TRANSCULTURAL

PERSPECTIVE IN MENTAL
HEALTH NURSING
BSN 4-BGroup2
Catedral, Catubay, Ciudad, Custodio, de Asis, Diamansil,
Dignadice, Edaño, Ganado, Hipolito

 Mental Health Beliefs and

Practices and Specific Cultural
Groups and Subpopulation
1 Blacks 4 Asian North Americans

Middle Eastern Cultural

2 North American Indians 5
Groups

Culturally Competent Nursing Care for

3 Hispanic Americans 6 Clients with Mental Health
Considerations
INTRODUCTION
The two largest consumer groups of mental health care today are the chronically, seriously
mentally ill and the aged. Nurses are increasingly involved in rehabilitative training,
resocialization program, spatial hospitalization centers, and support groups in addition to
one-to-one relationship. In addition, every group has discernible patterns that help in
distinguishing from other group, most of the time, individual expresses beliefs or
traits that do not match the same group norm.
REMEMBER!
It is important for nurses to be culturally sensitive, knowledgeable, and
skillful because they become the the advocate for mental health concepts
to other societies.
INTRODUCTION
Mental illness is always socially constructed, there were time when mental illness
did not exist as a separate conceptual category. People who are "mad" were
more likely to be viewed as "fools" or "possessed" rather than ill.
Due to the growing social consciousness, mentally deranged were given
refuge in asylums, wherein they were isolated and received at least a modicum
of care and shelter.
INTRODUCTION
The medium for collaboration treatment and diversity management is mutual
communication. wherein it portrays the client as someone who is more expert about
his or her situation that the health care provider, and from then on, the nurse can
learn to understand the situation of the client. a culturally competent transcultural
nurse has the ability to manage diversity effectively, wherein management of diversity
is defined as helping each person to reach his or her full potential. Moreover, the key
to managing diversity is understanding the perspective of the patient and the
ways it is grounded in his or her culture.
REMEMBER!

Awareness, sensitivity, and knowledge, combine with cultural

assessment, communication, and other mental health nursing skills,
can produce respectful culturally acceptable, and effective
nursing interventions for diverse people in specific/ individual
situation.
 MENTAL ILLNESS
AND
MENTAL DISEASE
Illness- subjective behavioral, psychological,
sociocultural, and experiential dimension of
disorder

Disease- chemical, physiologic, and objective

phenomena related to sickness
The rate of mental illness and mental diseases
do not seem to vary much among groups
when social and economic factors are
controlled. There is no conclusive evidence that
mental illness and disease rated vary with race
or other intrinsic human characteristics,
although they are clearly associated with low
socioeconomic status, low educational level,
separation, and loss
Mental health diseases is evident across the globe. However, diagnosis can
be difficult because the expression of symptoms varies so much aside from
cultural differences. Moreover, the downside of mental health is that, despite
of international epidemiologic and research efforts, there is still no
international centers focused on the mental health treatment programs.

Furthermore, every societies has a system of beliefs and practices related to

health care, and specific persons trained as healers. There are still many
places wherein biomedicines are not available and the community is still
reliant on traditional healers.
Shamans and traditional healers are often not
effective in treating chronic mental disorders, the
outcome for some conditions tends to be more positive
in societies where client are not negatively stigmatized
and are not alone with their problems. in contrast,
people with mental illness who are devalued, are more
likely to be demoralized and isolated, feel
dehumanized, and to curtail the development of
potential support system.
The etiologic beliefs of mental health care
professional is commonly acknowledge due to
variety of reason or simply by chance, parts, system,
families, or individuals take on characteristics that
are assessed by dysfunctional. By contrast, members
of many cultural groups believe illness is caused
by a supernatural being (a deity or god), non
human being (ancestor, ghost, evil spirit), and other
human being (witch or sorcerer).
 DIAGNOSIS
The symptoms of mental illness are dependent on the person's behavioral
expression and the appropriateness of behavior
Language of distress- a pattern used by a client to express concern or
disorder
There are times that cultural groups has a altered interpretation that some
culture viewed it as a mental disturbance.
 Psychotic
Addiction
Disorders
Occurs in every society
Addictive substances
Primary symptoms: social
has a different views and emotional withdrawn,
on using addictive auditory or visual
hallucinations, general
substances, some
delusions, flat affect, mood
traditions reserve this changes, and insomnia.
during special Ex. Suicide is an
acceptable escape from
occasions and rituals
problems due to personal
reasons
Somatization
symptoms expresses
psychological distress
Ex. Common among
Hispanic or Chinese- they
deny of being depressed
but describe on having
headaches, backaches,
stomachaches, and other
physical phenomena,
these ailments might be
due to sorrow and
suffering
Delusions and Posttraumatic Stress Disorder
Hallucinations
known as- Culture-bound Fright/ Soul Loss by Hispanic-
syndrome- it exist within sudden start to sneeze
Can be specific cultural groups Mal Ojo (Evil eye)- occurs
psychological, China- Neurasthenia; unintentionally, ex. nurse fails to
religious/spiritual, symptoms are produced touch the child she noticed or
moral or social, by social stressors and examined.
may corresponds to Treatment: herbal remedies, rubbing,
naturalistic or
Western medicine- massage and physical manipulation
supernatural, or depression by curanderos or curanderas.
physical or medical
other treatement used: home remedies and prayers, or trip
to religious shrines or charismatic folk healers to alleviate
distress
Anorexia Nervosa REMEMBER!

