Principles of Multicultural Psychiatric Rehabilitation Services

PRINCIPLES OF MULTICULTURAL PSYCHIATRIC REHABILITATION SERVICES
Executive Summary

PRA recognizes the striking disparities in mental health care found for cultural, racial and ethnic minorities in the United States, and endorses these ten principles as the foundation for providing effective multicultural psychiatric rehabilitation services. This endorsement supports recommendations regarding multicultural diversity published in Mental Health: A Report of the Surgeon General (1999) and Mental Health: Culture, Race, Ethnicity: Supplement to Mental Health: Report of the Surgeon General (2001).

Principle 1: Psychiatric rehabilitation practitioners recognize that culture is central, not peripheral, to recovery, as culture is the context that shapes and defines all human activity.

Principle 2: Psychiatric rehabilitation practitioners study, understand, accept, and appreciate their own cultures as a basis for relating to the cultures of others.

Principle 3: Psychiatric rehabilitation practitioners engage in the development of ongoing cultural competency, in order to increase their awareness and knowledge, and to develop the skills necessary for appropriate, effective cross-cultural interventions. 

Principle 4: Psychiatric rehabilitation practitioners recognize that thought patterns and behaviors are influenced by a person’s worldview, ethnicity and culture, of which there are many. Each worldview is valid and influences how people perceive and define problems; perceive and judge the nature of help given; choose goals; and develop or support alternative solutions to identified problems.

Principle 5: Psychiatric rehabilitation practitioners recognize that discrimination and oppression exist within society; these take many forms, and are often based on perceived differences in color, physical characteristics, language, ethnicity, gender, gender identity, sexual orientation, class, disability, age, and/or religion. Psychiatric rehabilitation practitioners play an active role and are responsible for mitigating  the effects of discrimination associated with these barriers and must advocate, not only for access to opportunities and resources, but also for the elimination of all barriers that promote prejudice and discrimination.

Principle 6: Practitioners apply the strengths/wellness approach to all cultures.

Principle 7: Psychiatric rehabilitation practitioners show respect towards others by accepting cultural values and beliefs that emphasize process or product, as well as harmony or achievement. They demonstrate that respect by appreciating cultural preferences that value relationships and interdependence, in addition to individuality and independence.

Principle 8: Psychiatric rehabilitation practitioners accept that solutions to any problem are to be sought within individuals, their families (however they define them), and their cultures. The person using psychiatric rehabilitation services and his/her family are sources of expanding the practitioner’s knowledge about that culture, how to interpret behaviors, and how to integrate these cultural perspectives into a rehabilitation/recovery plan. Alternatives identified by service providers are offered as supplementary or educational, rather than compulsory.

Principle 9: Psychiatric rehabilitation practitioners provide interventions that are culturally syntonic, and accommodate culturally determined strengths, needs, beliefs, values, traditions, and behaviors. 

Principle 10:  Psychiatric rehabilitation practitioners are responsible for actively promoting positive inter-group relations, particularly between the people who attend their programs and with the larger community.

PRINCIPLES OF MULTICULTURAL PSYCHIATRIC REHABILITATION SERVICES

PRA recognizes the striking disparities in mental health care found for cultural, racial and ethnic minorities in the United States, and endorses these ten principles as the foundation for providing effective multicultural psychiatric rehabilitation services. This endorsement supports recommendations regarding multicultural diversity published in Mental Health: A Report of the Surgeon General (1999) and Mental Health: Culture, Race, Ethnicity: Supplement to Mental Health: Report of the Surgeon General (2001).

Principle 1: Psychiatric rehabilitation practitioners recognize that culture is central, not peripheral, to recovery, as culture is the context that shapes and defines all human activity.

Every individual has a worldview and culture. Culture includes, for example, gender, gender identity, sexual orientation, race/ethnicity, level of ability/disability, age, religion/spirituality and socioeconomic status. Worldview refers to the essential truths and assumptions on which interactions with others and reactions to events are based. Worldview determines a person’s perceptions and understanding of his or her relation to spirituality, humans, nature and the universe. Culture is a predominant force within worldview, shaping behaviors, values, and institutions. A culturally responsive psychiatric rehabilitation practitioner understands and appreciates that a person’s strengths can be rooted in each person’s culture, and that differences between people are to be appreciated as sources of enrichment that can expand the options available to solve problems. Psychiatric rehabilitation practitioners respect the unique, culturally-defined needs of all individuals, and believe that diversity within cultures is as important as diversity between cultures. Psychiatric rehabilitation practitioners also recognize that each individual is unique and has retained varied aspects of the beliefs, traditions, and values of his or her culture(s) of origin, although an individual may or may not accept those beliefs, traditions, and values. In addition, any individual may have assimilated or acculturated to the dominant culture to a greater or lesser degree. Factors related to a person’s country of origin and immigration, and that of his or her family, impact understanding and acceptance of the dominant culture, whether that immigration or migration was recent or distant.

