Learning Cloud International

(v1)

ASSESSMENT 6
Name: Georgeta Tufis
Score: 100%
Passmark: 100%
Attempted: Monday, February 20, 2017
Attempt Number: 1
Time Taken: 00:29:38
Locked: No
Marking Required: No

1: Correct 1. Define

a. culturally appropriate services

b. culturally acceptable services
c. culturally accessible services
d. cultural sensitisation

1. Culturally appropriate services

Appropriate means suitable, right for a particular situation or purpose. For being appropriate one
should be previously aware of or having the knowledge of the nature of that situation and tailor an
appropriate solution. A prerequisite for appropriateness might be sensitivity. Sensitivity to other
cultures refers to the awareness of how other cultures differs from one`s own and may be manifested
through a wide array of theoretical knowledge and practical skills (language, manners of speech,
norms and values, customs and beliefs, historical and socioeconomic realities).

Appropriateness is correlated to meaningfulness, to practicality and usefulness, to action and results.

A culturally appropriate service has to be meaningful, beneficial and effective by its results to its
beneficiaries. Delivering culturally competent services has become more and more a constant
challenge to policy makers, health care systems and professionals.

Designing culturally appropriate services and provide with the most functionnal tools, methods, and
human resources is far from being the easiest task as one may be inclined to assume. Being culturally
competent as a counselling organization and having culturally competent professional involves more
than being armed with a set of good practices, up-to date theories, goodwill, good intentions, some
international experience; involves more than just being aware of other cultures, ethnic groups and
customs; involves more than being tolerant, culturally open to different lifestyles.

As a mental health provider, public or private organism, has to prove flexibility and the capacity of
integrating services, methods and human resources, to implement programs, to research and study
cultural variations, to develop culturally sensitives and appropriate measures to approach, diagnose
and heal, to accommodate culturally different tools, to adjust and cross-institutionally and cross-
culturally communicate by twining programs and partnerships between different social actors.

A culturally appropriate health service is contingent on the inclusion of client's cultural beliefs and
practices into intervention plans and their interaction and communication with mainstream health
services

Starting with bearing in mind that there is no single perfect counselling system, no single
transcendental healing principle and no single best therapy for designing and delivering culturally
appropriate mental health services should be a first step for designing an ethnocentrically
universalist free health care approach.

2. Culturally acceptable services

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 Nowadays, in the majority of multicultural cities, with a tradition in or just exposed recently to a
massive immigration we can notice, at almost every corner of the street, welcoming signs inviting
immigrants, refugees, asylum seekers, veterans, homeless people, unemployed people indigenous
women, individual affected by light or severe mental disorders, people affected by PTSD ( Post-
traumatic stress disorder), etc.

Public, inter-governmental organization, NGO, voluntary ad-hoc organisations, organisms or other

kind of centres or professionals, all these community organisations providing general or specialized
services to different social target categories dedicate their work, resources, time, goodwill to restoring
the general wellbeing of their clients.

The fact there these kind of centres and organisations open their doors to people in need is most than
laudable and helpful. As long as they provided accessible services to the target groups, such as
different facilities, accessible locations, appropriate resources, culturally acceptable levels of health
care appropriate to that segment of clients these organisations may make a big difference.

More often than not, these centres have their doors open to receive indiscriminately individuals from
all cultures, regardless of their race, ethnic background, native languages spoken, and religious or
cultural beliefs. Usually they are concentrated in central areas even if we can find them usually in local
communities.

Some of them are very specialized and dedicate their services to specific categories of people or
problem. From my own experience, as I approach quite a few during my stay in Canada, Belgium or
Spain I would say that I have had different experiences according to country and also to the type of
service delivered. On average, the main trait of almost of all these tenths organisms approached is
that their services were not at all tailored to individuals specific needs and unfortunately, sometimes
the staff was far from my expectations, professionally speaking.

I have had the impression that the services provided were generally configured and delivered and the
cultural competence was far from being present or incorporated in the services provided in order to
work effectively in cross-cultural situations.

3. Correlated to a culturally acceptable service for a service to be culturally competent has to be a

culturally accessible service.

The accessibility of the service in regards to location, transport, linguistic skills, gratuity, type of service
provided, minority targeted, awareness about the existence of such a service, opening hours should
be a common sense requirement. These aspects seem to be the most obvious and basics
requirements for a service to be accessible.

