The Benefit of a Culturally Informed Approach During … Benefit of a Culturally Informed Approach During Practice Development: “One Shoe Size Does Not Fit All”. 2 Abstract An

The Benefit of a Culturally Informed Approach During Practice Development: “One Shoe Size Does Not Fit All”.

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The Benefit of a Culturally Informed Approach

During Practice Development:

“One Shoe Size Does Not Fit All”

Author: Cordwell Thomas

September 2013

“Leaders who do not act dialogically, but insist on imposing their decisions, do not organize the people – they manipulate them. They do not liberate, nor are they liberated: they oppress.”

Paulo Freire


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Abstract An investigation of empirical and real life practice informed the researcher of a

communication gap between professionals and service users. More so, when Forensic

Community Mental Health Team (FCMHT) social workers at times ‘grapple’ with the

concept of culture when communicating with diverse service user groups. At the same

time, a snapshot from a cohort of local African-Caribbean mental health service users

perceive their cultural needs and voices go unheard amongst social care and health

professionals, potentially placing them at greater risk should their cultural needs not be

adequately reflected within assessments or during crisis interventions.

The researcher’s intervention led to the development of an ‘Advance Decision

Information Document’ (ADID) framework. The purpose of the ‘ADID’ is to contribute to

the learning organisation and practice education by augmenting cultural dialogue

between ‘essential contacts’ / professionals and service users. This approach

promotes inclusiveness during service user’s assessments and moves towards an

equitable distribution of social care and health services.

The researcher used a mixed methodical approach, which included action research,

questionnaires, primary and secondary data, worked collaboratively with a sample of

four participants (co-researchers) and a mental health service user focus group.

The researcher found that the ADID makes reference to the African-Caribbean

discourse within a whole system assessment, as opposed to an assessment that

significantly focuses on risk aversion. Mental health community leaders and

participants agreed that the use of a culturally informed approach, namely the ADID is

highly relevant within social care assessments and practice education.

In conclusion the ADID’s objective is to contribute to the improvement of professional

and service user’s dialogue, thus attempting to remove the ‘Berlin Wall’ between social

care / health professionals and service users / carers.


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Abbreviations and Definitions

Advance Decision Information Document (ADID) - Is a retrospective multifunctional

document which contains the wishes and feelings pertaining to a service user’s future

social care and health treatment, should he / she lose mental capacity to make their

own decision.

African-Caribbean - The term African-Caribbean within this inquiry refers to

individuals whom are of African ancestry, descendents of the Caribbean.

Agency – Is another word for organisations, but particularly organisations that serve

the public.

Berlin Wall – A metaphor for any significant division between people and groups

derived from the wall that separated West Berlin from the former German Democratic

Republic.

Carer – The term ‘carer’ (sometimes referred to as unpaid or informal carer)

recognises a key role and comes with formal entitlements embodied in legislation.

CIA - Culturally Informed Approach.

Collaboration - The application of knowledge, skills, values and motives to translate

the goals of partnership into effective practice.

CPD – Continual Professional Development.

Dominant Discourses – The researcher identified Sutherland (2011) conceptual

literature, its unique central African-Caribbean discourse to derive from the African-

Caribbean culture, which Sutherland expresses it is a culture that encompasses

community, identity and spirituality. Sutherland’s basis is integrated into the ADID

framework to promote the African-Caribbean’s general well-being when planning core

services for this group.

Essential Contacts – the researcher’s term ‘essential contacts’ as used within the

ADID interchanges with the term professionals at times. In this instance Essential

Contacts are those professionals and affiliated staff in partnership to provide specialist

skills, knowledge and or particular services for the service user. Essential Contacts

may come in the guise of several entities, such as the carer, statutory, voluntary and

the church for example. Generally the role of the named Essential Contact on the ADID

is involved in the service user’s commissioned care / support / care plan to assist and


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sustain the service user’s mental health, physical health and spiritual welfare during

the service user’s crisis, intervention and recovery.

Essential Shared Capabilities Framework (ESC) – is a government framework,

which makes it explicit what should be included as core in the curricula of all pre and

post qualification training for professional and non-profession staff as well as being

embedded in induction and continuing professional / practitioner development.

Forensic Community Mental Health Team (FCMHT) – Service users diagnosed with

a severe mental health disorder for example Paranoid Schizophrenia, with a known

history with the Criminal Justice System and living in the community will usually receive

a social worker from the FCMHT.

Good Mental Well-Being – is a state of feeling satisfied, positive, being productive,

realising your abilities, being able to cope with the daily stresses and survive situations

which are difficult. (Ask.com, 2012).

GRRAACCEESS -Gender, Race, Religion, Ability, Age, Class, Culture, Ethnicity,

Education, Spirituality and Sexuality is recognition of the individual’s uniqueness,

promoting and respecting the individual’s unique difference(s).

GSCC - The GSCC, was the former regulatory body for social workers, which became

obsolete in 2012.Superseded by the Health Care and Professional Council (HCPC)

which is now the regulating body for social workers and other health and care

professionals.

Inter-professional Education – Involves educators and learners from two or more

health professions and their foundational disciplines who jointly create and foster a

collaborative learning environment. The goal of these efforts is to develop knowledge,

skills, and attitudes that result in inter-professional team behaviours and competence.

Partnerships – Tends to be used particularly when formal, cooperative arrangements

are being described. Whether formal or not, partnerships may be thought of as a state

Person-Centred - Person-centred working means that the wishes of the service user

are the basis of planning and delivering support and care services.

Practice Learning- SCIE (2003) defines practice learning as; “that learning from

practice is an essential feature of a competent workforce”. As “we know that for many

employers and social workers their first priority is to improve a social worker’s range of

skills so that they can identify and apply in practice the most appropriate interventions”

(SWRB, 2010).

Service User – People who use care services.


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SWRB – Social Work Reform Board.

SWTF – Social Work Task Force.


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Chapter 1

Introduction

Within the introduction chapter it is the researcher’s intention to express what informed

his inquiry and the development of the ADID framework.

From a descriptive level, the researcher’s use of the term African-Caribbean within this

inquiry denotes a group of people whom are of an African ancestry, descendents of the

Caribbean.

