesslon ll - Hollstlc approach to plannlng
RECC - ESC Advanced Module
TRAINERS NOTES
SESSION 11 HOLISTIC APPROACH TO PLANNING
Review Work Task 10: Improving holistic assessments 30 minutes
Split people up into small review groups (three or four per group).
Each participant should use Work task sheet 10.3 in their Practice Development
Workbooks to present their Work Task to colleagues.
In the large group, each review group should feedback their individual key mes-
sages for senior managers (one for each participant) and this should be noted
down or written onto a fipchart.

Group Activity 11 Annettes Story (1 hour)
Overview:
The exercise brings together many elements of learning from previous sessions around
institutional discrimination, cultural appropriateness of services, powerlessness and empow-
erment, the principles of a holistic approach and the full process of assessment and person-
centred planning.
Purpose:
To encourage people to think more creatively in providing assistance to a BME person in
mental distress with complex needs.
Instructions:
- Review the full holistic assessment and planning process using Slide 11.1 (see Handout
11.3 - Learners notes for full presentation information) and the Five Service Accomplish-
ments using Slide 11.2.
- Split into small work groups.
- Ask people to read the story about Annette (Handout 11.1).
- Now their task is to use the Five Service Accomplishments to help defne her desired life-
style. They can use the blank grid on Handout 11.2.
- The group should also come up with some creative service and non-service options to help
Annette achieve her desired lifestyle if she were a service user of their services.
- Trainer takes feedback in the large group from each of the work groups.
Resources:
Slides 11.1, 11.2, Handouts 11.1,11.2 & Handout 11.3 - Learners Notes on Five Accomplish-
ments.
Time:
1 hour - 10 minutes review of previous materials, 20 minutes in small groups, 30 minutes
feedback in large group

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)

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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
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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
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Annettes desired lifestyle
PRESENCE
PARTICIPATION
RELATIONSHIPS
CHOICES
VALUED ROLES
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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

BME service user quote


I needed time and somebody to validate my feelings - I needed nurturing not
drugs.
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down at an early stage. The approach taken here is to use the rainbow model
of culture to assess appropriateness of any interventions. If there are any con-
cerns about risk, an assessment focused on this issue should be undertaken
prior to any package of assistance being constructed.
Put together a package of assistance.
A fnal agreement has to be reached with the service user about what needs can
and cannot be met by the services and interventions being offered. Service us-
ers and their families and carers should be clear about what services are being
provided, who by, when and to what standards. Any service provision should be
linked to specifc objectives within the plan of assistance with criteria for quality
so that the plan can be accurately monitored and reviewed by the service user,
their family and service providers. Any written agreements should be communi-
cated to service users in an accessible and understandable format.
Plan for monitoring and review of assistance package.
The monitoring and review of any plan of assistance must be conducted with the
fullest participation of BME service users and their families/carers. Such an ap-
proach will provide further safeguards against culturally inappropriate services.
This may well include overcoming language and other communication barri-
ers. The power dynamics inherent in any monitoring and review process must
be carefully considered and the systems and procedures involved adapted to
ensure participation of BME service users.

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The Five Service Accomplishments
(Adapted from John OBrien & Connie Lyle, 1987)