There are also most hidden aspects that in reality may make the services culturally inaccessible to
different minority groups, such as health insurance coverage, administrative papers, having a regular
doctor in order to have access to preventive services, diagnosis, treatment or access to mental or
physical care. Some type of services even if physically there are in fact inaccessible to most of people
by their internal conditions or restrictions.

Other services are so far away from the community as for getting there is quite a voyage costing
money, a lot of time and in the end, the service if accessed prove to not be free of charge for people in
need. Another important requirement for these services to be culturally competent is to give the feeling
to the individual served that are efficient, pragmatic and result-oriented.

Most of the time, people in need do not access these kind of services designed because of multiple
factors, such as ignorance of their existence, of their services or role; mistrust, lack of means; most of
the time, people in need give up to access these services because after several visits they find
themselves frustrated, disoriented as before; find the services inefficient, unsupportive to their specific
needs, vague and without tangible results in immediate or medium-term future; the communication or
the interlocutors when far from their expectations are the frequent complaints or reasons for giving up
to approach the services.

The problem usually encountered is that even minority group members seek out mental health
services, they often fail to stay in treatment. In the remarkable book, Counselling the culturally
different: Theory and practice (1990), Sue , D.W., and Sue, D. (1990) identified several barriers to
treatment among minority groups.

One of them is the cultural norm against seeking help to professionals outside one`s own culture
usually explained by a preconception about Western knowledge or because of negative previous
experiences when dealing with professionals coming from the dominant culture. Moreover, language
barriers, and the frustrating experience with bureaucracy of the host country make them reluctant to
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 approach the health and mental health centres destined to them.

Generally, the access of the services provided by the most organisms are free of charge but it is
always true that the nature of their offer is quite general, limiting to general guidance and diffuse
support. The high rates of unemployment and poverty among the minority groups make impossible the
possibility of paying for appropriate health insurance and afford therapy, effective treatment or follow-
up support.

It is always true that such personalised services cost a lot of money and require long periods of time
for a concrete result. Apart from the lack of financial resources, one major deficiency is also the
shortage of skilled counsellors, who could provide culturally specific and tailored forms of therapies
and treatment.
The absence of a cultural congruence (an approach consistent with cultural beliefs and expectations
provided by culturally competent therapists) is a major stumbling block in most of the cases.

4. Cultural sensitisation

Cultural sensitisation may be defined as an awareness of our own culture, values, beliefs, lifestyle. We
take for granted our own culture and have, most of the time, the illusion that we master it, we have the
deep knowledge of its complexity just because it happened to be born there or spend our life in.

It is quiet normal to judge the reality according to some constant norms and it is inescapable to be
ethnocentric in some way. I tend to believe that the awareness is a process that starts when one go
away from the familiar, from what he knows better and do not question anymore.

Usually one become aware of,or more present when one encounters the difference, the opposite, the
other.

In a world of similarities, we see similarities and think according the same patterns we are used to.
Even at a personal level, we used to become aware of our competences, our intelligence, talents or
limits when comparing to others. Nosce te ipsum definition, the Ancient Greek aphorism may be the
entry door towards the other.

There are many different ways and techniques to practice in order to increase the awareness of
ourselves, simulations, role playing in a controlled milieu that allow us to analyze different perceptions
and how they change. It is amazing to experience the changing of our own perceptions and the way
how our truths becomes our doubts.

The concept of Cultural sensitivity is narrowly related to cultural awareness and cultural competence.

Generically being culturally sensitive means being aware of, and understanding, a deeper level of
emotions people attach to their culture, values, symbols, history, lifestyle, customs etc.

Being aware of and curios to learn more about the value and meaning some cultural symbols have in
other cultures it may be the first step for an increasing in tolerance and interest in building bridges for
a better and deeper communication and relationship. Being culturally sensitive does not mean
necessarily approving or accepting different cultural practices, diverse ways of understanding, activing,
behaving; sometimes it would be really difficult, even for a very open minded individual to accept, for
instance, some cultural practices consisting of genital mutilation, forces or early marriages, patients
refusing to take medication or letting their children die instead of allowing them to have blood analysis;
Chinese mothers postpartum that refuses to have their baby bathed frightening that warm water will
harm the baby etc.