Psychiatry is not homogenous,

can be seen in most sociocultural and cross-cultural
countries where there is approaches exist that extend the
abundant supplies of thinking of many psychiatric and
food. mental health providers to allow
cultural, social, and holistic
explanation on the client's behavior
 SOCIOECONOMIC FACTORS
INFLUENCING MENTAL HEALTH
Social and environmental conditions often
leads to mental health problems children and
adolescents are vulnerable to mental health
effects the current social and economic
conditions.
PARENTING STYLE
"Good parenting" - keeping a child safe,
fed, and clean, without including activities
that stimulate cognitive, effective, and
physical development
There are number of children and
adolescents live in poverty, with severe
mental health
Whereas, children and adolescents of every
social class and ethnic background are
vulnerable to to sexual and physical abuse
In the United States, children are likely to be exposed at a
young age adult sexual roles and violence through mass
media. Moreover, high rates of depression are associated

with problems in areas such as family and personal

relationships, finances, and general living conditions.
crime, drug use, and suicide are prevalent problems that
might be associated with perceived limitations on hope.

 Poverty and Lack of Social Support

disorganized and dysfunctional families are not specific to poor people, the poor
often have higher mortality and morbidity rates and access to relatively few
treatment resources.

Increased geographic mobility and separated living styles

this could result to loose social networks and increased alienation

Single-parent Extended Family

t alone in child-rearing
Socialization responsibilities
responsibilities

Increase divorce rate often disrupt
the flow of personal support
Traditionally cohesive type of people
find themselves isolated from culturally
relevant support persons, they are
challanged to establish a meaningful
ties in merged, blended, or diparate
families or support system
Traumatic societal and personal events such
as painful separations, torture, loss, sudden
death, bereavement, uncertainty, and violence
have made posttraumatic stress syndrome a
general diagnostic category for person of any
age and any traumatic background
Noninvasive therapies such as storytelling
and therapeutic writing are increasingly used
for treating PTSD
Approaches such as self-disclosure vary on
cultural orientation, however, this practice
have a positive result among diverse groups
hypnosis, self-reflection, and spirituality also
has a significant help for treatment
 L A C K
B

DE ASIS & CATUBAY

According to Kess- Gardner (2004), distinguishing African
Americans from others who come to the United States from
the Caribbean islands, Africa, or other parts of the world, it
is obvious that people of color, sometimes collectively
called "Blacks," are very diverse. Centuries of
discrimination in a predominantly "White" culture has
perpetuated a focus on differences and leaves "Blacks"
and "Whites" artificially divided and many people of color
without access to culturally congruent mental health
resources. Various ethnopsychiatric innovations have
helped fill the need.

