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Culturally competent social work
Introduction
The importance of social workers, counsellors and psychotherapists
developing a culturally competent practice for working with children and young
people cannot be overstated. If we are to truly reach them therapeutically and
create the crucial relationship within which they can begin to understand
themselves better then we need to work hard at knowing them fully. This
means adapting and developing our methods and models of practice to fit the
child- not the other way round. It means resisting offering a monotherapeutic
experience to every child or young person regardless of their unique
characteristics. In so doing we can engage them and enable their needs to
permeate our working practices more comprehensively. It means ensuring
that we do not make generalisable assumptions about a child or young
person’s home life, customs or beliefs from a cursory question or relying
solely on information about religion, ethnic origin or family background
(Parekh 2000, Kehily & Swann 2003, Hartley 2003).
Children and young people are developing psychologically in an external
World in which information and the power it has to influence and shape their
beliefs and feelings have never been greater. Control and manipulation of that
information is being concentrated in a few hands themselves closely identified
with a narrow ideological doctrine that legitimates certain forms of behaviour,
attitude and culture. Western developed countries led by America dominate
the production, marketing and distribution of products representing brand
names and iconic images aimed at maximising profit in the global marketplace
(Hall 1993). Children and young people are viewed as consumers and in this
context the nature of their indigenous culture is seen as another part of their
identity to be moulded in order to maintain cultural conformity. Young people’s
desperate need to fit in, be included and be the same as other children is
exploited relentlessly by corporations propagating certain values that reinforce
the consumerist culture of the early 21st Century.
Children and young people face considerable challenges in maintaining their
cultural integrity in the face of institutional racism, homophobia, economic
activity or migration patterns. The consequences may lead to significant
emotional and psychological problems expressed for example by high rates of
school exclusion among African –Caribbean children (Okitikpi 1999), suicide
and para-suicide of gay and lesbian young people (Trotter 2000), or
unemployment among Bangladeshi youth (Jones 1996). The cultural assets of
minority children regularly go unrecognised, denied or devalued within the
wider community (Newman 2002). It is crucial therefore that support offered
by counsellors or psychotherapists includes opportunities to celebrate their
heritage and creates links with other members of their cultural or social group.
Children from migrant cultures are especially vulnerable to feelings of
inferiority resulting in frustration, anxiety and poor school attainment (Spencer
1996). In the USA the promotion of resilience in black communities is an
important strategy aimed at developing cultural confidence and enhancing
problem solving capacities (Reynolds 1998).
Culture is a word that appears in everyday discourse- so much so that as with
much common parlance it ceases to require any great effort at understanding
what it means. We all seem to know what we are talking about when we
mention culture. Yet the variety of definitions and interpretations of the word
allow it an elasticity that is more a hindrance to clarity than a help. The
increasing need to improve our therapeutic work with children and young
people requires us to examine their changing cultural environment for
evidence of how we might harness new ways of understanding them and their
troubles. At a general level culture is associated with high art, refinement,
superior taste etc.. or there is popular culture which is associated with the
masses, low taste, tabloid media, and TV soap operas.
We can also acknowledge that there is a ‘therapy culture’- that is, something
associated with Western methods of responding to individual human
psychological difficulties. Depending on the context it can be used as a term
of criticism implying that the problems of society are caused by the culture of
therapy which posits people as victims and weak-willed (Masson 1988, Furedi
2003). Or it can be used in a benign sense illustrative of how advanced
societies are becoming in attending to the stresses and pressures of modern
life. What is certain is that those of us seeking to help troubled children and
adolescents need to develop our understanding of how cultural influences
affect, maintain and ultimately provide solutions to, the psychological
difficulties of young people.
Culture in the anthropological sense has come to mean the way of life
followed by a people. This concept developed as the history of Western
expansionism and colonialism encountered manifestations of difference
around the World. These encounters prompted a reaction at several levels of
consciousness. Politically there was a need to justify the appropriation of
native land and resources, economically the imperial explorers required raw
materials to service industrialisation, but psychologically there was a fear of
difference that had to be rationalised. Hence the early attempts at racial
categorisation and efforts to construct order from diversity and chaos in
human lifeways. Culture can also be defined in opposition to nature- the
product and achievement of human beings representing a rising above of our
natural instincts. In this sense human nature is typically understood as the
opposite of culture. Culture can also mean the difference between humans
and animals- the capacity to use language and complex communication to
symbolise that which is not present (Jenkins 2002).
Thus the bearers of a culture are understood to be a collectivity of individuals
such as a society or community. However the cultural patterns that shape the
behaviour of children and young people in groups should not be confused with
the structure of institutions or social systems, even though there is a link
between them. We can think of culture in one sense as the organisation of
experience shared by members of a community including their standards for
perceiving, predicting, judging and acting. This means that culture includes all
socially standardized ways of seeing and thinking about the world; of
understanding relationships among people, things and events; of establishing
preferences and purposes; of carrying out actions and pursuing goals
(Valentine 1976, Haralambos 1988, Jenkins 2002). As the history of the past
three centuries demonstrates the impact of Western imperialism has
reproduced its economic and political structures worldwide resulting in the
development of industrial societies in former agrarian countries that have
disrupted cultural patterns.