(by OBrien, 1989)
The Five Service Accomplishments model (outlined in Handout 11.2) has been around for
many years but still provides a good practical checklist of things that a service needs to pay
close attention to if it is to deliver responsive and effective services. This model is a good
way of helping people to defne their desired lifestyle. It can also help us to evaluate the
true quality of services from a service user perspective of what is effective and relevant as-
sistance.
Presence in the community refers to the importance of services ensuring that BME mental
health service users are assisted to share ordinary places in a multi-ethnic community that
are frequented by any member of the public. This means people must be given opportunities
RECC - ESC Advanced Module
BME service user quote
I want people to accept me for what I am, give me a chance to work again
and be a successful member of the community.
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to move away from using only segregated service settings and to be present in communities
that are signifcant for them as BME people or as people from other social groups.
Participation in the community is about enabling service users to develop and contribute
their skills and talents within their community and not to restrict people to using them only in
service settings. This involves recognising skills and talents within the persons own cultural
context even though they may not be commonly valued within the majority community. Com-
munities have to be challenged to recognise and value the diverse contributions of everyone.
Relationships refer to giving people opportunities to grow and develop within a network
of personal relationships. This may require services to help people to re-establish contacts
with families and create new friendships and relationships in their lives. Family networks are
often central for BME people and have to be taken into consideration. Experiences of mental
distress often create tensions or even fracture existing important relationships of people and
services can usefully help BME service users to rebuild bridges between themselves and
people who are signifcant in their lives.
Choices focus on redressing the power imbalances that build up for BME service users with
people who are assisting them and which often results in people losing control of their lives.
Helping people to make choices is a process that can require risk-taking and may take some
time, especially if people have been affected by institutionalisation, stereotyping, loss of
self-confdence and internalised oppression. The process may begin with simple choices but
must aim to achieve as much autonomy and control as the person wishes to achieve in their
everyday life. The process may also require helping and supporting people to face up to their
responsibilities and the consequences of their choices.
Valued roles often result from the other four accomplishments and refers to ordinary val-
ued roles that non-service users often take for granted such as being a friend, a parent, an
employee or student. It is important for service to challenge damaging racist stereotypes and
negative images of BME people who experience mental distress. The reputation and status
of the person within their own community should never be jeopardised by services and the
persons cultural identity and confdence should be strengthened and enhanced by the way
services are delivered to people.
Try the following group activity:

Group Activity 11 Annettes desired lifestyle & creative options
BME service user quote
Conventional psychiatric treatment encourages you to push out spirituality
and destroy it but I fnd that spirituality helps me to embrace my pain and
gives me a context in which to cope with it.
Personal Refection
If Annette was a service user in your area, how easily would you be able to provide some
of the creative options you have come up with for her?
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References
John OBrien (1989) Whats Worth Working For? - Leadership for Better Quality Human
Services; Responsive Systems Associates, Georgia: USA
John OBrien & Connie Lyle (1987) Framework for Accomplishment; Responsive Systems
Associates, Georgia: USA
Kleinman, A. (1988) Rethinking Psychiatry: from Cultural Category to Personal Experience.
New York: Free Press.

Page l43 Page l43
Session 11 - Practice Development Tips
Choose a BME service user to focus on and ensure that their desirable lifestyle has
been identifed using the Five Accomplishments model.
Check that options generated and the fnal package of assistance for the person are
culturally appropriate using the rainbow model outlined in Session 4.

BME service user quote


They forget to adjust your medication when you get better.
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RECC - ESC Advanced Module
TRAINERS NOTES
SESSION 12 ANTI-DISCRIMINATORY RISK WORK
Review Work Task 11: Improving assessment & planning processes 30
minutes
Split people up into small review groups (three or four per group).
Each participant should use Work task sheet 11.4 in their Practice Development
Workbooks to present their Work Task to colleagues.
In the large group, each review group should feedback their individual key mes-
sages for senior managers (one for each participant) and this should be noted
down or written onto a fipchart.
Use the following Slide to introduce and discuss the concept of risk to participants and refer
people to Handout 12.4 Learners Notes for this Session.
Defning risk
Slide: 12.1

Chinese for Crisis
Chinese character wi DANGER
+
Chinese character j CRUCIAL POINT
(j is neutral, it can either turn out for better or for worse)