More recent and more respectful mainstream mental

health efforts have drawn attention to Black resilience and
strengths and away from association of difference with
psychopathology (Hartmann, 2002).
History of African
Americans
History of African Americans began when 20 Africans were dropped in the English colony of
Virginia in 1619.
Slaves in Virginia in 1661 and in all the English colonies by 1750.
They are considered an inferior race with heathen culture.
They were forced to work in the farmlands of the New World.
They were sold as merchandise by European traders on slave ships across the Atlantic
Ocean to the West Indies.
At least one-sixth of them died during the journey due to shock, disease and suicide.
Africans and African Americans were forced to work on plantations work as slaves on
tobacco, rice, and indigo plantations of the southern coast during 17th and 18 centuries.
Thomas Jefferson passed legislation in 1807 to end the slave trade. However, it did nothing
but boosted the domestic slave trade in the country. Free black people still made up one
tenth of the African American population, but were not allowed to vote, own property, or
travel freely.
Blacks often remain enthusiastic about religion and spirituality, are characterized as adaptable
and bicultural (that is, able to function in two worlds, one Black and one White, which requires
considerable effort and energy), and typically value work and education despite a history of
limited opportunity to acquire or use those institutions. Traditionally, strong networks extended
beyond households to multiple collateral relationships. Expectations for culturally congruent care
among Blacks usually include general concern for one another (the "brothers and sisters")
according to Kess-Gardner, 2004; Miller, Serner, & Wagner, 2005. In a society in which dark skin
rendered people socially invisible for centuries (Kavanagh, 2005), genuine respect and
acknowledgment are essential to acceptable care (Evidence-Based Practice 10-2)
Black folk medicine, traditionally not separated into mental
and physical components, contains elements of various origins
(Baer, 2001). In addition to a strong and adaptive knowledge
of the use of herbs, early 19th-century Haitian slaves rebelling
against French masters brought with them a form of voodoo (a
blend of European Roman Catholicism and African tribal
religions with modified aspects of humoral pathology). This
spread through the Protestant American South and assimilated
practices from 17th and 18th-century European occultism,
probably because of the insistence on using English rather
than African languages. Reflecting its multiple origins, Black
folk medicine today provides widely varied terms and methods,
including, for example, "root" medicine, "rootwork," "mojo,"
"conjuring." "voodoo," and "hoodoo." There remains a
tendency to bring to the health care situation a mixture of
somatic, psychological, and spiritual problems (Baer, 2001).
In traditional Black belief systems, diseases may stem
from causes that are natural or spiritual in nature
(e.g., punishment for sins or violation of sacred beliefs).
The causes of disease may be viewed as natural
(such as failure to protect the body against inclement
weather) or unnatural (for instance, divine punishment
for sin) and tend to represent a perspective that holds
the world to be a dangerous and hostile place. The
individual is traditionally viewed as being vulnerable to
outside attack and dependent on outside help (Harvey,
2003). This perspective was reinforced by nearly 3
centuries of slavery and then another century of struggle
for full rights.
North American Indians

Custodio & Catedral

There are more than 500 different Native
American and Alaskan Native tribes and
nations, and tremendous diversity among
those. Thus, generalizing "the American Indian
culture" is no more realistic than stereotyping
a culture as "Black".
Members of various groups may share
aspects of history, language or culture yet
may be notably different from each other in
significant ways.
It is never safe to stereotype groups or
individuals on the basis of presume similarities.
North American Indians are priorly known as American Indians, First Nations,
Amerindians or Indigenous Americans and variously including or excluding
Native Hawaiians, some indigenous groups in the United States are
recognized by the federal government and others at only the state or local
level (Oswalt, 2006).
Aboriginal peoples, North American Indians and status and non-status Indians
are terms commonly used in Canada to identify native peoples in both legal
and social terms (Li, 1999).
It is important to know individual and group references for being called
Native American or North American Indian; there is no one correct label.
Most native peoples with tribal affiliations identify with tribal names (for
instance , Cree, Cherokee, Lakota, Mi'kmaq, or Navajo) rather than with the
pan- Indian collective terms (Native American Native Canadian or North
American Indian).
Most indigenous population in the Americas shared a traditional
orientation to being in the present (rather than to doing and to the future,
which is more typical of European North Americans), cooperation rather than
competition, to giving rather than keeping, and to respect age rather
than youth (Oswalt, 2006; Reyhner and Eder, 2004)
Traditionally, the life cycle emphasizes rhythmic , natural phenomena aim at
a balance between living and working toward achieving Indian goals; self-
development is never completed. Non-interference is valued, and behaviors
that imply manipulation or control may be offensive (Biolsi, 2001; Adams,
2000).
The astute clinician makes sure that the North American Indian client is aware
of the consequences of behavior but then leaves it to the individual to decide
how to proceed. Silence and a conservative show of interest ( including for
example minimizing eye contact) are respectful, caring behaviors.
The potential for personal confusion is obvious in a situation where
mainstream society devalues most of the concepts integral to traditional
Native North American philosophies and ideologies.
North American Indian ideas about health and illness place less
emphasis on dysfunction of the body than is typical of biomedicine and
more on relationship within society.
For many Indians, health typically denotes a special, balance relationships
between humankind and its physical, relational, and supernatural
environment.
Illness implies having fallen out of balance and harmony with the world
(Melton, 2005).
Traditional self-care prevention measures may include religious or
traditional magical elements (for example, singing special songs, burning
herbs or candles, wearing amulets, reciting prayers or making offerings) (Tom-
Orme, 2002).
Although the prevalence of alcohol in drug use varies by tribe and by age
within tribes (as it does within other groups, such as European North
Americans, Latinos and Blacks {Singer, 2001).
Native North Americans tend to have higher rates of alcoholism than those
experienced by other groups. Associated phenomena include high suicide
rates among the young domestic (spouse and child abuse) violence and
homicide (Christie, 2001).
However, many tribes today pride themselves on their increasing social
pride, their tribal stability and sovereignty, and the rates of sobriety that are
markedly higher than in the past when their peoples were more of
oppressed (Lowe, 2002; Struthers and Lowe, 2003).
 Stress-producing socioeconomic situations accompanied by psychological,
cultural spiritual stressors lead to perceptions of loss and depression. Those who
are least acculturated to White society and who have strong tribal identities often
tend to have the fewest problems, whereas those living in two seemingly
contradictory societies are greatly challenged.
Group therapies with an emphasis on society have been found to be especially
useful for treatment (Schwarz, 2001). Often they are family-network therapy,
traditional Indian group talking (such as talking circles), and purification therapies
such as ritual sweats Adams, 2000; Steeler 2001).
Cultural groups on or life stages in diverse ways. Here tobacco ties and sage, circular
in form to reflect unity, mark a traditional Lakota grave.
Clinical Application
Accept and work with the fact that some Black clients will be hostile toward
White, middle-class heath care professionals who are likely to be perceived (and
to inadvertently behave) as privileged.
Recognize that although the client is a unique person with special attributes, he or
she may also have patterns of reaction and outlooks that reflect a historical
oppression. If hostility is recognized, it can be recognized and managed in the
milieu of the therapeutic relationship.
Mental health professionals must be accepting and sensitive to cultural variations
in their clients, and willing to explore client’s perceptions of “White” culture.
Ways Nurses Can Establish Trust With American Indian Patients
To help combat disparities in care, nurses and healthcare providers can help establish trust
with their American Indian patients. Hudson and Scott offer some tips and advice for
nurses to consider:
Listen to Patients
By listening to their patients and increasing cultural competence in nursing, nurses can
learn about traditional practices that could impact healthcare. Nurses who can find ways
to bridge any gap between culture and Western European medicine have a better chance
of connecting with their patients and building trust.
Participate in Community
Connection Knowing the challenges many American Indians face that impact medical care,
such as access to water, refrigeration, and transportation, allows nurses to modify their
patients' care and troubleshoot any issues. Nurses can also demonstrate genuine interest
by participating in community events to better understand American Indian populations
and culture.
 Understand Traditional Health
Practices By understanding how traditional health practices influence American
Indians' perception of illnesses, nurses can determine how to provide medical care
while being conscious of their patients' practices or beliefs.
Advocate for Access
Nurses can contact policymakers on a local and national level to advocate for access
to running water, electricity, transportation, and high-speed internet, among other
necessities, for American Indian communities. Providing American Indians with these
basic needs can help them focus more on their health.
 Seek Education and Training
Participating in courses or training on cultural competence can provide nurses with ways to
connect with a diverse group of patients. Relating culturally to American Indians can allow
nurses to effectively interact and treat their patients, which might help to create culturally
sensitive healthcare settings.
Research About Patient
Populations By learning more about specific tribal nations closely tied to their area, nurses
can gain knowledge that may help them understand cultural and traditional practices that
could impact medical care. Nurses can educate themselves by reading biographies,
researching articles, and speaking with elders or traditional
Hispanic Americans Dignadice & Ganado
Generally, the terms Latino and Hispanic refer to Spanish ethnicity, language skills, and ancestry, but, as
is true with other groups, they also imply significant cultural variation.