Inequalities in the distribution of wealth among these newly developing
countries has created expectations and increasing demands for fairer trade
relationships. Globalisation combined with instant International
communications has brought the consequences of these unequal
relationships and the needs of poor nations closer to our attention than ever
before. Thus developed nations are confronted with a variety of cultures with
a common experience of exploitation and a need to reconcile conflicting
feelings, guilt, confusion and responses. There is still a requirement for
systematic knowledge about groups or categories of humanity who are more
mobile and are attracted to Western lifestyles of wealth, materialism, and
welfare. In the early part of this 21st century the recent history of ethnic
conflicts, population changes and poverty has prompted the emigration of
refugee and asylum seekers towards the West.
The more privileged and comfortable strata of Western societies, as well as
new urban communities in former agricultural economies, are facing the
reality of desperately poor people who feel more and more marginalised and
neglected. Resentment is a feature of the reaction of wealthier nations to
inflows of dependent people and the realisation among refugees that they are
not universally welcome. There is a need therefore to render knowledge about
difference and cultural diversity coherent in order to inform public attitudes
and social policy, as well as enhance therapeutic practice. One way of doing
this is to attribute a culture or subculture to a broad variety of social
categories. Hence we encounter relatively meaningless terms such as the
culture of poverty; youth culture, pop culture, black culture or drug culture.
There is even a refugee culture that apparently explains the motivation of
families from troubled or impoverished regions to take incredible risks to seek
refuge and safety.
Conceptualising culture
Cultural competence can initially be understood in the context of a desire to
improve our practice in order to meet the needs of the growing multi-cultural
and ethnically diverse society developing around us. It assumes that historical
and orthodox assumptions about human growth and behaviour have served
their purpose in meeting the needs of troubled children and young people in
particular circumstances and at particular points in time. Now in the early
stages of the twenty-first century changes are required to address and
respond to the psychological and emotional problems of a modern generation
of families and offspring who cannot be easily fitted into existing theoretical
paradigms. There is increasing evidence for the need to refine and develop
our methods and models of assessment and intervention so that they are
more relevant and accessible to children and young people from a much
wider range of backgrounds than was the case in the not too distant past
(Madge 2001).
This is not to say that children and young people in the majority ethnic
communities do not require improved methods of help and support. They are
being socialised and exposed to a quite different society than former
generations. The pace of life, enhanced stressors, individualism, and
consumerism are blamed for producing heightened states of arousal and
stimulation. Evidence has begun to emerge of genetic changes, the
development of new illnesses and of course a range of new risk factors to
their mental health- especially the availability of cheap psychoactive drugs
and greater access to alcohol. Depictions of family life for example in
children’s literature has changed dramatically in the past 40 years from
misleading idyllic paternalistic havens of safety and security to the grim reality
of poverty, child abuse, divorce, mentally ill parents and personal and
institutional racism (Tucker & Gamble 2001).
Ethnicity requires some clarification as another term that can be used in a
variety of contexts but without much thought as to its meaning. Its use
alongside the term culture causes confusion especially when the two become
almost synonymous. This is because there is no easy definition, but we at
least need to know the complexities of the use of the term ethnicity because it
perhaps reflects something deeper and more ambivalent about the way we
internally manage difference and other-ness. Part of the problem lies in mixing
up birthplace with ethnic identity. A white person born in Africa and a black
person born in Britain can be defined by their ethnic grouping and place of
birth. Further confusion has historically prevailed due to the way the official
census data have been collated. In the UK since 1951 the methods of data
collection have altered from just recording the country of birth, to the
birthplace of parents, to 1981 when there was no question on ethnicity. In
1991 a question on ethnicity offered a range of categories and in 2001 there
were further changes to account for citizens with dual or mixed heritage.
The term ‘race’ is now generally accepted to be redundant as a meaningful
scientific category however the idea of race as a general descriptor of
assumed national, cultural or physical difference persists in society (Amin
1997). The concept is embraced at the policy level with legislation such as the
Race Relations Act in the UK and institutions such as the Commission for
Racial Equality. Legislation such as the 1989 Children Act, the 2005 Children
Act and Children’s National Service Framework which contextualise work with
children and young people expects practitioners to take account of a child’s
religious persuasion, racial origin, and cultural and linguistic background,
without adequate guidance as to what is meant by ‘race’ or ‘culture’. The issue
becomes more complex when we consider census data that show the
increase in numbers of children from dual and mixed heritage backgrounds
and consider the particularly complex set of problems they can encounter.
