“Culture and language influence the way that we all interpret, explain and communicate mental illness”.
In Australia, when people from a culturally and linguistically diverse (CALD) background engage with mental health practitioners, misunderstanding may lead to the misdiagnosis and mismanagement of mental health conditions.
The Influence of Culture
“Culture provides people with ways to make sense out of life, aiding in imposing meaning on thoughts, behaviours and events and allowing us to make assumptions about life and how it ought to be led”. (Chrisman, 1991).
It is believed that culture influences all people’s norms, values and behaviours as well as how they understand, interpret and respond to their own selves and needs, as well as other people and the world around them.
Different cultures view mental illness in very different ways. In order to work effectively with individuals from a CALD background, mental health practitioners need to learn about the cultural context and factors which shape mental illness, including the way that it is understood and explained. (Seah, Tilbury, Wright, Rooney, & Jayasuriya, 2002.)
Some of the cultural factors that can affect the interaction between the clinician and the consumer include:
- The explanatory model;
- The perceptions of the mental health practitioner;
- Social context and the role of family and other social networks;
- Language difficulties; and
- Religious beliefs.
Somatisation: “In interactions with any individual from a CALD background, it is vital not to assume a particular degree of acculturation or assimilation”.
An individual from CALD background who has a mental illness may present more often to their treating doctor with somatic rather than psychological symptoms eg insomnia, headache, lethargy, abdominal, muscular back and joint pain, rather than low mood or negative thoughts. The term “somatisation” can be understood as a culturally appropriate way of expressing discomfort in many cultures.
Explanatory models: “How we communicate about our health problems, the way we present our symptoms, when and to whom we go for care, how long we remain in care and how we evaluate that care are all affected by cultural beliefs”,
Understanding an individual’s psychological problems in mental health settings can be influenced by the individual’s conceptualisation of their experience for their mental illness. It may include the individual’s beliefs, concerns and treatment expectations for their illness, and influenced by cultural and social factors such as socioeconomic status and educations.
Generally, mental health practitioners employ the biomedical model and seek organic symptoms to determine individual mental health problems, however individuals from CALD backgrounds may see their mental illness differently and could possibly have different contexts of their mental health problems.
Clinicians need to recognise these factors; failure to do so can lead to several negative consequences, including misunderstanding, the loss of the client and poor treatment outcomes. For example, in Italian and Greek culture, ‘nerves’ or nervous breakdowns’ are not highly stigmatised but are viewed instead as common, and minor illnesses, which can be treated with prayer, by attempting to adopt a better attitude, or seeking a change in the social or physical environment. (Kiropoulos, Blashki, & Klimidis, 2005.)
Thus, the explanatory model seeks to understand the following:
- Why something happened;
- Why it happened to that particular person at that particular time and in that particular way;
- How it came to happen or what caused it;
- What should happen over the course of time;
- What should be done about it;
- What will happen with a given response?
“With the knowledge of the patient’s explanatory models about illness, you will be able to effectively negotiate with the patient a treatment approach that will be acceptable and effective for the patient”. (Seah, Tilbury, Wright, Rooney, & Jayasuriya, 2002, Pp. 24-29.)
NB: please follow the link to access further transcultural assessment resources that includes an explanatory model of clients’ mental health problems: https://www.dhi.health.nsw.gov.au/transcultural-mental-health-centre-tmhc/health-professionals/cross-cultural-mental-health-care-a-resource-kit-for-gps-and-health-professionals/cross-cultural-mental-health-assessment
The Perception of the Mental Health Practitioner: “There are some other programs of lifeline that they call crisis management through phone and our community people are not comfortable with that as language is a barrier. So this is only organization that I am aware of and if you are having mental illness and crisis that you go to them. What I know so far, people who are close to me, I know from experience, if you do not build trust and friendship, relationship it is hard to know the particular problem.”
An individual from a CALD background may have different expectations, concerns, meanings and values for their doctors/mental health practitioners and may see them as an expert to treat their problems. They may report their somatic symptoms rather than emotional, social and psychological difficulties. Therefore, it is likely that the mental health practitioner treats presented symptoms which result in the individual accepting passive treatment rather than being a participant.
In certain circumstances, individuals from a CALD background are more likely to present to the mental health practitioner at a later stage of their mental illness. They may have developed resilience to tolerate their emotional and psychological distress for a long time, rather than seeking professional help.
They may only consider consulting with a mental health practitioner after they have consulted with other culturally appropriate healers, or used other culturally sanctioned remedies and rituals for their mental health. However, when they realise that they have a mental illness, they have certain expectations of their mental health treatment eg long hospital stays, and so are reluctant to accept community-based treatment due to stigma and social problems. (Kiropoulos, Blashki, & Klimidis, (2005)).
Social context: the role of family and other social networks: “It is very hard and lonely here. I do it all on my own. Sometimes I wonder whether I should take my son home. In my country there would be more people to give us support. There is a different system there where there is much more support for people like him. He might even be able to get a job. Here there is only me: I have to do it all. It’s very tiring, but I can’t ever give up”.
Mental illness may be influenced by adverse social circumstances eg:
- political context of arrival;
- reasons for migration (refugee, economic);
- level of contact with the Australian majority group and with their own community;
- level of exposure to high risk industries and lower post migration employment status;
- changed social role responsibilities and expectations;
- change in living situation;
- loss of family, culture and religious support;
- loss of occupation identity and financial pressure (Poropat, Qadeer & Gooding, 2014, Pp. 13-14).
