Reinventing Children: Communities, Culture and Mental Health Policy

1
Re-inventing Children Communities, Culture and
Mental Health Policy

• Begum Maitra
• Consultant Child and Adolescent Psychiatrist
• East London and the City Mental Health Trust

2
Culture in practice Clients

• 2 year old Rokeya in Care proceedings (under the
  Children Act) for significant harm thought to be
  attributable to parental neglect
• little evidence available of the impact of
  diverse cultural styles of child care and
  parent-child interaction
• professional bias in observation, and
  attribution of meaning (the nature of cultural
  training)
• little relationship between psychological and
  legal criteria
• ME professional refers 5 year old Osman for
  disturbed behaviour (challenges authority,
  disrespect for women)
• who judges appropriateness of cultural
  patterns ?

3
Culture in practice Clients

• White mother (convert to Islam, S Asian dress,
  name and language) with 2 children of dual
  heritage judged more severely for parenting
  difficulties common to other single parents
• the failure of notions of racism or ethnic
  identity to address hybrid, and often
  changeable, identities that are based on only
  partly conscious choices
• British Asians who choose partners from their
  country of origin with the express intention to
  renew cultural ties and resources
• social class and relationship hierarchies
  impact on cultural practice, child care
  expertise family, community relationships
  (C of O Br Asians other diasporic communities
  mainstream Br culture)

4
Culture in practice Professionals

• ME staff in NHS mental health services
• Hierarchical relationships (often white
  British seniors)
• Pressure to accommodate to British norms of
  interpersonal behaviour
• Training produces uneven mixed belief systems
  (expectations and behaviour)
• What impact do these factors have on the
  identity of these professionals ?
• Organisational policy on race
• NHS - culture-blind stance the expectation
  that the patient will lead Social services -
  matching race in allocations (and placements)

5
The uneasy place of culture in mental health

• Culture and mainstream (adult) psychiatry
• Universals and culture-bound syndromes
• Cultural psychiatry - a move from categories to
  contexts
• Race and Organisations
• The effects of racist mental health services -
  poor access, abusive and culturally irrelevant
• The influence of systemic therapies on child
  mental health
• Thinking in relational/interactional terms
• UN Convention on the Rights of Children
• Universal notion of the best interests of all
  children

6
Recent events Impact of Race/Culture on Mental
Health Policy

• Race Relations (Amendments) Act 2000
• Report on Ethnic Health Inequalities 2001
• Children
• High rates of smoking and alcohol use among
  Irish children
• Low rates of dental care in all ME groups
• Low rates of participation in sports/exercise in
  all ME girls

7
Recent events Impact of Race/Culture on M H
Policy (contd)

• Inside Outside Improving Mental Health Services
  for Black and ME communities in England
  2003
• 10 point Race Equality action plan (Chief Exec
  NHS) 2003
• Report of the Social Exclusion Unit
  June 2004
• Appt of NHS Equality and Human Rights Director
  Oct 2004
• Celebrating our cultures
  Dec 2004
• Guide to mental health promotion with BME
  communities

8
Recent events Impact of Race/Culture on M H
Policy (contd)

• Delivering Race Equality (DRE) in Mental Health
  Care Jan 2005
• Ensuring MH services are more responsive to BME
  patients
• Better links between services and communities
  through
• 500 new community development workers
  and the (expertise of) independent sector BME
  providers
• Black and Minority Ethnic National Steering Group
  
• National Institute for Mental Health in England
  (NIMHE) and Department of Health BME Mental
  Health Programmes

9
and Children ?

• National Service Framework (NSF) for Children,
  Young People and Maternity Services 2004
  
• Funding (total 1.5 million) March 2005
• over 2 years for 5 projects aimed at developing
  culturally competent services for young BME
  people

10
Culture the Childrens NSF

• Services for children and young people should be
  provided irrespective of their gender, race,
  religion, ability, culture or sexuality.
  (Rationale, 2.11)
• Emphasises the importance of improving access to
  CAMHS to ensure greater equity
• Specific arrangements may need to be made to
  provide appropriate mental health care for
  children and young people in families of
  refugees/asylum seekers

11
Culture the Childrens NSF(contd)

• Concepts of mental illness and the understanding
  of the origins of childrens emotional and
  behavioural difficulties vary across cultures.
  Services need to be sensitive to these
  differences and ensure that staff are equipped
  with the knowledge to work effectively with the
  different groups represented within the community
  they serve. (Enhancing partnerships with BME
  groups, 5.3)
• Ensure all staff working within CAMHS are
  sensitive to the particular needs of ch and yp
  from different BME groups
• Training is available for staff to work
  effectively with families from specific BME
  groups within their community

12
Culture the Childrens NSF (contd)

• Provide local directories of services for ME
  groups to enable BME ch, yp and their families to
  receive appropriate support
• Recruit and train professionals from the ethnic
  minorities for whom services are being provided
• Review the provision and training of interpreters
  to ensure that best practice is achieved
• Planning commissioning services to be based on
  locally adjusted epidemiological information on
  the prevalence of MH problems to reflect the
  diversity of the population

13
Common Features

• Ethnic monitoring
• To provide data on ethnic patterns of service
  provision and service uptake
• Improve access to services
• Provide interpreting and translation
• Provide information leaflets
• Promote user feedback (on relevance and
  satisfaction)

14
Common Features (contd)

• Increase cultural awareness / sensitivity /
  competence
• Staff training on diversity issues
• Recruit BME staff
• Capacity building in ME communities
• Engage communities through consultation, use
  of advocates
• Address cultural needs - dietary needs,
  respect for religious belief
• Modernising the professions for a new health and
  social care system
• Evidence based practice
• User/Patient involvement, service design,
  choice

15
The problem with (some) solutions

• Response to Inside Outside Report -
  Transcultural Psychiatry Society (UK) in 2003
• Vague recommendations the only new money is
  for old (and ineffective) solutions eg CDW. CDWs
  need to be at a senior level. Their training,
  supervision and accountability to be defined with
  the BME communities, not statutory authorities
• MH Professional culture pervasive influence of
  narrow, culturally biased views of child
  development, long-term psychological goals,
  health and illness, culture
• A new and jarring brand of (friendly) jargon
  Race
  Equality champions Facing up to
  difference (FUD) Challenge, consult, compare
  and compete