Ethnicity and culture
The linkage between race, ethnic identity and inequality has been repeatedly
established in terms of its effect on wealth, status and power. These socio-
economic and other environmental variables are recognised as risk factors for
the development of child and adolescent mental health problems. The data
show that black and other ethnic minority young people and adults charged
with anti-social behaviour are more likely to receive punitive or custodial
disposals in the criminal justice system rather than community options geared
to a better understanding of their causality. High levels of psychological
problems are reported from male and female black populations within young
offender institutions. Socially constructed notions of racial difference thus
remain a potent basis for identity-our sense of sameness and difference
(Bilton et al 2002). This has led to frequent criticisms of discriminatory and
stereotyping attitudes by the legal system.
Earlier scientific work in the 19th and 20th centuries had attempted to
conceptualise race and classify people in different countries according to their
supposedly inherent superiority or inferiority. Similar comparisons were made
on the basis of gender and class which permitted the tolerance of inequalities
based on innate biological differences. A eugenics movement was inspired by
these findings whose aim was to improve the genetic stock of the human race
by eradicating people with less than perfect genetic dispositions. In the latter
part of the 20th century advances in genetic research were able to dismiss
these earlier notions of racial hierarchies, classifications and the supposed
link between biology and behaviour (Kohn 1995).
However vestiges of these outdated concepts still survive at the popular level
as people try to understand where they fit into an ever-shrinking world where
much more is known about other countries, customs and culture. Cheap air
travel, faster communication and the creation of refugee and asylum seekers
from troubled areas are bringing images, experiences and feelings to our
collective consciousness. Skin colour, language and religion are still
interpreted as signifiers of more profound differences in abilities and outlook,
as well as being used to justify discriminatory practices or outright racism. For
some people the notion of white superiority is barely below the surface
especially in the context of a colonial history and latter immigration. Table 1.1
provides an example of the incredible cultural diversity in the United Kingdom
that belies populist notions of an anglo-saxon monoculture. This is a clear
example of an economically successful country that benefits from immigration
while perpetuating xenophobia and racist hysteria reflected in popular media.
It is therefore important to understand the specific manifestations of cultural
differences in every country rather than try to prescribe a universal
explanatory theory. We need therefore to find an explanation for racial
inequalities that can attend to the social construction as well as the individual
internal construction of difference and the link with cultural competent
practice.(insert table 1.1)
Developmental resources
In considering the various ways in which children’s mental health is
understood it is useful to consider some of the orthodox theoretical and
research-based evidence on human growth and development as part of the
standard repertoire of guidance available. Counsellors and therapists are
expected to have a sound grounding in these subjects to help inform all
aspects of their work with a range of child and adolescent age groups. The
theories are vast and to do them justice would require more space than this
text permits. Some of the classic authors and contemporary literature need to
be critically reviewed as part of a professional and theoretical discourse that is
notable for its lack of culturally competent concepts. They illustrate the way
conventional child development is conceptualised offering a normative model
of childhood that assumes a universalist application when it should be used
as a limiting starting point requiring adaptation and amendment as you begin
the process of engagement with your client.
A good starting point is in a sense where some of the theories end. Wherever
the emphasis is placed on the spectrum of the nature versus nurture debate
and any
explanation for human behaviour in the literature, you need to be clear where
you place yourself as a practitioner. Not for the purpose of trying to prove a
theory right or to convince yourself of the correct explanation for the behaviour
of a child or young person, but to make more explicit your own personal bias.
This is not a weakness but a strength. A practitioner knowing where they
stand and understanding there are other perceptions and beliefs about a
child’s development, and adopting an inquisitive, culturally flexible stance will
be acting more in the child’s best interests. Rather that, than trying to defend
the indefensible or answer the unanswerable.
Recent advances in genetic research and refinement of developmental
instruments for assessing children and young people’s emotional and
behavioural health have concluded that to regard nature and nurture as
separate and independent is an oversimplification. A more helpful answer to
what shapes children and adolescent’s mental health is both nature and the
environment, or rather, the interplay between the two. Thus it is crucial to
incorporate an understanding of culture and the way it can shape both your
perception of a child and young person’s psychological difficulties and affect
that young person’s perception of themselves. The multi-disciplinary
complexion of many staff groups working with child and adolescent mental
health problems and the structural/organisational changes towards more inter-
agency and inter-professional working mean that a variety of counsellors and
psychotherapists will be familiar with the orthodox developmental theorists.
These suffice as a baseline starting point from which to modify and improve
upon so that they maintain their relevance in a rapidly changing multi-cultural
society.
Whether the ideas of Freud, Klein, Piaget, Eriksen, Skinner, or Bowlby and
others help or hinder the process of your work, the important point is that it
permits the adoption of some intellectual rigour to the way your work is
organised (Mills & Duck 2000, Beckett 2002). This can provide a framework
within which the selection of assessment and intervention methods and
models can take place. Crucially, it will enable a more systematic process to
proceed in a recognisable direction or provide a knowledge base to discuss
ideas put forward by other staff. This will be helpful in supervision, case
conferences, legal proceedings, or report writing contexts. Sometimes it is
helpful to acknowledge that there is no clear-cut explanation, or there are
multiple interpretations for a child’s emotional and behavioural problems that
are concerning others.
