Introducing an integrated model of cross-cultural assessment

Relational

Mastering the nuances of the myriad cultural backgrounds of consumers is unachievable.^1,2 Therapeutic breakdowns with CALD consumers are caused by more than just a clinical unfamiliarity with cultural norms and practices. Moreover, a consumer’s capacity to meaningfully participate in a clinical encounter rests beyond mere cultural traditions. It will reflect their unique experiential reality, their prior interactions and personal perceptions of these dynamics. Clinicians are better served employing generic traits such as open-mindedness, good listening skills, patience, flexibility, a warm verbal communication style, an empathetic posture and non-judgement. ² This engenders an environment where a consumer will feel more comfortable sharing and educating the clinician on (cultural) issues they deem relevant to the interaction without clinical presumption.

The inability to develop rapport is a regular concern noted by CALD individuals when describing their disinclination to utilise mainstream clinical services. ³ The requirement for a robust and durable rapport is especially important when assessing or treating CALD consumers for several reasons. First, CALD consumers may feel some level of social rejection and perception of differential treatment by mainstream society and its institutions. This may stem from previous negative/discriminatory interactions in the community or other internalised stigmas. If such dynamics are not well understood by a clinician, the consumer may perceive the clinical process to be an extension of the exclusion they already experience in society. Second, for many CALD individuals, expectations of stoicism within families are prioritised, with sometimes little modelling on how to openly discuss emotions. These family dynamics can be transferred into clinical settings. Moreover, cultural stigmas about mental health may deter CALD consumers from willingly seeking assistance for mental health concerns or adhering to treatment schedules.

To minimise the non-disclosure of information and avoid triggering distress, a relational disposition and a commitment to rapport building is recommended.^3,4 This process may take longer for CALD consumers, many of whom will be reluctant to divulge information they may consider to be private or shameful. Pushing for early disclosure of past traumas or intimate family dynamics ahead of current needs is a barrier to engagement. A trusted, safe and respected interlocutor is of greater importance than merely being of the same cultural background or understanding obscure cultural facts about particular groups. It is also prudent to avoid particular behaviours (i.e. patronising body language, superior/condescending tones and premature intrusiveness) that may quickly induce feelings of social rejection among CALD consumers who may be sensitive to subtle, non-verbal cues. The purpose of being relational is to provide a trusted secure space and to be keenly aware of how clinical behaviours can influence consumer engagement.

Cultural

This component helps to identify the extent to which culture-related issues may be implicated in behaviour and discerning available support networks. Extracting cultural information should be an organic and subtle exercise. Once relational efforts have been made to engender a trusted dynamic, careful lines of questioning can be employed. The DSM-5 Cultural Formulation Interview ⁵ (and forensic iterations ⁶ ) and other resources^7–9 provide a list of questions that gently probe cultural motivations and rationalisations for behaviours. Introduced in 2013, The DSM-5 Cultural Formulation Interview was designed to help clinicians in all mental health care settings better understand their patient’s cultural experience of illness and help-seeking behaviours. ⁵

The tables include examples of particular non-intrusive questions (taken from or inspired by the interview schemes) that clinicians can employ to prompt relevant cultural information (see Table 1).

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Table 1.

Questions prompting cultural information

How would your community/family members view your problem (legal or psychological matter)?

How would you describe it to them?

What is bothering you most about your current problem (legal/psychological matter)?

What do you think are the causes of your current issues?

Do you think that your problem is an illness?

What would your family/community describe as the causes to your current issues?

…Is this relevant in your case?

How do you think I can help with this problem?

What kinds of support would make your current problems better?

What has gotten in the way of you seeking help?

Are people with these behaviours normally helped or punished in your community?

Do you have any wishes for or concerns about treatment?

What are your thoughts about medications or psychotherapy?

Has anyone else you know ever had this problem?

What activities has this problem stopped you from doing?

Do your friends and family talk with lawyers/psychologists about problems like the one you have?

Do you think your friends or family would be upset if you spoke to lawyers/psychologists about your problems?

Similarly, particular questions can be employed to ascertain the client’s level of acculturation or cultural attachment (see Table 2).

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Table 2.

Questions prompting information on acculturation

Have you or your parents lived in a different country?

Was your life different where you were living before you came here? Was your role in your family different before you came to this country?

Are there cultural differences between you and your parents?

Did your parents/family have challenges or bad things happen to them/were treated badly before they came to this country?

…How did this impact them and you?

