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Multicultural Healthcare Practice in Mental Health ZM2004

This assignment is based on a client met during placement at one of the London Primary Care Trusts community health settings. The clients brief history, cultural issues that influences his health seeking behaviour will be discussed. The clients presenting problems, needs and potential problems will be identified and the two priority problems identified, goals, implemented and evaluated. Reflective account and summary will be made. Clients confidentiality and anonymity was maintained by adopting the name of Yusuf. This was in line with NMC Code of Professional Conduct (2008). Yusuf is thirty seven years old single Muslim man from Iran who came to England as a refugee ten years ago. He speaks Farsi and understands and speaks English to some extent. Yusufs problem has had drug misuse problems, low mood, self esteem and was also diagnosed with schizophrenia . He presents both negative and positive symptoms such as low mood and auditory hallucination . He claims to hearing voices that tells him of being useless and a disgrace to his family. He reported to feeling depressed and low self -esteem. Yusuf reported being unemployed, depressed and was in dire need of accommodation and employment. In order to understand Yusufs beliefs in relations to his mental problems, cultural issues were explored. He reported to having started smoking cannabis from a tender age of 12 years. Recent studies of substance abuse amongst Iranian high school students reported that drug and substance abuse were high and quite serious. Momtaz et al (2010) attribute this behaviour to parents who were also drug users who lacked cultural moral authority to challenge it. Yusuf said that his increased drug

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intake was due to life stresses wayward friends and long working hours in pubs around the London areas. Yusufs drugs of choice were heroin and cannabis.

Studies done in Canada on Iranian refugees by Jafari et al ( 2008) observed that refugees needed long adjustment time in terms of local cultures and customs which they seem ill prepared to accept due to lack of skills. While Yusuf was in Iran, he was unable to seek any help because he concealed his drug taking habit s to the family. He was afraid of the stigma and family disapproval since they were a practicing Muslim family. Drugs and alcohol taking are prohibited in the Muslim faith.On the other hand, Yusuf sought assistance from the UK health care system by a combination of factors such as easy access to information drug advocacy groups and the risk of police encounter s all spurred him to seek help. The research finding by Sheikh (2000) dismissed culture being the main reason for seeking professional help in the UK based ethnic minorities. Bhugra et al (2000) viewed culture as a shaper of a persons identity, belief system, values and behaviour. Other aspects would include race, ethnicity, religion, gender sexuality lifestyle and experience . Barker (2009) stated that culture also influences how a person views health and illness. This view contradicts Sheikhs research findings.

Throughout this assignment, effort was madeto be cultural sensitive as a clientcentred care plan was crafted. Ten Essential Shared Capabi lities (2004) emphasises

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the importance of cultural sensitivity and competence from the health professionals. To improvecultural competencies research on Iranian culture was undertaken. According to Barker (2009), various cultures have a different underst anding of what constitute mental health problems. It is essential to understand the clients views on what they understood the illness was from their own cultural perspective. Mottaghipour et al (2001) was of the opinion that families from developing count ries had lower expressed emotion than their counterparts from developed countries with poor family support networks. Assessment of Yusuf to obtain b aseline information was obtained during ourinitial interview and subsequent meetings held with him. We met at his brothers home after his discharge from hospital. We removed our shoes in line with the Middle Eastern culture of shoe removing when entering the hosts home. (www.kwintessential.co.uk/resources/global -etiquette/iran-country-profile.) The brother offered us tea or soft drinks, which my other colleagues refused politely. A glass of water offered by the host was accepted as it also coincided with my own culture on hospitality etiquette. Papadopoulos et al (2004) recognised four main elements of cultural competencies as being aware of ones own cultures in relations to the clients culture, understanding cultural diversity and sensitivity. My acceptance of his hospitality showed cultural understanding on my part; the host smiled and nodded his head in approval and appreciation. We introduced ourselves and thanked the brothers kind permission to allow us see Yusuf at his home at such a short notice. The reason of our visit was to meet Yusuf and learn about his problems and needs. Permission to proce ed was asked for and granted. We assured them that all information was to be kept confidential and shared only by members of

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the team working on his case. NMC Code of Professional Conduct (2008) calls for consent, confidentiality and team work. Refer to appendix 1 and 2 for consent and care plan attached.

The presenting problems for Yusuf were that he experienced low mood, anxious and depressed about the future and he felt useless hence self -harming. He mentioned feeling guilty about the worry he had cau sed his brother when he attempted to harm himself. He intimated that suicide and self-harming was strictly forbidden in Islamic faith hence his familys disapproval of his attempts and was a source of shame. QuranSahihBukhari vs. 2.446. Yusuf claimed to have stopped his drugs taking habit and self -harming. The brother confirmed that he was only taking prescribed medication and that he does not self harm anymore. This development was due to successful drug rehabilitation programme he was involved. Yusuf and the brother prayed at noon whilst we maintained silence to give them an opportunity to practice their faith with dignity the occasion demanded.