Staff with a systemic or psychodynamic perspective can especially utilise
theoretical concepts from social policy and sociology to add to their framework
of explanation. This distinguishes your contribution from most other agency
staff in child mental health work. The combination can be powerful, adding
weight to professional arguments and provide authority for interpretations.
They can also be burdensome and confusing and should therefore always be
used cautiously. They enable a social model of mental health to be
acknowledged alongside others and therefore more readily advance a
culturally competent practice. The choice is again vast in the area of sociology
alone. Marx, Durkheim, Mills, Parsons, Popper, or Habermas and others offer
a rich and diverse knowledge base (O’Donnell 2002). The important point is
that the chosen theoretical preference can be identified and acknowledged,
and a plan can proceed consistently within that premise.
The importance of reflective practice whilst undertaking culturally competent
work with children and adolescents cannot be emphasised enough. In the
process of using measures of human growth and development it is crucial.
This is because children and young people are constantly changing as are
their circumstances. Your assessment could be out of date within weeks,
reliant on too few factors or based on inaccurate referral information. This
requires a high level of concentration and alertness to changes that will be
unique and unpredictable, as well as changes that appear to conform to a
predictable developmental transition. Such changes may have nothing to do
with your intervention and some may have everything to do with it. The key is
in appreciating that developmental issues are significant and require you to
have a good grasp of them (Thompson 2002).
Human growth and development theoretical resources should be seen as part
of a wide spectrum of potential, rather than deterministic, interactive causative
factors in the genesis of child and adolescent mental health problems. Some
social psychologists criticise the emphasis in child development theories on
normative concepts and suggest enhancing the judging, measuring approach
towards one that embodies context, culture, and competencies (Woodhead
1998). An illustration of developmental measures is shown in Table 1.2 and
should be adapted to every individual situation encountered and always
considered against the white, eurocentric perceptions they embodied when
first constructed. (insert Table 1.2……….) A more recent view of personality
development lists five factors that combine elements of the older more classic
ways of understanding a child or adolescent together with notions of peer
acceptability and adult perceptions. Its simplicity and integrated structure offer
a useful addition to other conventional schemas (Hampson 1995, Jones &
Jones 1999):
Extroversion- includes traits such as extroverted/introverted, talkative/quiet,
bold/timid
Agreeableness- based on characteristics such as agreeable/disagreeable,
kind/unkind, selfish/unselfish
Conscientiousness- reflects traits such as organised/disorganised,
hardworking/lazy, reliable/unreliable, thorough/careless, practical/impractical
Neuroticism- based on traits such as stable/unstable, calm/angry,
relaxed/tense, unemotional/emotional
Openness to experience- includes the concept of intelligence, together with
level of sophistication, creativity, curiosity and cognitive style in problem-
solving situations
Diversity and difference
Culture defines accepted ways of behaving for members of a particular
society. But such definitions vary from society to society leading to
misunderstanding and a failure to engage therapeutically in a helping
relationship. Klineberg (1971) offered an example of just such a
misunderstanding. Amongst the Sioux Indians of South Dakota, it is regarded
as incorrect to answer a question in the presence of others who do not know
the answer. Such behaviour would be regarded as boastful and arrogant and
an attempt to shame others. In addition the Sioux regard it as wrong to
answer a question unless they are absolutely sure of the correct answer. A
white American teacher in a classroom of Sioux children and unaware of their
culture, might easily interpret their behaviour as a reflection of ignorance or
hostility. In a therapeutic context we can imagine our reaction to exploratory
questions which resulted in a silent response with consequent interpretations
of resistance with further attention being paid to that area. An understanding
of the role of certainty and respect on the other hand could open up creative
possibilities for engagement.
Culture is not static it is an organic living entity with an external and internal
presence. Any attempt to define it or them is bound to be provisional because
people- and more especially children and young people- are developing
rapidly at many levels of physicality and consciousness. They do so in an
equally fast changing and bewildering societal context that sets the scene for
our understanding of culture. It is possible however to select some common
characteristics that can help us think about the concept of culture in a more
useful way that enables us to focus our therapeutic efforts to the best
advantage of children and young people (Jenkins 2002):
Culture is definitely human it is the characteristic way that humans do things,
rooted in our capacity for complex communication and reflexive relationships
It carries within it implications of controlled development and change. Culture
is the medium within which human individuals grow and become competent
Culture is also a matter of differentiating human collectivities, and their
characteristic patterns of behaviour, one from another
It is important to understand the different ways in which child and adolescent
development is conceptualised by diverse communities. In Western
industrialised countries there is a more clearly defined division between
childhood and adolescence compared with developing countries. The change
is less pronounced and shorter in countries where there is less tradition of
further and higher education and greater sharing of domestic or agricultural
labour between adults and younger family members. There is an assumption
in Western industrialised countries that adolescence has been stretched so
that it covers a much greater time span than in previous generations. This is
cited as a cause of much problematic behaviour and psychological problems
in contemporary young people. There is also evidence of the earlier onset of
puberty in the more affluent societies and delays in the onset of menarche
has been reported in girls who are exceptionally physically active (Beckett
2002). On the other hand children from non-Western countries or whose
parents were raised there will have expectations and experiences based on a
very different time span. Parents may have been married at the age of 12 or
13 years old and perhaps have served as soldiers in civil wars, or been
responsible for the care of several younger siblings.