Review Work Task 11: Improving assessment & planning processes


(30 minutes)
Presentation: Defning Risk (use Slide 12.1) (10 minutes)
Group Activity 12.1 Tamukas story (50 mins)
Work Task 12: Anti-discriminatory risk work
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Group Activity 12.1 Analysing Risk Situations - Tamukas Story
(50 mins)
Overview:
This exercise synthesises several strands of learning from previous sessions by looking at
cultural differences (particularly the dimension of individuality); institutional discrimination,
stigma (in relation to both the mental illness label and HIV/AIDS issues); the role of family/
carers; holistic assessment and planning as well as issues of risk. A deeper level of analysis
is advocated to arrive at a proper risk assessment in this complex situation.
Purpose:
To illustrate how judgements about risk in complex situations involving BME people are
heavily infuenced by the depth of analysis of the situation made by practitioners.
Instructions:
Split people up into small work groups.
After reading Tamukas story, participants should use the IPSA model introduced in Ses-
sion 9 and address the following questions for Tamuka and his mother:
What key questions or issues should be addressed at each of the Four Levels of analy-
sis in the IPSA model?
Get people to write down their ideas in fipchart.
Take feedback in the large group.
Finally, take people through the example of a IPSA analysis provided in Handout 12.3.
Resources:
Learners Notes on Four Levels of Understanding in Session 9, Handouts 12.1, 12.2, 12.3 &
12.4.
Time:
50 minutes
- 20 minutes in small groups, 30 minutes feedback and discussion in large group

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Handout 12.1
The Four-Levels of Understanding
The Four-Levels of Understanding (IPSA)
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 im-
mediate events.
Level 2 Understanding
(P) Patterns of discrimination
Patterns of discriminatory behaviours or events provide a higher level of under-
standing 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.
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 im-
pact on the quality of life individuals, including their experiences of services. This
level of perception yields a much more in-depth understanding of the wider so-
cial 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 sys-
tems 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 straightfor-
ward 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 Ses-
sion 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.

