How is access to mental health care for
linguistically and culturally diverse
groups provided in your country and
what are the main issues and
Professor Rachel Tribe
Linguistically and culturally diverse groups
Mental health and Communicating across Language and Culture
Linguistically and culturally diverse groups :
mental health
• 1. Overview of different migrant groups- though
definitions are contested
• 2. Language :Culture :Mental Health
• 3. Idioms of distress, explanatory health beliefs
and presentation
• 4. A critical psychology/psychiatry perspective
on PTSD or is it a normal reaction to abnormal
events partly constructed by culture?
• 5. Guidelines on working with Interpreters
/bi-cultural workers
• In the UK mental health services have been found to be
inaccessible or inappropriate (Patel, 2000; Lago, 2011; Lane
& Tribe, 2014)
• Usage of mental health services by migrants is poor
compared to the white community (Bhugra & Gupta, 2011;
Tribe, 2014)
• Racism may play a role and perceived discrimination may
adversely affect psychology well-being (Fernando, 2014,
Mckenzie, 2003)
• Stigma and fear around mental health may be influenced
by different cultural formulations and models (Bhugra,
2009; Royal College of Psychiatrists, 2015 )
In the UK almost everyone historically is a migrant
Notion of migration contested- in the literature and politically
Working party on Mental Health and Migration set up by the
World Psychiatric Association
Bhugra, D., Gupta, S., Bhui, K., Craig, T., Dogra, N., Ingleby,
J.D., Kirkbride, J., Moussaoui, D., Nazroo, J., Qureshi, A., S
tompe, T. & Tribe, R. ( 2011) World Psychiatric Association
Guidance on Mental Health and Mental Health Care In Migrants.
World Psychiatry, 10,1, 2-10
1.Overview of different migrant groups
Contextual variables - Different groups may
have different needs
Recent migrants
who remain
largely within
and do not
politics and
age may
play a role
The Multicultural
Refugees and asylum seekers
Many asylum seekers and refugees report feeling that they
were ‘silenced’ or their voices were ‘taken away from them’
by political regimes which did not allow for multiple accounts
or voices which stifled criticism prior to them seeking asylum.
Thus talking about their problems with a health professional
may feel difficult, issues of trust may have become
compromised (Tribe, 2010).
It is often assumed
by people who speak
only one language
that an interpreter
simply replaces one
word for another
2. Language: Culture: Mental Health
 different languages are not
directly inter-changeable in the
way that is often supposed
(Mudarikri, 2003; Tribe, 2003/7).
 Language not only transmits
meaning it may also construct
and shape it. Language is not a
transparent medium but may act
as a defining structure in itself,
(Anderson & Goolishian, 1992;
Burr, 1995) ex Ms, patronising, birthdates
Organisational, institutional and cultural barriers for
health professionals and service users include;
•Time – health professionals are increasingly busy and resource
intense patients or those viewed as such may not be welcomed
•Cultural beliefs and fears about mental health (Bhui, 2015;
Bhugra, 2015)
•Assumptions that a western diagnostic system is the only
mechanism for understanding distress, though it is culturally
located (Summerfield, 2001; Fernando, 2014)
•Lack of understanding of diversity (Fernando, 2014; Bhui, 2015)
• Notion that as people from certain communities don’t use mental
health services - an assumption is made that they don’t need
them and it becomes self perpetuating (Fernando, 2014: Tribe,
Language:Culture:Mental Health II
Understanding diversity- multicultural cube applies to everyone
“An individual practitioner may strive admirably
to understand the contribution of their client’s
culture to the conversation created between
them ……, but will rarely give the same scrutiny
to the role of their own culturally-determined
belief system”. Patel et al (2000)
Idea that much of mental health/
psychology/psychiatry been built
around a set of assumptions
located in the west, which may not
always be generalisable.
Issues to consider when building and sustaining a
health system sensitive to the needs of linguistically
and culturally different communities in respect of
mental health particularly?
Community psychology or engagement as
a form of critical psychology in building
accessible and appropriate services - a
challenge to the status quo within mental
health? (ex- football, tai chi, Chinese older adults, Sri Lankan well
being project)
Community engagement
Implementing NICE guidance
NICE advice [LGB16] Published date: March
Local authorities have a responsibility to promote and
protect health, tackle the causes of ill-health and address
health inequalities – engaging effectively with the local
community can help achieve this (Health 2020; Healthy
lives, healthy people; Fair society, healthy lives)
Key messages
If local authorities and their partners get local communities involved in
decisions about how to design or improve services this will make services
more effective, cost-effective and sustainable – and there will be greater
Engaging with the community can build trust in local authorities and their
partners by improving accountability. It can also help develop a sense of
community and encourage people to adopt more healthy attitudes and
behaviours (Strategic Action Programme for Healthy Communities
Literature Review - Phase one: November 1999–March 2000.