Globalisation and identity
The term globalisation has begun to feature in the literature reflecting
profound shifts in the economic and social patterns of relationships between
the richer industrialised countries and the poorer developing countries. It
involves closer international economic integration prompted by the needs of
Capitalism, but also has demographic, social, cultural and psychological
dimensions (Midgley 2001, Pieterse 2004). Consistent with the link between
the social context of child and adolescent mental health problems, it is
therefore important to consider the global context in terms of the challenges
for building culturally competent practice.
Critics of globalisation argue that its impact is to maintain unequal power
relationships between the richer and poorer countries so that patterns of
wealth and consumer consumption in Europe and North America can be
sustained. This involves the exploitation of labour and other resources in
poorer countries thereby preventing them achieving a diverse and equitable
economic and social structure within which health and social welfare
programmes can develop. The consequences of globalisation are being
noticed in the way traditional social care systems are taking on the
characteristics of business ethics and commercialism (Dominelli 1999, Mishra
1999). One of the side effects of this process is the standardisation and
conformity required for consumer consumption patterns in order to maximise
profit. The consequence is the steady and inexorable erosion of traditional
markers of indigenous cultural identity combined with the elevation of global
branding.
This critique of the latest phase of capitalist development echoes earlier
concerns about the impact on economic growth and subsequent erosion of
traditional government policies of full employment and social welfare
(Corrigan & Leonard 1978, Bailey & Brake 1980).
A failure to fully develop social welfare services, or to have them subjected to
the gyrations of speculative global financial markets, invariably corodes the
quality and the depth of services designed to reach children and families in
personal and culturally appropriate ways. This means that services are pared
to the minimum, oriented towards crisis intervention and designed in the
narrowest terms to conform with inflexible eligibility criteria that limits access.
These features are inconsistent with culturally competent practice that aims to
spread accessibility, improve acceptability and enrich our creative potential to
respond to a diverse society.
The paradox of globalisation is that as new varieties of cultural expression are
encountered and celebrated there is an underlying impulse to impose a
sameness by the powerful Western nations on the developing nations. Thus
at a supra-national level there is a parallel process occurring of the individual
rejection of difference by the powerful countries with the technology and
military capacity to influence the majority powerless countries. This must both
steer and reinforce the latent fear of the other inside individuals who then feel
they have permission to reject black and ethnic minority families. This
contradiction is further illuminated by government policies against racism and
yet resorting to draconian measures to control the immigration of refugees
and asylum seekers.
The globalisation of culture produces deeply contradictory states for
individuals and groups with consequences for the development of an
integrated sense of self. Hence we observe the way Black youth are regarded
as predisposed to violence and disorder resulting in persecutory oppression
and aggressive reactions which are interpreted by police as evidence of anti-
social predisposition. On the other hand Black athleticism and success in
International sport produces a celebratory image masking denigratory
undertones (Briggs 2002). White youth can be seen and heard imitating Black
youth culture in terms of dress and accent, while African-caribbean
youngsters for example learn the patois of their grandparents, celebrate
Rastafarnairism wearing dreadlocks, which some regard as a hostile anti-
establishment stance. Young Asian women are torn between the aspirations
of their white peers for sexual independence and socialisation and the
expectations of some parents for social restrictions and arranged marriage.
Culturally competent practice
Dilemmas in trends towards cultural competence have been highlighted by
reference to the practice of forced/arranged marriages and dowry, genital
mutilation of children, and harsh physical punishments condoned by some
societies (Midgley 2001). These practices can be used to counter the
argument for respecting ethnic and cultural diversity and support the notion of
universal values as the basis for competent practice. Ethnic rivalries and the
pride in national identity on which they are based also sit uneasily with
culturally competent aspirations of international collaboration and mutual
understanding.
However, rather than seek answers to these difficult issues in an introspective
way, this emphasises the need for therapists and their professional
representatives to reach out to the international community with service users,
to continue to debate, discuss and strive for ways to discover solutions. In the
area of child and adolescent mental health we need to understand the impact
such practices and the beliefs on which they are based are having on the
mental health and emotional development of those adults promoting them and
the children and young people experiencing them.