Some common themes among Hispanic Americans include:

Roman Catholicism (although increasing numbers of Hispanics are turning to Protestant religions
and Pentecostal sects)
Orientation toward extended family systems (which may include god- parents [compare] and other
nonbiologic kin)
Distinctly different roles for men and women, a high value of respect for self and others
The priority of spiritual and humanistic over commercial values
Clear hierarchy and patriarchy
Fairly common reliance on folk systems of medicine
Because Hispanic Americans tend to value being listened to and having time spent
with them, task-oriented hurrying about is viewed as uncaring. Involvement, loving,
and empathy are valued caring behaviors (Berry, 2002).

There is a wide variability in levels of acculturation (that is, integration into the
mainstream European American system) (Baer, Weller, Garcia, & Rocha, 2004;
McEwen, 2005). Although the average Mexican American was born in the United
States, and many members of other Hispanic groups are American by birth,
numerous others are immigrants.
Hispanic, Latin American, and Puerto Rican traditions of folk medicine, despite
some variation by place and group, clearly reflect their humoural antecedents as
well as Roman Catholic ritual and beliefs about supernatural influences (Baer,
2001).

Many illnesses, whether predominantly physical or mental, are "hot" or "cold,"

based on a long tradition of humoural theory. These qualities do not refer to
temperature but to symbolic properties. Ill persons are treated with medicines and
foods of opposite characteristics.
By understanding the hot/cold interpretations to which specific patients or groups
ascribe, care and treatment regimens can be negotiated with patients within that
framework.

