Information for use with the CALD Assessment Tool

The CALD Assessment Tool (provided in the learning programme 'Working with CALD Clients in a Mental Health Context') is applicable for working with Asians. Additional culture-specific information is provided below. Clinicians are reminded that religious or spiritual practices and beliefs are an important part of mental health assessment and intervention.

A. Cultural and ethnic identity

Family's Ethno-cultural Heritage

Detailed questioning about the family's past background, including the cultural origin of both parents is needed to establish ethnic heritage. Making assumptions based on name and language spoken with Asians can lead to inaccurate stereotyping.

When assessing ethno cultural heritage with Asian clients be aware of, and explore the impact of the following factors:

• In China - the One Child Policy.
• In Hong Kong - Western influences.
• In Taiwan - the patriarchal system of the 'old world'.
• Southeast Asian countries - the impact of past and current political issues.

Migration Issues

It is prudent to note that if migration factors are seen as causative of/or contributing to the presenting problem, when exploring the migration history in detail, that clients are not pressured to discuss events that they may not be ready to deal with. Clients should never be pressured into saying more than they want to and the history needs to be taken slowly and skilfully. Paniagua (1994) notes also, that some clinicians fail to ask for information about migration at all in the belief that this has no relevance to the presenting issue, or simply overlook the information. Clients sometimes conceal pre-existing clinical issues for a variety of reasons. Sensitive questions about possible pre-migration conditions will be important for compiling an appropriate treatment plan.

Pre-migration Issues

Trauma and torture experienced by refugees, prior to migration can have a long-lasting effect on mental health. In some cases presentation of mental health issues may occur 10 or more years after settlement. Some Vietnamese, Cambodian and Laotions who arrived in New Zealand in the 1970's and 80's still suffer consequences of pre-migration trauma. The impact of their experiences can be carried into subsequent generations if they were not resolved. Currently (2012), people from Burma (Myanmar) and Nepalese people from Bhutan are arriving as refugees to New Zealand. (For more detail on working with refugees please see CALD 3 'Working with Refugees' and the second supplementary resource to CALD 9 'Working with Middle Eastern and African clients in Mental Health'). Some migrants also leave their home countries to avoid or escape personal or familial difficulties, and sometimes these issues will be integral to presenting problems.

Post-migration Experience and Cultural Shock

• Many immigrants experience a loss of or disruption to their family and social support networks.
• Loneliness is especially problematic for students.
• Families can be disrupted by members returning to their country of origin to work. This leads to marital stress and behavioural problems in the children.
• Older migrants have more difficulties building supportive connections.
• Stress can also be caused by legal problems and sponsor relationship.
• Families often experience racism, prejudice, and discrimination.

Work and Financial Stresses

Many Asian migrants and refugees in New Zealand struggle to find jobs. Their qualifications are often not accepted and the fact that they are older and have no work experience, serve as barriers to employment. Unemployment leads to lack of self-esteem and status, restricted social contact and financial stress, which may lead to depression. Under-employment may have a similar effect.

B. Explanatory models of illness

Below are those most common to Asian cultures. Culture, educational levels, age and level of acculturation will affect which models are most influential:

• Moral model
  This model involves the belief that the condition is caused by a moral defect such as laziness, weak will, or selfishness.
• Spiritual/religious model
  This holds that illness results from spiritual or religious transgressions or from unmet religious obligations. Offended spirits, gods or God bring punishment. It may be useful in some cases for religious leaders to be included in intervention plans and management.
• Magical or supernatural model
  Some people attribute ill health to supernatural causes (like sorcery, witchcraft or other supernatural elements) and employ various strategies to manage it. Treatments may involve finding the person who placed the curse, or a shaman to lift or counteract the spell, the performance of ritual or the use of talismans.
• Ancestor worship
  Some people believe that an ancestor can place a curse because of misconduct. Ritual or activity may be necessary to appease the offended ancestral spirit.
• Astrology
  It is believed that the constellation of planets can pre-determine health or mental health problems. Readings by an Indian or Chinese Astrologer may provide explanations and some direction for management of ill health. Some clients may believe that once dates of bad luck have passed, the health problem will recover spontaneously (Shih, 1996).
• Karma
  It is a belief in the Hindu and Buddhist faiths that all actions have consequences. Congenital or acquired mental health problems can be seen as the result of bad actions in a past life, or present life if the onset is late. The karmic debts may belong to the affected client and to their family members.
• Harmony and balance/imbalance
  Health is viewed as a state of harmony within an integral body-mind system and between the individual and his/her environment and nature. Imbalances at any level are seen as a reason for ill health.
  • In Traditional Chinese Medicine (TCM) disharmony in any one area results in systemic imbalances that can lead to ill health in general, or to mental illness. More specifically, an imbalance of yin and yang, a blocked or weak chi, or imbalances in particular organs lead to ill health and if unchecked, eventually to disease.
  • In Ayurvedic Medicine an imbalance of doshas can lead to systemic imbalances in the body and psyche.]
  • In Buddhism (and Hinduism) disharmony can emerge as a consequence of previous wrongful actions, or because of an imprudent lifestyle.
  • In Taoism disharmony results because of an imbalance within the individual system, or between the individual and nature, or because of discord with ancestors.
  • In Confucianism disharmony results when the five basic relationships of society are disrupted.
• Biomedical model
  Biological causes are seen to be the basis for illness in this model. This is characteristically used in Western allopathic medicine as well as Chinese medicine, Ayurvedic medicine, homeopathy, osteopathy and various herbal medicine traditions.
• Psychosocial stress model
  This model attributes illness to overwhelming psychosocial stressors. Treatment would include addressing the stressors.

Implications for practice

Exploring the client's own interpretation of their discomfort or illness is critical for establishing a good therapeutic relationship, for defining goals, for follow-on and compliance, and also for diagnosis. This requires an exploration beyond symptom presentation.

It is also important to ascertain whether a client is simultaneously undergoing traditional treatments and/or taking traditional remedies. Assessing their health-seeking pattern will provide more information about the client's model of illness (as well as an indication of levels of acculturation).
(See CALD 7 supplementary resource for detailed discussion on TCM and other traditional practices, and how to work with these in clinical practice).

C. Cultural factors related to psychosocial environment and levels of functioning

Some Asian families may have one or more of the following strengths and supports:

• Confucian teaching of the "middle way".
• Buddhist teaching of karma and compassion.
• Strong focus on the importance of family harmony and interpersonal relationships.
• High value of education and hard work.
• Emphasis on family, friends, and ethnic community.
• Families can usually count on support from extended family members, friends and ethnic community network and organisations.