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Cultural Sensitivity Training

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					Handling Diversity




   Nimmi Hutnik D.Phil. (Oxon.) C.Psychol.
   Director of Studies IAPT PWP
   University of Surrey
                                                        Index

HOPED FOR OUTCOMES
•   TO INCREASE PROFESSIONAL COMPETENCE WITH CULTURALLY
    DIFFERENT PATIENTS THROUGH INCREASED AWARENESS AND
    SENSITIVITY OF ONE’S OWN ISSUES

•   BY EXPLORING OUR OWN CULTURAL ISSUES THROUGH EXERCISES AND
    SELF-REFLECTION

•   BY LOOKING AT CBT AND CULTURAL DIVERSITY: PADESKY AND BECK

•   BY EXAMINING SOME IMPORTANT DIFFERENCES BETWEEN EASTERN AND
    WESTERN CULTURES

•   LOOKING AT THE DIFFERENT LEVELS OF CULTURAL SENSITIVITY
                      Index

Broad Brush Strokes
                                   Index

What did people want?
• Newly arrived in Britain:
  – To learn how British people think and
    make decisions
  – To learn how to from relationships
    particularly romantic relationships
  – To learn how things work: NHS, banks,
    mortgages
  – To learn to manage time in the British
    way
                                     Index
People who had been here a long
time
• Expressed a lot of pain and hurt at the
  loss of parts of themselves Eg. Maria
  Angela, Gabriella, Clara...

• Wanted to know how to deal with covert
  prejudice and discrimination eg hostility
  which seems based on race or ethnicity
  but is them covered up as irritation at
  them not knowing how to do things
                                 Index

‘White’ People
• Expressed an avoidance or safety
  behaviour i.e. they avoided talking
  about race or culture for fear of being
  labelled ‘racist’.
• Some particularly those who were
  born in the 50s and 60s expressed
  some shame at Britain's colonial
  past.
• Others expressed national pride
                                          Index

Ground Rules?
  – Anonymity
  – ‘I’ Language rather than ‘You’ or ‘One’ or ‘We’
  – Non-judgemental accepting attitude
  – Empathy reflection summarising, not
    ‘discussing’ or ‘debating’
  – Jumping in to share, but being sensitive to
    those who are by nature more silent
• 5 MINS WRITING
• 5 MINS SHARING WITH YOUR
  NEIGHBOUR
                                          Index

Names
• Think about your name
• Talk to your neighbour for 5 mins ie 2.5 mins
  each on how you were named.
                               Index

Debrief
• What was this process like for
  you?

• dvd
                       Index

Workbook: Exercise 1
• Early Memories
                                          Index
Workbook Exercise 2: Thought
Record
• Recall an event when you felt uncomfortable or
  perhaps out of place or different in a situation
  with people of another race or culture. Describe
  this event. Re-read your description of this event
  out loud to yourself
• How do you feel when reading this passage?
• What are your thoughts? What is the hot
  thought? What is the evidence for this hot
  thought? What is the evidence against this hot
  thought?
• What is your alternative balanced thought?
• Now Re-rate your mood.
                                Index

Debrief Ex 2.
• What did you discover during this
  exercise?
• Did it work for you?
• If so, please state two reasons why
  worked for you
• If not state two reasons why it did
  not work for you
                                                           Index



Some Statistics …
  See Handout pg. 12 – 24
  Overall:
             7.9% BME (pg. 12 Fig. 1)
             3.6% are Muslim (pg. 13. Table 2) while 93.1 are
             Christian
  South East: This is Us!
             13.4% BMEs (pg. 14. Table 3.)
             28.8% BMEs Greater London
  Unemployment: ( pg. 21. Table 5)
  BMEs 2 ½ times as likely as white British to be unemployed
                                        Index
Health differentials
( pg. 22. Fig. 4)
• BME Females far more likely to be unhealthy
  than white people and even BME males (Physical
  illness: diabetes and heart problems)
   – Pakistani, Bangladeshi, Black and Asian
      women suffer limiting long-terms illness
      above the average (which on the graph is
      100)
   – Black African, Chinese and ‘other’ are below
      the average
                                                                                  Index

 Some More Statistics …
                Ethnicity and Mental Health
                      Post Note 2007
BME people are much more likely to receive a diagnosis of mental illness than
the White British. Studies show up to 7times higher rates of new diagnosis of
psychosis among. Black Caribbean people than among the White British.