Many Americans fear that large numbers of immigrants, for example, peoples of
Hispanic origin, in the United States may lead to division of the country into two
languages and two cultures (Grossman, 2004).
America's history is, in large part, one of immigration, but over time, the offspring of
earlier immigrants generally dropped their original languages and acculturated (that
is, while retaining some traditional ways, learned to get along in Euro-American
culture), or even assimilated wholly into the English-speaking, European-based
cultural mainstream.

Today's multiculturalism demands more adaptation on the part of the host country's
populace, parts of which resent what it sees as economic erosion at the hand of
people from other places. As with the other groups discussed, generalizing and
stereotyping fail to do justice to the needs of the people encountered in the mental
health system, both on an individual basis and as a group.
 Examples of Hispanic Culture-Bound Syndromes
Ataque de Nervios
-Out-of-consciousness state resulting from evil spirits.
Cólera
-Anger and rage disturbing body balances leading to headache, screaming, stomach pain,
loss of consciousness, and fatigue.
Mal de ojo
-Medical problems, such as vomiting, fever, diarrhea, and mental problems (e.g., anxiety,
depression), could result from the mal de ojo (evil eye) the individual experienced from
another person.
Susto, Miedo, espanto, pasmo
-Tiredness and weakness resulting from frightening and startling experiences.
Wind or Cold Illness
-A fear of cold and the wind; feeling weakness and susceptibility to illness resulting from the
belief that natural and supernatural elements are not balanced.

Source: Modified from Paniagua, F.A. (2000). Culture-bound syndromes, cultural variations, and psychopathology, in I. Cuéllar & F.A. Paniagua, Eds., Handbook of multicultural
mental health: Assessment and treatment of diverse populations (pp. 140-141). New York: Academic Press.
Barriers To Mental Health Care

Language Barriers
Poverty and Less Health Insurance
Coverage
Lack of Cultural Competence
Legal Status
Acculturation
Stigma
Nursing interactions for caring Hispanic patients should
include:
the participation of other family members in the care plan
support of cultural beliefs
emphasis upon the present rather than future
the use of touch
the protection of modesty
facilitation of communication
Asian North Americans

iudad & Hipolito

NORTH ASIAN AMERICAN VALUES
AND CULTURE
North Americans of Asian ancestry represent
numerous diverse cultures from Japan, China,
Korea, India, the Philippines and other Pacific
islands, Southeast Asia, and many others whose
families have lived in the United States for
generations.
Strong Asian values generally involve harmonious
interpersonal relationships, webs of obligation, and
fear of shame.
The family and its honor are of great importance, and
family sharing is a major construct in care.
Cultural factors, such as language, age, gender,
and others, can influence the mental health of
Asians, particularly immigrants
Traditional (adhering to native values) Asians place
great value on the family as a unit. Each individual
has a clearly defined role and position in the family
hierarchy and is expected to function within that
role, submitting to the larger needs of the family
Social stigma, shame, and saving face often
prevent Asians from seeking behavioral health care
Asian patients are likely to express psychological
distress as physical complaints
CULTURAL FACTORS THAT INFLUENCE
MENTAL HEALTH
Language
Level of acculturation
Age
Gender
Occupational issues
Religious beliefs and spirituality
Traditional beliefs about mental health
 TECHNOLOGY
Urbanization and industrialization have led to
increasingly diverse lifestyles and a need to
discard stereotypes of well-satisfied, well-cared
for, and respected ill persons and elders
 INTERVENTION IN ELICITING PATIENTS'
VIEWS ABOUT THEIR ILLNESS

Culturally competent assessment and treatment of mental health

problems in Asian Americans require that health professionals ask
patients and their family members to share their cultural views on
the cause of the problem, past coping patterns, healthcare-
seeking behaviors, and treatment expectations. In the context of
health care, the physician-patient relationship is not seen as a
partnership; rather, the physician is considered the authority. Asian
patients will answer questions but are not likely to raise issues, and
they will tell the physician what they think he or she wants to hear.
The healthcare provider must reassure patients that they may talk
about their problems and no judgments about them or their family
will be made.
Successful assessment of mental health
problems in the Asian American patient is
based on:

Practitioner awareness of individual patient

demography
The patient's beliefs about health and mental
health
Eliciting an explanatory model from the patient
Negotiation around acceptable diagnosis and
treatment
Use of the family support system to increase
adherence to treatment regimens and to reduce
barriers
 Middle Eastern Cultural Groups

Diamansil & Edaño

 I wish Eid mubarak to you and your family.
May Allah guide you to the road of success and
happiness
Middle Eastern groups are those people who are: Arabs, Turks,
Turkomans, Persians, Kurds, Azeris, Copts, Jews, Assyrians, Maronites,
Circassians, Somalis, Armenians, Druze, and more.
In 2001, ethnic diversity and immigration has been a trend leading to
stigma, homeland security, and terrorism.
Arab Americans moving to United States experiences great stress
associated to acculturation difficulties.
 How the world views Middle
Eastern groups?
In particular, the 911 incident sparks a great stigma among the
Middle Eastern people and the Western Nation. The Arabs have
experienced a great backlash on racism, bias, distrust,
aggression, discrimination on the basis of their cultural belief and
practices, and hate crimes.
This backlash can negatively affect the mental health of these
groups.