Cultural competence has been defined as developing skills in assessing the
cultural climate of an organisation and being able to practice in a strategic
manner within it. It has also been broadened to include any context in which
workers practice in order to permit effective direct work at many levels
(Baldwin 2000, Fook 2002). Whether at the strategic organisational level or
the direct interpersonal level we can actively resist those pressures to
conformity and routinised practice that in often discreet and inconspicuous
ways, can undermine efforts to practise in culturally competent ways. The
requirements of social justice demand vigilance and creativity in order to
contribute towards an emancipatory practice that can liberate both workers
and service users from prescribed practice orthodoxies. Such practice is the
antithesis of stereotyped, one-dimensional thinking and is characterised by
(Leonard 1994):
A commitment to standing alongside oppressed and impoverished populations
The importance of dialogic relations between workers and service users
Orientation towards the transformation of processes and structures that
perpetuate domination and exploitation
These characteristics are in harmony with culturally competent practice. They
do not imply that therapists should reject statutory practice for the voluntary
sector, child care for community work, or psychodynamic theories for
advocacy. These simplistic oppositional devices do not help us manage the
complexities and dilemmas in seeking different practice orientations (Healy
2002). The possibilities for creative practice within organisational constraints
are there. They may be limited and subjected to pressures of time but in the
personal relationship with service users and particularly children and
adolescents with mental health problems, the rewards are unquantifiable for
both worker and client. Even introducing a small change in practice can have
a much larger disproportionate and beneficial impact.
There is growing interest in the development of multidisciplinary and
interprofessional working in order to maximise the effectiveness of
interventions to meet the diverse needs of multi-cultural societies and service
users (Magrab et al 1997, Oberheumer P 1998, Tucker et al 1999). The
characteristics of such work apply in a framework familiar to health and social
care staff working therapeutically. It begins with assessment then proceeds
through decision-making, planning, monitoring, evaluation, and finally to
closure. It is argued that this common framework offers the optimum model for
encouraging reflective practice to be at the core of contemporary work (Taylor
& White 2000, Walker 2003). Reflective practice offers the opportunity to shift
beyond functional analysis to making active links between the value base,
policy-making process, and the variety of interventions conducted.
Combining reflective practice with culturally competent practice, we have the
opportunity to make a major contribution towards responding to the social
policy aspiration of inclusion and anti-oppressive practice. In so doing we can
facilitate closer co-operation between professionals coming into contact with
vulnerable families on a shared agenda of challenging institutional and
personal discrimination (Eber et al 1996, VanDenBerg & Grealish 1996,
Sutton 2000). Drawing together the elements of practice that can contribute
towards a model of culturally competent care means it is possible to define
cultural competence as a set of knowledge-based and interpersonal skills that
allow individuals to understand, appreciate and work with families of cultures,
from other than their own. Five components have been identified (Kim 1995)
comprising culturally competent care:
Awareness and acceptance of cultural differences
Capacity for cultural self-awareness
Understanding the dynamics of difference
Developing basic knowledge about the family’s culture
Adapting practice skills to fit the cultural context of the child and family
These are consistent with other work which critique the historical development
of cross-cultural services and offer a model of service organisation and
development designed to meet the needs of black and ethnic minority families
(Dominelli 1988,Moffic & Kinzie 1996, Bhugra 1999, Bhugra & Bahl 1999).
Culture has been defined as the sets of shared cultural perspectives,
meanings, and adaptive behaviours derived from simultaneous membership
and participation in a multiplicity of contexts such as geographical, religion,
ethnicity, language, race, nationality and ideology. It has also been described
as the knowledge, values, perceptions and practices that are shared among
the members of a given society, and passed on from one generation to the
next (Leighton 1981). Four particular theories have been identified in modern
systemic practice for example that attempt to harmonise systemic theory with
cultural competence (Falicov 1995):
Ethnic focused- this stresses that families differ but assumes that the
diversity is primarily due to ethnicity. It focuses on the commonality of
thoughts, behaviour, feelings, customs and rituals that are perceived as
belonging to a particular ethnic group.
Universalist- this asserts that families are more alike than they are different.
Hence, universalist norms are thought to apply to all families.
Particularist- this believes that all families are more different than they are
alike. No generalisations are possible, each family is unique.
Multidimensional- this goes beyond the one-dimensional definition of culture
as ethnicity, and aims at a more comprehensive and complex definition of
culture that embraces other contextual variables.
An attempt to elaborate a theoretical framework for multicultural counselling
and therapy suggests that an overarching theory needs to be employed that
permits different theoretical models to be applied and integrated. The
synthesis between systemic and psychodynamic practice offers a more
comprehensive way of achieving this. In this way, both client and worker
identities can be embedded in multiple levels of life experiences with the aim
of enabling greater account being taken of the client’s experience in relation to
their context. The power differentials between worker and children and
adolescents are recognised as playing an important role in the therapeutic
relationship. Clients are helped by developing a greater awareness of
themselves in relation to their different contexts resulting in therapy that is
contextual in orientation and can, for example draw upon traditional healing
practices (Sue et al 1996).
