Social and Cultural Diversity Paper

Feature Cultural safety, diversity and the servicer user and carer movement in mental health research Leonie G. Cox aand Alan Simpson b aQueensland University of Technology, Brisbane, Qld, Australia, bCity University London, London, UK Accepted for publica tion 31 January 2015 DOI: 10.1111/nin.12096 COXLGandSIMPSONA. Nursing Inquiry 2015; 22: 306 –316 Cultural safety, diversity and the servicer us er and carer movement in mental health research This study will be of interest to anyone concerned with a critical app raisal of mental health service users’ and carers’ participa- tion in research collaboration and with the potential of the postco lonial paradigm of cultural safety to contribute to the service user research (SUR) movement. The history and nature of the ment al health eld and its relationship to colonial processes pro- vokes a consideration of whether cultural safety could focus at tention on diversity, power imbalance, cultural dominance and structural inequality, identi ed as barriers and tensions in SUR. We consider these issues in the context of state-driven approaches towards SUR in planning and evaluation and the concurrent rise of the SUR movement in the UK and Australia, societies with an intimate involvement in processes of colonisatio n. We consider the principles and motivations underlying cul- tural safety and SUR in the context of the policy agenda informing SUR. We conclude that while both cultural safety and SUR are underpinned by social constructionism constituting similariti es in principles and intent, cultural safety has additional dimen- sions. Hence, we call on researchers to use the explicitly political a nd self-re ective process of cultural safety to think about and address issues of diversity, power and so cial justice in research collaboration. Key words: carers, cultural safety, diversity, mental heal th, power, research, service users/consumers. The study offers a critical appraisal of the participation of mental health service users in research collaboration and the potential of cultural safety to c oncentrate researchers’ atten- tion on power imbalance, 1cultural dominance and struc- tural inequality 2informing research practices and mental health service users’ experienc e. According to Kara, the liter- ature on mental health service user 3research involvement ‘suggests that power imbalances and identity issues are at the root of most dif culties and gaps’ (Kara 2013, 122). Kara suggests that these matters relate to the diversity 4of players in mental health research, which, along with service user involvement, is central to policy in both the UK and Australia (Australian Health Ministers 2010; HM Government 2011a, b). Diversity concerns are evident in the work of the UK’s Mental Health Research Network (NHS National Institute Correspondence: Dr Leonie G. Cox, PhD, BA (Hons); RN Senior Lecturer; School of Nursing, Queensland University of Technology, L3 N Block, Kelvin Grove Cam- pus, Victoria Park Road, Kelvin Grove, Brisbane, Qld 4059, Australia.

E-mail: 1Power is a contested concept in deep, ongoing philosophical debates. We are indebted to Berger and Luckmann’s (1966) social constructionism that overcame the agency (Weber) and structure (Mar x) debate in arriving at a concept of power that recognised it as an aspect of social relationships occurring in the dialectic between individuals and structures.2By structural inequality, we mean systematic unequal rewards, access to resources and their control and opportunities in education, health and so on that are a consequence of social processes and relationships experienced by groups such as mental health service users. 3We use the term service user to refer to mental health service consumers and carers. Various other terms are used in the UK and Australia, for example people with lived experience, consumer, carer and survivor. We use the term service user research (SUR) to denote the movement advocating their involvement in research.4Our use of the term diversity refers to social experience related to ethnicity, gender, gender identity, sexual orientation, physical and intellectual dis/ability, age and socioeconomic status. Nursing Inquiry 2015; 22(4): 306–316 ©2015 John Wiley & Sons Ltd for Health Research 2013) and of a proposed Australian National Mental Health Consumer Organisation (Craze 2010; also see http://mhconsumer.org.au/).

These similarities between the UK and Australia re ect their close sociopolitical relationship and shared history in colonial projects and so they were chosen as the context for our discussion. Today both societies grapple with control of bodies, minds and discourse in increasingly complex socie- ties created through globalisation and colonial diasporas. As Bell et al. note: ‘As Europeans expanded their borders, the cultures, peoples and diseases they embraced began diffus- ing through permeable membranes back towards their impe- rial cell bodies’ (Bell, Brown and Faire 2006, 589).

