Recapping key information from CALD modules 1 - 4 and 7

For viewers of this resource who have not yet completed CALD modules 1-4 and 7, and for viewers who completed these modules some time previously, some key points are summarised below. It is highly recommended that viewers access this information as understanding cultural values and practices are germane to working in mental health.

A. Key points in working with CALD clients covered in modules 1 - 4

1. Cultural competency requires sensitivity, knowledge and the ability to apply this as skill.
2. Migrants have settlement challenges and an unfamiliar culture in which to create a new life, including understanding a complex and possibly significantly different health system. Language and cultural barriers, non-recognition of previous qualifications and skills as well as discrimination, prejudice and stereotyping are experiences common to many migrants.
3. Refugees face similar challenges overlaid with traumatic experiences, including torture and multiple losses. They have little or no choice about their journeys, arrive with nothing, often don't know the whereabouts of family and have no possibility of going home if they don't settle well.
4. Professional interpreters need to be used when there is no or little English language proficiency. Family or friends should not be used as interpreters for health settings unless in an emergency.
5. Health professionals need to know how and when to work with interpreters, have a clear understanding of their roles, and know how to brief the interpreter and structure a session. Translated resources for healthcare need to be offered where available.
6. Both culture and religious diversity influence the way people view disability and mental health, and the expectations they have for treatment and outcome.

B. Key points from CALD 7 supplementary resource, 'Working with Religious Diversity' (focussed on South, East and Southeast Asians)

'The Three Teachings'

East Asian cultures and Southeast Asian cultures have been greatly influenced by Chinese Confucianism, Taoism, and Indian Buddhism. These three philosophical systems arose much around the same time and so each has had some influence on the other. Folk Religion is another influence.

Some knowledge of the core principles of these systems is necessary for health practitioners to develop a deeper understanding of their East and Southeast Asian clients, and of their beliefs, expectations, practices and how these impact on mental health presentations and outcomes. Some of the terminology and concepts from these systems are familiar to many Westerners (e.g. acupuncture, yin/yang, chi, karma) however the principles are often oversimplified, misinterpreted, or not necessarily understood within a health context. Viewers are strongly encouraged to complete the CALD 7 programme and supplementary resource on 'Working with Religious Diversity' for more information on all the religions mentioned below, in relation to healthcare.

Core concepts and beliefs of the three systems

The merging of the three philosophies in daily life

The principles that emerge most strongly as a value from each of the systems, is interpersonal harmony and benevolence. These shape interactions, including that between a client and a health provider. Interpersonal harmony takes precedence over individual needs in societal inter-relating, and particularly amongst and between family members.

Many other social mores developed because they serve the principle of interpersonal harmony. These include: the importance of fulfilling obligations, the importance of reciprocating kindness, politeness, 'saving face', patience, being accommodating, cooperative and conciliatory, being receptive rather than confrontative, indirectness, modesty, and a reliance on non-verbal communication because disapproval can be communicated in ways that are not socially disruptive. Conformity, social sensitivity and not dominating others also enhance interpersonal harmony and are generally valued amongst East Asian cultures. (Uba, 2003).

Implications for practice

It is important to note that whilst values from the three philosophical systems may be embedded in much of East and South East Asian cultural practices and attitudes, not all people subscribe to the doctrines overtly, and many younger people may not relate to them at all. Reference to the doctrines may not always be appropriate with clients; reference to the principles as cultural values may be more meaningful.

Other religions common to Asian cultures 

For many clients, spiritual principles and practices are integral to health. Supporting clients in including practices that they believe in will be of benefit to their wellbeing.

C. Key points in understanding traditional family values covered in CALD modules 1 - 4 and 7]

The strong traditional values held in most Asian cultures, create the expectation that individuals function within clearly defined roles. Mores of obligation and shame help sustain these roles. In general there is an emphasis on harmonious interpersonal relationships, mutual obligations and interdependence. When dealing with Asian clients with mental health problems, issues of stigma and shame may be more prominent than with other cultures.

The family is seen as the fundamental unit of society, and family cohesion and the concept of community is paramount in sustaining the community (and the state, in China).

• Marital subsystem
  Due to the agricultural influence in many Asian societies, it was common practice to have three or four generations living in one house. This was regarded as economical and practical and ensured the continuity of the husband's line of the family. Most marriages were arranged by the parents and/or grandparents. Even in current times, after the marriage it is still common for the wife to live with the husband's family. He is regarded as the head of the household and the main breadwinner and she is the child bearer and homemaker. Traditionally the wife's role is subjugated to the elders, husband and sons. There is a hierarchy of values, and if children are involved, the role of mother takes precedence over the role of wife. Traditionally, sons get preference over daughters. Any marital discord is settled by one of the elders through mediation. Divorce is uncommon. Confucianism taught that the relationship between husband and wife should be based on mutuality; the underlying spirit is division of labour rather than dominance.
• Parent-child subsystem
  The father is regarded as the disciplinarian and the mother the provider of food, support and nurturing. The women usually have a closer relationship with their sons. Aunts, uncles, grandparents and other members of the extended family all care for the children. Parents expect obedience and respect from their children and children are expected to care for elderly parents.
• Sibling subsystem
  Younger siblings are expected to obey older siblings who stand as role models. The oldest siblings will act as surrogates in the absence of parents. When resources are limited, the oldest son is favoured in terms of education and younger siblings are expected to support the rest of the family. In turn the oldest son would be expected to become the support and representative for the family (Park & Chesla, 2007). In the larger Asian families, the eldest daughter is expected to help with child-care. Sibling rivalry is common.
• Family Harmony
  Maintaining harmony in the family is paramount. However, migration and resettlement issues often disturb patterns of relating and result in family conflict. Traditionally, open conflict is avoided and only those members who are entitled to have an opinion will voice it, the others are expected to suppress their opinions.
  Common causes of family conflict:
  • Role reversals
  • Elderly and the role they play in a hierarchical system
  • Different rates of acculturation
  • Intergenerational conflict
  • Satellite husbands
• Attitude toward the elderly
  Whilst there is an expectation that the elderly are cared for by their children, levels of acculturation may affect this. In some cases, the elderly who migrate to be with their children often feel abandoned once the children acculturate and live their own lives in rejection of cultural values. They often feel too much shame to return to their home countries.

In China and other countries where Confucianism has influence, 'The Five Principles' clarify relating between ruler and subject, parent and child, husband and wife, sibling to sibling, and friend to friend. In addition to the above:

• Ruler to subject
  Peace, harmony and social order are dependent on each person upholding their responsibilities and knowing their place in society.
  The importance is in the reciprocity between members of the relationships. Park & Chesla (2007) point out however, that the responsibilities incumbent on the superior in each relationship became neglected over time, resulting in a rigid justification of social hierarchy. Nevertheless, these are valued at least in principle.
• Friend to friend
  Respect by the younger for the older is very important and applies in friendship and all social networks. Respect is earned also through the demonstration of benevolence and care.