Ethnocentric and particularly Eurocentric, explanations of emotional and
psychosocial development are not inclusive enough to understand the
development of diverse ethnic minority groups. Failure to understand the
cultural background of families can lead to unhelpful assessments, non-
compliance, poor use of services, and alienation of the individual or family
from the welfare system. By using an anti-discriminatory, empowerment
model of practice we are ideally placed to work with other professionals in
multi-disciplinary contexts to enable the whole team to maintain a focus on
culturally competent practice. For example, the increased demand for help
from parents and children themselves suffering the effects of mental health
problems has prompted policy initiatives to invest in and reconfigure child and
adolescent mental health service provision in more acceptable and accessible
ways.
The aim is to make them more accessible and acceptable to all cultures by
improving multi-agency working (House of Commons 1997, Davis et al 1997,
Mental Health Foundation 1999). However, in order to be effective all staff
need to address the different belief systems and explanatory thinking behind
psychological symptoms. Skills and values are required to articulate these
concepts in such teams. Challenging crude stereotypes, questioning implicit
racism and simply ensuring that other staff stop and think about their
assumptions can help. Combined with respectful consideration of indigenous
healing practices within diverse populations can optimise helping strategies.
The traditional methods and models of therapeutic practice have failed to take
full account of cultural factors but contemporary literature is attempting to
catch up. The following areas offer guidance to enhance your communication
skills (Whiting 1999):
Families may have different styles of communicating fear, grief, anxiety,
concern and disagreement
Emphasis should be placed on listening with the goal of understanding the
family’s perspective
Care should be taken to explain to the family the agency culture
Steps should be taken to recognise and resolve conflicts which occur between
the cultural preferences, understandings and practices recommended by
professionals
Communication is enhanced if you can demonstrate sensitivity towards the
family’s cultural values
Appreciating the family’s cultural understanding of the problem will help build
a trusting relationship
Case illustration
A family of Iraqi asylum seekers fled the country before the recent American
and British invasion in 2003. The father Mohammad had worked in a civil
service position in a government agency connected to the petroleum industry.
He had been accused of passing information to the UN regarding breaches of
the sanctions imposed on the use of oil revenues. Mohammad claims he was
tortured and had death threats made against his wife and three children. The
children are all under ten years of age and his wife Saleha is a nursery
teacher. Some of the children speak very little English. The family have been
dispersed to a market town in a northern county where there are very few
Iraqis, or any families from Middle Eastern countries. The local Housing
Department have referred the family to your office following reports of racist
attacks on the run-down council estate where they have been housed in
emergency accommodation. A teacher has called your team three times in the
past fortnight expressing concern about one of the children who is wetting and
soiling in class provoking bullying and humiliating behaviour from other
children.
Commentary
Using a systems perspective your first task is to make a map of all the people,
agencies and services connected to this family. You will find it helpful to then
make contact with as many as you can within a realistic timescale to start to
plan your response. This information-gathering exercise will enable you to
begin to evaluate the different agendas and perceptions of other staff working
with or concerned with the family. Your priority is to establish meaningful
contact with the family and gain factual evidence of racist incidents for
possible criminal prosecution against the perpetrators, as well as offering a
caring, sympathetic relationship. Bear in mind that the family are likely to be
highly suspicious of your motives and will require a lot of genuine evidence
that they should trust you. Their naturally defensive behaviour may come
across as hostile/uncommunicative and you need to deal with this in a non-
confrontational manner.
A translator/interpreter should accompany you having been fully briefed
beforehand about your task, the different roles each of you holds, and to
assess their suitability for this particular task. Do not assume that every
interpreter is the same, and try to evaluate their beliefs/attitudes and whether
there may be ethnic or religious differences between them and the family. For
a variety of reasons they might be inappropriate for this task despite having
the right language skills. Strict translation of words and terms will be unhelpful
therefore time needs to be spent on the interpretation of the interpretation.
Right from the start you can better engage with the family by:
Enabling everyone to have their say
Circular questioning to enable expression of feelings
Reinforcing the integrity of the family system
Noting patterns of communication and structure
Having established a helping relationship a systems perspective enables you
to locate the family system within a wider system of agencies, resources and
a local environment that is generally hostile. Your networking skills can
mobilise the statutory agencies to provide what is required to attend to the
immediate areas of concern and clarify roles and responsibilities. A case
conference or network meeting can put this on a formal basis with an action
check list for future reference to monitor the plan. One option may be to plan
some family sessions together with a colleague from another agency such as
Health or Education. This could combine assessment and intervention work to
ascertain medium term needs whilst using therapeutic skills to help the family
establish their equilibrium. The key is to enable them to re-establish their
particular coping mechanisms and ways of dealing with stress, rather than
trying to impose an artificial solution. Maintaining a systems-wide perspective
can help you evaluate the factors and elements building up to form a
contemporary picture of their context. Working with them as a family and
demonstrating simple things like reliability and consistency will provide them
with an emotional anchor- a secure enough base to begin to manage
themselves in due course.
