"A transcultural perspective is necessary in mental health care"

"When we talk about a transcultural perspective, we mean that when we treat people from other cultures, cultures far removed from our own, we have to take into account that their way of perceiving the world, their beliefs, values, rituals, and even their very concept of what health or illness means, can vary. Most of the professionals who work in the field of mental health in our country come from a Western culture, with a Judeo-Christian tradition, with specific values that may be completely different from those of the person in front of us."

We don't usually even consider what aspects of our thoughts, beliefs, and ways of doing things are mediated by our own culture; we are not aware of it.

One of the riches of working with people from other cultures is that it forces you to open your mind, to look at your own cultural identity and see how you manage the fact that the person you are serving has a different experience.

In the dialogue we establish with people from other cultures, we must build together , explore, negotiate, and not take things for granted. It's about applying this open-minded approach to find, with respect, the best solution to the situation we are managing, without trying to impose solutions designed for a population with a Western tradition.

"I believe it's important at all levels of healthcare. For example, if we're treating a Muslim person with diabetes and we know they're going to observe Ramadan, we already know that they probably won't take their medication during the fast. It's a matter of having that sensitivity. In our case, in mental health care, it's especially important because the diagnosis is based on words . The narrative of distress that the person expresses is heavily influenced by cultural aspects. For example, there are cultures that focus more on the body; they express distress more with somatic complaints and not so much with psychologically charged expressions, as is the case in Western countries."

The same applies when considering treatment and its acceptance . If we're dealing with someone who believes an illness stems from the evil eye or witchcraft, they may not understand a treatment based on medicine. Often, these individuals fully understand that they're coming to a Western hospital and the role of medicine in treatment; you must still incorporate this factor to validate its causality and respect their beliefs. It's a negotiation between respecting their beliefs and offering a solution from our perspective as physicians.

There's another particularly interesting topic: the concept of time, which is cultural. In the West, we have a linear concept of time (past, present, future), while other cultures have a cyclical or circular concept of time. This has implications for issues like prevention . For many cultures, illness is understood as the here and now. They don't understand why they should take medication for months if they feel well now.

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"At SATMI, we've been working with this perspective since 1997; we're probably one of the first mental health services with this approach. I think progress has been made; in fact, a national training plan on cultural competence has been implemented at the primary care level and in specialized centers. There's a professional awareness of the need to understand these issues, which can be essential depending on the area of the city where one works. It's true that, although we've been dealing with the migration phenomenon for years, we're far behind countries like the United Kingdom, France, the United States, or Canada, which have much more experience in this field. These countries are leaders in research and programs, with Canada standing out as an example of a multicultural society that has implemented inclusive policy strategies aimed at combating stigma."

"In the case of medical school, which is the one I'm familiar with, the topic of cultural diversity isn't addressed, at least not in my time, and I know for a fact that it still isn't. Subjects like anthropology aren't studied, and this is probably a fundamental deficiency. Ultimately, professionals who develop these cultural competencies do so out of personal interest; it's not a required requirement."

"In the 25 years we've been operating, the profile of the people we serve has changed a lot. Initially, the most common profile was that of a North African man who came alone, hoping to find work and who, over time, would reunite with his family. Now we've moved to a much more diverse migration in terms of countries of origin, where asylum seekers predominate and whose socioeconomic conditions have been steadily worsening."

Mental suffering can develop due to different factors:

• Pre-migration factors , which they already had in their country of origin: exposure to violence, war, precariousness, etc.
• Situations suffered during the migration journey : traumas linked to the conditions of the journey, to death, to human trafficking, for example.
• Post-migration factors : access to the necessary documentation to reside and work, isolation, language difficulties, precariousness and homelessness.

Even if you are a person with personal resources, all these factors eventually take a toll on anyone's mental health. We commonly encounter adjustment disorders, post-traumatic stress disorder, or psychosis.

Regarding pre-migration aspects and everything surrounding the journey, it's difficult to act without a supranational approach, but we can certainly improve the conditions in which we receive these people. For example, migrant minors under the guardianship of the Directorate General for Child and Adolescent Care (DGAIA), upon reaching 18, had a residence permit but not a work permit. This has changed in the latest reform of the Immigration Law. We have already noticed this improvement among our clients; they arrive more relaxed and happy at the prospect of having the opportunity to work.

It is clear that the tools to change the situation are not only from the health field, but also involve legal, social, economic aspects… ».

"Most of the people we assist at SATMI share a vulnerable socioeconomic situation. A high percentage are people without documentation, living in unstable housing conditions in centers, shelters, or on the street, without family, without the possibility of working, traveling, etc."

We also assist migrants for whom the language barrier hinders effective support. We have translators for various languages, an essential tool for our work.

We work especially with groups that are in a particularly vulnerable situation:

• Minors under the guardianship of the DGAIA and who, therefore, have accommodation and access to the education system, but who frequently need psychological/psychiatric intervention to address issues such as unmet expectations or substance abuse
• Migrant women who are victims of gender-based violence or human trafficking. In these cases, the entire traumatic process is addressed, including issues such as the loss of previously assumed roles, such as wife or mother. These women need time to adapt; to learn the language, and to navigate a lifestyle that is not what they expected.
• Asylum seekers. We address the symptoms manifested after exposure to traumatic situations, often prolonged over time.
• Migrant people living on the streets or in very precarious conditions who do not have access to the usual mental health network (lack of a health card, referrals from the Red Cross). In these cases especially, the approach is comprehensive; we address priorities such as ensuring these people have minimum living conditions (access to housing, to soup kitchens) and, from there, we address the rest of the problems.

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"There are many challenges. We have aspects that we, as a society, must improve, such as the persistent social racism and prejudice against migrants. If we add mental health problems to this stigma against migrants, it becomes even more complex."

I would say that it is necessary to make a clear commitment, a national pledge, to develop strategies that allow us to welcome these people with efficient resources and that, at the level of political management, the need to work in the same direction is understood when dealing with problems that have a cross-cutting impact."

Photograph by Pol Rius.