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Handout: 12.2
Tamukas Story
Tamuka is a 26 year old Black African man born in Zimbabwe who currently lives with his
mother, who is very ill at present, in a small fat on the 5th foor of a tower block. The fat
where Tamuka and his mother lives is not properly heated, it is very damp and poorly fur-
nished. He has been a mental health service user for nearly three years, soon after enter-
ing the country to live with his mother who has been resident in this country for ten years.
Tamuka had been living with his father in Zimbabwe up until he came to the UK following his
fathers death. Tamuka has been compulsorily detained on one occasion two and half years
ago when he was working as a minicab driver and got into an altercation with a customer
over a fare. Tamuka had threatened to kill the customer and bring evil down on his family.
The police were called by the customer and Tamuka was eventually taken into hospital on
Section 136 in an agitated state according to the offcers who attended the call-out. He
allegedly attacked a police offcer and it is written in the records that he was violent and abu-
sive towards a nurse soon after admission causing some minor injuries. He was in hospital
for two weeks before being discharged and he had been diagnosed with schizophrenia
during his stay. He was prescribed anti-psychotic drugs and has always been happy to take
his medication without questions even though he had some unpleasant side-effects initially.
Tamuka has been keeping quite well and has had only one minor crisis two years ago when
he received some intensive support from the local Community Mental Health Team and
Home Treatment Team. He is still currently under the local Community Mental Health Teams
caseload but with minimal contact in the past nine months.
Tamuka claims that he has always had special powers since he was very young. In Zimba-
bwe he is considered to be a svikiro a spirit medium who can talk to ancestral spirits. He
often talks to his deceased father (Mukanya) out loud and hears him talking back to him.
Tamuka says that his father gives him good advice and cheers him up sometimes when he
is feeling very down. He is still very angry with his father though as he took his own life in
Zimbabwe after being diagnosed with AIDS following a short illness. His father had carefully
planned his suicide and had waited for the time when Tamuka was away from home on a trip
to visit relatives. Mukanya then left specifc instructions for Tamuka, and made arrangements
for him to be kept away from their home he stayed instead at the relatives home - from the
day Mukanya died. Tamuka now feels his responsibility weigh heavily as head of the fam-
ily being the eldest son and must now make sure his mother is looked after. His mother had
divorced his father some ten years ago and Tamuka feels that she could have tried harder
to make the marriage work but he feels a great sense of duty to her and fnds it diffcult to
criticise her now, especially as she is very ill at present. He says after my father died I felt
I had to come here - I didnt think about all the ins and outs of the situation - I just knew in
my heart that my mum would need me. I get very down sometimes now and think I will just
follow my mum when the time comes.
Tamuka says that he wants help with his mother as she is very ill and dying because she
has AIDS. His mother has been diagnosed as HIV positive and is currently on triple combi-
nation therapy which had improved her condition a lot after she frst went onto it. She had
been in hospital but was not happy to stay there. She was discharged over eight months ago
with some domiciliary care put in to give her help with cleaning, shopping and some general
assistance. Tamuka is unhappy with the number of hours and the tasks that the Home Care
staff provide. He had an argument with one of the Home Care staff and he said to her I know
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you have rules but what can YOU do for me? After his outburst she refused to come back
again and now he has someone else that he doesnt know. He says that now he does all
the cooking as no-one else knows the kind of food his mother likes. He also says that his
mother has got much worse in the past few months there does not seem to have been any
recent review of his mothers needs. He is not sure what to do as he doesnt understand the
system and he doesnt read English very well.
Tamuka is very proud of being a svikiro and he says I have respect amongst my people
because Im a svikiro - everyone respects them, dont they? He is particularly concerned
to get back to Zimbabwe in the next two months to perform an important ceremony at his
fathers grave which welcomes his spirit back into the family otherwise his fathers spirit will
wander unhappily and bring ill-fortune to the whole family. Tamukas mother thoroughly dis-
approves of her sons beliefs as she is a born-again Christian and this gives him a lot of pain
as his spiritual beliefs are very important to him. The topic of spirituality has been a source of