1.1. Researcher’s Ontology, Epistemology

The researcher identifies himself as a Black British man, of Jamaican descent, born

and lives within inner London. The researcher’s concrete experiences, knowledge,

passion and curiosity of working within humanism and the classical dominant discourse

of economic, legal and biomedical structures and its dichotomy, also interests the

researcher.

The researcher’s status is that of a mental health advocate, of fifteen years, working in

an inner London mental health, third sector organisation that has a constitutional

mission to advocate for vulnerable African-Caribbean adult mental health service users

and carers equitable access to appropriate services.

1.2. Rationale and Background Information

The researcher’s use of a mixed methodical and empirical inquiry aims to address and

improve cultural understanding during the interface of health and social care

professionals, when communicating with service users during the course of health and

social care assessments. Within the context of culturally diverse groups Bhate and

Bhate (1996) argue that communication difficulties can arise and be a barrier due to

professional’s and service user’s cultural differences.

For the development of culturally sensitive communication that supports professionals

during service user's needs assessment, the researcher relied upon a Culturally

Informed Approach (CIA). Graves et al (2009) defined a Culturally Informed Approach

as “using a cultural lens” to address various issues such as cultural, social and health

issues. CIA is grounded throughout this inquiry.


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The researcher’s purpose of applying a CIA within the research inquiry is to enable the

exploration of a deeper cognitive and educational understanding of the professional

and service user’s assessment challenges. For example, at times black disabled

people have multiple identities and support needs, “their experiences have been

described as ‘double’ or ‘triple’ discrimination (e.g. as a black disabled woman) as

multiple oppression. Services aiming to support black disabled people must recognise

the complexity of identity” (Singh 2005, Sutherland, 2011).

The Advance Decision Information Document (ADID) (Appendix 1) aspires to be a

local, pluralist action that contributes to a local strategy provision detailed prevention

and crisis planning document. The researcher’s ambition to create a CIA based

safeguarding framework was influenced by detained mental health service user’s

deaths in detention.

The ADID was influenced by:

The Schizophrenia Commission (2012), which reviewed how outcomes for people with

Schizophrenia and psychosis can be improved. The ADID contributes to five of its

recommendations namely:

1. “Greater partnership and shared decision making with service users valuing

their experiences and making their presence central to a recovery focused

approach adopted by all services.

2. Extending the popular ‘Early Intervention for Psychosis’ services.

3. Delivering effective physical health care to people with severe mental illness.

4. A stronger focus on prevention including clear warning about the risks of

Cannabis, [un-prescribed drugs and the abuse of prescribed drugs].

5. A better deal for long-term carers who should be treated as partners”.

Secondly, The Report of the Independent External Review of the Independent Police

Complaints Commission (IPCC) (2013) investigation into the death of Mr B (as known

within this inquiry).

The IPCC inquiry of the death of Mr B, found that Mr B’s care trust, particularly the

FCMHT was criticised for not having in place a comprehensive joined-up professional’s

crisis strategy plan that was ‘fit for purpose’ at the time. As a consequence, Mr B’s

local FCMHT’s intervention was identified not to deliver the expected performance

within “No Health without Mental Health” (2011), which states that “fewer people will

suffer avoidable harm”.


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The ADID endeavours to advance the integration of service user’s person-

centeredness during an assessment and / or planning process, by informing essential

contacts of the content of the service user’s ADID to sustain ones mental health,

physical health, recovery and the significance of an individual’s good mental well-

being.

The service user’s wishes and feelings within the (dated and signed) retrospective

ADID once disseminated shall become active during a crisis and / or resolution

intervention, should the service user become significantly mentally impaired.

To deliver and increase service user’s participation on a ‘collective’ scale, the

researcher relied upon Beresford (1993) democratic model of participation. A

democratic model of participation is about service user’s participation to achieve

greater influence and control. To compare personalisation and a democratic model of

participation, a democratic model of participation relates to service provision, at the

level of policy making, resource allocation, organisation and management, as a means

of changing the experience for service users collectively rather than individually.

A democratic model of participation approach was also selected due to its properties

to work to a wider agenda of empowerment and inclusion, seeking improvements not

just in service provision but in all aspects of social experience as people want more

say in their lives, not just in services.

1.2.1. ADID an Addition to an Organisation’s Safeguarding Protocol

An analysis of the mental health situation for African-Caribbean detained patients and

service user’s on community treatment orders, reveals group vulnerability, due to over-

representation which is exacerbated owing to a lack of equitable access to culturally

appropriate services, which continues to detrimentally impinge on this community.

The perpetual damage of the problem can be seen when “ethnic minorities are both

more likely to be compulsory detained under the 1983 Mental Health Act and more

likely to receive the diagnosis of ‘psychosis’ (Mercer, 1993) and are 50% more likely to

access mental health services via police intervention through the use of Section 136 of

the Mental Health Act (1983)” (BMHUK, 2012).

“Black groups show the highest bed occupancy ratios in comparison with the White

British population, and most other BME groups. It is now well-known that, such data on


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admission levels show disproportionately high levels of detention amongst Black

patients in particular Black-Caribbean and Black-African patients” (Mental Health Act

Commission, 2009). However, Singh (2013) asserts that there is no general black

patient over- representation within psychiatric services, stating the over-representation

as a “variation in detention levels in ethnic groups is possible due to location and

service provision [rather] than ethnicity per se”.

Within a local context, at times the preventative and or crisis management of detained

African-Caribbean mental health patients have been identified by a cohort of local

African-Caribbean mental health service users as ‘significantly’ contributing to incidents

of fatalities, as illustrated below:

Vignette 1:

Mr. A. a 38-year old African-Caribbean psychiatric patient who died in 1998

from being restrained by staff whilst “being held in a face down restraint...

leading to positional asphyxiation” (MHAC, 2009) in a medium secure

psychiatric unit.

Vignette 2:

Mr. B. a 40 year old African-Caribbean man, diagnosed Paranoid

Schizophrenic, died in 2008, on a Section 136 (Mental Health Act, 1983)

whilst detained in police custody. The police watchdog, Independent Police

Complaints Commission (IPCC) found police officers acted reasonably and

proportionally. A later Inquest found lack of leadership... unnecessary force

from the police and an absence of appropriate care and urgency of response by

the police when he was in the ‘cage’ at the police station more than minimally

contributed to Mr B’s death by way of prone positional asphyxiation.

