As a psychologist and an educator in transcultural mental health for the past eight years the issue of cultural competence is omnipresent and of paramount importance. As the person charged with the responsibility of developing education programs for mainstream mental health clinicians which enable them to provide equitable services to people of culturally and linguistically diverse (CALD) backgrounds, what constitutes ‘cultural competence’ is never far from my mind. In multicultural Queensland, as in other parts of Australia, there is great cultural diversity with over 200 cultural communities, and mental health clinicians need to be prepared to provide equitable services to individuals and families from any of these communities. What makes this challenging is the fact that numbers within many of these groups can be relatively low and clinician contact with individuals from these groups may be very infrequent. Even more challenging is the fact that great diversity exists within cultures, migrants are moving along an acculturation continuum, and each human being exists as a unique individual situated within layers of context.

To understand what constitutes cultural competence one needs to look at the situational context in which it is being used and utilised. For me it is in the context of busy public mental health services which deal with acute psychiatric conditions and which have many competing priorities with limited funding. As an educator my job has been about ensuring mental health clinicians are able to work within the multicultural framework articulated by the Queensland Government and are able to provide equitable services to all members of the community regardless of cultural background or language spoken.

After about three years of developing and delivering transcultural mental health education programs I became increasingly aware that what we are trying to promote in our programs is what I have come to call ‘contextual competence’ (1). That is, the ability and willingness for a clinician to be able to place the unique human being that they are assisting, otherwise known as a consumer, into the various contexts in which that particular consumer exists. All human beings are unique with individual differences and different experiences, and while generalisations and stereotypes may provide useful starting points, respectful curiosity is required of the clinician to understand consumers and carers in all of their contexts. None of these contexts should take a superordinate position over others. Contextual variables don’t occur in isolation. There are numerous variables at play at any given time, however all these variables react with each other to form hybrids with unique consequences. We who specialise in transcultural mental health need to take care that we don’t promulgate the notion that ‘cultural competency’ can exist in isolation from other contextual variables.

For the past eight years the Queensland Transcultural Mental Health Centre has been training the mental health workforce to utilise both the ‘Explanatory Model’ approach and the Cultural Formulation (2). The overall aim of this nine-module program is to equip clinicians with some knowledge and skills in transcultural assessment and treatment, acquire an awareness of potential cultural contexts and variables and to enable them to ‘think on their feet’, consider all the variables and come up with a clinical approach that maximises the potential of achieving positive clinical outcomes. Broadly this approach generally involves the clinician ascertaining the level of English profi ciency of the consumer and carers and deciding whether or not an interpreter is required, deciding whether they need the assistance of a bilingual/bicultural mental health consultant, utilising the knowledge and skills in transcultural assessment and treatment they have acquired through training, and deciding whether they need to refer to the specialist transcultural clinical service.

I am not a supporter of attempting to articulate all the specifi c competencies that may be required to be ‘culturally competent’. The list of specifi c competencies can become endless. Who chooses the competencies and are some competencies more important than others, and if so who chooses the hierarchy? In attempting to cover every situation which requires the clinician to have competence in, we are falling into the trap of developing the cookbook recipe – that is, if you follow all the prescribed steps you will be competent in providing the best clinical care in any given situation. In their recent article on cultural competency, Kleinman and Benson (3) point out some of the problems with such ideas of cultural competency.

I fully support the ethnographic approach endorsed by Kleinman and Benson and although we have not used this term it is exactly the approach that we have utilised with the QTMHC training program over the past eight years. Perhaps the most important aspect of our training is the focus on clinical outcomes within the context of the situation (Step 6 of the revised cultural formulation in the Kleinman and Benson article). We want clinicians to broaden their thinking and throw off the shackles of reductionism. It is simply not good enough for clinicians to say that as scientist-practitioners they provide what they see as evidence-based practice and if the consumer is treatment noncompliant or resistant then it is not their problem. The fact remains that in such a situation a positive clinical outcome has not occurred. We need to work in ways which maximise the potential for positive clinical outcomes.

Interestingly, in many ways this fi ts with a ‘recovery’ framework which requires the clinician to keep an open mind, to be innovative, to consider the client within all of their contexts, and to be prepared to provide a service that has positive clinical outcomes for the consumer and their carers, as opposed to a ‘one size fi ts all’ approach which is safe for the clinician.

Individual and organisational cultural competence goes hand in hand, and you cannot have one without the other. An organisation may employ individuals who have attained a high degree of cultural competence, however if the organisation has not developed policies, procedures and an organisational culture which enables and promotes their clinicians to utilise their cultural competence then such competence cannot be harnessed and utilised. In such situations goal incongruency will increase and the motivation and passion of the culturally competent clinician will wither. So in addition to sending their staff off to transcultural mental health training, organisations need to adopt the characteristics of an effective and equitable mental health service such as those articulated by Minas (4) and others.

In conclusion, I would like to reiterate that cultural competency must fi t in and be a component of contextual competency. Cultural competency is a process, not a long list of specifi c ‘content’. In the context of multicultural Australia I believe a definition of cultural competency is:

The ability and willingness to strive toward providing an equivalent level of professional care, with equivalent positive outcomes, to all individuals presenting for care … no matter what the cultural, ethnic and/or language background they are from.

In multicultural Australia this means being able to provide this level of care to individuals and families originating from over 200 cultural and language groups. It means being able to develop and deliver mental health services to all Australians, not just those who speak English or those from Anglo or similar cultural backgrounds. It doesn’t mean that clinicians need to always provide the services themselves, but it does mean that they know when and how to work with interpreters, know how to get cultural advice, and know how to refer and work with specialist transcultural mental health services. This is the essence of true and genuine non-discrimination in a true and genuine multicultural society.

References

1. Turner, G. (2003). Transcultural Health Education for Multicultural Australia. Synergy 2003 (3).
Sydney: Multicultural Mental Health Australia.
2. Queensland Transcultural Mental Health Centre (2002). Managing Cultural Diversity in Mental
Health, Train-the-Trainer Program. Brisbane: Queensland Health.
3. Kleinman, A. & Benson, P. (2006). Anthropology in the Clinic: The Problem of Cultural Competency
and How to Fix it. PloS Medicine 3 (10), 1673-1676.
4. Minas, I.H. (2001). Service responses to cultural diversity. In G. Thornicroft & G. Szmukler
(Eds.), Textbook of Community Psychiatry (pp. 193-206). Oxford: Oxford University Press.

About the Author

Greg Turner is currently the Statewide Policy & Liaison Coordinator with the Queensland Transcultural Mental Health Centre. Greg is a Psychologist by profession and has worked with the Centre for the past eight years as Education, Development & Training Coordinator.

He can be contacted by email Greg_Turner at health.qld.gov.au