Local authorities may be at risk of challenge or judicial review if
community engagement does not adhere to legislation. There is also the
risk of getting community engagement wrong and there is legislation on
when and how it should be done, for example, the Equalities Act 2010
and the Gunning Principles (R v Brent London Borough Council, ex parte
Gunning [1985] 84 LGR 168).
Lane, P. & Tribe, R. (2010) Following NICE 2008: a
practical guide for health professionals on community
engagement with local black and minority ethnic (BME)
community groups
Health & Care, 7, 2,105-14.
Service users/experts by experience and health workers from
culturally and linguistically diverse backgrounds
can inform service provision and help and
ensure that services are more accessible and appropriate
3. Idioms of distress, explanatory
health beliefs, health seeking
behaviour and presentation
• Idioms of distress
-Way distress is presented may be culturally
• Culture bound or concept bound ‘syndromes’
- syndromes which are specific to a particular
culture or area
What does it take to build and sustain a linguistically and
culturally sensitive health system in respect of mental
health particularly?
Need to consider idioms of distress, explanatory health beliefs,
health seeking behaviour and presentation
Idioms of distress and presentation
-Way psychological distress is presented may be culturally located ( Sierra Leone)
cartesian split,fever in sl
Explanatory health beliefs
How people understand their health and well-being, may not fit with
western constructions ( possession by spirits / jinn, notions of causality and heredity – marriage pros)
Health seeking behaviour
How and from where might help be sort (elders, indigenous healers,
rituals) pathways to care etc
4. A critical psychology/psychiatry perspective
on PTSD or is it a normal reaction to
abnormal events partly constructed by
The debate about whether the language of mental
health/illness is the most appropriate when some one
has been through a traumatic event/s is a complicated
issue, and one that raises strong opinions. Practitioners
in mental health services frequently report that few
refugees ( or migrants- Bhui & Bhugra, 2013) present
themselves (Bernier, 1992; Miller, 1999).
There are three major hypotheses that dominate the
literature on migration and specifically refugees, trauma
and mental health:
Summary of the 3 major discourses on PTSD
1. anyone who has been through the experiences of an
asylum-seeker and has lost so much must be ‘damaged’ or
traumatised. The diagnosis applies across cultures and is
2. people are very resilient and any reaction they have must
be a normal one to abnormal events. A label of PTSD is
unhelpful and is not culturally generalisable (Summerfield
3. many refugees go through immensely trying times, which
may be extremely distressing. Traumatic reactions
can be many and may not constitute PTSD
• Culture and meaning may act as
intervening variables. Some people may
benefit from appropriate psychological
help, which may not always be best
presented as Western Medical/psychiatric
A diagnosis can be functional for an asylum seeker in
terms of asylum reports and accessing resources. It can
also be containing and make the health practitioner feel
better and that they have ‘dealt with the issue’.
It is important to remember that becoming a migrant or an
asylum-seeker or migrant is always a major event in an
individual's life.
However, it is not the defining characteristic but rather a
part of their whole life.
5. Working with
Interpreters/Bicultural workers
Guidelines for psychologists working with
interpreters produced by Prof R Tribe & Dr
K Thompson for the British Psychological
• Guidelines available from
• Free DVD & brief guidance notes available from me or the DVD at
British Sign Language
• British Sign Language (BSL) interpreters for deaf people, has its
own specialist literature,
• We note with concern the National Institute for Mental Health
(NIMHE, 2004) findings that the level and organisation of mental
health services for Deaf people was far from adequate.
• The NIMH report also comments on the need for more BSL
interpreters to be trained as well as the need for clinicians to work
alongside them and undertake relevant training.
• More recently, the UK government has recognised BSL as a
language in its own right.
Linguistically and culturally
diverse groups: Mental Health
1. Overview of different migrant groups- though
definitions are contested
2. Language :Culture :Mental Health
3. Idioms of distress, explanatory health beliefs and
4. A critical psychology/psychiatry perspective on
PTSD or is it a normal reaction to abnormal events
partly constructed by culture?
5. Working with Interpreters/bi-cultural workers