People from culturally and linguistically diverse backgrounds

Little research has been carried out in Australia on people from culturally and linguistically diverse (CALD) backgrounds in AOD services – let alone on those with co-occurring mental health conditions. As such, it is not clear whether co-occurring conditions are more common among people from CALD backgrounds than other groups. It should also be noted that there are differences between organisations in how people from CALD backgrounds are defined (e.g., country of birth, language spoken at home), which has implications in terms of the ability of some services to adequately capture and respond to behavioural patterns and trends in some CALD communities.

Findings from the most recent Australian National Drug Strategy Household Survey illustrate that compared to people from non-CALD backgrounds, people from CALD backgrounds are less likely to use alcohol, tobacco, or illicit drugs [1697]. While there is some evidence that people from CALD backgrounds may be more likely than those from non-CALD backgrounds to use harm reduction strategies with regards to their alcohol use [1698], the reverse has been observed among men from CALD backgrounds who inject performance enhancing drugs [1699]. As with other population groups, people from CALD backgrounds are not homogenous and there is variability between groups in terms of prevalence rates of mental and AOD use disorders.

Australians born overseas are underrepresented in AOD treatment services. Although 30% of Australia’s population in 2020 were born overseas, the proportion of clients born overseas entering AOD treatment services in 2019-20 was only 13% [432, 1700]. This underrepresentation is likely a product of many barriers to treatment including [389, 1701–1704]:

Strong feelings of shame and guilt.
Fear of stigmatisation/judgement surrounding treatment and associated social disconnectedness.
Cultural differences between client and therapist.
Confusion and lack of education or exposure to public health campaigns.
Different expectations of treatment and difficulty clarifying these due to language barriers.
Lack of familiarity with what AOD treatment services are available, and how to access services.
Lack of available culturally accessible services.
Language difficulties which make participation in AOD treatment programs difficult.
Fear of deportation or being placed in detention.
Fear of authority related to previous experiences with government services.

Due to the multicultural nature of Australian society, it is imperative that AOD workers develop an awareness of issues related to working with people from CALD backgrounds. Each geographic area has its own unique cultural diversity and AOD workers should learn as much as possible about the cultures represented in their treatment populations. In particular, AOD workers should be aware of conventions of interpersonal communication (e.g., communication style, interpersonal interactions), expectations of family, understanding of healing, views of mental illness, and perceptions of substance use. However, it is fundamental not to make assumptions based on the client’s culture – just because they are from a certain cultural background, that does not mean that they necessarily subscribe to the values and beliefs of that culture [102, 1705, 1706]. Reid and colleagues [1707] recommend consultation with the separate cultural communities to develop culturally relevant strategies for AOD treatment.

It has been suggested that information about three aspects of clients’ lives is of crucial importance when treating CALD clients [1708]:

Context of migration: If the client migrated to Australia, why they left their country of origin, how they got to Australia, their legal status, whether they have residency, any trauma experiences in the context of their country of origin or migrating to Australia (e.g., refugees of war). Helping clients to place their AOD and mental health conditions in the context of such experiences can help to reduce shame and increase self-compassion.
Subgroup membership: Ethnicity, gender, sexual orientation, area in which they live, refugees or immigrants, religious affiliation.
Degree of acculturation: Traditional (client adheres completely to beliefs, values, and behaviours of their country of origin); bicultural (client has a mix of new and old beliefs, values, and behaviours); acculturated (client has modified their old beliefs, values, and behaviours in an attempt to adjust); assimilated (client has completely given up their old beliefs, values and behaviours and adopted those of the new country).

Even migrants from English-speaking countries are likely to struggle with cultural confusion and stressors associated with changes in environment, jobs, social supports, and lifestyle. Migrants may experience a loss in social and occupational status if their qualifications are not recognised in Australia, or face issues such as high unemployment levels, overcrowded living conditions, isolation, poverty, racial discrimination, and family conflict.

Some people in the Australian CALD community may feel pressured to consume alcohol to adapt to the Australian culture [1709]. AOD use may also be used as a strategy to cope with trauma experienced both pre- and post-migration, such as political oppression, living in refugee camps, witnessing death of family members, and violence [1710]. These unique stressors not only increase the risk of developing a mental disorder [1711], they can also act as barriers to seeking and engaging with treatment and, as such, AOD workers should develop strategies to manage or reduce these stressors [389].