However, surveys on the prevalence of mental illness in the community show
smaller ethnic differences.

There is evidence of ethnic differences in risk factors that operate before a
patient comes into contact with the health services, such as discrimination, social
exclusion and urban living.

There is also evidence of differences in treatment. For example, Black Caribbean
and African people are more likely to enter psychiatric care through the criminal
justice system than through contact with the health services. Some researchers
suggest that psychiatrists diagnose potential symptoms of mental illness
differently depending on the ethnicity of the patient
                                          http://www.parliament.uk/documents/upload/postpn276.pdf
                                                            Index

Race Relations Act
•   The Race Relations Act 1976 was established by the Parliament of
    the United Kingdom to prevent discrimination on the grounds of
    race.
•   Items that are covered include discrimination on the grounds of
    race, colour, nationality, ethnic and national origin in the fields of
    employment, the provision of goods and services, education and
    public functions.
•   The Act also established the Commission for Racial Equality with
    a view to review the legislation.
•   The Act incorporates the earlier Race Relations Act 1965 and Race
    Relations Act 1968 and was later amended by the Race Relations
    Amendment Act 2000, notably including a statutory duty on public
    bodies to promote race equality, and to demonstrate that
    procedures to prevent race discrimination are effective.
•   In 2006 additional legislation, the Racial and Religious Hatred Act
    2006, included the additional offence of inciting religious hatred.
                                                                 Index
Delivering Race Equality in
Mental Health Care
• Established in 2005
• For 5 years
• 12 characteristics including less fear of
  mental health services among BME
  communities
• The Prevention of deaths in mental health
  services following physical interventions
• Increased BME satisfaction with services
• Higher BME recovery rate
•   http://www.mentalhealthequalities.org.uk/silo/files/delivering-race-
    equality-in-mental-health-care-a-review.pdf
                                                                 Index

New Horizons (DoH 2009)
• De- emphasizing BME mental health
  and emphasizing whole population
  mental health
•   Mother and toddler groups
•   School health initiatives that promote self-respect or better relationships
•   Older people's lunch clubs
•   Community arts projects - there is evidence that improving the built
    environment is good for mental health and well-being
•   Reading initiatives which improve literacy, social skills and self-esteem.
    An example is the "Get into reading" project in the Northwest
•   Inner-city sports projects which promote team work, self-respect and
    physical health


• http://www.dh.gov.uk/en/News/Recentstories/DH_097701
                          Index

Exercise: The spaceship
• Divide into 6
  groups of 4 by
  numbering off 1-6
                                 Index

Exercise: The spaceship
• Divide into 6 groups of 4 by
  numbering off 1-6.
                               Index

Workbook : 15 mins.
• Questions 3, 4 and 5 only.
                               Index

Debrief
• What strategies did you evolve?
• How did you feel?
• What parallels do you see with
  groups other than LGBT?
                                                                         Index

Typically….
•   expressed a desire to maintain their Earth life style

•   reported that they would experience a variety of negative emotions

•   wanted to continue their romantic relationships but experienced a sense of
    threat and unease when considering doing so (even private acts of physical
    intimacy conducted in private are outlawed)

•   were able to find others who felt the way they did: they would develop secret
    societies and meeting places; identify themselves with unique tattoos,
    jewellery, or clothing; and lead a “double life.”

•   approximately half the groups advocated the use of unilateral, illegal, and
    unethical activities to retaliate against the Aurorans and restore their lifestyle.

•   develop collective action: Martin Luther King, Gandhi, Mandela non-violence
    but the cost is very high

•   some said they would use violence and terror.