The above vignettes represent two service user’s deaths who were detained under the

Mental Health Act (1983). Both fatalities occurred within agencies that the Mental

Health Act 1983, define as a ‘place of safety’, which have left a legacy of:

• Individual and community trauma,

• The deceased family members are mistrusting and have confidence with

today’s social and health care, the families perception derived from their

experience from respective organisations.


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It is the researcher’s intention that this research inquiry is not to vilify any agency for

the above deaths but rather to satisfy organisation’s assessments and crisis

intervention gaps by using local service user and co-researcher’s intelligence to

improve local care planning systems.

The researcher makes the case that there is a professional and moral responsibility for

leaders to develop and articulate solutions to achieve the strategy vision of “No Health

without Mental Health”, to ensure that “fewer people will suffer avoidable harm” (DH,

2011) from those who possess a ‘duty of care’ under the Mental Health Act (1983)

when providing a ‘public safety’ service. This requires leaders with competence to lead

within social care and health, as the researcher views that service user and

professional dialogue is pertinent as “people under the Mental Health Act account for

61% of all deaths of people detained by the state” MacAtram (2012).

1.2.2. Trauma

Local African-Caribbean mental health services users and carers informed the

researcher that, “the death of Mr. B remains ‘traumatic’ and ‘poignant’ with us” (Source,

service user group discussion. November, 2011).

To enable the researcher to understand the affect of ‘trauma’ upon service user’s

cognitive psychology, the researcher discussed ‘trauma’ with the service user group.

The consensus from the group was that trauma was a dominant factor, which has had

an historical impact on service users from service providers.

Tummala-Narra (2007) conceptualised trauma in differing ways, from the more

stringent criteria of the Diagnostic and Statistical Manual of Mental Disorders-Fourth

Edition (DSM-IV) of ‘one adverse event’ to ‘a more ecological view of trauma in which

psychological harm can arise from a wide array of experiences over time that interact

with development’. Frederick (1995) illustrates the view of local African-Caribbean

service user’s and carer’s diminished feelings of trust and confidence from local social

care and health services.

1.3. Research Mindedness

“The responsibility to improve and protect our health lies with us all-government, local

communities and with ourselves as individuals” (DH, 2012), compelled the researcher’s

interest to implement the ADID framework to contribute to the diversity of a systematic

assessment process within and across social care / health practice, as assessment is


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“a core social work skill” (Crisp et al, 2003) to inform practice. During times of social

change and global population movement, it is necessary to raise the capacity of health

and social care professionals to be diverse in their engagement and / or when working

with clients from a different cultural background. In addition my attempt is to raise

public trust in social work and health practice with and within the local African-

Caribbean communities.

1.3.1 Ethics

The researcher gained ethical agreement from his organisation and learning institute.

The researcher viewed ethics within the research to be pivotal as a safeguarding moral

code of conduct to protect participant’s:

• Confidentiality,

• Voluntary – all participants entered and were allowed to exit the research

voluntarily without coercion or duress,

• Transparency - the researcher outlined the purpose and methods used within

the research,

• The research intention was not to harm.

• The researcher encouraged impartiality with participants, such as the non-

practice of bias during the research.

The ADID framework is grounded within “plural structures” (Winter, 1989), such as the

above example of ethics. Ethics were applied because “in social work and social care,

ethics are typically expressed as descriptions or codes of required professional

conduct” (Whittington and Whittington, 2006). Moreover, the researcher observed

social work professional ethical principles of anti-oppressive practice, anti-

discriminatory practice, person-centeredness, the uniqueness of the individual to

empower service user’s participation as Payne (1997) states that “empowerment seeks

to help clients gain power of decision and action over their own lives”.

For the ADID to aspire to an ethical watermark the researcher compared Mills-Powell

and Worthington (2007) G.R.R.A.A.C.C.E.E.S.S. against researcher [ethical] principles

(D.H., 2005), which states “whenever relevant, researchers need to take into

consideration age, disability, gender, sexual orientation, race, culture, ethnicity and

religion in the research design”. The researcher viewed that G.R.R.A.A.C.C.E.E.S.S.

which encompassed Gender, Religion, Race, Ability, Age, Class, Culture, Ethnicity,


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Education, Spirituality, Sexuality represents the local and wider scope of the populous’

uniqueness.

1.3.2. GRRAACCEESS, Culture, Community, Identity and Spirituality

During the inquiry, a reliance will be placed upon the individual’s

G.R.R.A.A.C.C.E.E.S.S. Specifically, culture with an emphasis on the disenfranchised

African-Caribbean mental health consumer, will be explored by means of Sutherland

(2011) African Centred Approach discussion, which asserts that African-Caribbean

culture to be dominated by its own culture, community, identity and spirituality.

Sutherland purports services should incorporate an African Centred Approach when

developing services to be used by African-Caribbean people.

1.4. Compliant with Statute and the Recovery Model

The researcher’s CIA framework will be developed in best practice with the Mental

Capacity Act 2005 (MCA, 2005) principle framework, points one to five, when

supporting people to make decisions.

The ADID respects the ‘Recovery’ model, to raise service user’s social engagement.

“For many people, the concept of recovery is about staying in control of their life

despite experiencing a mental health problem. The ADID is founded on recovery

principles and ‘values based practice’ (VBP) as they were found to dovetail well. VBP,

like recovery, promotes service users delivery of genuine options in care, which derive

from diverse skills and resources of a multi discipline team. Moreover VBP, like

recovery, promotes those most directly concerned such as individual users and

providers working together in the real-life contingencies of day to day care to be

significant within the decision-making process (Allott et al, 2002).

1.5. The Four Components of Cultural Competence

For greater insight to assess and promote cultural competence awareness during the

development of pre and post questionnaires the researcher was informed by the

Diversity Officer Magazine, (2011). Moreover its headings which state that the term

‘educational’ has four major components, which are:

1. Awareness.

2. Attitude.

3. Knowledge.

4. Skills.


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1.6. Lean Thinking

On a macro level, the impact of central government’s lean thinking austerity measures

upon public services has also impinged upon the delivery of the researcher’s

organisation “core business” (Fairtlough, 2006), which led to the closure of a whole

department and the redundancy of six colleagues that provided an assertive outreach

service for disabled, hard to reach African-Caribbean mental health clients living in the

local community. Bosely, (2012) states that “the reduced funding to mental health

problems, which account for almost 40% of all illnesses but only 13% of NHS funds are

devoted to their treatment”. The ‘scandalous’ scale of the NHS’ neglect of mental

illness is described in a report by the London School of Economics, which suggest that

only a quarter of those who need treatment are getting it.