One example relates: traditional practitioners of Indochinese medicine were not allowed to touch the
body of their female patients, except to take their pulse. A female figurine was provided by the
physician, and the wise physician could diagnose physical complaints of female patients based on the
patient pointing to the area on the figurine corresponding to her own symptoms. (Hoang and Erickson,
1985)

Cultural boundaries are a major source of discrepant views of reality.In cross-cultural care, patient
provider interactions are complicated by the existence of parallel, usually discrepant, explanatory
systems that may include disparate descriptions of natural phenomena.

In multicultural environments, nowadays, it is a must for the health systems to have integrated in their
politics and internal practices the multicultural dimension in order to find a common language for better
communication. The final end is to correctly diagnose and prescribe treatment but also to make sure
the patient trust the help well enough to follow it. Communication with patients can be improved if
health care professionals can bridge the divide between the culture of medicine and the beliefs and
practices that make up patients' value systems. In the process of diagnose the professional have to be
sensitive to particular cultural aspects such as the vocabulary used (some terms like allergy,
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 depression, stress etc may be meaningless for people from other cultures. Moreover, building trust is a
major condition for a successful relationship with patients; in order to build it, the health professionals
have to be aware of even small cultural differences that might be more important to some ethnic
groups.

For instance, small details like addressing patients by their first names may be perceived as
disrespectful or diminishing.
As we can see, being culturally competent and sensitive does not limit to language knowledge,
empathy, communication, tolerance or awareness of the cultural differences.

Cultural competency and sensitivity encompass sexual orientation, gender, faith, tastes, age,
disability, profession, race, and ethnicity and do not stop here. Making the right questions, observing
attentively the behaviours and reactions, making sure the questions were well understood and/or
interpreted, taking into account and integrating alternative forms of therapies when possible or
adjusting services in order to respect cultural requirements are forms of acting and engaging in a
culturally sensitive approach.

A fantastic answer well done!

2: Correct 2. Write your report from Set Task 2. It should be a minimum of 1000 words,
maximum 2000 words in length.

"People subjected to prolonged, repeated trauma develop an insidious progressive form of post-
traumatic stress disorder that invades and erodes the personality. While the victim of a single acute
trauma may feel after the event that she is not herself, the victim of chronic trauma may feel herself
changed irrevocably, or she may lose the sense that she has any self at all." Judith Herman

As human beings, we are all susceptible to experience or to witness dramatic events that might
change irremediably the course of our life, our personality and relationship with ourselves and with the
external world. Personal drama or collective experiences rape, sexual or physical abuse, childhood
neglect, divorce, death, loss, torture, war, terrorist attacks, natural disasters, car or plane crashes,
immigration, may let us traumatised for ever.

Trauma is a personal experience even when lived collectively in the sense that each person's
experience is unique, each person reacts differently and affected to different levels of intensity.

Post-traumatic stress disorders (PTSD) is the name nowadays for the complexity of this severe anxiety
disorder that encompassed a series of common symptoms, such as: recurrent, intrusive reminders of
the traumatic event, including distressing thoughts, nightmares, and flashbacks; emotional numbness
and avoidance of places, people, and activities that are reminders of the trauma; the feeling of being
cut off from others; distress, guilt, fear; being on guard all the time, jumpy, and emotionally reactive, as
indicated by irritability, anger, reckless behavior, difficulty sleeping, trouble concentrating, and
hypervigilance; anxiety disorders that includes agoraphobia, generalized anxiety disorder (GAD),
panic disorder and panic attacks, social anxiety disorder, selective mutism, separation anxiety, and
specific phobias.

In the long run, this state of emotional, psychological and physical distress and disequilibrium create
all the conditions for vulnerability towards severe depression, anxiety and feeling suicidal.

Experienced at personal level, through pain and continual psychological and physical degradation, the
illness affects substantially all people around, family, friends, colleagues, community general word
including health organisms, mental health care providers, NGOs, religious or spiritual organisations,
etc.

How may PTSD be treated?

Despite a vast array of psychology and psychiatry theories, and their adjacent therapies, there is no
unique and universal functional prescription and/ or treatment to cope with the mental distress,
anxieties, depression or more severe disorders. Every professional defends his school, theories,
therapies, treatment and perspective strongly believing that his way is/ may be the right one to
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 alleviate the pain or to recover.

When it comes to human beings and their nature we should almost ever take with a pinch of salt or at
least to reconsider the universal recipes may it be in medicine, religion, spirituality, psychology or
other.