The resultant health inequity, poverty, stigma and racism (WHO2010)areofconcerninAustraliaandtheUK.Unsur- prisingly, these processes impacts on mental health and problems are compounded as service users experience dis- crimination and victimisation, poorer health outcomes and barriers to work, education, the practice of their civil rights and wealth creation (WHO 2014). These structural inequali- ties re ect and entrench the unequal power relations experi- enced and constitute the cycle of disadvantage that the mental health SUR movement sought to overcome.

We reasoned that cultural safety, a philosophy and approach to clinical nursing, nurse education and research that focuses on these concerns should be central to this con- versation. Further as a speci cally ‘postcolonial paradigm of inquiry’ 5(Racine 2009, 183) it is directly relevant to the men- tal health and social problems arising from colonial activity, related to what Joseph aptly calls the ‘...colonial ancestry of psychiatric violence’ (2014, 275). Therefore, we suggest that cultural safety with its focus on social justice and its challenge to mainstream cultural dominance in research practice and ways of knowing should be integral to mental health service provision, evaluation and research and conclude that it is a useful model to support SUR.

To ground the discussion, we start with an introduction to cultural safety and its de nition of culture that inverts diversity concerns by challenging where the locus of diversity problems should be. We then move on to an overview of SUR in its historical context, as state-driven policy approaches to service user inclusion in the UK and Australia, developed concurrently with it. We consider debates about the value and outcomes of such research processes in terms of power sharing and control of research practices in both contexts.We then turn to a discussion of calls for cultural change in SUR and the potential of cultural safety to bring it about.

We consider the role of cultural safety to confront power imbalances as the SUR movement struggles to achieve its aspirations within predominantly state-funded mental health research. Importantly, the context of this struggle is policy focussed on individualism and the reduction of human ser- vices to market forces, a form of cultural dominance obscured by government policy and rhetoric of inclusion and participation. CULTURAL SAFETY: INTRODUCTION TO THE CONCEPT Cultural safety was developed with the Maori community by Maori nurse scholar Irahapeti Ramsden in the 1990s, in the neocolonial context of New Zealand (1991; 2002). It aimed for cultural change by exposing and addressing power imbal- ances to decrease the impact of cultural dominance and rac- ism in health care, education and research (McCleland 2011). Ramsden was motivated by nursing curricula devoid of structural issues and designed by and for those who did not share her cultural position or experience of colonisation.

She wanted to challenge this form of cultural dominance and the way it shaped policy and developed nurses as mere biomedical technicians rather than agents of social change (Ramsden 2002).

Ramsden saw cultural safety as a way for nurses to con- sider how their socialisation and cultural position impacted on their work. She emphasised the links between ill-health and dispossession, economic status and political agendas, as against individualist biomedical notions that illnesses merely occur within bodies. Further, she argued that transcultural approaches focussed on the ‘cultural’ activities of patients, based on the idea that culture simply means ethnicity and that culture is, therefore, unchanging. As a consequence, transculturalism promotes stereotypical views of culture and limits nurses’ responses to diverse social experiences and positions (Ramsden 2002, 112).

In contrast, cultural safety is underpinned by social con- structionism so proponents accept that people create society and in turn society in uences human activities too. In cul- tural safety, culture is conceptualised as changeable, learned, strategic and sociopolitical and ‘...is used in its broadest sense to apply to any person or group of people who may dif- fer from the nurse/midwife because of socioeconomic sta- tus, age, gender, sexual orientation, ethnic origin, migrant/ refugee status, religious belief or disability’ (Ramsden 2002, 114). In cultural safety, these differences are accepted and respected as legitimate not as de cits to dominant norms. 5Note that Ramsden used the term neo-colonial in preference to postcolonial as she saw these power relations as continuous, so postcolonialism had not been achieved (2002, 1). Cultural safety in mental health research ©2015 John Wiley & Sons Ltd 307 Although these issues and aspects of cultural identity are the dimensions of diversity that policy in the UK and Austra- lia seeks to address in the mental health eld (cf. Australian Health Ministers 2010; HM Government 2011a) cultural safety challenges the dominant conceptualisation of diver- sity’s signi cance in two respects. First, under cultural safety’s de nition of culture, diversity does not belong to people of colour or those who differ in some way or other from main- stream culture. Dyck and Kearns (1995) discuss one of its key concepts, bi-culturalism, which, although subject to some criticism (Reimer-Kirkham et al. 2002; Harrowing et al.