 The backlash and and prejudices became the driving

factors of some Muslims to introduce their culture and
practices towards the world. they have been active to
dispel the negative image of their culture by educating
people and letting them know their way of life as a people
belonging in the Middle Eastern Group
Cultural beliefs about being possessed and sorcery or
the “evil eye” affect interpretation of mental health
symptoms.

Prior to seeing health care professionals, Arab Muslims

may seek traditional healers for mental health problems.
Traditional healers hold special importance to Arab
Muslim people because of their affiliation and
connection to the community. Traditional healers also
deal with mystical and unknown (Okasha, 2012).
Seventy to 80% of mental health clients in Arab countries
tend to present with somatic symptoms for psychological
issues. There is a stigma about mental health problems, and
the client who presents with somatic complaints is protected
from the stigma of being diagnosed with a mental health
illness.

However, this creates difficulties for the client as he or she is

treated for physical rather than psychological problems
(Okasha,2003).

Nurses and other health care providers in emergency

departments need to be aware of this phenomenon and
assess the client for any mental health concerns.
The subordinate position of Arab women places them at risk for
developing mental health disorders such as depression,
anxiety, and suicidal behaviors (Douki, Ben Xineb, Nacef, &
Halbreich, 2007).

For individuals from Arab communities, stigma associated with

mental illness is considered a major barrier to accessing
mental health services related to the shame associated with
disclosing personal and family issues to outsiders
According to a recent global study, the Middle Eastern region
suffers from the highest rates of depression, anxiety disorders,
PTSD (Post Traumatic Stress Disorder), and suicide. Furthermore,
there is a lack of awareness about mental health, limited mental
health services, and stigmatization which worsens the situation.
 Prevalence of Depression in the Middle East and
The Contributing Factors

According to a recent study, the Arab World is facing greater problems of depression,
compared to the rest of the World. The unique challenges faced by this region makes it
the most depressive region throughout the World, some of which are discussed as follows:

Stigmatization: Stigmatization of any mental health condition (in any region) worsens
the problem. A society where mental health problem is associated with shame,
disgrace, and disrespect and is considered as a taboo, people hesitate to talk about
their mental health problems and are less likely to seek medical and psychological
help. The internalization of the problems results in increasing mental stress, which
ultimately leads towards clinical depression and even suicides in most of the cases.
Lack of mental health awareness and psychological help: Despite increasing
mental health awareness throughout the World, the Arab World is still lacking it.
The Arab World has an Islamic culture, where mental health is mostly linked with
religion. People are encouraged to deal with their mental health issues by
maintaining a good relationship with God, involving in religious activities and not
to discuss your problems with others, due to the influence of culture. A limited
professional psychological help is provided, but due to the cultural and religious
beliefs, most people keep their issues to themselves and do not seek professional
help, resulting in higher levels of depression in the region (Pocock, 2017).
Culturally Competent Nursing
Care for Clients with Mental
Health Considerations
Transcultural nurses use many ways of understanding to move beyond the rigidity of
trying to fit diverse experiences, interpretations, and expectations into a few ready-
made (but culture-bound) categories.

Cultural groups share time-honored systems of health beliefs and practices; it is often
nurses who can interpret expectations within and between groups. Sensitive cultural
interviews are required to know who clients are.

Nursing, to provide culturally congruent care, attends to relationships between the self
and others; between mental illness and such phenomena as poverty, suffering,
violence, chronic illness, and aging; between the cultures of nursing and psychiatry and
those of our clientele; and between nursing ethics and the provision of appropriate
care.

When nurses and clients come from different cultural backgrounds, accurate
diagnosis, treatment, and care depend on time-consuming special knowledge and
skills (Kavanagh, 2005).
Transcultural nursing may involve:
collecting information about specific cultures
acquiring a culturally acceptable ally or advocate for the client
and/or a cultural consultant for the nurse
working with a translator
learning clients behavioral, attitudinal, and cognitive norms
or ensuring that only culturally fair psychometric tests and functional
measures are used.

