Spotlight on: Asian, refugee and migrant mental health and addiction support

Asian, refugee and migrant mental health and addiction support

“Health practitioners working with people from other cultures need a broad understanding of cultural differences to accurately perceive symptoms and diagnose illnesses.” Jackson, K. (2006, p.31)

This feature explores how health practitioners and services can better meet the needs of Asian, refugees and migrants.

The diverse range of cultural attitudes towards mental illness and desired treatments are not always captured in therapy approaches commonly used in New Zealand. Innovative approaches are being introduced in New Zealand and overseas to bridge the gaps between traditional service approaches and the unique needs of Asian, refugee and migrant groups.

The term “Asian” refers to people who identify with ethnic groups originating in the Asian continent, east of, and including Afghanistan, and south of and including China. Migrants is a general term for people born overseas, whereas refugees are people born overseas who were forced to flee their home country. ‘Second generation’ refugee or migrant refers to a New Zealand-born child of someone born overseas. Each of these groups represents a diverse mix of life experience, language, education and cultural affiliation and support needs.

How relevant are Asian, refugee and migrant populations for New Zealand services?

Asian and migrant groups make up a substantial part of New Zealand’s population; 20 per cent of New Zealanders were born overseas, and Asian is our third largest ethnic group (9 per cent of the population, behind European and Maori). Most Asian and migrant people settle in urban centres, and make up a substantial proportion of the population:

Figure 1: Migrant and Asian population groups as a percentage of the total population in main urban centres in New Zealand.

Refugee communities are much smaller. Each year around 1000 people are settled in one of the six urban resettlement cities, following a six-week orientation at the Mangere Refugee Resettlement Centre.  

Use the Statistics New Zealand Table Builder to develop Asian and migrant population estimates specific to your location.

Unique needs of Asian, refugee and migrant communities

Many members of these communities are exposed to a range of stressors that can increase the risk of mental illness. Risk factors related to settlement include language difficulties, limited access to appropriate employment and challenges maintaining family and social networks. Refugee communities also have added stressors associated with the forced nature of their migration; many have experienced trauma and/or family separation.

A number of case studies about the stressors that refugee youth may face, and suggested responses, are outlined in the Wellington refugee youth issues summary report (PDF, 830KB).

Collectivist values such as strong family responsibility are also key features of many cultures and need to be considered in service design, assessment and intervention. These broad cultural generalisations will not apply to all people of a given culture, and it is important that beliefs are explored on an individual basis rather than assumed because of ethnic group. 

Western bio-medical models do not always reflect people’s beliefs about the causes of mental illness or their desired treatment. Some cultural ideologies propose that mental illness has physical and spiritual causes and thus traditional treatments often focus on addressing physical and spiritual causes. Stigma and other negative attitudes towards mental illness can further limit the appeal of visiting typical New Zealand mental health services. Case studies and patterns of service access indicate that a number of Asian people, and refugees, delay seeking help for mental health symptoms.

A recent United Kingdom study investigated the importance of pre- and post-migration stressors for asylum seekers, impact on mental and social functioning, and experiences with health and other support services. A free copy of the article and other recent research can be obtained from the International Journal of Migration, Health and Social Care

In May 2011, Te Pou released the research study Developing culturally responsive services for working with refugee youth with mental health concerns which highlights the importance of building an understanding of people’s unique experiences, beliefs about mental illness, family dynamics and help-seeking preferences to work effectively with refugee youth and their families. One method that may help improve cultural understanding and rapport is by involving cultural support workers who are funded to assist with consultations or provide separate non-clinical support. 

A recent service evaluation report on the RASNZ Auckland Regional Refugee Mobile Team: A monitoring and evaluation project over two years, suggests that service users and other service providers value cultural support workers as a key to meeting refugee community needs. 

How can services and staff respond to these unique needs? 

New knowledge and innovative service models provide us with exciting opportunities to improve the mental wellbeing of New Zealand’s Asian, refugee and migrant communities. A meta-analysis of existing research (PDF, 135KB) indicates that culturally targeted service delivery can increase service access and reduce distressing symptoms, particularly for people whose cultural practices differ markedly from their new country.