2010) signals thateveryonehas culture.

This point is important as discussions about health inequality are often dominated by a ‘white’ cultural position where culture and ethnicity are seen as only belonging to so- called culturally and linguistically diverse (CALD) 6‘others’ (Tolich 2002; Cox and Taua 2013), positioning the source of social inequity rmly outside white mainstream domains.

Cultural safety, however, requires that health-care profession- als and researchers accept thattheyarebearersofculture; that they are socially powerful, privileged and positioned; that their status is related to historical and political pro- cesses; and that it is their own values, beliefs and assumptions that require examination to shift power relations and struc- tural inequalities.

Secondly then, the signi cance of culture and diversity is not differences in ethnicity, in art, ritual or ceremony, but in how people are treated differently in everyday life as they deal with social institutions such as health/welfare, busi- nesses, media and educational institutions. In this respect, cultural safety resembles mental health service users’ per- spectives that health professionals should ask them ‘what happened to you’ not ‘what is wrong with you’ (British Psy- chological Society 2013).

Being grounded in critical social theory, cultural safety recognises that health service delivery, education and research are not value neutral activities but re ect the values, assumptions and priorities of those involved and historical and sociopolitical contexts (Ramsden 2002; Reimer-Kirkham et al. 2002, 2009; Anderson et al. 2003; Browne et al. 2009; Racine 2009). Unless practitioners undertake processes of self-re ection, as required in cultural safety, unexamined relations of power can be perpetuated. Cultural safety pro- vokes us to ask who holds the power to de ne what counts as knowledge, as health, as recovery or as evidence; challengingus to bring to mind cultural assumptions that ‘culture’ and ‘race’ determine outcomes and blaming people for their social situation (Browne et al. 2009; Racine 2009; McCleland 2011; McGibbon et al. 2013).

Just as proponents of cultural safety say that it is sys- tems that need to change rather than users of such sys- tems, so Frankham (2009), writing about service user involvement in research, proposes that mainstream society is the appropriate locus for efforts at change. This posi- tion, which underpins the emergence of SUR to which we now turn, is in stark contrast to the neoliberal view that it is individuals who must engage in ever expanding pro- cesses of self-improvement. THE EMERGENCE OF MENTAL HEALTH SUR The 1990s saw a profound mental health reform agenda in Australia expressed in the First National Mental Health Pol- icy in 1992. Its evaluation and the development of National Standards for Mental HealthServices in 1997 emphasised the requirement for service user involvement at all levels of mental health services (Goodwin and Happell 2006). Con- currently in the UK, there was a drive to include service users in the commissioning, design, delivery and evaluation of health and social care services (Department of Health 1999a, b, 2000, 2005). Thus as Barber et al. (2011) establish, mental health service user involvement, speci cally in research, became expected in both contexts.

Beresford (2002) explains that these initiatives were partly in response to the growing demands of a mental health SUR movement to lead and control research that was about them and the issues that impacted on their lives, a pro- cess he calls the democratic approach to SUR. However, he reminds us that the New Right and the service users’ move- ment did not see participation and user involvement in the same way and, as Frankham argues, the impetus for the SUR movement was the desire to explore the disabling assump- tions arising from individualism and the institutionalised dis- abling practices of society (Frankham 2009, 2).

In a similar vein to cultural safety’s focus on how people are treated in society, Frankham’s point is that it is not diver- sity (e.g. gender, ethnicity, disability or age) per se which dominates people’s experience but how society impacts and respond to them. She discusses the social creation of de cit discourses that circumscribepeople’s identity and social experience more than the disability itself. Thus, the SUR movement sought to create knowledge that could explain the economic, political, cultural and environmental struc- tural drivers of these experiences and deprivations (Frank- ham 2009). 6In the UK, the acronym BME (Black and Minority Ethnic) or BAME (Black, Asian, Minority Ethnic) is used. Australia employs CALD and other terms such as non-English speaking background (NESB) or English as a Second Language (ESL).