Standardized tests are appropriate only when they are properly modified
to fit a client's cultural heritage and experiences. Some transcultural
nurses view culture brokering (bridging, linking, or mediating between
groups that differ in background or orientation) as part of their roles
(McElroy & Jezewski, 2000).
Ethnopsychiatry seeks to move beyond the assumption that Western ways o
understanding and treating psychiatric conditions are universally applicable
to all societies.
Ethno-nursing methods foster understanding of care-related
phenomena from the perspectives of people (Leininger, 2002b).
Clients must feel accepted to share their beliefs and
practices outside the biomedical system with health care
providers.
It is important to know the client's perspective to minimize the
possibilities of harm from treatments or medicines that interact
disadvantageously with those of the alternative systems. Many
indigenous approaches are harmless and should not be
discouraged because they provide pyschological support.
The risk involved in such behavior is that clients and health care
providers may work with different strategies or toward dissimilar
goals.

The nurse, for example, may hurry to include all items relevant to
health promotion for high-risk clients, when it is the nurse's
presence and the time spent with them that the clients value,
rather than the information.
 ASSESSMENT

People have different values and beliefs rooted in different cultures and subcultures,
and can use various practices to promote health and cope with illness. Whether or not
they are understood, people may have reasons for their behavior. Moreover,the
appreciation that one person's "superstition" may be someone else's firmly held
explanation or belief allows the culturally competent nurse to objectively consider the
behavior associated with that belief for its own merit, neutrality, or harm. Automatic
discrediting ideas/practices risks alienating clients and losing resources.
 Cross Cultural Communication

The crux of transcultural psychiatric/mental health nursing is communication, the

style of which varies greatly with the culture involved.

Groups also vary widely in their ideas about appropriate stance, gestures, language,
listening styles, and eye contact. Traditional Asian, Black, Native North, American,
and Appalachian people typically consider direct eye contact inappropriate and
disrespectful (Andrews, 2003).

Language differences can also complicate mental health treatment, so it is often

tempting to use the most readily available person to facilitate the process. However,
this might lead to complications if the patient and translator are not of the same sex,
class, or age.
The use of inappropriate translators may result in new problems being fabricated to
avoid stating the real ones in front of the individual solicited to translate. It is important
when using a translator to communicate with the client with a mental health condition
that extra time be allowed to discuss the client's responses.

For example, the nurse might want to ask the translator to be alert to nonverbal cues,
such as body language, eye contact, or other behavior that would provide helpful
information. Although linguistic assistance is vital, further difficulties arise when some
translators interpret rather than directly translate what the client says.
Mutual communication involves awareness and knowledge of
social process, and sensitivity to and recognition of barriers to
acceptance and sharing, as well as skill in communication
techniques.
Whereas the functional utility of words and gestures has
communicative value to all involved, most important is the ability
to empathize and to understand other beliefs, assumptions,
perspectives, and feeling (Kavanagh, 2005).

Effective communicator learns to acquire and to understand, to

the greatest extent possible, multiple perspectives. Tolerance and
acceptance of others' attitudes, beliefs, and behaviors, and the
willingness to expose oneself as interested but still learning
sensitivity, knowledge, and skills are important strategies.
 Self-Reflection and Awareness

Learning to understand the cultures of clients requires understanding one's own cultural orientation
and about themselves. This includes values and norms learned in the process of becoming a nurse, as
well as those associated with ethnicity, age, class, or gender background.

Self-knowledge is key to understanding which cultures or groups one tends to favor or avoid, and
which groups one negatively or unrealistically positively stereotypes. The nursing process must be
examined from the cultural perspectives of health care providers and consumers to maximize
appropriate use and quality of care.

People may avoid professional mental health care due to incompatible values and beliefs, poverty,
social stresses, language barriers, lack of education, social isolation, stigma, bureaucratic barriers,
and unequal distribution of services.
 Cultural-Specific Care
Failure to acknowledge
diversity denies meaningful
variations in real-life
experience.
Transcultural nurse ask- How
do you want to be cared for?
Culturally congruent nursing
care decisions and actions
have the potential to
intervene in three ways.
Cultural maintenance and preservation
Accomodation
Assisting client to negotiate or adapt to
new cultural ways
Culturally acceptable and appropriate care
Change to new or different behavioral patterns that are
meaningful, satisfying, and beneficial. moreover,
changing the person's point of view of events requires
altering the meaning of situation. however, the need for
such reconstructing is only partial behavioral repattering
 Ideologic Conflict in Psychiatric/
Mental Health Nursing

A growing awareness of the changing and complex nature of illness, the influence of social
context, and the importance of holistic perspectives can leave nurses in a quandary when the
dominant model in psychiatry focuses on organic and genetic factors as underlying causes of
mental disease (Duster, 2003).

For some, psychiatry`s realignment toward biology, high-tech brain scans, and powerful new drugs,
along with a reorientation away from staff-patient relationships and toward objective observation
and documentation, threatens to minimize the importance of the patient as a person or at
least to risk the sacrifice of communication and understanding to cold, hard documentation
(Kavanagh, 2005; Wagner, 2005).
 Ideologic Conflict in Psychiatric/
Mental Health Nursing

This substitution of psychiatric materialism for humanism may lead nurses who are
surrounded by others who think differently to question their ability and worth.