Rickwood [1712] provides a general summary of the types of problems that are specific to CALD groups in the community and makes recommendations regarding the provision of treatment services. These recommendations (such as cultural and religious awareness and the appropriate use of interpreters) would also apply to those with co-occurring mental health conditions. As with Aboriginal and Torres Strait Islander clients, screening tools should be validated for CALD groups and need to be administered and interpreted with care, although it should be noted that few validated screening tools exist.

Below is a range of useful points which may improve assessment and treatment when working with people from CALD backgrounds [431, 1705, 1713–1715]:

Contextualise the person’s ethnicity, cultural identity, and migration/settlement experience (e.g., ask about AOD use in the context of the client’s culture). Respond to client issues from a cultural perspective that resonates with the client’s own understanding of these issues. Notably, there is diversity between CALD communities in terms of conceptualising mental health and AOD use, as well as needs and preferences for treatment.
Keep what you know about mental illness in mind but ensure that you try to understand the client’s cultural understanding of their problems. People from different cultures often have different views on what constitutes mental illness. The DSM-5-TR [10] makes it clear that diagnoses can only be made if the person’s behaviour is abnormal within their culture. While there are similarities in the forms of illnesses across different cultures, the specific symptoms and signs vary for different societies. For example, a man in Australia with psychosis may talk of aliens controlling his thoughts, while a man in Fiji might blame black magic. It is also not uncommon for people from some cultures (particularly South-East Asian countries) to express psychological distress through somatic (physical) symptoms [431].
Provide holistic and family-sensitive care. Where possible, and with the client’s permission, involve the family in treatment. Allow the client to pick who from their family or community participates.
Be aware that some CALD clients may come from collectivist cultures (in which greater emphasis is placed on group identity, goals, and concerns than is placed on individual ones) and may require a greater involvement of family and community for successful treatment.
Be sure to address the client appropriately and pronounce their name correctly. Ask the client how you should address them.
Provide language support. Try to find out before the session if the client requires an interpreter and allow the client to make decisions about if/when an interpreter is needed. Keep in mind that even clients with basic English proficiency might benefit by having an interpreter because describing symptoms, especially feelings, can be very difficult when English is a second language. Be sure the dialect is correct and be aware that some clients may have a preferred gender for the interpreter. Allow the interpreter to brief the client on the role that they will play. Even when families are involved in the client’s treatment, it is inappropriate to use family members as interpreters. The client may not wish to divulge certain information to their family, or family members may not want certain information disclosed to people outside the family and may edit what is being said. Consider whether the interpreter may belong to the same community as the client, and if so, whether other options are available (e.g., telephone interpreters). When using interpreters, be aware that some meaning can be lost in translation and address issues of confidentiality.
Address gaps in health literacy, using unambiguous language and regularly checking that you and the client understand one another. Be clear, concrete, and specific.
Discuss and clarify the client’s expectations of treatment.
Address confidentiality and promote safety to increase engagement.
Ensure that all treatment options are clearly explained, including rationale and processes.
Provide flexibility in service delivery.
Make allowances for variations in the use of personal space, including degrees of closeness. For example, people from some cultures may feel more comfortable sitting next to AOD workers, rather than being separated by a desk [1705].
Customise the physical environment to be more culturally sensitive (e.g., hang culturally appropriate pictures).
Be aware of gender and age. Some cultures may have specific concerns about appropriate gender and age relations, such as talking about some subjects with a member of the opposite sex or a younger person.
Maintain a focus on healing, coping, or rehabilitation, rather than on cure.
Set aside at least twice the usual time, especially if you need to use an interpreter.
Be mindful of embarrassment and cultural taboos.
Use appropriate messaging to reduce stigma/shame.
Look for verbal and non-verbal signs of discomfort or confusion. Do not take silence as consent or agreement. Similarly, the word ‘yes’ may infer politeness or acknowledgment of possibility rather than assent in some languages [1716]. The client may have had negative experiences in the past when accessing services, so consider making time to discuss these experiences and learn about any discrimination they may have experienced, as doing so may help to build trust.
Support the client and their family in accessing other relevant services. People from CALD backgrounds may not have knowledge of services that are available to them, so be aware of other services that could be helpful and offer to connect them directly by making a referral and help coordinate their care (see Chapter B5) [431, 1714].
Work in partnership with CALD community leaders and bi-cultural workers.