I would like to describe what I have learnt from CALD families over the years of working in Child Youth Mental Health Service (CYMHS) and in Adult Mental Health. Harry Stack Sullivan, a Social Psychiatrist, once wrote that any therapeutic relationship involves the interaction between two cultures. By this, he was meaning that for any two individuals, even ostensibly from the same culture, there will be differences in gender, class and roles expectations and modes of expression. This difference means that any therapeutic endeavour requires some work to bridge this gap. One could argue that any therapeutic work, in some sense, needs to find a language that makes sense to both parties, even if it is through an interpreter. This is both the challenge and
the stimulation of the work. One of the challenges to our assumptions is the place of the family in different communities. Each CALD community will teach a clinician something new about the culture of family life. This difference interests me as one of my other professional interests is as a family therapist. Over the years there have been a number of key issues that I have found useful in clinical work. Although these points are generalised, I have found these themes helpful in
thinking about the experience of CALD families.

Strengthening
The experience of migration usually strengthens family ties. There is often a powerful feeling of the family surviving together, by working together. There is frequently a more potent sense of being responsible for each other, than in a family that has not had this experience. It is important not to rush to see these ties as over involvement or enmeshment, as this closeness has a significant survival function for all those involved. It is also worth remembering from a historic context that Western culture seems to be strikingly individualistic; that this culture may be the more unusual one in terms of the prominence of individual over family and community life. Interestingly some research by Richard Eckersley, Sociologist, indicates a correlation between
connectedness to others and mental health.

Children
Children are important for refugee and migrant families. Often children represent the new generation and provide hope for the future, in a new country. Sometimes parents feel more able to bring their children for psychological help, but it is more difficult to bring themselves, particularly with traumatised refugeefamilies. The school experience has also been an area of interest. This is a primary experience of being ‘one of the group’ for children. This potentially assists both the children and the parents in resettlement, as parents can have an important experience of being together with other parents.

Language
It is important to listen for the meaning of language. Some families have said they can only express certain emotions or subtleties in their own language and English is inadequate for what they need to say. I have asked families if they could describe what that difference is, to help me understand the areas that might be more difficult to express. The irony of this, is the conversation happens in English with myself, even if through an interpreter. At times in family sessions that may be happening in English, an important point may need to be expressed in the original language. Of course it is important to make space for this, even if it is later interpreted.

Homeland
The story of leaving one’s original homeland has been instrumental in my work. Of course this is important in both less traumatic migrations or more so for people who have been refugees. It is important to try to understand what has been left behind, e.g. one’s past and what were the hopes, dreams and anxieties that accompanied the journey. The story is important to have a sense of what the transition meant for the family, in terms of how much choice people felt they had or how powerless they felt. Sometimes in working with families I have noticed that one member may have had high hopes for the move to Australia and one member may miss their country of origin. It is important that both points of view are listened to, as at worst these differences can divide families in their resettlement. Perhaps one person is expressing the hope for the whole family and one person is expressing the grief for the whole family. It is important to differentiate this.

Communication
Being aware and thoughtful of the family members who have been left behind is important for the
clinician. With the advent of email and cheaper international telephone calls, absent family members are more readily available for advice and guidance, if there is a crisis. It is important that the clinician remains aware of the family members not present, as they may be a significant source of support. There is also the issue of ageing or frail grandparents or extended family in the country of origin that may be a significant source of anxiety for the family.
Particularly for refugees, if the political situation remains unstable in their original country, there is a tendency to become preoccupied with the fate of their remaining relatives. Sometimes there can be a ‘survivor’s guilt’ for the family who have managed to get away.

Stress
When working with refugee families there is a need to be aware of post-traumatic stress. When a child is exposed to a particular traumatic event, there is not only the trauma the child will experience, the parent often feels a secondary traumatisation by the fact they were unable to protect the child from witnessing the event that has instigated the trauma. Often it is important to work with the parents and the child. With the parents, the work may need to focus on restoring their sense of parenthood and the belief that they can protect their children, in less extreme circumstances.

Understanding
It is important to listen to cultural understanding of mental health. Many refugee families come from cultures where either there was little mental health care, or psychiatry was used as an agent of social control. Frequently there can be anxieties about shame which is felt to reflect on the family as well as the individual. It is important to listen for these anxieties and to give straightforward explanations of how the mental health service is able to help.

Spirituality
Equally important, many CALD communities make use of spiritual and religious supports for mental health difficulties. It is vital that mental health clinicians respect these, as frequently they are a support to the patient and their family. They often provide families with a pathway of recovery that is a source of security. Allowing a dialogue about the place of religious belief for the family is something that clinicians may find a new experience.

Generations
Every generation in a family may relate to their original culture differently. In my personal
experience, some CALD families in which the original migration occurred with the grandparents,
may show different patterns in each generation, between the trend to assimilate in mainstream
society and the trend to identify with the culture of origin. A parent who feels less comfortable with the language and culture feels left behind and perhaps deserted by their child. Sometimes with these dynamics I have found it helpful to inquire about how the parents themselves managed the culture or to identify with their culture of origin. There is a common difficulty that the young person who becomes very streetwise in mainstream Australia, can become detached and individuate from their own parents. This exploration can help the parents differentiate what is ordinary individuation and what is a more concerning rejection of the parents and the culture.

Life
It is important to listen and inquire about the rituals, roles and legends of family life.
Important transitions like births, deaths, marriage and the transition to adulthood will be marked
somewhat differently in each culture. Clearly in dealing with mental health issues, there is a need
to be alert to these aspects and to understand their cultural importance. Research on the cultural background of the families clinicians deal with, will go a long way to delivering suitable therapy. Equally important is to make use of transcultural mental mealth services and cross cultural consultants where necessary. Working with CALD families offers a particular challenge, in that
even when one does the research, there is still a lot left to learn. What we also need to do is learn about the family itself and how we can potentially help, within their framework. We can only be free to learn from the family, if we feel secure enough to feel we do not need to know everything.