The scarcity of available research of using a CIA during practice development i.e.

‘using a cultural lens’ at the core of delivering an equitable African – Caribbean mental

health assessment, led the researcher to develop a best practice ADID framework that

cuts across local social and health care to improve the present situation.

1.6.1. Using Dialogue to Gain a Competitive Edge

ADID intends to be an entrepreneurial interactive framework with the potential to

promote positive joined-up working whilst advocating for the service user. Jarvis,

(1999) suggests that to “maintain a competitive edge depends upon processes of

continuous [cross-organisational] improvement. There has been an emerging view that

this requires a commitment to continuous learning”. The competitive edge of the ADID

is influenced by P.E.S.T.L.E. Political, Environmental, Sociological, Technology, Legal

and Economic. Schein, (2011) states that; “we must put dialogue, culture and

organizational learning in the context of changes that are occurring in the

organisational world”. Millar and Ridings (2012) discussed dialogue as “a balancing of

advocacy and inquiry, as each has value and purpose”.

• “Without advocacy there is no shaping or aligning energy in a conversation, no

traction. A conversation may become circular, lacking focus and feeling

repetitive, leading to disengagement.

• Without inquiry, there is no supporting energy, no sense of space in which new

possibilities can emerge. A conversation may become confrontational, as each

party makes their point more energetically, perhaps excluding other voices and

generating frustration or anxiety”.


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1.7. Problem to Be Explored

“Epidemiological studies in the UK consistently reported increased incidence rates of

Schizophrenia among ethnic minority groups (Harrison et al 1997; Wessely et al 1991).

Moreover, “professional (and bureaucratic) models of the relationship of service

providers to service users tended to treat user’s views in assessment as inexpert and

subordinate” (SCIE, 2007).

A recent annual social worker conference discussed the state of today’s social work,

that there is “an over-emphasis on a bureaucratic medical model [that] is preventing

mental health social work from reaching its full potential” (BASW, 2013). In the context

of social workers engaging with clients there is a concern from some local mental

health service users “who use services and their families continue to report not being

listened to, being marginal to assessment and care planning and being rendered

helpless rather than helped by services” (DH, 2004). Mr B’s sister concurs that her

encounter with Mr B’s local FCMHT was not a positive experience, (source, community

meeting, July 2013).

Prima facie, the above professional (and bureaucratic) models demonstrate

deficiencies not compliant with the Mental Capacity Act (2005) principle framework

when supporting people to make decisions.

From a psychological perspective, the Psychologist Eric Berne’s Transactional

Analysis (Businessballs.com, 2013), theory of personality and communication suggests

that the psychological structure, the ego-state of the professional and or (bureaucratic

models) the organisation omitted to display an adult to adult interactive communication

when assessing / care planning for service user’s and families needs. It would appear

that the professional manifested as the powerful arbitrary parent and the service user

and / or the family as the submissive compliant child or in some cases the defiant child.

It can be construed that the above professional’s (and bureaucratic model) parens

patriae justification is operated on the basis that the state has the right to non-confer,

as it is the parent of its citizens, thus creating paternalism by law. When compelled the

state may demonstrate its responsibility to interfere into the liberty of the individual.

However, such an interference is devised to prevent harm to self and to prevent harm

to others. More so, such an interference should be a positive experience as stated by

the Utilitarian, John Stuart Mill (1974).


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From a local perspective, the researcher uses the metaphor ‘Berlin Wall’ to describe

the situation between local African-Caribbean service users and professionals, which is

corroborated by a plethora of research and reports prior and subsequent to “No Health

Without Mental Health” (D.H., 2011), which identified that mental health services fall

short to deliver an appropriate comprehensive service to African-Caribbean mental

health service users.

It is concerning that culture can potentially be misconstrued and detrimental to the

recipient’s health assessments, as observed by the researcher in his role as a mental

health advocate. The researcher’s recall of an assessment when his client was

restrained by a psychiatric hospital’s control and restraint (C and R) team. The control

and (intravenous) restraint was said to be justified by professionals because they pre-

empted a deterioration of the service user’s behaviour. It was said that ‘the service

user used too much hand gestures, which became more animated’ during his

discussion with the consultant about his socio-economic situation.

The researcher has observed that an individual’s social determinants of health can

manifest itself due to socio-economic situations and the impact can be compounded

further when linked to:

1. Chronic Mental health issues.

2. Chronic Physical health issues.

3. Living within substandard housing.

4. Chaotic childhood development.

5. Lack of decent employment.

6. Deficiency of nutritious food.

7. Weak policies and or practices, that contribute to social injustices.

8. Non-effective prevention and treatments, for example.

The above pathologies may severely contribute to ones social determinants of health.

The accumulative affect of the (above) client’s socio-economic plight induced his

inability to function within his community, which debilitated him to provide for his

family, which further affected the function of his overall mental well-being.

Subsequent to my client’s restraint, I had a discussion with two members of the control

and restraint team (who were both European, males) who interpreted the service

user’s gesturing to be threatening. The researcher discussed with them that the client

has a known tendency to use his arms during discussions, which seemed to pose no


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risk. The researcher further pointed out to the professionals that during dialogue such

arm movement is culturally appropriate and acceptable behaviour, which has now

become stereotyped as symptoms of abnormality or aggression. No response was

given from the C and R team members.

The shortcoming of professionals understanding of culture awareness is not a new

phenomena. It was considered half a century ago by Williams (1963) that, “the term

culture is one of the most difficult and contested concepts in social sciences and

humanities”. Whilst Williams was tussling with the concept of culture, poignantly the

same year in America, Martin Luther King Jr gave his ‘I Have a Dream Speech’. 2013,

the ADID inquiry is not to research a strict literature meaning of culture, but to be that

conduit that improves service user and professional’s culture dialogue, towards a more

comprehensive assessment and planning process, aiming to eliminate any service

user and / or professional assumptions and / or stereotypes.