Ideologic conflict is not new in psychiatric/ mental health care and continues to
shadow nurse-physician and nurse-client relationships (Estefan, McAllister, & Rowe,
2004; Kavanagh, 2003a, 2005)
 Ideologic Conflict in Psychiatric/
Mental Health Nursing

Despite the medicalization of mental health, nurses often feel that they must balance
structural requirements (which may conflict) with operationalizing knowledge of
care and therapy (which may be ambiguous), all the while communicating with persons
who may communicate not only in culturally diverse ways, but also abnormally (Este- fan,
McAllister, & Rowe, 2004).

Nurses must continue to explore diverse models of caring and attend closely to the
practices they actually use.
Welcoming, Gathering, and Accepting
Welcoming, Gathering, and Accepting involve creating effective relationships and
establishing open communication
The nurse's role is to suggest illness prevention and health maintenance practices, as well
as treatment strategies that fit with and reinforce client's cultural beliefs and practices.
Often "noncompliance" occurs because clients are trying to preserve their own priorities.
Confidentiality is important, but ethnic and other leaders know the issues and can often
suggest acceptable interventions
Try to make the setting comfortable.
Be prepared for the fact that children go everywhere with members of some cultural
groups, as well as with families who do not have options because of economic limitations;
 Knowing, Connecting, and Staying

knowing, Connecting, and Staying involve finding meaningful ways in which

clients, families, and others can contribute their own cultural input and goals
while both patterns and variations are recognized.

Becoming more aware of the potency of cultural expectations as well as personal

choices, all participants in cross-cultural relationships find themselves consciously
setting priorities and considering option regarding what to accept, reject,ignore,
or try to change.
Presencing, Attending, and Staying Open

Presencing, Attending, and Staying Open are confounded with time, which
continually frustrates modern health care and nursing.
Routinization and efficiency are valued by the dominant culture, whereas caring,
connecting, and learning take time.
Visiting, sharing stories, and many other simple encounters are useful strategies for
learning what care and caring mean to the client and family.
Presencing, Attending, and Staying Open

Acquire basic knowledge about cultural values, health beliefs, and traditional health-
related practices common to the group which you are working.
Also, know the folk illnesses and remedies common to he cultural group with which you
are working.
Build on cultural practices, reinforcing those that are positive; do not discredit any beliefs
or practices unless you know for sure that specific practices are harmful.
 Creating a Place and Keeping Open
Possibilites
Creating a Place and Keeping Open Possibilities entail working to establish caring
relationships and increasing sensitivity to our own implicit understandings and
expectations.

1. Present yourself with confidence

2. Shake hands if it is appropriate
3. Ask how client prefer to be addressed
4. Allow them to choose seating for comfortable personal space and culturally
appropriate eye contact
5. Avoid assumptions about where people come from; let them tell you
 Creating a Place and Keeping Open
Possibilites

6. Strive to gain the other's tryst, but do not resent it if you do not get it
7. Avoid body language that may be offensive or misunderstood- which may
involve some research and surprises
8. Determine the patient's level of fluency in English, and arrange for an
interpreter if one is needed.
9.Speak directly to the client, even if an interpreter is present
10. Choose a speech rate and style that promotes understadning and
demonstrated respect for the client
 Safeguarding, Preserving, Advocating
and Protecting
Advocacy roles require cultural sensitivity, knowledge, and skill; including a
willingness to examine personal values and those of the subcultures of
nursing and biomedicine, as well as those of other individuals and cultural
groups.

check for the client's understanding and acceptance of

recommendations.
be patient; do not expect rapid change.
be sensitive when describing or writing about groups.
relate social organization, structure, and process to each group's unique
history.
 Engendering Mutuality and Community
Health care providers and clients come together, to get to know and value
differences as well as commonalties, and form flexible, open, and creative
relationships and caring communities.

Avoid stereotypes by sex, age, race, ethnicity, socioeconomic status, and other
characteristics.
Understand your own cultural values and biases.
Emphasize the positive points and strengths of health beliefs and practices.
Be respectful of values, beliefs, rights, and practices.
Express interest in and understanding of other cultures without being
judgmental.
.
Letting Be and Letting Go

According to Kleinman (1988), Transcultural mental health nursing also necessitates

an additional genre of practices that constitute letting be and letting go to
expedite openness to learning.
Honor the uniqueness of clients and their dignity and worth.
Attempt to establish caring relationships that can overcome any cultural
misstep, and strive to help clients obtain their self-determined goals, to learn
client's explanatory modes and to get to know yourself as an effective
transcultural nurse.
THANK YOU
FOR YOUR KIND
ATTENTION