arguments between mother and son in the past.
Tamuka had been working as a minicab driver and had many friends in this community. Sev-
eral of the drivers were from Zimbabwe in the local area and Tamuka used to attend the Af-
rica Centre regularly where he enjoyed their company, in particular his friend Simba, who he
sees rarely now as he has moved to a nearby area Tamuka says he taught me a lot about
computers and how to survive here. He was also recognised at the Centre for his special
powers and he got on well with the sangoma (diviner-priest), who advised him about the
incomplete rituals left for him to fully inherit his powers and fulfl his potential. Tamuka was a
keen footballer and used to play for a local African team in an amateur league. He has not
played football for over two years now and has not worked as a driver during that time either
he says I miss the football but I watch on the telly. Tamuka used to enjoy having friends
visiting his fat but no-one has called for many months now and he suspects that they no lon-
ger call because of his mothers illness. His mother used to be very active in the local church
and had many friends there but she is no longer well enough to attend church. Tamuka rarely
leaves the fat now - he says I have to look after my mother.
Since coming to this country Tamuka has felt that he no longer has the respect he deserves
as a big man in his community. He says that sometimes people insult him and make fun
of his accent but he says that he will not take rubbish from anyone. He says that he does
not understand the racism in this country, in Zim you just trade insults maybe have some
boxing but then it is forgotten because you know what you are dealing with. But people here
smile at you to your face and then do something bad behind your back its hard to trust
these people. Tamuka says he would like to work in computers as he has fnished a course
in computers in the past and has learned more about how to fx them. He says everyone
used to come to me to fx their computers and I always knew what to do. However, he cant
see himself doing anything in the near future as he feels that you just have to accept your
fate and you must keep in touch with the spirits around you - You must honour your ances-
tors or you will invite evil and get bad luck. He still feels very down at times and he often
says I just cant stop thinking about what happened to my father it goes over and over
in my mind. The anniversary of his fathers death is approaching and Tamuka says that if I
dont get back to Zimbabwe soon and perform the ritual at his grave something very bad will
happen to me.
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Handout: 12.3
Analysis of risk in Tamukas Story using the IPSA model
Level 1
Individual discriminatory behaviours and events
What was the nature of the altercation with the passenger and did it
warrant police intervention?
What were the true circumstances in which Tamuka allegedly attacked
a police offcer and was violent and abusive towards a nurse?
Why did Tamuka not question or report his unpleasant side effects?
How has Tamuka kept well for the best part of two years?
Why has there been minimal contact with Tamuka despite the fact that
he has had to take on an onerous caring role with his mother during that
time?
How is Tamukas sense of family duty affecting the stress he feels?
What are the needs of Tamuka and his mother in relation to the suicide
of his father?
How could the domiciliary service have responded better to Tamuka and
his mother?
How much help has Tamuka and his mother received in relation to differ-
ences or conficts between them?
Level 2
Patterns of discrimination
What systems could pick up on the fact that two vulnerable people are
living in such poor housing conditions?
What are the impacts of the wider issues of police involvement with
Black young men in this situation?
What kind of safeguards in mental health services should there be in the
diagnostic and assessment systems for people like Tamuka?
What are the impacts of the wider issues of compulsory detention of
Black men under Mental Health Act in this situation?
How can the system of monitoring the side effects of drugs be improved
to pick up on problems even if people do not complain about them?
How is does the issue of AIDS and HIV affect people from the African
continent and how is this dealt with in the UK?
How accessible for BME people is the complaints/disputes procedure
around domiciliary care services?
How are rapidly changing needs of service users dealt with by domicili-
ary services?
Level 3
Systems that shape individual and institutional discrimination
How sensitive is the diagnostic process in the psychiatric hospital in situ-
ations involving Black men and the Police?
Why was the system of reviewing Tamukas needs not triggered by the
change in his circumstances?
What systems are there to better inform BME people who are experienc-
ing problems around AIDS and HIV?
How culturally appropriate are domiciliary services for elders and dis-