L G Cox and A Simpson ©2015 John Wiley & Sons Ltd 308 Such concerns stand in contrast to another facet of these developments; namely a consumerist approach. Far from ceding any power or control over research agendas or prac- tices to mental health service users, it is argued that ‘...

mainstream interest in user involvement in research and evaluation highlights feedinguser knowledge and experi- ence into existing research arrangements and paradigms...

‘(Beresford 2002, 101). Further, the complex dynamics of these power relations are often suppressed by discussions of inclusivity and community, overcoming any concerted effort to acknowledge and actually deal with diversity in people’s experience, interests and needs and with the complexity of knowledge production in such circumstances (Frankham 2009, 19).

While there are clearly worthwhile and robust bene ts to researchers and service users of inclusive approaches (Simp- son et al. 2014), these studies highlight the broader social- political in uences at play. According to Beresford, main- stream state institutions include service users in processes presented as inclusive, but which are motivated by the need to subvert and contain threats to the legitimacy of state con- trol over mental health policy, planning and research pro- cesses that the SUR movement signi ed. While the perspectives of service users can legitimate governments and their agencies and provide evidence of inclusivity, they can also be aimed at ‘ef ciency, economy and effectiveness’ and, in this process, service users become available as scapegoats should such policies fail or become unpopular (Beresford 2002, 97).

SERVICE USER RESEARCH: THE STATE OF PLAY In the decade or more since Beresford’s study (2002), con- certed efforts to include mental health service users in research and service evaluation are evident both in the UK (Rose 2003; Hodges 2005; Stickley and Shaw 2006; Wilson, Fothergill and Rees 2010; Repper, Simpson and Grimshaw 2011; Hancock et al. 2012; Simpson 2012; Staley 2012; Hutchinson and Lovell 2013; Simpson et al. 2014) and Aus- tralia (Lammers and Happell 2004; Craze 2010; Callander et al. 2011; Hancock et al. 2012). But the level and nature of that involvement most often remains disappointing. Staley (2012) overviews SUR in the UK’s Mental Health Research Network concluding that 40% of projects involved service users on steering groups with variable success and impact; 20% at the design stage with variable impacts and about 20% involved SURs through the whole project with strong in u- ence on the projects.Staley’s analysis is a far cry from the original intention of the SUR movement that service users should be involved in the whole process (Beresford 2002; Phillips 2006). Hutchin- son and Lovell (2013, 642) observe that, despite the appar- ently well-established nature of SUR involvement in the UK, there is not much evidence that their involvement in research is ‘...truly an integral embedded part of statutory mental health services’. In Australia too, Lammers and Happell (2004) argued that mental health consumer partici- pation in research was tokenistic while some eight years later ‘...genuine inclusion of consumers as members of the research team remains rare’ (Hancock et al. 2012, 218.) These commentators along with Kara (2013) point to the need for a much stronger focus on SUR participa- tion from inception to dissemination of research, to be in line with the philosophy of the SUR-led movement in both the UK and Australia and with mental health policy and expected standards in both contexts. It is for these reasons that there have been calls for a cultural change in SUR involvement. SERVICE USER INVOLVEMENT: TENSIONS AND DEBATES Appeals for cultural change in SUR involvement re ect its politicised nature and speak to the problem of power imbalance. In 2006, Phillips suggested that service users had gained some power and could advance their cause by lobbying, advocacy and positions of authority in health organisations. However, Frankham (2009) pro- poses that the central claim by proponents that research partnership processes are ‘empowering’ relies on a con- cept that is rarely de ned much less theorised. She calls for debate on the advantages claimed for partnership approaches and proposes that the political nature of SUR creates a kind of closed shop preventing analysis of its actual merit. Frankham (2009) argues that the combi- nation of government policy, funding body requirements and the unarguable moral rightness of including service users, militate against sound analysis of the practice. Nev- ertheless, some analysis does exist which clearly shows that power relations are an enduring problem.