Yusufs needs were identified during the Care Programme Approach (CPA) review meeting attended by the members of the multi-disciplinary team and Yusuf and his brother who also helped with translation since he spoke both Farsi and English fluently.

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An introduction of participants was made, and the purpose of the meeting stated in an appropriate language to gain cooperation and informed consent (NCM 2008).

The two most pressing problems identified and agreed upon were low mood that leads to Yusufs low self-esteem.

A care plan was designed in collaboration with Yusuf this was in line with the NIC E Guidelines on Drugs Misuses (2007) which, calls for a person-centred approach to interventions. The agreed problem statement was: Yusuf felt low mood. According to Norman et al (2009) a problem statement should contain a clear language that has been agre ed upon by the service-user. The goal was that Yusuf should be able to improve his low-mood within six months. A care plan was designed with Yusufs collaboration in order to build a therapeutic relationship with him by respecting his dignity, being non -judgemental showing cultural sensitivity, genuineness and empathy as advised by OCarroll et al (2007). Throughout the intervention Yusufs religion, family support and cultural beliefs were taken into consideration by speaking to him using his brother to translating from English to Farsi. Whenever he was met without the brother he was spoken to slowly using short, simple sentences. Non verbal cues like nodding and facial expressions were checked. This was to help him to improve his understanding and participation in the formulation of his care plan. NMC (2008) calls for arrangements to meet clients language and communications needs.

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To help Yusufs improve his social contacts he was encouraged to make contact with family, friends, and support network from the Mosques and the Iranian Refugee Network. These networks are vital for him to talk and socialise with his peers from his home country. He initially showed no interest but insisted until he finally agreed to improve his contact with them by meeting them at least once a week. Yusuf was using taarof which is an Iranian politeness system that calls for one to rej ect a proposal until the proposer insists. Nikazm(1998) To that end, Yusufs was helped to process his free transport pass. This was to improve his mobility to socialising with his peers and family. Yusufs intimated that his low mood was due to lack of suitable work and accommodation. His accommodation request became urgent, because his brothers family were returning from Iran and the brother was unable to accommodate him any longer. Yusuf verbalised that he was frustrated by the development which was culturally incompatible, because his brother should look after him particular during his time of dire need. Yusuf was helped with supporting letter and in filling in the Housing forms. An appointment with the Housing Officers for sheltered housing was secure d which was ideal because he will not be alone. As regards employment, Yusuf was referred to an employment specialist within the multidisciplinary team who recommended him to undertake some free electrical training course he had expressed interest in. The second problem identified wa s that of low self-esteem. The second problem statement agreed with Yusuf was that : Yusuf had low opinion of himself. The goal being for Yusufs to verbalise feelings of self -worth and recognise personal strengths and improve self-esteem within six months.

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To helphim build personal confidence initially Yusuf agreed to identify areas he formerly enjoyed. He identified that he used to paint using oils and water colours. Contact was made with the local art therapy group to conside r taking him. Yusuf was happy to meet them twice weekly initially he was to be provided achievable tasks and then given positive feedback. This provides positive reinforcement and enhances self-esteem. In his culture a man of his age should be able to wor k and to look after himself and members of his extended family. Culturally, the Iranians have strong close family ties and are always supportive to each other without any reservations . McGoldrick (2005). Yusuf was asked to identify some positive aspects a bout his life. This was meant to help him not to linger on past failures but on some positive achievements. He intimated that he used to sing some traditional songs and painting landscapes while in Iran. On further investigation we managed to get him two groups that would accept him to practice singing and his creative interests. Yusufs progress was going to be discussed and reviewed at the nest CPN meeting. However to-date his accommodation and employment needs are not yet met. Efforts are being made to continue to occupy Yusuf with various activities as agreed on the care plan.

Initially implementing the care planwith Yusuf was not easy as he was not very easy to engage with. Understanding Iranian taarof was quite a challenge as it needed to get used to. As a no did not mean no , it needed one to insist, and then a yes.would come, this was all meant to be polite.

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He was suspicious of medical staff as he feared that they could recommend him to be detained under the Mental Health Act. However after visiting him several times with my mentor we managed to gain his trust. I had empathised with him by disclosing that I was once a refugee and that I understood his situation. I also explained his rights under the Mental Health Act and reassured him that he was protected as he had the right to appeal against the section. His English comprehension was somehow limited as he continued to ask the same question on many occasions. He was spoken to calmly, softly and slowly using non jargon and repeating to aid comprehension. However an Iranian translator would have helped to translate when we met Yusuf at our offices for his weekly meetings with the care coordinator. My mentor informed me that the trust did not have funding for the translation services. Newell (2000) emphasised the importance of using translators to those who spoke little English.

