Suggested questions:

• How did you (and your family) come to New Zealand?
• Why did you leave your home country and who made the decision? (Explore duration, with whom they migrated, any significant family member(s) left behind).
• What anything left behind?
• What was your journey like? (This can bring up sensitive issues of trauma. Explore past trauma and grief – don’t avoid these).
• How did you leave? (This can bring up sensitive issues of immigration status. You could say: “Is your legal status a source of stress for you? I know that many people are afraid to get the services they need because they do not have legal status. This can put them in a stressful situation that affects their health. It is helpful for me to understand the challenges you are facing”?).

It is important to realise that identities develop in different contexts relative to conditions and that migration may influence this. For example, a migrant may have become part of an ‘ethnic minority’ although they may never have heard the term before they arrived here. People also often identify more (or less) strongly with their cultural group after migration.

Elements of the client’s migration history can be useful in understanding cultural identity. This history may provide information about the reasons for migration, the time and circumstances of the journey as well as loss and trauma pre- and post-migration (Kirmayer et al., 2011). This will be especially important for refugees whose circumstances have often involved violence and war. It’s also important to understand levels of acculturation and whether the desire/need for acculturation is externally or internally driven. This could help identify potential areas of strengths and supports.

Suggested questions:

• What language do you speak at home? With elders? With children? Or with sisters and brothers? With your friends?
• Did you learn any foreign language or second language in your home country?
• In what language did you have your education (primary / secondary / tertiary)?
• What language do you prefer your children to learn?
• Do you think children should learn their mother tongue as well?
• What language (mother tongue or host language) do you prefer to use when socialising with friends or relatives?

These questions ascertain how comfortable the client is in speaking the host language. While they may be comfortable speaking English for an official or professional visit, they may not be able to express themselves as well when discussing issues that cause them distress or that may not have a direct translation into English. They might find it easier to express themselves in their own language.

Note that one of the first decisions a practitioner needs to make in conducting an assessment is what language this should take place in. If the client and clinician do not speak the same language or the client does not have proficient English language skills an interpreter needs to be engaged. A culture-appropriate and language-appropriate interpreter should be engaged if necessary. The "CALD 4 Working with Interpreters course" is recommended to health practitioners to enhance essential knowledge and skills to work effectively with interpreters.

Allow extra time in the session if an interpreter is booked.

Suggested questions:

• These days, how much are you able to practise your traditional way of life? (This could include socialisation with own people, dress codes, greetings, participation of festivals, practising ethnically oriented family roles, restrictions imposed by traditions.)
• Explore ethnically shaped developmental experiences: Can you remember some of your childhood experiences and tell us some of them? Did you feel any change when you reached adolescence or adulthood? (Explain in regard to your cultural norms or practices.) Is there any special activity, ritual or social function you have gone through that you can remember? (Enquire about special rituals or rites of passage.)
• How are you adjusting or maintaining conventional family roles in the new environment? (Enquire about ethnically prescribed family roles.)
• Do you maintain the traditional dress codes at work? At home? At any family function or festival? (Enquire about traditional dress codes, special greetings.)

Establishing your client’s cultural practices will highlight the traditions that are most important to them. We all tend to turn to our core cultural practices in times of stress or distress – understanding your client’s traditions and practices may shed light on how they understand their disorder and how they would like to manage it. It can also give further insight into their level of acculturation.

Suggested questions:

• Do you think men and women should have different roles? Can you describe or give examples of some of the roles?
• Who in the family should be making key decisions (eg managing finances, buying a house)?
• Is there any hierarchy maintained in the family? (That means some family members have preference to others for certain things or activities.)

Understanding attitudes to gender differences can help clarify traditional roles or expectations.

Suggested questions:

• What do you think about elders’ roles in the family? Do you think these are changing in your family after migration? If yes, can you give an idea how? What used to be the role in home country?
• What do you think the role and responsibility of younger people in the family are now after migration? Have there been any changes? Can you tell us about these?

These questions help further understand how the client and their family have changed since migrating. Answers here could highlight key relationships, acculturation issues, change in status for the client or key members of their family.

Suggested questions:

• Do you have any sexual preference? (Heterosexual or same sex relationships.)
• What is the unmarried/married/divorced/separated person’s status in your cultural community? Have you noticed any change since you migrated? In what way?
• What do you think of using contraceptives? Does this differ for married or unmarried people?
• What do you think about the relationship between men and women living together (de facto relationship)?
• What do you think about sexual relationships outside marriage? Do you think that any changes have happened in this regard to you or your family since migrating?

Remember that raising sexuality issues often needs to be handled with extra sensitivity. These issues may trigger trauma related to sexual assault during refugee flight for refugee men, women and children.