Frankham (2009, 13) echoed earlier commentators in calls for a ‘cultural shift’ to address the fact that control still sits with academics. While it is reasonable to note that academic researchers spent decades gaining the quali cations and skills to lead research, it is still the case that major power differentials exist between the parties. A number of commentators point to power Cultural safety in mental health research ©2015 John Wiley & Sons Ltd 309 imbalances that work in favour of funding bodies and the academy such as devaluing service users’ knowledge (Phillips 2006); service users being outnumbered by aca- demics and not leading projects (Wilson et al. 2010); funders restricting applications to academics (Fothergill et al. 2013) and academics using exclusionary scienti c paradigms and language (Phillips 2006; Barber et al.

2011). Kara (2013) provides the evidence of service users’ being silenced; of academic researchers being able to keep private their experiences as service users or ca- rers and of the challenges of partnership research being laid solely at the door of service users.

Nevertheless, Wykes argues that over the past decade sound progress has been made in the mental health eld in terms of the ladder of participation, from consultation to col- laboration and then to service user led research paradigms ‘where the power in the relationship is reversed’ (Wykes 2014, 25), although she acknowledges that evidence to sup- port this remains a ‘scarce resource’ (Wykes 2014, 24). Stud- ies led by SUR Diana Rose (Rose et al. 2003; Evans et al.

2012) provide support for the emergence of SUR-led research, while standing out for their rarity.

Further insights can be drawn from Patterson, Trite and Weaver (2014) widespread study of SUR. It somewhat contradicts Wykes’ conclusions in reporting that while most respondents had positiveexperiences the potential of SUR involvement is constrained by experiences of stigma, discrimination and tokenism. Patterson et al. (2014, 7) described a need for ‘...continued attention to deep-level cultural change and development of robust mechanisms to ensure timely and meaningful engagement’ and a ‘...

critical examination of power hierarchies within psychiatry’.

It is with respect to challenging such power hierarchies to produce cultural change that cultural safety has much to offer.

Anderson et al. (2003) draw on critical theorists to argue that cultural safety directs our attention to imbalanced power relations that favour biomedical and professional dis- courses and silence other voices in research. The need for such attention is reinforced by Kara (2012, 131) in her review of SUR which showed: ...that power imbalances are situated between con- structed group identities: psychiatrists and patients, researchers and researched, and so on; perhaps even between subgroups of MHSUs (mental health service users), such as those who have been psychiatric inpatients and those who have not. We turn now to a brief account of the commonalities between SUR and cultural safety before teasing out the con- tribution cultural safety can make to SUR. ON COMMON GROUND: CULTURAL SAFETY AND SUR It is clear that the SUR movement and cultural safety arose for similar reasons and both drew inspiration from feminist, civil rights, emancipatory movements and critical theory (Beresford 2002; Ramsden 2002; Phillips 2006; Frankham 2009; Barber et al. 2011; Hancock et al. 2012; Hutchinson and Lovell 2013; Kara 2013). They were motivated by the desire to bring about social change by addressing the social and emotional consequences of ‘special’ legislative provi- sions applied to Indigenous people and the Mental Health Acts applied to those with mental illness and the fact that their voices and experiences were either absent or devalued in research, as in their everyday life. To borrow Goffman’s (1963) term, both movements sought to lessen the impacts of a ‘spoiled social identity’ related to a loss of power, status and rights; in terms of racism on the one hand and stigma on the other. 7 The thrust of methodological implications of culturally safe research is its strong focus on challenging power imbal- ances so that alternative knowledges, values and ways of understanding are on an equal footing to western scienti c models and such concerns are evident in some accounts of SUR (Phillips 2006; Stickley 2006; Barber et al. 2011; Hutch- inson and Lovell 2013; Kara 2013). Likewise, culturally safe research applied to SUR would support the latter’s ideal to engage service users in the whole research process in an equal research partnership (Wilson et al. 2010; Wykes 2014).

However, although other participatory models share many principles of cultural safety,the approaches are not the same as one could use a participatory model that was not culturally safe (Wilson and Neville 2009; Cameron et al. 2010). WHAT ARE THE IMPLICATIONS FOR CULTURAL SAFETY TO TRANSFORM SUR Allresearchinvolvesbasicassumptionsaboutthereasons for individual behaviours, what is an acceptable research approach, where it is appropriate to publish results, and so on. While these assumptions are often unstated and taken for granted, they strongly in uence what is actually studied and the way research is conducted. There is therefore a need for culturally safe research...

