1. Re-inventing Children: Communities, Culture and Mental Health Policy Begum Maitra Consultant Child and Adolescent Psychiatrist East London and the City Mental Health Trust

2. Culture in practice Clients 2 year old Rokeya in Care proceedings (under the Children Act) for significant harm thought to be attributable to ‘parental neglect’ little evidence available of the impact of diverse cultural styles of child care and parent-child interaction professional bias in observation, and attribution of meaning (the nature of cultural training) little relationship between psychological and legal criteria ME professional refers 5 year old Osman for ‘disturbed behaviour’ (challenges authority, disrespect for women) who judges ‘appropriateness’ of cultural patterns ?

3. Culture in practice Clients White mother (convert to Islam, S Asian dress, name and language) with 2 children ‘of dual heritage’ judged more severely for parenting difficulties common to other single parents the failure of notions of ‘racism’ or ‘ethnic identity’ to address hybrid, and often changeable, identities that are based on only partly conscious choices British Asians who choose partners from their country of origin with the express intention to renew cultural ties and resources social class and relationship hierarchies – impact on cultural practice, child care ‘expertise’ family, ‘community’ relationships (C of O; Br Asians; other diasporic communities; mainstream Br culture)

4. Culture in practice Professionals ME staff in NHS mental health services Hierarchical relationships (often white British seniors) ‘Pressure’ to accommodate to British norms of interpersonal behaviour ‘Training’ produces uneven mixed belief systems (expectations and behaviour) What impact do these factors have on the ‘identity’ of these professionals ? Organisational policy on ‘race’ NHS - ‘culture-blind’ stance; the expectation that the patient will ‘lead’ Social services - matching ‘race’ in allocations (and placements)

5. The uneasy place of culture in ‘mental health’ Culture and ‘mainstream’ (adult) psychiatry ‘Universals’ and ‘culture-bound’ syndromes ‘Cultural psychiatry - a move from ‘categories to contexts’ ‘Race’ and Organisations The effects of racist mental health services - poor access, abusive and culturally irrelevant The influence of ‘systemic’ therapies on child mental health Thinking in relational/interactional terms UN Convention on the Rights of Children Universal notion of the best interests of ‘all’ children

6. Recent events: Impact of Race/Culture on Mental Health Policy Race Relations (Amendments) Act 2000 Report on Ethnic Health Inequalities 2001 Children High rates of smoking and alcohol use among Irish children Low rates of dental care in all ME groups Low rates of participation in sports/exercise in all ME girls

7. Recent events: Impact of Race/Culture on M H Policy (contd) Inside Outside: Improving Mental Health Services for Black and ME communities in England 2003 10 point Race Equality action plan (Chief Exec NHS) 2003 Report of the Social Exclusion Unit June 2004 Appt of NHS Equality and Human Rights Director Oct 2004 ‘Celebrating our cultures’ Dec 2004 Guide to mental health promotion with BME communities

8. Recent events: Impact of Race/Culture on M H Policy(contd) Delivering Race Equality (DRE) in Mental Health Care Jan 2005 Ensuring MH services are more responsive to BME patients Better links between services and communities through 500 new ‘community development workers’ and the (expertise of) independent sector BME providers Black and Minority Ethnic National Steering Group National Institute for Mental Health in England (NIMHE) and Department of Health BME Mental Health Programmes

9. and Children …? National Service Framework (NSF) for Children, Young People and Maternity Services 2004 Funding (total £1.5 million) March 2005 over 2 years for 5 projects aimed at developing culturally competent services for young BME people

10. Culture & the Children’s NSF ‘Services for children and young people should be provided irrespective of their gender, race, religion, ability, culture or sexuality’. (Rationale, 2.11) Emphasises the importance of improving access to CAMHS to ensure greater equity ‘Specific arrangements may need to be made to provide appropriate mental health care for children and young people in families of refugees/asylum seekers’

11. Culture & the Children’s NSF(contd) ‘Concepts of mental illness and the understanding of the origins of children’s emotional and behavioural difficulties vary across cultures. Services need to be sensitive to these differences and ensure that staff are equipped with the knowledge to work effectively with the different groups represented within the community they serve.’ (Enhancing partnerships with BME groups, 5.3) Ensure all staff working within CAMHS are sensitive to the particular needs of ch and yp from different BME groups Training is available for staff to work effectively with families from specific BME groups within their community

12. Culture & the Children’s NSF (contd) Provide local directories of services for ME groups to enable BME ch, yp and their families to receive appropriate support Recruit and train professionals from the ethnic minorities for whom services are being provided Review the provision and training of interpreters to ensure that best practice is achieved Planning & commissioning services to be based on locally adjusted epidemiological information on the prevalence of MH problems to reflect the diversity of the population

13. Common Features ‘Ethnic monitoring’ To provide data on ethnic patterns of service provision and service uptake Improve access to services Provide interpreting and translation Provide information leaflets Promote user feedback (on relevance and satisfaction)

14. Common Features … (contd) Increase cultural awareness / sensitivity / competence Staff training on ‘diversity issues’ Recruit BME staff ‘Capacity building’ in ME ‘communities’ ‘Engage’ communities through consultation, use of advocates Address cultural ‘needs’ - dietary needs, ‘respect’ for religious belief ‘Modernising the professions for a new health and social care system’ Evidence based practice ‘User/ Patient ’ involvement, service design, choice

15. The problem with (some) solutions Response to ‘Inside Outside’ Report - Transcultural Psychiatry Society (UK) in 2003 Vague recommendations; the only ‘new money’ is for old (and ineffective) solutions eg CDW. CDWs need to be at a senior level. Their training, supervision and accountability to be defined with the BME communities, not statutory authorities MH Professional culture – pervasive influence of narrow, culturally biased views of child development, long-term psychological goals, ‘health’ and illness, culture A new and jarring brand of (‘friendly’) jargon ‘Race Equality champions’ ‘Facing up to difference’ (FUD) ‘Challenge, consult, compare and compete’