The role of families is central for many individuals from a CALD background. In many transcultural contexts it is the family rather than the individual, mental health practitioners often see more positive outcomes (eg reduced risk of further episodes of mental illnes) if the whole family is involved in the individual’s treatment.
Stigma: “We have people in our community who are suffering from mental illness but general situation is in my community background or culture there is a tendency to hide the problem if anyone having a mental problem and if you want to assist him/her, he/she may tell you “No I am alright and I have no problem” but when you look at him/her you will see that this person is dealing with something but they will tell “no I am fine and ok”.
Lack of information about mental illness, and uncertainty about navigating hospital health systems, often impacts the likelihood of symptom disclosure and help-seeking behaviour. It is recognised as a significant barrier to early and effective access to mental health services, and may be a reason for the presentation of somatic symptoms (pain, fatigue, lack of energy, and hopelessness). It may be viewed as more of a social problem than a psychological problem. Therefore, depressive symptoms may be seen as socially disadvantageous and, in some cultures, it may interfere with marriage prospects, diminish the social status, and compromise the self-esteem required to perform effectively in society (Poropat, Qadeer & Gooding, 2014.
Therefore, it is a priority in mental health practice to reduce the stigma of mental illness by providing support to the individual’s family and carers, and to promote their access to services that they need to manage their mental health.
Case scenario : “My husband, he has pension for mental illness from Vietnam war, He always in spring or autumn has got some problem like he is very angry and shouts….I know how to manage him for not being aggressive, I know how to handle him and I just let him alone, initial three years it was very hard but slowly I have adapted and know how to manage him after long 11 years. Even when my children come, I tell them do not touch your father and I will take care of him. I will not go to Doctor for him for this. However, in my husband’s case when my son bought a psychiatrist my husband was so angry and asked the doctor not to come here again. Afterwards all my communication with Doctor is finished.”
Language difficulties: Language preferences may affect the selection of mental health practitioners by people from CALD background.
When a non-bilingual mental health practitioner engages with a CALD consumer, they must consider using an accredited interpreter, keeping in mind that certain cultures have certain needs, eg client’s preferred gender, language and form (face to face/telephone) of interpreting. It is an expectation that the mental health practitioner should not use Google Translate, to avoid mistranslations of biomedical concepts and errors of oversights.
An objective interpreter may be preferred over a family member, as the patient may not want to disclose information in front of family or someone who may add their own interpretations.
Religious beliefs: “I have learned with the assistance of others who share my faith that God has given me an opportunity to share deeply in his pain of rejection, humiliation, and loneliness along with the debilitating symptoms of my suffering so that I may have ‘exceeding joy’.”
Individuals from a CALD background may link their mental health problems with their religious beliefs – eg evil spirits, bad karma, migration (living in one’s village, town or land), bad (criminal) deeds, disengaged community, and torture and trauma in a country of origin. Mental illness may be perceived as weak, spiritually bad or dangerous, resulting in a reluctance by members of the community to accept those living with a mental illness. (Seah, Tilbury, Wright, Rooney, & Jayasuriya, 2002.)
In many CALD communities, religion plays an essential role in recovery and is a protective factor. Faith and religious beliefs are a strong part of their culture, their identity and their centres of worship; so they seek social support through their religious leaders, reframing stressful life events and mental health problems (eg anxiety, adjustment disorder, grief and loss, depression) in the context of their relationship with God (Poropat, Qadeer & Gooding, 2014).
Author: Vishal Patel, M Social Work, AASW, AMHSW.
Vishal Patel is an Accredited Mental Health Social Worker, with significant experience in working with victims of trauma, abuse and violence. His area of interest includes addressing significant complex and challenging behaviours in children under the age of 12 years. He is able to provide therapy in English, Gujarati, Hindi and Urdu.
To make an appointment try Online Booking. Alternatively, you can call M1 Psychology Brisbane on (07) 3067 9129.
- Chrisman, N.J. (1991). Cultural Systems. Cancer Nursing: A Comprehensive Textbook. M. R. G. M. Baird S, WB Saunders Co, 45-54.
- Fitzgerald, M.H., Mullavey-O’Byrne, C., Clemson, L. and Williamson, P. (1996). Enhancing Cultural Competency: Video and Manual Training Package. Sydney, Transcultural Mental Health Centre, NSW.
- Kiropoulos, L., Blashki, G., & Klimidis, S. (2005). Managing mental illness in patients from CALD backgrounds: Australian Family Physician Vol. 34, No. 4, April 2005 Retrieved 1 June 2021, from https://www.racgp.org.au/afpbackissues/2005/200504/200504kiropoulos.pdf.
- Poropat, M., Qadeer, M., & Gooding, B. (2014). Latrobe City CALD Communities’ Access to Mental Health Service Mapping and Scoping (pp. 13-14). Commissioned by the Department of Health: Mind Australia and Gippsland Multicultural Services.
- Seah, E., Tilbury, F., Wright, B., Rooney, R., & Jayasuriya, P. (2002). Cultural Awareness Tool: Cross-cultural Mental Health Assessment – Transcultural Mental Health Centre. Multicultural Mental Health Australia Locked Bag 7118 Parramatta BC 2150.