Suggested questions:

• Do you have a faith or spiritual tradition?
• Did you practise this tradition in childhood?
• Have you changed your religion since then? If yes, can you tell me the reasons for change?
• Do you have any regular religious practices?
• Do you have any food preferences in relation to religious beliefs?
• Do you like to maintain your ethnic dress codes and greetings?
• Have you come across any difficulty with religious practices?
• Did you or your family belong to any social class before migration?
• What do you think of your or your family’s social class (in home country) since you have migrated?
• Do you think there is a change in your social class now? If Yes, in what way?

Religious beliefs influence how clients perceive and manage their health. Religious leaders may become included in the treatment team and add additional community support. Note: the "CALD 7 Working with Religious Diversity" course provides knowledge about a range of religious beliefs and practices from Islam, Sikhism, Hinduism and Buddhism. It will enhance learners' understanding of the influence of religious beliefs of clients and their families' health, behaviour, and wellness as well as interventions.

Suggested questions:

Suggested questions:

• What do you think caused your problem?
• Why do you think it started when it did?
• What do you think illness does to you?
• What are the chief problems it has caused for you?
• How severe is your illness?
• What do you most fear about it?
• What kind of treatment / help do you think you should receive?
• Within your own culture, how would your illness be treated?
• How are your family and community helping you?
• What have you been doing so far?
• What are the most important results you hope to get from the treatment?
• When would you like to come back?

Understanding explanatory models can also help prevent misdiagnosis. Culturally appropriate beliefs can be misunderstood as psychopathology. This is important in determining what information should be taken into account when making judgements about what is normal or abnormal in a culture and can avert any differences in beliefs being regarded as psychopathological. For example, in some cultures, it is normal for a person to hear the voice of a loved deceased person; and this could be diagnosed as auditory hallucinations.

An example from clinical practice is a man presenting in a Buddhist robe carrying Buddhist literature and answering questions in a philosophical way. The clinician assumed he was a monk and assessed him as being depressed. However in a subsequent interview his family expressed concern about his strange dress and behaviour. It turned out that he saw himself as a reincarnation of Buddha with a mission to save the world. It is easy to jump to conclusions based on cultural stereotypes and using cross-cultural assessment guidelines can help prevent making these assumptions (Andary et al., 2003).

Sometimes the severity of a disorder can be misjudged. In one example, a woman was diagnosed with an acute episode of paranoid schizophrenia and her symptoms remitted quickly (Andary et al., 2003). At the end of her treatment, the client wanted to sacrifice a chicken to repel the curse that she saw as a cause of her illness and this was seen as a further symptom of her delusion. Subsequent consultation revealed that this was a normal cultural practice for treating curses; this information could have avoided her being unnecessarily hospitalised for a longer period.

Appropriate treatment rests primarily on accurate diagnosis; and understanding the client’s explanatory model is essential for making treatment plans that will be effective.

Suggested questions:

• What are the major sources of support in your life?
• What are the major stressors in your life?

If there is an indication of possible family violence / abuse, follow with:

• Is your partner a source of support for you?
• Does your partner make you feel bad about yourself?
• Have you (or your children) been hit, kicked, punched or otherwise hurt by someone in the past year? If so, by whom?

If no family violence, continue with:

• Are family members a source of support for you?
• What are some of the family problems that affect you?
• Is it important for you to find a community that fits with your cultural background?
• Have you or your family felt accepted by this community (host or ethnic, as relevant)? Why or why not?
• How respected are your values by the mainstream culture?
• Do you participate in any community religious activity? (If not already answered under spiritual beliefs.) Is there anything stopping you from practising your faith here? Do you think your spiritual or religious influences have hurt you or contributed to your problem? (This may be a major source of guilt or stress.)
• Are there any religious or spiritual resources that could help you overcome your problem?
• Would it be helpful if a religious leader or traditional healer was consulted in your treatment?

Include family members in the assessment. Be aware that sometimes other members will offer information that the client is too shy or unwilling to relate to. Use non-verbal cues and observe family interactions, including in the waiting room, for an understanding of relevant dynamics.

Enquire about individual strengths (faith, skills, cultural knowledge and commitment to own cultural wisdom), family and community-based support (extended family, religious and traditional celebrations and rituals, recreational activities, involvement in political or social groups) and environment-based culturally-related strengths (space and time dedicated to prayer and ritual, dietary preferences, outdoor interests, and access to outdoors for recreation). It is important that psychosocial functioning be assessed across various settings including home, family and the ethnic community as well as the mainstream community.

It may be preferable with some cultural groups or some clients to conduct assessments at home. Mental health issues are commonly stigmatised in CALD communities and this may prevent the client/family from accessing services. Home visits are also useful to assess the client context and family dynamics.