Bhopal (1988) argued that “the medical literature on the health of Black and minority

ethnic communities has been inappropriately dominated by studies of relative risk.

There has been an over-emphasis on diseases with high relative risk among Black and

minority ethnic populations [such as psychosis] as compared to the White population

[depression], considered as the norm” from a clinical interpretive perspective. Likewise,

“several authors have postulated that cross cultural biases” (Littlewood and Lipsedge;

1981a; Sashidaran, 1993; Strakowski et al, 1996, McKenzie, 1999, Zandi et al, 2010).

In regards to professional practice and practice education, there are concerns from

Allain (2007), a principal lecturer in social work, who states that “public discourse and

debate regarding issues of culture... and faith remains contested and complex

concepts”. Allain (2007), states that; “the issues are also debated by social work

practitioners who grapple on a daily basis with how they should respond to the diverse

cultural needs of service users”.

The ‘Berlin Wall’ to tackle may be compounded further with the demanding schedule of

the modern social care / health professional and other essential contacts who may be

constrained by their non-exhaustive duties, that “much social work intervention

continues to be punitive and is aimed disproportionately against working-class woman

and a variety of minority groups” (Jones, 2001). As a consequence, social and health

care services can create barriers that prevent service user’s involvement during what

should be a congruent assessment to evaluate needs, as “the idea of professional or


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organisational assessment is an inherent feature of contemporary practice in care

services” (SCIE, 2012). Allain (2007) further states that, “there are challenges and

concerns when professional’s practice is informed by a sheer Eurocentric approach,

based upon the exclusiveness of evidence based practice”.

The ‘rigidness’ of social work practice was also discussed within the Munro Review of

Child Protection: Final Report (2011), whereby “services have become so standardised

that they do not provide the required range of responses to the variety of need that is

presented” within today’s changing society. Munro, recommends “a radical reduction in

the amount of central prescription to help professionals move from a compliance

culture to a learning culture, where they have more freedom to use their expertise in

assessing need and providing the right help” would mean an improved change from

the present situation within the ‘learning organisation’. To comprehend what a learning

organisation should look like, SCIE (2004) describes that a learning organisation

consists of:

1. Organisational Structure.

2. Organisational Culture.

3. Informational Systems.

4. Human Resources Practices.

5. Leadership.

1.7.1. Facilitate Change / Improvements

To achieve the intended paradigm shift, the researcher shall use his professional

influence with social care, health and the third sector and community leaders to

diligently introduce the ADID framework within his organisation and cross

organisation’s change streams that perform a duty of care role with service users to

develop crisis planning contingencies. Moreover:

• Strengthen the researcher’s organisation and across organisation’s continual

professional development (CPD) and organisation policy.

• Contribute to the researcher’s organisation and cross organisation core

business delivery of advocacy, reputation and strategic direction continuum, in

particular when collaborating with his local African Caribbean service users and

carers to be participants of their care plan and design of appropriate local

services.

• The ADID is to contribute to the researcher’s organisation and the wider local

whole systems assessments of cross organisations when delivering inter-


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professional ‘joined up working’, to deliver service user’s ‘personalisation’ plans,

with the intention to “improve the quality of communication and interaction

between different cultures and ethnic groups” (Bowie et al, 2011).

1.8. Central Research Questions

1. How relevant is dialogue between service user and essential contacts when

creating culturally sensitive safeguarding interventions?

2. How beneficial is Sutherland’s (2011) African Centred Approach discussion

within the inquiry?

3. How relevant is a CIA during social and health care practice / development?

1.8.1. Researcher’s Community Knowledge

The researcher shall rely on his experiential learning and self-directed knowledge of

change processes, business acumen, project management skills, service user

engagement and reflective practice. Cohen and Manion, (1989), suggests that “it is

appropriate in any context when specific knowledge is required for a specific problem

in a specific situation, or when a new approach is to be grafted on to an existing

system”.

The researcher’s ADID is a new approach to be grafted on to an existing [social and

health care] assessment system” to deliver meaningful desired outcomes to service

user and professionals alike. It is with the above reference from Cohen and Manion

(1989) that the researcher aims to explore and build upon the (below 1-3) local,

national and international drivers to develop a local culturally informed approach ADID.

1. The researcher shall apply local service users’ responses from his organisation’s

publication of Reachin’ Out (Frederick, 1995), to develop the ADID framework.

2. The researcher shall explore the relevance and implication(s) of Zandi et al (2010)

benefits of a culturally sensitive assessment and Sutherland’s (2011) African

Centred Approach within the plausible design of a local ADID.

3. The ADID endeavours to implement the Delivering Race Equality (DRE) in Mental

Health (DH, 2005) agenda, specifically:

• The development of appropriate, sensitive and responsive services;

• The engagement of BME communities and

• Good quality, intelligently used information on the ethnic profile of local

populations and of service users (DH, 2005).


19

The Health and Social Care Act (2012) has made explicit the aim to achieve parity of

mental health with physical health in effect reaffirming. This reaffirms “No Health

without Mental Health” (2011) the National Mental Health strategy. Underpinning this

enquiry is the compelling vision of “No Health without Mental Health which sets out six

objectives to facilitate improving mental health for the nation:

1. More people will have good mental health

2. More people with mental health problems will recover

3. More people with mental health problems will have good physical health

4. More people will have a positive experience of care and support

5. Fewer people will experience stigma and discrimination

6. Fewer people will suffer avoidable harm.

Chapter 2

LITERATURE REVIEW

To perform the inquiry, the researcher was informed by literature from various primary

and secondary data to gain an objective input, such as: specialist health and social


20

work subscriptions, books, journals, websites, reports, newspapers, professional social

worker bodies, statutes and library databases.

Fox (1969) discussed two kinds of literature which should be reviewed. “The first is

‘conceptual literature’ those written by authorities on the subject, giving opinions, ideas,

theories or experiences and published in the form of books, articles and papers. An

emphasis is given to Sutherland (2011) within the literature review chapter and

throughout the body of research. The second is empirical ‘research literature’ which

gives account and results of research which has been undertaken on the subject (in

this instance from a culturally informed approach) and is often presented in the form of

papers and reports”, such as Zandi et al (2010), which shall be discussed within this

chapter and subsequent chapters.