Principle 2: Psychiatric rehabilitation practitioners study, understand, accept, and appreciate their own cultures as a basis for relating to the cultures of others.

The essence of multiculturalism is the study of one’s own culture and ethnicity as the basis for understanding and identifying with those from others. Interpersonal encounters are not “objective” or “value-free” even when these encounters occur in a therapeutic or rehabilitation relationship. In many cultures, encounters and experiences influence simultaneously the mind, body, and spirit, creating both objective and subjective effects. The insights, suggestions, and approaches offered by a psychiatric rehabilitation practitioner arise naturally from the practitioner’s personal beliefs, values, and social positions.  Psychiatric rehabilitation practitioners need to be aware of their own worldviews, ethnicities and cultures and how these affect their approaches to providing rehabilitation and recovery-oriented services. Psychiatric rehabilitation practitioners may know intellectually about the importance of preventing their own biases from interfering with their ability to work with people in recovery. However, psychiatric rehabilitation practitioners also need to appreciate their own culture as a basis for forming partnerships with people in recovery. Psychiatric rehabilitation practitioners also accept that their own identities are complex and contain aspects of cultures with which they have interacted. 

Principle 3: Psychiatric rehabilitation practitioners engage in the development of ongoing cultural competency, in order to increase their awareness and knowledge, and to develop the skills necessary for appropriate, effective cross-cultural interventions. 

Psychiatric rehabilitation practitioners need to be committed to learning about problems and issues that adversely and disproportionately affect the various cultural groups with whom they work. They must recognize that every human encounter is a cross-cultural encounter, as no two individuals have identical experiences and backgrounds. Cultural competency training provides more than information about individual cultures; it provides ongoing opportunities for personal exploration and developing self-awareness. In addition, cultural competency training goes beyond a focus on providing services to individuals, but considers cultural competence within supervision, at the program and organizational levels, and throughout the larger service system.

Principle 4: Psychiatric rehabilitation practitioners recognize that thought patterns and behaviors are influenced by a person’s worldview, ethnicity and culture, of which there are many. Each worldview is valid and influences how people perceive and define problems; perceive and judge the nature of help given; choose goals; and develop or support alternative solutions to identified problems.

Individuals who use psychiatric rehabilitation services are recognized as the drivers of the rehabilitation process, and choose their own goals. Psychiatric rehabilitation assessments examine strengths and needs relative to achievement of those person-centered goals. Psychiatric rehabilitation practitioners routinely include an exploration of an individual’s worldview as part of the process of psychiatric rehabilitation, recognizing that this worldview will influence the selection of personal goals and the commitment to achieving them.  Any person from a non-mainstream cultural/ethnic group has to be bicultural to succeed in the mainstream culture, and psychiatric rehabilitation practitioners recognize that this bicultural stance, along with demands to acculturate, creates its own set of mental health issues and identify conflicts. People’s relationships to their reference group, along with their personal satisfaction, goals, and comfort need to be considered when they are making choices influenced by cultural identity, whether that identify be mono- or multi-cultural.

Principle 5: Psychiatric rehabilitation practitioners recognize that discrimination and oppression exist within society; these take many forms, and are often based on perceived differences in color, physical characteristics, language, ethnicity, gender, gender identity, sexual orientation, class, disability, age, and/or religion. Psychiatric rehabilitation practitioners play an active role and are responsible for mitigating the effects of discrimination associated with these barriers and must advocate, not only for access to opportunities and resources, but also for the elimination of all barriers that promote prejudice and discrimination.

Stigmatization, rejection, and discrimination must be addressed as rights violations, as well as barriers to the attainment of health and full participation in society and community. Every defined population group and every individual has unique, culturally defined needs and strengths. Psychiatric rehabilitation practitioners understand that people who use psychiatric rehabilitation services are usually best served by persons who are part of or are aware and knowledgeable of that culture, while recognizing that membership in a particular cultural group does not, in itself, create competence as a practitioner.  In order to ensure the inclusion of all, psychiatric rehabilitation practitioners need to actively engage in their programs people from diverse backgrounds that reflect the demographics of the community served. In addition, it is a moral and ethical obligation of psychiatric rehabilitation practitioners to combat discrimination, to advocate for inclusiveness, and to remove barriers to service use.