(Ramsden 2002, 105) 7There are complex cumulative impacts for those experiencing a mental illness and who are Indigenous or who are the target of racism or other isms (cf. Happell et al. 2013) chapter 8 for a full consideration of these factors. L G Cox and A Simpson ©2015 John Wiley & Sons Ltd 310 Although cultural safety is recognised as an Indigenous and decolonising research methodology (Smith 1999; McCleland 2011), it is applied more broadly to research practice (Reimer-Kirkham et al. 2002, 2009; Tolich 2002; Anderson et al. 2003; Racine 2009; Harrowing et al. 2010; Seaton 2010; McCleland 2011) and has methodological implications for the conduct of research. These implications centre around the fact that research encounters re ect the diverse and shifting sociocultural positions of those involved; they are ‘power-laden’ (Dyck and Kearns 1995, 142). From the perspective of cultural safety then, what matters most is the social experience and social positioning of those involved as these in uence research problems, questions, design, methods, analysis, ethics and outcomes (Tolich 2002).

The crux of cultural safety is that researchers undertake a process of critical re ection to bring their cultural values, priorities, assumptions and social experience to mind to rst acknowledge and then address imbalanced relations of power and the dominance of certain forms of knowledge.

Although undertaken by individuals, these processes are not individualistic as they require re ection on structural posi- tion, power and privilege. Therefore, they could help to address structural inequality by challenging government pol- icy and priorities and their in uence on topics and methods and the very conceptualisation and focus of research pro- jects. Such processes provoke a crucial change of emphasis from locating the source of issues in the diversity of people to how society responds to diversity; a change in focus from individualistic to systemic concerns.

A critical research practice based on cultural safety would go far beyond the transcultural approach of including ‘diverse’ groups in recruitment and translating established research instruments and information into various lan- guages. For example, cultural safety would provoke re ec- tion on which groups and languages are included/excluded and why and what such decisions say about researchers and the political and economic context of their research prac- tice. In this vein, Kalathil (2008) notes that in research black and minority ethnic (BME) people are often stereotyped as being hard to reach, experience racism and are included minimally to show policy adherence.

Kalathil (2008) makes the observation that three decades of service user involvement has seen little change in mental health services, citing these circumstances as a major barrier to their being involved in service user activities. Kalathil (2008, 10) writes ‘...service user involvement will become a meaningful reality only if the damage done to individuals within mental health systems is acknowledged, and the roles and power relations between users and mental healthprofessionals...evaluated’. Kalathil (2008, 16) discusses an intersection of race and class where middle class profession- als, who have the resources and willingness to volunteer their time, feel awkward around black people with whom they are otherwise unfamiliar. These dynamics were identi ed as additional barriers to BME (and, we would argue, working- class) involvement in SUR. Kalathil’s work suggests that a cul- turally safe approach could make a strong contribution to easing such concerns by facilitating a re ection on such dynamics among researchers. Indeed, McCleland (2011) advocates starting with community protocols rather than with ready-made academic methods which shows how pro- foundly research processes and the excluding academic par- adigms discussed by Barber et al. (2011) might change if power relations were more balanced.

Anderson et al. (2003) extend the applicability of cul- tural safety beyond Indigenous and immigrant groups by arguing that English-speaking Europeans also suffer and experience barriers to accessing resources and services. As we have seen, cultural safety, although arising from a focus on Indigenous groups and non-English language communi- ties, nonetheless considers power relations not only on the basis of ethnicity and experiences of racism and colonisation but also on dimensions of age, gender, class, ability, sexual orientation and so on. It considers such factors in terms of the sociopolitical context of inequality, suggesting that cul- tural safety ‘...should have explanatory power for all of our research participants’ (Anderson et al. 2003; 210). This is particularly so since, as Anderson et al. (2003) point out, var- ious scholars argue against the idea that ‘colonised’ and ‘coloniser’, or ‘whites’ and ‘blacks’ are always opposing categories. This is not only because colonial experience is nuanced with colonised and colonisers co-operating, collud- ing or resisting in state regimes but also because these expe- riences dehumanise everyone, regardless of where we are positioned.