Brockbank and McGill, (1998) suggests that the researcher’s “capacity to engage in

reflective practice becomes one of the means of enhancing the quality of the

educational process and of promoting learning appropriate to higher education”. The

insightful knowledge gained from the literature review enriched the researcher’s

contribution and raised taxonomy.

The researcher used the term ‘educational’ throughout the inquiry as opposed to

education, as Whitty (2006) states that “education research should characterise the

whole field whilst educational research should refer to the narrower field of work

specifically geared to the improvement of policy and practice”, which is what the ADID

offers.

2.1. Local Service User Participation

A conceptual literature within this research inquiry that reflects the reconstruction of the

local service user’s focus group is Tummala-Narra’s (2007) definition of trauma, as

discussed above, remains a factor of the local African-Caribbean service user’s

reticence to engage in a positive dialogue with local social care and health

professionals.

The present communication between local service users and professionals may seem

‘grim’. Likewise, local service user’s participation may outwardly seem ‘hard to engage’

due to their scepticism of the rhetoric derived from related policies.


21

It is the researcher’s experience from previous research that local African, African-

Caribbean service users are willing to be involved in practice education research

provided that transparency, respect and other ethical matters are adhered to. In

contrast, Singh (2005) stated that “Black communities are tired of taking part in

research that asks them what they want from services, only to find nothing happens

until five years later when they are asked the same questions over again”.

The researcher’s optimism, informed by the dialogue principles (above at 1.6.1.) that a

positive change of the present situation can take place to engage local service users to

plan and / or co-plan their own preventative / crisis care plans. On a larger scale, Webb

(2008) states that, “service user participation is now a global phenomenon, with

stakeholder involvement having high priority on many current government policy

initiatives”, as illustrated within:

• ‘No Health without Mental Health’ (D.H, 2011), wherein “users of services will

increasingly be able to make decisions about their own healthcare, they and

their carers may wish to become involved in the planning and design of local

services”.

• ‘Time to Change’ (2008)’, involves service users and carers on a national level

to be participants to promote the nation’s mental health anti stigma and anti

discrimination campaign.

• Network NSUN, an independent service user led charity that connects people

with experience of mental health issues to the shaping policy and services.

2.2. A Partnership Approach

Just as service users participated within ‘No Health without Mental Health’ (D.H.,

2011), ‘Time to Change’ (2008)’ and the present research inquiry on a local level. The

involvement of service users during the design of services was discussed within

“Delivering Racial Equality” (DH, 2005; Frederick, 1995), which along with the

Modernisation Agenda’s “wide-ranging policies introduced... for alignment within a

globalised, market-driven world in which business performance standards should apply

to all... so did partnership, between services and with service users, in pursuit of

efficiency and a more effective, consumer-orientated service” (SCIE, 2009).

Marketisation defined as “a system where relationships and behaviours are driven by

competition and profit” (Health Service Journal, 2013) is yet to be evaluated for its

emergency activity to deliver diverse, real life changing outcomes in the best interests

of local African-Caribbean mental health service users, from the context of a


22

reconfigured local FCMHT, health care service provision and a recent pilot British

transport police and Metropolitan police Triage service. The Triage aim is to enable the

joined-up working of mental health professionals and the police during community

patrols, to “give [police] officers the skills they need to treat vulnerable people

appropriately in times of crisis” (SLaM TWIG (2013).

In regards to competing service delivery, Frederick (1995) service user’s summary

(Appendix 2) provided the researcher with a local service users’ summary of local

mental health assessment services. Sixteen years on from Frederick’s (1995)

supposition, the national strategy of “No Health without Mental Health” (2011) states

that “there is clear evidence that mental health services do not always meet the needs

of certain groups, particularly black and minority ethnic (BME) communities”.

In spite of Frederick (1995) and “No Health without Mental Health” (2011) endeavour to

bring about local and national equitable changes within African-Caribbean mental

health services, the researcher identified the implementation of Frederick (1995), “No

Health without Mental Health” (2011) to have its own limitations. Specifically, both were

without a framework of how their vision was to be amalgamated into;

1. Social and health care practice education.

2. How to improve local organisational and inter professional partnerships.

3. It was neither discussed what knowledge and skills were required to fulfil

organisation’s core business when engaging with local service users, in

contrast to the five year plan of “Delivering Race Equality in Mental Health

(DRE), (2005) ”three point national vision (see 1.8.1), which derived from the

high profile death of Mr. B and subsequent government inquiry.

The DRE (2005) required five hundred Community Development Workers around

England and Wales to engage with Black and Minority Ethnic (BME) communities to

become involved with the mental health needs of their local community and fed local

data and intelligence back to the service planning commissioners, for the purpose of

designing appropriate mental health services within a demographic area.

Albeit that the vision of DRE was quite apt, it was criticised for its limitations of non-

inclusive practice, which allowed for “Black and minority ethnic (BME) communities [to

be] frozen out of consultations” (Community Care, 2012). Lessons learnt from the DRE

(2005) strategy informed the researcher to practice inclusiveness and partnership,


23

which includes having dialogue with service users, carers, social care and health

stakeholders about how to improve the relevant local situation.

2.3. Moving Forward

In contrast to Frederick (1995) and “No Health without Mental Health” (2011), an effort

to raise inter-professional’s, joined-up working, practice education within the whole

systems of mental health services was the “10 Essential Shared Capabilities” (ESC)

(2004), a framework for the whole of the Mental Health Workforce.

The Department for Education and Skills (2005) stated that “this [joined-up working]

trend has been further cemented in place by the gathering impetus of government

reforms to the children’s workforce, which sought to establish a common skills and

knowledge base for practitioners, demanding a more integrated approach based on

multi-disciplinary teams working around the needs of children and young people which

share an increasingly common language and understanding".

Much of the joined-up working was spearheaded through by the Laming Report into

Victoria Climbie and subsequent legislation such as the Children Act 2004 (Laming

Report, 2003: Department for Education and Skills, 2004). Parton (2006) argues that

“these recent developments represent a dramatic escalation of the urgency with which

the government has begun to pursue the objective of ‘joined-up’ working”.

