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cross- cultural mental health training and further research
on evaluation will be discussed. The need for the development
of cross- cultural training will be exemplifi ed from German
and Swedish experiences. Development is necessary as both
Germany and Sweden have a high proportion of migrants and
refugees, and a scanty history of institutionalized support for
cross- cultural mental health training. Both countries face the
urgent challenge to adapt mental health care to the increasingly
more cultural diverse population in combination with
some form of social and political acceptance for adaption of
mental health care delivery.
2. Cultural diversity and mental health care
in Sweden and Germany
In the EU- 27 states there are currently 47.3 million foreignborn
residents, corresponding to 9.4% of the total population [16],
1.6 million recognised refugees and about 514,000 stateless
people living in the EU- 27 [47]. In Sweden, immigration consists
to a great extent of refugee immigration and family reunions.
First and second generation migrants in Sweden constitute
18.6% [40] of the population. The main country of origin is
Finland (172,218 persons), followed by Iraq (117,919 persons)
and former Yugoslavia/ Serbia Montenegro (71,578 persons).
The total population is 9.3 million [40].
Germany currently has 16 million people with a so- called
migration background. These are foreign- born residents and
their offspring, which is an equivalent of 19% of the general
population of 82 million [41]. Germany is the industrialized
nation with the largest refugee population (594,000) [18]. The
largest migration groups are comprised of people with their roots
in Turkey (3.0 million), in the succession states of the former
Soviet Union (2.9 million) and in the succession states of the
former Yugoslavia (1.5) [41].
Sweden and Germany have made various attempts to adapt
the mental health care system to the needs of patients with a
migration and cultural minority background. In Sweden, clinics
for treating victims of trauma were established in the 1980s. The
use of interpreters is free of charge and separately fi nanced. Over
the years there have been several local time- limited projects on
improving care for refugees and migrants [3].
In 1999 the Transcultural Centre was established by
Stockholm County Council, the regional government responsible
for care in the area of Greater Stockholm. Today the Transcultural
Centre offers support and training to health professionals in
hospitals and local health care units in psychiatric care, somatic
care and dental care in the Stockholm area. The Centre also provides
supervision, networking, and information regarding issues
related to culture, migration and asylum and refugee status [3].
Until recently very little has been done to educate immigrants
and refugees about the possibilities of, and routes to, the
(mental) health care system. In the past few years projects with
health communicators have been established in some counties
in Sweden. The health communicators inform newcomers about
health care and health- related issues [4].
In Germany, psychological counselling services were the
fi rst institutions in the 1970s offering specialised services for
S. Bäärnhielm et al. / European Psychiatry 27 (2012) / supplement n°2 / S70-S75 S71
migrants. Since then a movement called “intercultural opening”
(“Interkulturelle Öffnung”) has tried to focus more on the
needs of patients with a migration background [20]. More and
more bilingual in- and outpatient treatment programs have
been implemented. Currently more than two dozen institutions
offer such a bilingual psychotherapeutic treatment
program [33]. A major impact was a health political movement
to improve the psychiatric, psychotherapeutic as well
as the general practitioners’ health care service for migrants
resulting in the “12 Sonnenberger Guidelines” [29]. These
addressed issues of easier access to psychosocial health care
institutions, cross- cultural sensitive and competent staff with
heterogeneous cultural background, organisation and usage of
psychological trained interpreters, provision of information
material in different languages as well as specifi c (further)
education opportunities.
3. Cross- cultural training
3.1. Conceptualisation of cross- cultural training
Conceptualisation of training to improve professionals’
capacity to work with culturally different patients has often,
especially in the USA, been in terms of cultural competence
training [37]. Qureshi et al [37] point to that cultural competence
represent an approach in the provision of mental
health service and that is not a unitary concept, but rather
a generic term that has no fi xed defi nition. This is apparent
given the vast amount of defi nitions as well as models of
cross- cultural competence [12,14]. The National Centre for
Cultural Competence in the USA defi ne cultural competence
as a developmental process that evolves over an extended
period where both individuals and organisations are at various
levels of awareness, knowledge and skills along the cultural
competence continuum [34].
In general, cultural competence training aims to increase
cultural awareness, knowledge and skills of the staff and to
modify their sensitivity and behaviour as well as to improve
patient- staff interaction. It is seen as an instrument to improve
communication between health- care providers and patients.
Tseng [46] adds the aspect of cultural appropriate attitudes and
empathy. Cross- cultural competence is seen as an on- going,
active and nonlinear process [43].
How competence training has been carried out varies.
It has a broad spectrum of approaches with regard to target
group, duration, content and method. Published cultural
competency training programmes have been developed
for different health care groups, e.g. medical students [25],
nurses [12], physicians [30], mental health counsellors [48],
geriatric care settings [51] and mixed groups of mental health
care providers [49]. Training can vary from 4 hours [48] to
10 weeks full- time [19] and the contents in general health
care settings range from language training, specifi c cultural
content, general concepts of culture to patient- provider
interaction [36]. Little content has been published specifi cally
regarding cultural competence training in mental health care
settings [9].
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