RECC - ESC Advanced Module


Page l50 Tralners Manual : Sesslon l2 - Antl-dlscrlmlnatory rlsk work
abled people?
How are spiritual needs refected in assessment and planning proce-
dures?
How are wider social and relationship needs refected in assessment
and planning procedures?
Level 4
Assumptions and beliefs that shape systems of institutional discrimination
Were there any common stereotypes about Black young men that were
operating in the way that Tamuka was dealt with?
Have Tamukas spiritual beliefs infuenced the diagnostic process?
Were there any assumptions made about Tamukas needs that resulted
in the immediate prescribing of drugs for schizophrenia?
What different assumptions may be made about Tamukas belief that he
communicates with the spirit of his dead father regularly?
Do domiciliary services assume that everyone has similar cultural
needs?
How much importance is given to Tamukas spiritual beliefs in helping
him to recover from his mental distress?

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RECC - ESC Advanced Module
Handout: 12.4
LEARNERS NOTES
SESSION 12 ANTI-DISCRIMINATORY RISK WORK
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.

Chinese for Crisis


Chinese character wi DANGER
+
Chinese character j CRUCIAL POINT
(j is neutral, it can either turn out for better or for worse)
Approaches to risk work in mental health involve making judgements about the balance
between risk minimisation and risk taking.
Thinking about the Chinese word for crisis what do you think it tells us about this balance
between risk minimisation and risk taking?
What are the dangers for everyone involved of getting this balance wrong that is too
much of one approach or the other?
Where do you think this balance lies in relation to your service?
Where do you think the balance is in your service in relation specifcally to BME service
users?
Page l52 Tralners Manual : Sesslon l2 - Antl-dlscrlmlnatory rlsk work
Risk in our culture usually infers some kind of crisis and both concepts are viewed as
things that are largely negative but this is not true of every culture. People responding in
crisis situations often fall back on their habitual behaviours which increases the infuence
of their beliefs and assumptions. We tend to judge situations and behaviours from our own
cultural standpoint and the judgement of risk evokes a lot of feelings for most practitioners,
not just around personal safety but also around their self-image as a professional and the
consequent judgement of them as practitioners by their employers and wider society. The
combination of these factors with the existence of prejudice, racist stereotypes and institu-
tional racism makes the judgement of risk particularly fraught when it comes to BME people.
The negativity around the concepts of risk and dealing with crises combined with the nega-
tive imagery around BME people, particularly the powerful image of big, Black and danger-
ous, have resulted in an over-reaction or under-reaction for BME people generally (one of
the Themes of Institutional Discrimination introduced in Session 6). The existence of these
stereotypes infuences the reading of risky situations by all practitioners as we are all infu-
enced by these widely promoted stereotypes. In other words there is an in-built bias in our
perception of the situation from the very beginning, as discussed in Session 3. Practitioners
have to be aware of these dangers if they are going ensure that they focus on real evidence
of risk rather than unreal perceived threats based on personal prejudice and bias.
The negativity around the concepts of risk and dealing with crises combined with the nega-
tive imagery around BME people, particularly the powerful image of big, Black and danger-
ous, have resulted in an over-reaction or under-reaction for BME people generally (one of
the Themes of Institutional Discrimination introduced in Session 6). The existence of these
stereotypes infuences the reading of risky situations by all practitioners as we are all infu-
enced by these widely promoted stereotypes. In other words there is an in-built bias in our
perception of the situation from the very beginning, as discussed in Session 3. Practitioners
have to be aware of these dangers if they are going ensure that they focus on real evidence
of risk rather than unreal perceived threats based on personal prejudice and bias.
Activity 12.1 Analysing Risk Situations - Tamukas Story
Finally, review the Ten Principles of Anti-discrminatory Risk Work following.
RECC - ESC Advanced Module
Personal Refection
Look at the Chinese word for crisis in the diagram.
What do you notice about it?
BME service user quote
My hope for the future is that I allow myself to make mistakes.
Page l53 Tralners Manual : Sesslon l2 - Antl-dlscrlmlnatory rlsk work
Ten principles of anti-discriminatory risk work
A holistic and culturally appropriate approach is necessary for accurate risk work with
BME people. Narrow medical or clinical approaches to mental distress must be avoided.
Risk minimisation must be balanced with risk-taking to ensure change and opportunities
for personal growth and development within the persons particular cultural framework.
Risk work is an ongoing process that changes according to the BME persons needs and
circumstances at any particular point in time.
BME service users must be facilitated to actively participate in the process of risk work
as much as possible despite a legacy of poor service; this will lead to more effective risk
management.
Practitioners must refect on their own practice in risk work especially their prejudices
and stereotypes and the impacts on the way they make judgements about risk.
Decisions about risk should not lead to people being blamed for being the problem. In
other words, risk being seen as inherent to the individual rather than being present in the
situations in which people fnd themselves.
Risk factors must not be used stereotype or make assumptions about particular groups
of people. Practitioners must still make judgements based on the evidence about the
individual person and their specifc situation.
Record-keeping and communication with other professionals involved in risk work must
be accurate and free from stereotypes and discriminatory or prejudicial language.
Confdentiality of information gained in risk work is bound by the legal principle that
where a clear and signifcant risk exists of the person causing harm to others confdence
may be broken if there is no other way of dealing with the situation.
Clear and accurate communication with everyone working with the person is essential
for good practice, especially where English is not the frst language of the person.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
BME service user quote
The system only reacts to people who are noisy and a public nuisance -
theyre not interested in your real problems, if youre suffering inside.
Session 12 - Practice Development Tips
Guard against risk assessments that are too narrowly focused around symptoms of
mental distress or problematic behaviour and make the assessments more holistic.
Ensure that BME people who are deemed to present high levels of risk are having
their general needs met in an anti-discriminatory and culturally appropriate way (par-
ticularly watching out for stereotyping of people on the basis of race, ethnicity, gender,
sexuality, age, class or religion).