In terms of research, this insight challenges notions that health professionals and researchers always belong to the dominant colonising ‘white’ culture and the researched from oppressed minorities (Anderson et al. 2003; Reimer- Kirkham et al. 2009) and binary opposites of service user/ academic are not sustainable in SUR (Phillips 2006; Kara 2013). However, such binaries are powerful, for example when BME people are pressured to separate out parts of their identity (ethnicity) from other parts (service user) and silenced when they raise issues of racism, being told that they are there as a service user not as a member of a particular group (Kalathil 2008). Cultural safety could support SUR teams in negotiating such dynamics by encouraging partici- pants to articulate how their social experience is related to Cultural safety in mental health research ©2015 John Wiley & Sons Ltd 311 structured responses to ethnicity, culture, class, gender, dis- abilities and sexuality, for example and what implications for their research might arise from such endeavours (Simpson et al. 2014).

Cameron et al. (2010) make similar points in explor- ing the possibility of a ‘culturally safe epidemiology’. For example, they argue that in epidemiology the practice of deeming ethnicity as an independent risk factor has been discredited as ‘black box’ epidemiology that merely homogenises diverse people on the basis of cultural ste- reotypes. Such an approach cannot enhance understand- ing of the complex interplay of social experience, health determinants, historical factors and power issues which inform high rates of morbidity and mortality. In contrast, culturally safe research requires researchers to turn the research lens back to ‘...their own cultural assumptions and analyse critically the impact their theoretical stance has on the knowledge they generate’ (Cameron et al.

2010, 95).

As Browne et al. (2009, 171) argue, cultural safety draws attention to ‘critically orientated knowledge’; their research shows ‘...that it is not primarily cultural beliefs or cultural barriers that in uence how people manage their health, ill- ness or access to care’ but structural constraints and limits to life opportunities. So just as we saw that it is ideas about dis- ability that are disabling so too we can see that health inequality is not so much about worldviews (idealised notions of the cultural beliefs of ‘others’). It is how life is experienced that holds the keys to understanding inequality, injustice and ill-health (Kelly 2006; Cox and Taua 2013), a research paradigm that would be a consequence of a cultur- ally safe approach.

Browne et al. (2009) offer a sophisticated analysis of the epistemological 8foundations of cultural safety seeing cultural safety as compatible with critical enquiry con- cerned with human freedom and social justice. They, like Anderson et al. (2003) and Racine (2009), draw on post- colonial feminist theory to develop what Seaton (2010, 151) calls a ‘critical cultural theory’. Such a theory would consider human freedom by emphasising ‘...intersecting oppressions’ (Browne et al. 2009, 168). Together these studies make a convincing argument that cultural safety can help us consider whether research is dominated by certain cultural agendas, views or positions and what this means for the capacity of research to improve the human condition. THE LIMITATIONS OF CULTURAL SAFETY A limitation of cultural safety is that it draws attention to cul- ture which can lead researchers’ focus away from marginali- sation and oppression. However, applying cultural safety’s ways of thinking about culture is transformative and deepens understanding of the diversity and complexity in peoples’ everyday experience (Browne et al. 2009). This is an impor- tant point as research shows that assumptions about race, colour, age and gender impact on medical care and health (Kelly 2006; Kalathil 2008) and Tolich (2002) suggests that similar dynamics apply in research.

For example, in Australia, an inverted age pyramid related to decreased life expectancy and high birth rate for the Indigenous population vs. the general population, prob- lematises age-based criteria. There new immigrants too are younger than the general population while longer term immigrants are older (Minas et al. 2013). Therefore, selec- tion criteria must be nuanced to avoid skewed results and unnecessarily excluding sections of the population (McMurray 2004; Minas et al. 2013). In another example, Browne et al. (2009) cite the case of people identifying as Canadian being assigned to ‘groups’ (Chinese or Asian) for recruitment. A process of cultural safety could limit these problems by researchers examining assumptions informing recruitment.

Dyck and Kearns (1995) and Browne et al. (2009) ques- tion the utility of cultural safety in multicultural societies, built on ideas about equality of class, opportunity and so on.