•   others said they would conform
                                         Index

Findings of research
• Improved attitudes towards
  homosexuals
• Greater empathy towards ‘different’
  groups

• Before you judge a person, walk a
  mile in their shoes
                   Blog Posted by Geekgirl in psychology
                                   Index

Padesky (1989)
• The route to positive self-identity for
  newly identified lesbians may be
  rocky due to
  – her own negatively held stereotypes of
    what it means to be lesbian and
  – negative reactions from others to
    lesbianism
                                                 Index
Padesky (1991) The Prejudice
Hypothesis in Schema Therapy
• Can you think of someone who has a prejudice against
  some sort of person where you can see that their prejudice
  is wrong? Think of a particular person.

• Turn to your neighbour and tell them what this person does
  when he or she is confronted with evidence that goes
  against his prejudice. Think of specific instances.
  Hypothesise if you cannot recall any actual instances.

• Eg. Sigmund: women are inferior to men. What does
  Sigmund do when he observes a woman doing something
  as well or even better than a man?
                                                   Index

If they own homophobic beliefs
• But are in denial that they do:
• Therapist might say:
   Most of us don’t like to admit having prejudices but it is
     nearly impossible to grow up in the world without being
     taught negative things about lesbians and other
     minority groups. What are some of the things that you
     have been taught about lesbians?

   Then evaluate the belief eg: 50% lesbians are masculine,
     98% being lesbian eliminates her chance of having
     children, and 10% lesbians are uptight sexually

   The process is then to test these beliefs in ways that you
     are already familiar with eg BE, thought diaries etc.
                                Index

Homophobia in others
• Hopefully transferable to racism in
  others towards you
• or ageism
• or sexism
• or classicism
• or able-ism
• or fat-ism
                                                   Index
Dealing with prejudice in others
towards your client
• Pg. 6 of handout

• Cl: I can’t think of why my parents are so bigoted (re my
  lesbian identity). They have known me for 30 years.

• Th: When you first began to think of yourself as a lesbian
  were you 100% about the idea?

• Cl: No, not 100%. But when I got more experience I could
  see that it was good for me and not everything I feared was
  true.

• Th: How many experiences have your parents had to help
  them evaluate their beliefs about lesbians?
                                                          Index
More balanced beliefs towards self= more
able to cope with negative attitudes of others.
•   Using CT techniques requires some emotional distance. In ACT
    they call this process de-fusing and developing psychological
    flexibility. (Read dialogue pg. 151 152)

•   By helping the client to remember that it took some while for her
    to come to terms with her own lesbianism, the therapist facilitates
    in her a willingness to see attitude change in her parents as a
    developmental process as well
                                                          Index

Extreme Homophobia in others
•   Learning to cope with rejection
•   A period of mourning of loss of relationships
•   After this, arrive at alternative balanced thoughts about the
    rejecting person: e.g. a friendship is not totally wrong because
    one person cannot accept everything about another
•   Role playing with the client might help
•   Each person must come to their own individual solutions re
    display of affection, others’ expectations of heterosexuality in
    relationships at work, financial and legal constraints on lesbians,
    family pressures to appear at Xmas without one’s lover, decisions
    about how and when and to whom to ‘come out’
•   Encourage client to engage in collective action to get some
    change in broader society
                                                          (Padesky 1989)
                                                            Index
More balanced beliefs towards self= more
able to cope with negative attitudes of others.
•   Alice’s mother: ‘You’ll never be able to live a happy, normal life’

•   1st Using skills acquired in CT, Alice clarified that for her mother.
    ‘normal’ meant doing things with heterosexuals
•    2nd reminded mother of a female couple they had known and liked
    in their bridge group Mother: but they didn’t tell everyone about
    their relationship. Alice then talked to her mother about how she
    decided when to tell people about her relationship

•   Using CT techniques requires some emotional distance. In ACT
    they call this process de-fusing. (Read dialogue pg. 151 152)

•   By helping the client to remember that it took some while for her
    to come to terms with her own lesbianism, the therapist facilitates
    in her a willingness to see attitude change in her parents as a
    developmental process as well
                   Index