Before analysing some important points to approach (PTSD) in all its complexity I would like to point
out some aspects for reflection when we think about the universalism-relativism in culture. We have to
resist the temptation of assuming a priori that all people coming from one culture identifies completely
with his original culture (for instance, one individual can be Nigerian by birth and origin, by culturally to
feel like more attached to Canadian culture supposing here he was born or lived or being in contact
more with other culture than his own).

Another example may be even if one individual is from an ethnic group, let`s say Zhuang it would be
wrong to assume apriori that he would be prone to refuse a western perspective of treatment we
may be surprise for instance to find out he strongly believes in psychanalisis or cognitive behavioral
therapy.

How may PTSD be treated?

There is not an easy answer and not a unique one, or short one. Very succinctly, I will try to highlight
some of the main alternatives we can take into account when approaching this challenge and
problematize some aspects as a propaedeutic way to stay alert and reconsider periodically our beliefs.
We may envisage and take into account some relevant aspects, combine methods, following different
steps/ stages according to the nature and the pathology of each individual case.

Usually during the first assessment information have to be collected in order to draw up the personal
profile of the patient; psychological, emotional and physical symptoms; the time passed since the
traumatic event; family history, cultural baggage; type of trauma and origin; if witnessed or personally
experienced; previous attempts to clinically cure it; previous medication etc.

Specific data have to be gathered according to the complexity of the case and cross-services
collaboration established for a accurate diagnosis and treatment.

Based on the severity of symptoms, further clinical investigation has to be done and plan of treatment
established and assessed with the patient and family; frequency, intensity of distress; kind of distress
and psychological troubles. There are multiple options and strategies to approach the treatment:
psychopharmacology, psychotherapeutic interventions such as psychodynamic psychotherapy,
cognitive behaviour therapy, stress inoculation, imagery rehearsal, and prolonged exposure
techniques.

Further investigation have to be done in order to establish if there is a risk for suicide which should
require prompt intervention and closer approach.

The determination of a treatment setting should be correlated with the willingness of the patient to
adhere and participate in the treatment plan and as a precondition the clinicians have to take into
account is the process of establishing trust.
I am not going to enter in any more specific details now about the process of diagnosis, treatment,
method used, follow up and monitoring the management of the whole physician patient interaction
because I wish to focus the analysis on other aspects, such as the ethnic and cross-cultural factors
and the cultural competency and how anthropology may be integrated in the clinic.

Taking in consideration the main ideas already discussed in the first part of the assignment, I will open
the debate now on the role of the cultural considerations when approaching mental health problems
and also how cultural competency may be acquired and applied.

There is an abundance of studies on the importance and the need to incorporate cultural awareness
into the healthcare system. There is considerable evidence from medical anthropology suggesting that
illness explanatory frameworks differ profoundly both within and across cultures; the differences in
understanding, expressing, communicating the illness of different ethnic groups are different. Disease,
illness, health care-related aspects of societies are articulated as cultural systems, according to the
anthropological perspective whilst the clinical position approaches them universally.

Where, if any, might be the intersection point between culture and psychiatry?

The debate has a long history and the studies of Kraepelin are known for their position for the
universality of the psychotic symptomatology. This perspective has been criticized for committing a
category fallacy of reifying the categories and criteria of one ethnocentric classification as universal
and natural. The anthropological approach emphasizes the relation between psychiatric nosology and
the social forms in which it is produces, pointing on the relevance of cultural factors in shaping the way
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 illness and therapies have to be interpreted.

Nevertheless, this anthropological position falls prey to several criticisms, among them: the relevance
of mental disorders in DSM as real phenomena; the scientific validity of the concepts, methods, tools
in psychiatry; the reality of an illness etc.

How is PTSD experienced and expressed differently in different societies?

A monkey and a fish were caught in a terrible flood and were swept downstream by torrents of water
and debris. The monkey spied a branch from an overhanging tree and pulled himself to safety from
the flood waters. Then, wanting to help his friend the fish, he reached into the water and pulled the fish
from the water onto the branch.

Moral of the story: Good intentions are not enough. If you wish to help the fish, you must understand
the culture (Ancient Chinese Fable)

We can find the results of a lot of research done and despite all the differences we can find a lot of
commonalities. Even if there were found universal or quasi-universal disorders or somatic symptoms,
one cannot ignore the effect of culture and society on their diagnosis, treatment, and experience.

There are many well-known examples of culture-specific expressions of anxiety disorders, such as
khyl attacks in the Cambodian population, taijin kyofusho of the Korean and Japanese cultures, and
ataques de nervios of the Puerto Rican and Dominican cultures.