2.4. Essential Shared Capabilities (ESC)

It is at the point of professional induction, supervision, team meetings and CPD that the

researcher visualises the egalitarian ADID to be introduced via training to an

organisation’s workforce and to be implemented by a leading practitioner / manager

who adopts fully the joined-up working approach of “the ESC framework [which] is

aimed primarily at influencing education and training provision within the mental health

community” (DH, 2004). The ESC stipulates that professionals and affiliated staff must

achieve educational best practice, specifically:

1. Working in partnership.

2. Respecting diversity.

3. Practising ethically.

4. Challenging inequality.

5. Promoting recovery.

6. Identifying people’s needs and strengths.

7. Providing service user centred care.


24

8. Making a difference.

9. Promoting safety and positive risk taking.

10. Personal development and learning.

The introduction of the ESC made “explicit what should be included as core in the

curricula of all pre and post qualification training for professional and non-

professionally affiliated staff as well as being embedded in induction and continuing

professional / practitioner development” (DH, 2004).

The ESC design framework is an influential resource document that shall contribute to

“more inter-professional working” (Smith and Anderson, 2008). This issue of

continuum professional / practitioner continuing professional has been made more

significant since the Social Work Reform Board (SWRB), “Building a Safe and

Confident Future: One Year On” (2010) cited Social Work Task Force’s (SWTF)

“Facing Up to the Task” (2009) report, which commented on social work CPD,

highlighting that, “CPD is not yet properly valued and supported in all places and

organisations”.

The researcher’s discourse from the perspective of a third sector employee is that the

ESC contributed to the raising of the third sector worker and manager’s capability, as

CPD opportunities and access to training in the present financial climate is not always

readily available within the local social care provider community. “As for many charities,

getting through the next financial year with their services intact is the highest priority”

(Browning, 2012).

In contrast, the General Social Care Council (GSCC), now Health Care and

Professional Council (HCPC), stipulates that registered qualified social workers should

demonstrate a commitment to CPD (GSCC, 2012a, GSCC, 2012b) and employers also

have a responsibility to ensure CPD opportunities are offered to social workers (GSCC,

2002). However, the researcher is not thwarted by the two tier CPD opportunities.

Quite the contrary, the researcher concur with Vicky Browning, Director of

CharityComms, the body for charity communications professionals, when she stated

that; “charities have become more resourceful because of the cuts”, as demonstrated

within the endeavour of this ADID inquiry to influence shared learning and

development training opportunities within the professional mental health community.

2.5. Evidence Based Practice and Evidence Informed Practice


25

During the development of the ADID, the researcher placed an emphasis on the

importance of the five principles of evidence based practice, as the systematic use of

evidence is a requirement of the social work degree, which the social worker

fundamentally relies on “the conscientious explicit, and judicious use of current best

evidence in making decisions about the care of individual patients [service users]”

(Sackett et al, 1996). The five principles of evidence based practice being:

Step 1. Formulating a well-built question,

Step 2. Identifying articles and other evidence-based resources that answer the

question.

Step 3. Critically appraising the evidence to assess its validity.

Step 4. Applying the evidence.

Step 5. Re-evaluating the application of evidence and areas for improvement”

(University of Minnesota, 2012).

From evidence based practice derives “skills, techniques and strategies that can be

used by a practitioner individually or in combination” (Fixsen et al, 2005), “such as

motivation systems and social skills teaching strategies” (Grinnell and Unrau, 2011).

2.6. The Implication of the Munro Report

The Munro review intimates that ‘one shoe size does not fit all’. The effect of such a

“standardised” approach has had a detrimental effect to areas within social care

profession when delivering a diverse innovative service to the differing public, as

echoed by the concerns discussed above by Allain (2007), D.H. (2005), D.H. (2011)

and Frederick (1995).

Nationally, there has been a commitment to encourage collaboration between sectors

of the economy and government departments to tackle the big public health questions,

yet some sectors are not as optimistic of change as the researcher. Eames, (2012),

state that “with fewer resources available, it is going to become much tougher to

change fatalistic attitudes towards public health, particularly in communities with high

levels of social deprivation”, “as where you’re born is still the biggest determinant of

how long you live” (Selbie, 2012).

From the perspective of a leader, it is the researcher’s view that at times radical

interventions are necessary to obtain significant organisational changes. For that

reason the researcher viewed it vital not to rely on the ‘exclusiveness’ of an all

evidence based practice approach during the development of a culturally sensitive and


26

responsive framework. The researcher viewed this approach vital as ‘No Health

without Mental Health’, (DH, 2011) illustrated unambiguous evidence that its mental

health strategy did not always meet the needs of certain groups, specifically African-

Caribbean communities, consequentially reminding the researcher that “it is not

necessary for a common model to be introduced everywhere” (Dixon and Chantler,

2013) as the researcher frets that more of the same will deliver the same poor

outcomes.

2.6.1. Single to Triple Loop

To explore a creative solution divorced from the present single loop problem, towards

a ‘triple loop’ (Munroe, 2011) dialogue approach, the researcher’s dovetail of evidence

based practice, with the wider autonomous model of an evidence informed practice,

which should be understood as “excluding non-scientific prejudices and superstitions,

but also as leaving ample room for clinical experience as well as the constructive and

imaginative judgements of practitioners and clients who are in constant interaction and

dialogue with one another” (Nevo and Slonin-Nevo, 2011).

An absolute reliance on evidence informed practice, may not be conducive in all

circumstances. The researcher views its limitation is based on professional and service

user’s capacity to elicit (service user’s) wishes and feelings should a cultural barrier

exist. However, for evidence informed practice to support evidence based practice the

professional may rely upon a triangulation approach and / or regular supervision from a

senior practitioner for guidance. A perceived limitation of evidence informed practice

may be the professional who practices in silo. Furthermore, to gather service user’s

wishes and feelings by way of a triangulation may be time consuming, but the third

party information could be informative to complete the task.

Under the evidence inform practice approach, there is no need for evidence based

practice model’s five-steps procedure (as discussed at 2.2), but only that “practitioners

will become knowledgeable of a wide range of sources [such as] empirical studies,

case studies and clinical insights and use them in creative ways throughout the

intervention process” (Nevo and Slonin-Nevo, 2011).

Moreover, Rubin and Parrish, (2007) summarised four disadvantages of evidence

based practice;

• That it “is too mechanistic and ignores the unique characteristics of both clients

and practitioners.