Gay Pride Parade
                                                  Index

Beck (2001)
• Sept 11th 2001
• Cognitive Distortions of Terrorists:
   – over-generalisation (the supposed sins of the American
     government are spread to encompass the whole
     population
   – dichotomous thinking: a country is either totally good or
     totally bad
   – tunnel vision: once engaged in their mission they
     remain focussed on destruction (no attention paid to the
     loss of their own lives) thus challenging the
     technological and economic superiority of the
     Superpower to humiliate it and to bring it down.
                           Index

Ethnic matching is not a given
                                                              Index




From Hutnik, N. (1991) Ethnic Minority Identity:
A Social Psychological Perspective, Oxford: Clarendon Press
                              Index
Some Important Differences between
‘Eastern’ and ‘Western’ cultures
         Index

Versus
                        Index

Linear time vs. circular time
Task orientation vs.       Index

relationship orientation
           Index

I vs. We
Antithesis vs. synthesis   Index

Dualism vs. Non-dualism


    A = non A
    X = A + non A
                                            Index



•   It was six men of Indostan
    To learning much inclined,
    Who went to see the Elephant
    (Though all of them were blind),
    That each by observation
    Might satisfy his mind.
    The First approach'd the Elephant,
    And happening to fall
    Against his broad and sturdy side,
    At once began to bawl:
    "God bless me! but the Elephant
    Is very like a wall!"
    The Second, feeling of the tusk,
    Cried, -"Ho! what have we here
    So very round and smooth and sharp?
    To me 'tis mighty clear
    This wonder of an Elephant
    Is very like a spear!"
    The Third approached the animal,
    And happening to take
    The squirming trunk within his hands,
    Thus boldly up and spake:
    "I see," quoth he, "the Elephant
    Is very like a snake!"
                                               Index



•   The Fourth reached out his eager hand,
    And felt about the knee.
    "What most this wondrous beast is like
    Is mighty plain," quoth he,
    "'Tis clear enough the Elephant
    Is very like a tree!"
    The Fifth, who chanced to touch the ear,
    Said: "E'en the blindest man
    Can tell what this resembles most;
    Deny the fact who can,
    This marvel of an Elephant
    Is very like a fan!"
    The Sixth no sooner had begun
    About the beast to grope,
    Then, seizing on the swinging tail
    That fell within his scope,
    "I see," quoth he, "the Elephant
    Is very like a rope!"
    And so these men of Indostan
    Disputed loud and long,
    Each in his own opinion
    Exceeding stiff and strong,
    Though each was partly in the right,
    And all were in the wrong!
    MORAL.
•   So oft in theologic wars,
    The disputants, I ween,
    Rail on in utter ignorance
    Of what each other mean,
    And prate about an Elephant
    Not one of them has seen!
•
                             Index

IAPT
• PWP course: 1 whole module is
  devoted to Handling Diversity
  Issues.
                                            Index

Improving Access to services for BMEs
• BMEs do not access mental health services in
  any significant proportion via the health route
•
• David Clark: Much more likely to do so if the
  service is a self-referral service (Sept 11th 2009
  IAPT Course and clinical Leads Day)
                                    Index
What I believe:

• Along with Rogers (1986), I believe that
  what is crucial to effective intercultural
  interaction and culturally sensitive
  professional healthcare is the ability to
  meet people at relational depth
                                  Index

Relational Depth
• a very high level of empathic
  understanding,
• a very warm extension of unconditional
  positive regard,
• a deep sense of congruence in the
  relationship so that what you are on the
  outside matches what you are on the
  inside
Index
                                                                      Index

References
•   Asch, S.E. (1956) Studies of independence and conformity: A minority of 1
    against a unanimous majority. Psychological Monographs: General and
    Applied, 70, pp. 1-70.
•   Beck, A. (2001) Prisoners of Hate: The mind of the terrorist.
    http://www.padesky.com/clinicalcorner/pdf/atb_prisoners_terrorists.pdf
•   Chryssochou, X. (2004) Cultural diversity: Its Social Psychology. Blackwell
    Publishing Hillman, J., & Martin, R. (2002). Lessons about gay and lesbian
    lives: A spaceship exercise. Teaching of Psychology, 29, 308-311.
•   Hodson, G., Choma, B., & Costello,K. (2009)Experiencing Alien-Nation:
    Effects of a simulation exercise on attitudes towards homosexuals. Journal of
    Experimental Social Psychology, 45,974–978
•    Hutnik, N. (1991) Ethnic Minority Identity: A Social Psychological Perspective.
    Oxford: Clarendon Press.
•   Lemaine, G., Kastersztein, J. Personnaz, B. (1978) Social differentiation. In
    Differentiation between social groups: Studies in the social psychology of
    intergroup relations. (ed. H. Tajfel) Academic Press London.
                                                      Index