Evidence for a variety of strategies for adapting mental health services to better meet the needs of these communities is included in Factsheet 3 of the Te Pou Service responsiveness to Asian, refugee and migrant populations series. 

Research-based recommendations for adapting services include a combination of:

New Zealand's mental health service specifications for Asian, migrants and refugee services released in July 2010 incorporates these principles in a range of service models to better meet the needs of these groups.

Recent examples of adapting services for these communities include a cross-sector collaboration to develop the Refugee Youth Action Network (PDF, 440KB) (RYAN) programme targeting leadership development, early intervention and career development for refugee youth. Further examples are profiled in Te Pou’s Stories of change,  Refugees as Survivors New Zealand (RASNZ) and their mobile mental health service and Bo Ai She, a Chinese peer support organisation.

Additional strategies for achieving cultural competency are recommended in an Australian National Cultural Competency Tool (NCCT) for Mental Health Services, recently released by Multicultural Mental Health Australia. The standards document outlines a range of strategies, a “how-to” guide for implementation and provides a checklist for organisations to self-assess how well they are meeting cultural competency standards. The strategies outlined above are also applicable for other sectors such as disability and similar considerations apply when working with Maori and Pacific communities.

Building cultural responsiveness in therapy

A range of resources can assist clinicians and other staff to enhance cultural competence in their work.

Let's get real, Real Skills for people working in mental health and addiction describes the knowledge, skills and attitudes for everyone working in mental health and addiction services. One of the seven Real Skills, Working with service users, identifies the importance of establishing a connection and rapport. Having the right knowledge and skills to use culturally appropriate protocols and processes to work with service users is essential in engaging with people from different cultures. Being able to acknowledge the personal, physical, social, cultural and spiritual strengths and needs of each person, including the service users’ interpretation of their own experiences are all needed to work effectively with service users from different populations. The Let's get real roadmap provides an overview of the resources and helps services to access the range of tools and learning modules available. 

Te Pou practice guides Talking Therapies for Asian People, Therapies for Refugees, Asylum Seekers and New Migrants and Talking Therapies for Pasifika Peoples outline ideas and recommendations for building therapeutic engagement and adapting talking therapies for these groups. 

Waitemata and Auckland District Health Boards (DHBs) have an online and face-to-face training programme to improve cultural competency underway. The Culturally and Linguistically Diverse (CALD) programme website provides information about the training and lists a range of research and resources and services available. 

Refugees as Survivors New Zealand (RASNZ) also provides CALD training workshops for professionals working with migrants and refugees at the service’s own site, or at the RASNZ centre in Mt Roskill. The publication Cross-cultural Resource for Health Practitioners working with Culturally and Linguistically Diverse Clients can be ordered from the organisation.

Recommendations for adapting other training programmes to include aspects of cultural competency are outlined in the recent Te Pou report Building evidence for better practice in support for Asian mental wellbeing: An exploratory study. 

Implications for primary health services

Primary care services can play a crucial role in mental health support for Asian, refugee and migrant groups. These are also typically the first point of care for a variety of health concerns, and anecdotally they carry less stigma in these communities than secondary mental health services. Primary care services have the potential to:

Resources, time and training influence the ability to perform these functions.

Services can use free interpreting services for people with limited English language skills accessing primary health care providers in the Auckland region. Recent research reviews from 2005 and 2007 (PDF, 200KB) present evidence that well-trained interpreters can positively impact on service access, medical costs, service user satisfaction and understanding of diagnosis and treatment options.

Multicultural Mental Health Australia developed a Cultural awareness tool for mental health workers in primary care that provides guidance to primary care mental health workers about delivering culturally sensitive care.

Informing future developments

The Ministry of Health identified that further research was an important part of improving the responsiveness of services to the mental health and addiction needs of these groups. Te Pou has developed two research agendas in consultation with the sector, one for Asian communities and one for refugee and migrant communities. In addition, links to New Zealand research and tools for researchers working with these groups are provided and a series of factsheets, outlining evidence relevant to improving services, was published in 2010.

Two new research updates were released in early May 2011, on refugee and migrant, and Asian, mental health service responsiveness. They provide summaries of recent research articles to inform the practice of mental health and addiction clinicians working with Asian, refugee and migrant individuals, families and communities.

Further information and useful links