Browne et al. (2009) say these ideals ‘...masked the histori- cally mediated unequal power relations and the dominant cultural positions’ of powerful groups in society which in fact go against standards of respect and sensitivity to others. This criticism is similar to Beresford’s (2002) about the inclusive rhetoric surrounding consumerist policy and service user involvement described earlier. We argue the slippage between ideals and practice, also evident in Australia, can be addressed by cultural safety as it draws attention to these con- textual issues and how people really experience everyday life (Cox and Taua 2013). Cultural safety brings the context of suffering (the lifeworld) into view provoking ‘...us to ques- tion all of our vulnerabilities and our common humanity’ (Anderson et al. 2003, 212).

As Dyck and Kearns (1995) observe, cultural safety tack- les power at the level of individuals with their differing histo- ries, social status and experience and at the collective level by focussing on the socioeconomic and historical conditions producing health inequity. Assuggested, it is our view that this argument remains relevant today particularly in the UK and Australia, as cultural safety encourages researchers to 8Epistemology is a branch of philosophy that studies the nature of knowledge, ways of knowing things and the limits of knowledge.

L G Cox and A Simpson ©2015 John Wiley & Sons Ltd 312 look at current inequity within the historical context that led to it (Reimer-Kirkham et al. 2002; Seaton 2010). We would argue that these aspects of cultural safety make it highly applicable in multicultural contexts such as the UK and Aus- tralia where poor health, educational issues, poverty, incar- ceration and mental distress disproportionately affect immigrant families and Indigenous families (HM Govern- ment 2011a,b).

McGibbon et al. (2013, 6) summarise the important questions provoked by a culturally safe methodology: evi- dence according to whom; evidence according to which worldview; evidence according to whose voice? These con- cerns, also raised by Faulkner and Thomas (2002), Phillips (2006) and Cameron et al. (2010) get to the heart of power relations in terms of epistemological considerations in research, about what constitutes knowledge and how class, gender, sexuality, ethnicity and other social complexities in uence knowledge construction, legitimisation and trans- lation. CONCLUSION Our discussion shows that while there has been consider- able activity over decades in service user involvement in mental health research, there are a number of tensions arising from the practice. Overall, our work suggests that matters concerning power, culture and social responses to diversity are only sometimes taken into consideration in such collaborations. In considering the relevance of cultural safety to the mental health SUR movement, we established that they share social constructionism as the underlying theory and have similarities in principles and intent (Ramsden 2002; Kara 2013). However, we found that cultural safety has a stronger focus on ongoing pro- cesses of cultural self-re ection on the part of research- ers and on challenging assumptions about how knowledgeiscreatedandwhatcountsasknowledge/evi- dence. Further cultural safety is historically positioned and recognises that nothing is value neutral so power imbalance, a central concern of cultural safety, informs allresearchandremainsaprofoundtensioninresearch collaboration.

It can be assumed that mental health research seeks to transform clinical practice and improve outcomes for service users and providers and in these endeavours cultural safety calls for a stronger research focus on social and structural issues as opposed to considering individuals the measure of all things. This perspective is echoed by Frankham (2009, 16) in her call for questioning whose interests are prioritised in actions on change, where there are complex andcompeting ideas from service users, service providers and policy-makers on what improved outcomes might look like.

We argued that as cultural safety is a speci cally ‘postcolonial paradigm of inquiry’ (Racine 2009, 183), it is an apt approach given that many mental health and social prob- lems are outcomes of colonial activity. Globalisation along with colonial processes has resulted in people from many nations and communities being dispersed all over the planet.

The resulting health inequity, social marginality, poverty, stigma and racism are of central concern in Australia and the UK as elsewhere. These circumstances raise many ques- tions and suggest the researchagenda also needs to focus on underpinning social determinants of health inequalities as required in culturally safe research, rather than sticking plas- ter responses to its symptoms and feeble attempts to heal.

In discussing cultural safety and the quest for new ways of knowing, Anderson et al. (2003) are ...arguing for a scholarship that will transcend our tribal- ism, and that will open up the space for dialogue that will move us closer to transformative practice. The concept of cultural safety...holds promise, we believe, for opening up such a space. Likewise, we see cultural safety as crucial in locating research practice in the sociopolitical settings where it takes place, in bringing about critical re ection on the part of researchers and in advancing equity and social justice (Browne et al.

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