References Contd.
• Padesky, C. (1989) Attaining and Maintaining Positive Lesbian
  Self-Identity: A Cognitive therapy Approach. Women and
  Therapy, 8 (1,2) 145-156.
• Padesky, C. (1990) Schema as Self-prejudice
  http://www.padesky.com/clinicalcorner .
• Tajfel, H. (1981) Human Groups and Social Categories: Studies
  in Social Psychology. Cambridge: Cambridge University Press.
• Vethanayagam, S. & Barrett, M. (2006) Ethnic minority
  children’s cultural practices and patterns of national and ethnic
  identification. Paper presented at Milan conference on
  Developmental Psychology and available at
  http://epubs.surrey.ac.uk/psyconferencepapers/13

• Mothertongue multi-ethnic counselling and listening service.
  PO Box 2409, Reading RG1 1ZQ. Tel: 0118 957 6393 Fax:
  0118 323 4575.info@mothertongue.org.uk.
• New Horizons
  http://nds.coi.gov.uk/Content/Detail.aspx?NewsAreaId=2&Relea
  seID=398462&SubjectId=16&AdvancedSearch=true
                                                                       Index

Bibliography
•   Department of Health, 2005. Delivering race equality
    in mental health care: a summary. London: DoH Publications.
•   Ethnicity Online. Useful web resources and good practice guidelines at
    www.ethnicityonline.net/resources.htm
•   HM Government Office for Disability Issues at www.officefordisability.gov.uk/
•   Hutnik, N. (2005) “Towards holistic, compassionate professional care: Using a
    cultural lens to examine the practice of psychotherapy in the West”.
    Contemporary Family Therapy, 27, 383-402.
•   Hutnik, N. & Street, R. (2010) Profiles of British Muslim Identity: Adolescent Girls
    in Birmingham Journal of Adolescence doi:10.1016/j.adolescence.2009.05.016
•   Hwang, W. C., Wood, J. J., Lin, K. M., & Cheung, F. (2006) "Cognitive-
    Behavioural Therapy With Chinese Americans: Research, Theory, and Clinical
    Practice", Cognitive and Behavioural Practice, . 13,4, pp. 293-303.
                                                                    Index

Bibliography contd
•   Hwang, W. C. & Wood, J. J. (2007) "Being culturally sensitive is not the same as
    being culturally competent", Pragmatic Case Studies in Psychotherapy, 3, 3, pp.
    44-50.
•   Jacobs RH; Klein, J.B, Reinecke MA; Silva, S.G; Toev, S; Breland-Noble A,;
    Martinovich Z.; Kratochvil CJ; Rezac AJ; Jones J,; March, J.S. (2008) “Ethnic
    Differences in Attributions and Treatment Expectancies for Adolescent
    Depression”, International Journal of Cognitive Therapy1,2, 163-178. 2008.
•   MIND Factsheet on Lesbians, gay men, bisexuals and mental health at
    www.mind.org.uk/Information/Factsheets/Diversity/Factsheetlgb.htm
•   Myles, P. & Rushforth, D., 2007. A complete guide to primary
•   care mental health. London: Robinson. Chapter 2.1.
•   National Center for Cultural Competence (US) at
    http://www11.georgetown.edu/research/gucchd/nccc/index.html
•   O’Hagan, K., 2001. Cultural competence in the caring professions. London:
    Jessica Kingsley.
•   Prior, P., 1999. Gender and mental health. Basingstoke: Macmillan.
•   Royal National Institute for the Blind at www.rnib.org.uk

				
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