To sum up my experience, working with the client I learnt that where family support system was lacking, the health care professionals had a crucial role to play. This refers to housing provision for the client. The clients health seeking behaviour was active in the UK than in the Iran due cultural influences. If I were given a second chance what I would do differently would be to use translating services . This would help my understanding of my clients thoughts much better. I would also give him leaflets in Farsi the clients native language. The client welcomed the interventions designed to deal with the identified problems. I felt confident to demonstrate my cultural competence, as some of the clients culture was similar to mine.

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Reference List Baker, P. (2009) Psychiatric and Mental Health Nursing the Craft of Caring.2ndedn.Hodder Arnold. Luthra, A., and Bhugra, D. (2000) Serious Mental Health Nursing: cross culturalissues, in Gamble, C., and Brennan, G., Working With Serious Mental Illness. A manual for clinical practice. London: BailleTrindall. Newell, R., and Gournay, K. (2000) Mental Health Nursing An evidence based approach 2nd ed. Churchill Livingston Elsevier. OCarroll, M., Park,A., Nicol, M. (2007) Essential Mental Health Nursing Skills. 1stedn. Mosby Elisevier. Schultz, J.M., and Videbeck,S.L. (2009) Lippintcotts Manual of Psychiatric Nursing Care Plans. 8 thedn.Lippincott-Raven Publishers. Simpson, H., and Price, B.(1991) Peplau's Model in Action (Nursing Models in Action. 7thedn. London MacMillan. Fazlur,R(1989) Major Themes in the Quran. Bibliotheca Islamica. Townsend, M .C. (2006) Psychiatric Mental Health Nursing Concepts of Care in Evidence Based Practice.5thedn.FA Davis Company. Sheikh,S. and Furham, A, (2000) A cross- cultural study of mental beliefs and attitudes towards seeking professional help. Soc Ps ychiatry, Epidemiology Department of Psychology: University College London.

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Shepherd, G.,Boardman. J, and Slade,M. (2008)Making Recovery a Reality. Sainsbury Centre. Papadopoulos, P., Tliki, M., and Lees, S. (2004) Promoting cultural competence in health care through a research -based intervention in the UK Diversity in Health and Social Care1: 107-15.[Online] Available at: http://pubs.asetts.org.au/Cultural%20Competencies pdf (Accessed: 16 th July 2010). Nursing and Midwifery Council 2008.Standards of conduct, performance and ethics for nurses and midwives.p.73. NMC. London. National Service Framework and Suicide .(1999) London: Department of Health. Department of Health (2004c) The Ten Essential Shared Capabilities . A frameworkfor the Whole of the Mental Health Workforce . London: Department of Health. National Institute for Clinical Excellence Guidelines (2007) on Drug misuse: Psychological Interventions. McGoldrick, M, Giordano,J.,Garcia, N., Ethnicity and Family Therap y. 3rdedn. Guilford Publication Mottaghipur,Y., Pourmand,D., Maleki, H and Davision, L. (2001) Expressed emotion and the course of schizophrenia in Iran. Soc Psychiatry Epidemiology 36: pp.195 199. Department of Psychiatry ShahidBeheshti Medical Science: University Tehran Iran.[Online] Available at: http://www.ncbi.nlm.nih.gov/pubmed/11518033 (Accessed: 5 July 2010). Momtaz, Saeed, Rawaon, Richard (2010) Current Opinion in Psychiat ry Substance abuse among Iranian high school students .Volume 23 Issue 3-p221-226.[Online]

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Available: http://journals.lww.com/co psychiatry/Abstract/2010/05000. (Accessed on 12 July 2010). Nikazm,C.T. Politeness in Persian Interaction: The Preference Forma t of Offers in Persian.Vol.1.pp.3-11. Regents of the University of Califonia. Jafari, S., Babarlou, S., and Mathias, R., (2010 ) Knowledge of Determinants of Mental Health Among Iranian Immigrations of BC, Canada : A Qualitative Study J Immigrant Minority Health (2010)12:pp100 -106. Springer. 0stamo,A., and Lonnqvist,J (2001 ) Excess mortality of suicide attempters. Social Psychiatry and Psychiatric Epidemiology. 36: pp29-35Springer. Websites visited: Available at: http://www.kwintessential.co.uk/resources/global -etiquette/iran-countryprofile.html(Accessed: 17th July 2010).