27

• Is not clear enough, ignores research flaws and makes exaggerated claims

about the evidence at hand,

• It is hard to implement due to resource limitations such as time, training and

supervision,

• Due to the nature of scientific process, the empirical findings are outdated by

the time they appear in print”.

2.7. A Culturally Sensitive Diagnostic Instrument

Sutherland (2011), conceptual African-Centred Approach discussion to achieve better

outcomes by “using better evidence about what works [locally], and with more energy”

(Hughes, 2011) inspired the researcher to be guided by service users and co

researcher’s data themes to create the ADID.

The researcher’s ADID should focus on the whole person to reduce the disparity

between mental and physical health, spiritual, religious needs (if relevant) of the

African-Caribbean service user to eliminate stereotypes and assumptions, which

Fernando (1991) argues that “western conceptions of reality, rather than expressing

given actualities, based on linguistic and social constructs such as ‘individuality’,

‘competition’, ‘independence’, and ‘autonomy’.

During the inquiry, the researcher and participants discussed Sutherland (2011) and

Zandi et al, (2010) an original literature research, to complement the Eurocentric

evidence based practice approach, with an empathetic objective approach that elicits

local service user intelligence to the aspirations of “Delivering Race Equality in Mental

Health” DH (2005), as DH (2005) states that “mental health services should be good

quality, intelligently used information on the ethnic profile of local populations and of

service users”.

Zandi et al (2010) ‘single unit’, empirical research explored “whether the incidence

rates of psychotic disorders including Schizophrenia among Moroccan immigrants to

the Netherland remain increased when a cultural sensitive diagnostic interview

(assessment) is used”. The researcher relied on the originality of Zandi et al (2010) as

it was accepted that its assessment process broke out of the normative method by

demonstrating the application of a cultural sensitive instrument during the mental

health assessment, that ‘resulted in a substantial psychosis attenuation’. As a result


28

Zandi et al transformed the assessment process offered to Moroccan (immigrant)

patients and benefited service user’s good mental well-being.

The proposed introduction of the ADID within a local service user’s assessment differs

to that of Zandi et al (2010), as the nature of ADID is fundamentally a local

safeguarding, contingency document, based on the service user’s expressed

retrospective wishes and feelings, within a bi-lateral contract, as opposed to Zandi et al

(2010) clinical assessment approach that is active within the biomedical discourse.

Zandi et al (2010) research successfully elicited broader cultural social context

information to ascertain greater history evidence from non-Dutch service users during

assessments, attaining better service user outcomes. As a result, Zandi et al (2010)

relatability data provided strong evidence to support the validity and reliability of the

ADID proposal, hence giving merit to the introduction of a culturally informed approach

within local health and social care assessments.

Zandi et al (2010) research proved itself to be reliable and different from the traditional

Eurocentric assessment that is offered to European Dutch natives and others, “as

without the interaction brought about by dialogue critically reflective learning may not

happen” (Brockbank and McGill, 1998).

The researcher observes that the English Mental Health Act (MHA) (1983, 2007) has

created an institutional bias as it does not create a legal duty upon local authorities to

provide a cultural assessment service to vulnerable mental health adults. Furthermore,

the MHA (1983, 2007) disproportionately offers less safeguarding protection to

disabled mental health service users compared to another vulnerable group, namely

children, whom the legislators have protected the child’s rights to have their “religious

persuasion, racial origin, and cultural and linguistic background” given due regards

within local authorities assessments, by virtue of the Children Act (1989), Section 22

(5) (c).

In regards to adult mental health assessment safeguards, the Scottish Mental Health

(Care and Treatment) (Scotland) Act 2003 (SMHCTSA, 2003), also scopes wider than

the provisions of the English Mental Health Act (1983, 2007) to extend a duty to

provide access to cultural appropriate services, virtue of Section 2(a) (SMHCTSA,

2003).


29

2.8. An African Centred Approach

The researcher’s findings within Sutherland (2011), Zandi et al (2010), SMHCTSA

(2003) and the Childrens Act (1989) raised the indispensable equality and diversity

elements within the ADID to complement Eurocentric evidence base practice and

informed base practice to deliver adult assessments diversely within social and health

care organisations.

To validate the ADID’s acknowledgement of culture within local English health and

social care assessments, the researcher relied on the ‘Protected Characteristics’ and

prohibited conduct within the Equality Act 2010, Part 2, Chapter 1, which states that

public service providers must recognise the nine protected characteristics headers that

a public service provider should not discriminate against its citizens when providing

services, under the headings of:

1. Age,

2. Disability,

3. Gender reassignment,

4. Marriage and civil partnership,

5. Race,

6. Religion and Belief,

7. Sex,

8. Sexual Orientation

9. Pregnancy and maternity.

To promote an anti-oppressive, anti-discrimination assessment fit for a multicultural

Britain, reliance was placed on the Equality Act 2010 headers to promote the

distinction of local African-Caribbean culture needs within local health and social care

assessments, to honour service user’s spirituality, identity and positive community

networks to sustain the African-Caribbean service user’s good mental well being.

Alleyne (1996) corroborates the African-Caribbean differentiation by stating the

“African-derived features of Caribbean societies include the oral tradition, proverbs,

and parables, music, dance, art, social patterns, burial rituals, existential beliefs about

the nature of the human personality”, which goes further than the example given above

(at section 1.7) of the Afro [African]-Caribbean culture.


30

Just as Sutherland recognised the benefit of spiritual up-liftment during one’s mental

health recovery journey, Lobl (2012) presented a similar concept presented within an

American research on people with serious mental illness, concluding that “alternative

practices seem to promote a recovery process beyond the management of emotional

and cognitive impairments. Amongst care practices with individual benefits were

religious or spiritual activities such as prayer, worship attendance, and religious or

spiritual reading”. Other examples of spiritual beliefs and energy healing

complementary practices that the researcher has heard his clients to use to promote

their own recovery and well-being are:

• ‘Bush’ flowers, such as Moringa leaves

• Reike

• Meditation

• Massage.

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The Equality Act 2010

Documents

The Benefit of a Culturally Informed Approach During … Benefit of a Culturally Informed Approach During Practice Development: “One Shoe Size Does Not Fit All”. 2 Abstract An