Principle 6: Practitioners apply the strengths/wellness approach to all cultures.

Culturally competent psychiatric rehabilitation practitioners understand and appreciate that individuals’ strengths are often based in their cultures, and that each culture has its own values for defining wellness. For many people, culture can give warmth, security, and a sense of belonging and identity, although this may not be a universal experience. Psychiatric rehabilitation practitioners seek understanding of the positive and healthy contributions provided by a person’s culture(s). Psychiatric rehabilitation practitioners function with the awareness that people’s dignity is not guaranteed unless the dignity of their culture and people are preserved. 

Principle 7: Psychiatric rehabilitation practitioners show respect towards others by accepting cultural values and beliefs that emphasize process or product, as well as harmony or achievement. They demonstrate that respect by appreciating cultural preferences that value relationships and interdependence, in addition to individuality and independence.

Psychiatric rehabilitation has its origins in a Western humanistic worldview, based predominantly on United States and British culture. Most mental health service systems in the U.S. place a great deal of emphasis on outcomes, especially achievement of independence and success in role functioning, such as competitive employment. Psychiatric rehabilitation practitioners recognize that people who use psychiatric rehabilitation services will have a variety of definitions of what constitutes success, satisfaction, and recovery. Rather than relying on a single, standardized set of procedures and outcomes, psychiatric rehabilitation practitioners help create processes relevant to the individuals seeking services, and focuses on goals and outcomes that have meaning for those individuals, their families (as relevant), and their culture(s).

Principle 8: Psychiatric rehabilitation practitioners accept that solutions to any problem are to be sought within individuals, their families (however they define them), and their cultures. The person using psychiatric rehabilitation services and his/her family are sources of expanding the practitioner’s knowledge about that culture, how to interpret behaviors, and how to integrate these cultural perspectives into a rehabilitation/recovery plan.  Alternatives identified by service providers are offered as supplementary or educational, rather than compulsory.

Natural systems (e.g., family, community, church, healers) are the primary mechanisms of support for many individuals and populations. Individuals are served in various ways and to varying degrees by their natural system. To the extent desired by individuals, and accepted by their culture(s), these natural systems need to be active components in people’s rehabilitation and recovery.  When desired by the person receiving psychiatric rehabilitation  services, practitioners start with the person’s “family” as the primary and preferred point of interventions—with “family” being defined by that person’s culture (i.e., nuclear, extended, and/or fictive [chosen]).

Principle 9: Psychiatric rehabilitation practitioners provide interventions that are culturally syntonic, and accommodate culturally determined strengths, needs, beliefs, values, traditions, and behaviors. 

Racial, ethnic, and cultural factors play major roles in the expression of distress, help-seeking behaviors, and ways of understanding problems and psychiatric disabilities. Psychiatric rehabilitation programs and practitioners should strive to conduct all rehabilitation activities in the preferred communication style and language of consumers, their family members, and/or significant others. Treatment and rehabilitation modalities often need to be modified in order to be compatible with other factors, for example: family/group patterns and structures; communication, cognitive, behavioral, and learning styles; identity development; perceptions of illness; and help-seeking behaviors. Informed consent and individual choice also may require involvement of family members and significant others.

Principle 10: Psychiatric rehabilitation practitioners are responsible for actively promoting positive inter-group relations, particularly between the people who attend their programs and with the larger community.

An important principle of psychiatric rehabilitation is that of integration into the community. This principle applies not only to assisting individuals to become integrated into their communities of choice, but also to the integration of psychiatric rehabilitation programs into the surrounding communities. Involvement of persons who use psychiatric rehabilitation services, their families, significant others, and representatives from all communities served is needed to foster community integration and maximize access to services. Involvement in the program should be encouraged from community members, especially elders, leaders, and representatives of the diverse groups within the larger social context, while recognizing that one may need to reach far in order to get the needed expertise.  Similarly, psychiatric rehabilitation practitioners should generate mechanisms for their programs to receive feedback and contribute to the communities that support them.

Resources:

Mental Health: A Report of the Surgeon General (1999);
http://www.surgeongeneral.gov/library/mentalhealth/home.html

Mental Health: Culture, Race, Ethnicity: Supplement to Mental Health: Report of the Surgeon General (2001);
http://download.ncadi.samhsa.gov/ken/pdf/SMA-01-3613/sma-01-3613A.pdf