What the above tells us is that the subjects of culture, race, ethnicity are
evolving all the time as society changes and develops according to
demographic changes, advances in social science research, and the personal
internal psychic changes happening as a result of external modifications to
the environment-and vice versa. We can observe that previous assumptions
about superiority, normality and behaviour among different peoples have been
discarded. Thus we need to hold in mind a provisional understanding of what
is at present acceptable as terms and descriptions to describe the diversity of
populations. These may not be suitable in the changing landscapes of the
future (Alibhai-Brown 1999).
Restricted conceptualizations of culture as a set body of information-
something to be learned in order to better understand a child or young person
offers a static model for engaging with all troubled children. It is more useful to
think of culture as a process for generating frameworks of perception, a value
system, and a set of perspectives. Knowledge about culture is not something
external to be found memorized and then utilized. Cultural competence is
therefore best understood as engaging in the process of transaction where
difference is encountered and we try to evolve our meaning-making skills
(Tseng 2002).
Holliday (1999) takes up this notion by trying to distinguish between large
culture and small culture, in which he emphasises the need to move beyond
the orthodox definition of culture as related to ethnicity, national and
international characteristics. Small also is distinct from sub-culture which is
normally taken to mean something within and subservient to large culture.
Small culture in Holliday’s meaning is a way of understanding many cultures
in all types of social grouping which may or may not have significant ethnic,
national or International qualities. Thus the apparent patterns and
characteristics of cultures reveal on closer inspection the variations and
variability within and between cultures in reciprocal patterns of influence.
A prescribed, normative and superficial notion of large cultural difference
leads to an exaggeration of those differences resulting in the psychological
concept of ‘other’ reduced to a simplistic, easily digestible or exotic or
degrading stereotype (Holliday 1999). An example from ethnographic
research in Southall West London revealed that people there had a
sophisticated understanding of culture and community. When asked what was
meant by culture it became clear that a person could speak and act as a
member of a Muslim community in one context, in another take sides against
other Muslims as a member of the Pakistani community, and in a third count
himself part of the Punjabi community that excluded other Muslims but
included Hindus, Sikhs and even Christians (Baumann 1996). Thus a more
enlightened concept of culture accepts it is a dynamic, ongoing group process
which operates in changing circumstances to enable group members to make
sense of and operate meaningfully within those circumstances. For
counsellors and psychotherapists it offers a way of illuminating the full inter-
cultural complexity of our World.
Summary
Children and young people face considerable challenges in maintaining their
cultural integrity in the face of institutional racism, homophobia, economic
activity or migration patterns. The consequences may lead to significant
emotional and psychological problems.
The cultural assets of minority children regularly go unrecognised, denied, or
devalued within the wider community. Children from migrant cultures are
especially vulnerable to feelings of inferiority resulting in frustration, anxiety
and poor school attainment.
Cultural competence can initially be understood in the context of a desire to
improve our practice in order to meet the needs of the growing multi-cultural
and ethnically diverse society developing around us. Historical and orthodox
assumptions about child development need to change to address and
respond to the psychological and emotional problems of a modern generation
of families.
Staff with a systemic or psychodynamic perspective can especially utilise
theoretical concepts from social policy and sociology to add to their framework
of explanation. They enable a social model of mental health to be
acknowledged alongside others and therefore more readily advance a
culturally competent practice.
Culture is not static it is an organic living entity with an external and internal
presence. Any attempt to define it or them is bound to be provisional because
children and young people are developing rapidly at many levels of physicality
and consciousness. They do so in an equally fast changing and bewildering
societal context that sets the scene for our understanding of culture.
Critics of globalisation argue that its impact is to maintain unequal power
relationships between the richer and poorer countries so that patterns of
wealth and consumer consumption in Europe and North America can be
sustained. The consequence is the steady and inexorable erosion of
traditional markers of indigenous cultural identity combined with the elevation
of global branding.
Combining reflective practice with culturally competent practice, we have the
opportunity to make a major contribution towards the social policy aspiration
of inclusion and anti-oppressive practice. It is possible to define cultural
competence as a set of knowledge-based and interpersonal skills that allow
individuals to understand, appreciate and work with families of cultures, from
other than their own.
Ethnocentric and particularly Eurocentric explanations of emotional and
psychosocial development are not inclusive enough to understand the
development of diverse ethnic minority groups. Failure to understand the
cultural background of families can lead to unhelpful assessments, non-
compliance, poor use of services, and alienation of the individual or family
from the welfare system.
Steven Walker
BASW UK Standards and Ethics Board member
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