Do you feel a strong connection to any groups of people?

How close do you feel towards your community?

Does you reside near their family/community? (Is the client geographically isolated?)

What are the most important aspects of your cultural background (if client identifies)?

Finally, specific questions can be employed to ascertain the extent to which the client’s cultural background may be implicated in, or could alleviate social difficulties (see Table 3).

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Table 3.

Questions on culture and social challenges

Have you been treated badly because of your race/ethnicity/culture/religion?

How did this impact you?

Sometimes people misunderstand each other because they come from different backgrounds or have different expectations of each other. Has this been a concern for you in your life?

Are there any aspects of your cultural backgrounds that can help with your problem or perhaps that are contributing to your problem?

The tables are not exhaustive lists, and further information can be obtained from the original sources. Moreover, one must be judicious with the order and timing of these questions. The explicit use of medicalised vocabulary may need to be tempered initially with some consumers to avoid cultural stigmas and negative connotations associated with these terms. Confidentiality must be explicitly assured for consumers who may be concerned that members of their family or community will discover their discreet utilisation of services. Clinicians must be clear about the information they will keep on record and under what circumstances they will be expected to break confidentiality.

Individual

Every consumer, regardless of their cultural heritage, possesses a unique intersectional profile which comprises various sub-cultures and identities and their own personal expression of these identities. The relevance of cultural information can be established by considering this information with regard to other facets of their life and social context. Where cultural reasons are believed to be implicated in various attitudes and behaviours, it is important to consider other plausible and more parsimonious explanations for the behaviour. This not only avoids inadvertently linking culture and problem behaviours, but it ensures that clinical decisions are informed by relevant data. For example, there are other personal attributes that should not necessarily be conflated with culture that will impact immediate behaviour including an individual’s age, gender, level of education, socio-economic status, cognitive ability, personality type and temperament. Moreover, individuals’ identities and attributes (or various combinations thereof) may activate, or engender, unique experiences under specific circumstances.

Institutional

An organisation must facilitate an environment in which the above three clinical components are enabled. Over-bureaucratised services can restrict this ability, limiting the capacity of clinicians to build relationships with CALD clientele. ¹⁰ Over-burdened, time-poor staff will face difficulties engendering trust under these circumstances. Errors in judgement, biases and shortcuts are more likely to manifest under these conditions. A CALD consumer may perceive an inflexible, administrative-heavy experience to be insensitive and impersonal, deterring them from further help-seeking.

There is already a perception among some CALD communities that mainstream services are transactional rather than relational. ¹¹ It is important that consumers do not sense a culture of compliance, which encroaches on person-centred care. Again, initial capacious interactions are important – the presence of (cultural) liaison officers pre-assessment to assist with paperwork, address any confusion, vouch for the service, and de-stigmatise the experience may be useful. Consumers could perhaps have some input over the location of initial clinical interactions. Prior work has suggested that mainstream clinical services partner with smaller culture-based community organisations to alleviate some of these concerns. ¹² Such services are often in close proximity to their communities, possess unique insights into the needs of their constituents and their families, and engage in regular outreach. Last, some programmes may need to be re-named to avoid cultural stigmas if they contain explicit references to mental illness.

Educational

Services, with permission, should collect localised data on the different sub-groups that utilise the service to ascertain the presence of non-mainstream factors, behaviours and presentations. Collecting consumer data may be useful in informing practice and can also be juxtaposed with the demographics of the local catchment area to identify which groups may be under-utilising the service.

Drawing on the practical expertise of clinical staff with cultural knowledge and other practitioners from CALD communities may assist others in the organisation to navigate cross-cultural interactions. These individuals can often provide more focused practical advice and can frame their recommendations within organisational frameworks. Undertaking supervision in multi-cultural clinical settings from a clinician with practical cross-cultural knowledge is probably the strongest form of cross-cultural education. Services may benefit from identifying these resources already within their ranks or local community (i.e. staff or community outreach workers who possess specialised cross-cultural skills and intimate knowledge about particular cultures) rather than seek advice from external generic trainers and consultants.

A service provider may also benefit from the development of working groups to discuss practical cross-cultural issues. The group would engage in practically oriented troubleshooting and open discussions where staff members could air their experiences, challenges and solutions to cross-cultural clinical encounters. Ideally, the working group would be a forum where staff members can share concerns without judgement and receive mentoring and advice from other colleagues in a relaxed supportive space. Here, staff could also produce a body of knowledge that may be useful for other staff members.