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Appendix RECC Report to Senior Managers
Introduction
The set of templates in the Senior Managers Report are linked to the twelve Work Tasks
contained in the Practice Development Workbook. The purpose of the Work Tasks is to en-
able RECC participants to bring their learning into their practice. However, in undertaking
these Work Tasks practitioners will generate very useful information and evidence of practice
in the service that would be valuable for senior managers who are responsible for designing,
planning and developing local mental health services.
In order to collect this information in an anonymised form and accurately but succinctly
capture the key points that staff would wish to communicate to senior management, this
report gives space for one point from each participant on each of the tasks they undertake.
The process for practitioners in identifying learning and defning a key message they wish to
send to senior managers is supported through at least one supervision session with a staff
members line-manager and then discussing fndings with colleagues in the RECC training
programme group. The RECC trainer is responsible for compiling the report as participants
focus down on their key points through the follow-up exercise on each task at teaching Ses-
sions or on follow-up half days if RECC is being delivered as a series of one-day Workshops
covering four Session per day.
So the report presents a really valuable opportunity to get some base-line evidence of cur-
rent mental health practice in a locality with BME service users. This data can then be used
for staff to improve their practice and managers to create a better service culture, design bet-
ter systems and understand the impact of policy and procedures on staff and BME service
users. Copies of the report could be handed out to participants to enable them to have some
baseline information about services as well, particularly if people are planning to do further
practice development work in BME mental health after the RECC programme ends.
Ten principles of anti-discriminatory risk work
A holistic and culturally appropriate approach is necessary for accurate risk work with
BME people. Narrow medical or clinical approaches to mental distress must be avoided.
Risk minimisation must be balanced with risk-taking to ensure change and opportunities
for personal growth and development within the persons particular cultural framework.
Risk work is an ongoing process that changes according to the BME persons needs and
circumstances at any particular point in time.
BME service users must be facilitated to actively participate in the process of risk work
as much as possible despite a legacy of poor service; this will lead to more effective risk
management.
Practitioners must refect on their own practice in risk work especially their prejudices
and stereotypes and the impacts on the way they make judgements about risk.
Decisions about risk should not lead to people being blamed for being the problem. In
other words, risk being seen as inherent to the individual rather than being present in the
situations in which people fnd themselves.
Risk factors must not be used stereotype or make assumptions about particular groups
of people. Practitioners must still make judgements based on the evidence about the
individual person and their specifc situation.
Record-keeping and communication with other professionals involved in risk work must
1.
2.
3.
4.
5.
6.
7.
8.
RECC - ESC Advanced Module
Page l55 Tralners Manual : Sesslon l2 - Antl-dlscrlmlnatory rlsk work
be accurate and free from stereotypes and discriminatory or prejudicial language.
Confdentiality of information gained in risk work is bound by the legal principle that
where a clear and signifcant risk exists of the person causing harm to others confdence
may be broken if there is no other way of dealing with the situation.
Clear and accurate communication with everyone working with the person is essential
for good practice, especially where English is not the frst language of the person.

9.
10.
RECC - ESC Advanced Module
Page l56 Tralners Manual : Appendlx (PLCC Peport to Senlor Managers)
RECC REPORT
TO
SENIOR MANAGERS
Report by RECC Trainers:
Date:

RECC - ESC Advanced Module
Page l57 Tralners Manual : Appendlx (PLCC Peport to Senlor Managers)
Work Task 1 Understanding Culture Change
To enable participants to refect on change in their service culture and gather useful
data for managers on this issue.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Trainers Comments:
RECC - ESC Advanced Module
Page l58 Tralners Manual : Appendlx (PLCC Peport to Senlor Managers)
Work Task 2: Examining own beliefs & assumptions
This activity begins to unpack the cultural infuences on people who work in mental
health services and those who use them.
~ Describe one common belief about mental health service users that has most
infuenced your services culture in relation to BME issues. Share an example of how
this happens in your service with your colleagues and managers.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Trainers Comments:
RECC - ESC Advanced Module
Page l59 Tralners Manual : Appendlx (PLCC Peport to Senlor Managers)
Work Task 3 Breaking the circles of fear
To enable participants to refect on how their service engages with BME people and
identify ways of reducing fear between BME service users and practitioners and
improving access to services.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Trainers Comments:
RECC - ESC Advanced Module
Page l60 Tralners Manual : Appendlx (PLCC Peport to Senlor Managers)
Work Task 4 Breaking barriers to communication
To identify barriers to good communication between BME service users and practi-
tioners in local service settings.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Trainers Comments:
RECC - ESC Advanced Module
Page l6l Tralners Manual : Appendlx (PLCC Peport to Senlor Managers)
Work Task 5 Team & Organisational Culture
To examine areas of cultural differences between personal, team and organisational
cultures which may the source of tensions within organisations.
~ Identify one way of creating a more inclusive culture in your service
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Trainers Comments:
RECC - ESC Advanced Module
Page l62 Tralners Manual : Appendlx (PLCC Peport to Senlor Managers)
Work Task 6 Promoting Race Equality
To look at ways that local mental health services can better promote race equality.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Trainers Comments:
RECC - ESC Advanced Module
Page l63 Tralners Manual : Appendlx (PLCC Peport to Senlor Managers)
Work Task 7 Empowering BME service users
To use the model of personal empowerment presented in this session with a current
BME service user.
~ Identify one main way that your team and your service as a whole can help you to
implement these strategies for individual empowerment of BME service users.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Trainers Comments:
RECC - ESC Advanced Module
Page l64 Tralners Manual : Appendlx (PLCC Peport to Senlor Managers)
Work Task 8 Empowering BME families
To identify an empowering approach to working with BME families and carers and
understand the importance of community context for many BME service users.
~ Identify one main way that your team and your local Community Development
Worker could help you to implement your strategy for empowerment of the BME
family/carers involved.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Trainers Comments:
RECC - ESC Advanced Module
Page l65 Tralners Manual : Appendlx (PLCC Peport to Senlor Managers)
Work Task 9 Understanding discriminatory situations
This activity encourages practitioners to take a deeper look at discriminatory situa-
tions involving BME service users in their own services and consider if more effec-
tive responses are possible.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Trainers Comments:
RECC - ESC Advanced Module
Page l66 Tralners Manual : Appendlx (PLCC Peport to Senlor Managers)
Work Task 10 Identifying needs in a holistic way
To identify practical ways of making assessments of BME service users more ho-
listic. ~ Write a short statement about your plan to improve assessments for BME
service users, including why it is important for local services.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Trainers Comments:
RECC - ESC Advanced Module
Page l67 Tralners Manual : Appendlx (PLCC Peport to Senlor Managers)
Work Task 11 Improving assessment & planning processes
To ensure a person-centred approach to planning following a holistic assessment
and checking the cultural appropriateness of service responses.
~ What are the main barriers to creating a culturally appropriate package of assis-
tance for this BME service user in your area?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Trainers Comments:
RECC - ESC Advanced Module
Page l68 Tralners Manual : Appendlx (PLCC Peport to Senlor Managers)
Work Task 12 Anti-discriminatory risk work
To evaluate risk work in local mental health services against the principles for anti-
discriminatory practice presented in this Session.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Trainers Comments:
RECC - ESC Advanced Module
Centre for Clinical and Academic Workforce Innovation,
University of Lincoln is based at:
K2, Mill 3
Pleasley Vale Business Park
Mansfeld
NG19 8RL
Tel: 01623 819 140
ccawi@lincoln.ac.uk
www.lincoln.ac.uk/ccawi

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