Taijin kyofusho (TKS) for instance is a culturally specific expression of social anxiety in Japanese and
Korean cultures. People affected by this disorder are concerned about doing something, or presenting
an appearance, that will offend or embarrass the other person (rather themselves, as in social anxiety
disorder). A typical expression of TKS is the fear to offend others by emitting offensive odors, blushing,
staring inappropriately, and presenting an improper facial expression or physical deformity. Taijin
Kyofusho is a disease foreign to Western society and is one of the cultural-bound disorders and the
Japanese psychiatrist Shoma Morita developped a therapy known under the name of Morita therapy

According to Morita therapy, the pacient has to learn to accept the internal fluctuations of thoughts and
feelings and ground his behavior in reality and the purpose of the moment. Cure is not defined by the
alleviation of discomfort or the attainment of some ideal feeling state but by taking constructive action
in ones life which helps one to live a full and meaningful existence and not be ruled by ones
emotional state.

This is one example for showing that the symptoms can be diverse and in the case of PTSD diverse
symptoms may have diverse approaches and possible effective cures according to patient, to his
culture, to his reaction to treatment.

How can therapists be aware of all the complexities of the cultures, the particularities of their patients
and to what extend can we speak about expertize in cross-cultural disciplines.
In recent years cultural competency has emerged as a term in medicine, signifying the phenomenon
that by understanding the background of patients, physicians will be better able to understand and
treat them in healthcare settings.

While this biosocial approach seems to show great promise in creating an informed and cooperative
healthcare system, professionals must be cautious not to reinforce essentialist and reductionist ideas
about culture when attempting to demonstrate cultural competency.

We can not expect to make tabula rasa of our Western knowledge, but to examine thoroughly the
limits of this knowledge or its applicability in regards to mental health. The goal now is to engage in
pragmatic efforts to alleviate human pain and distress and not to play with academic theories and
concepts without any correspondent in reality or at least meaningless to subjects.

We have to activate our critical thinking and be open and ready to integrate new approaches.

On the other side, realistically to what extend is cultural competency a technical skills susceptible to be
taught and learnt by professionals in health systems? They are not anthropologists and being aware
of, open to, informed may not be of any use concretely.

Given that physicians have such little time to spend with patients, how, then, are they supposed to
adequately meet the demands of culturally competent care?

Often, culture is reduced to language, nationality, or a checklist of essentialist cultural components.

The fundamental problem with the idea of cultural competency as it is utilized in healthcare settings is
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 its consideration as a technical skill that can simply be acquired, or an issue that can be handled by a
translator.

This way the concept of culture is reduced to a set of ethnic dos and donts that can be learned and
referred to when a physician encounters a patient who fits a given description.
We run the risk of making of caricature of such a complex problem, especially when it we work with
human beings, their health, wellbeing and their life.

As always, we find beautiful studies and research on how the cultural competencies can be learnt by
training, cultural exposure, cultural awareness, etc and, on the contrary, the extreme approach on how
unrealistic is to lure into thinking that the anthropology can be transferred easily to other disciplines
(health, educational system, etc) or that all professional may be trained of acquire this sensitivity to
cultural dimensions at a deeper level.

One major problem with the idea of cultural competency is that it suggests culture can be reduced to
technical skills for which clinicians can be trained to develop expertise. We can find a lot of examples
of professionals that have beautiful and deep reflections about African/ Asian Culture and never visited
or interacted with real people. Obviously, travelling or having now and then some contacts does not
mean the contrary, as we have already discussed in our previous assignments.

Ideally, the potential workable solutions are inter-disciplinarily, multicultural teams, institutional
partnerships, cooperation between services, institutions, organisms to develop explanatory models,
training in ethnography, integration of non Western therapy approaches, and above all, stopping to
treat culture, ethnicity, race, nationality as abstract identities.
There is no single healing therapy, no single best therapy or counselling system and no single
conclusion at the end of this assignment. Culture is not static, there is not, for the time being, an
exhaustive theory, approach or solution for the complexity of human pain or health.

A life-long-learning approach, a constant improvement of our knowledge, skills and competences, an

extension of our personal and professional experiences, looking always beyond our inherent
limitations are ways of escaping from the trap of our vanity and come closer to understanding human
nature in all its complexity.

Excellent work.You have demonstrated a very good understanding the module. Keep up the great
effort and I look forward to your next submission, Dee

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