Working with culturally and linguistically diverse people
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Description
This online training module is an introduction to working with culturally and linguistically diverse (CALD) people. The information in this module is general in nature. Every organisation does things differently and has different policies and guidelines.

Duration: Approximately 60 minutes (you can close the training and pick up where you left off at a later date).

Language used in this training module is based on the following national standards:

- National practice standards for the mental health workforce (2013)
- National framework for recovery-oriented mental health services (2013)

Last updated: October 2021

Content and links in this training were correct at the time of publication. We check these regularly; however, if you find broken links or errors please contact transitionsupport@flinders.edu.au



Training objectives
Lesson 1 of 6
Training objectives
This module is for people who want to learn more about working with culturally and linguistically diverse (CALD) groups.
By the end of this module you will understand:
•	Some of the factors affecting mental health and wellbeing in CALD communities
•	Issues faced by CALD communities when navigating mental health systems and services
•	How to apply the recovery model in CALD communities
•	Tips and strategies for engaging CALD communities in mental health services and activities

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Assumed knowledge
This module is for people who want to learn more about working with culturally and linguistically diverse (CALD) groups. We have other training modules that cover NDIS topics which may be relevant to this module. They can be found on the training page of our website. There is no assumed knowledge for this module.


Defining CALD and cultural considerations for people with disability

Defining cultural and linguistic diversity (CALD)
In Australia, 'cultural and linguistic diversity' is typically used to describe people and cultures other than English-speaking, Anglo-Australian people and cultures. Australia is highly multicultural, with individuals from many cultural, linguistic and religious backgrounds. People from CALD backgrounds can be born overseas, or in Australia.
People from CALD backgrounds in Australia
According to the 2016 Census of Population and Housing, almost half of Australians (45% or 10.6 million) were either born overseas (26% or 6.2 million) or have at least one parent who was born overseas (19% or 4.5 million).
Over 300 languages are spoken in Australia:
• 1 in 5 (21%) people speak a non-English language at home
• English is not the first language for 15% or 3.5 million people
• English is not spoken at home for 0.5% or 117,000 people
The diversity of people from CALD backgrounds
It is important to acknowledge the diversity of CALD communities. There is no single CALD community and each group has distinct needs. Consideration should also be given to other identity-driven needs and roles a person may have that may overlap with other communities, including:
•	LGBTI people
•	people living in rural, regional and remote locations
•	young people
•	older people.

It is also important not to forget that each person has their own needs, views and preferences above and beyond their cultural background or identity.
National Practice Standards for the Mental Health Workforce (2013)
Standard 3 in the National Practice Standards for the Mental Health Workforce refers to working with people with diverse needs. It requires mental health practitioners to facilitate care and support that is respectful of differences in the community, and describes what culturally sensitive practice looks like. Being aware of the National Practice Standards for the Mental Health Workforce is important to your role.
Mental health in CALD communities
Below, various considerations are presented with respect to people from CALD backgrounds and mental health.

Slides

Slide 1: Front
Comparatively poorer mental health outcomes.
Slide 1: Back
People from CALD backgrounds have poorer mental health outcomes than the Australian-born population, exacerbated by low proficiency in English, separation from family, racism, discrimination and the stress of migration.
Slide 2: Front
Refugees and asylum seekers
Slide 2: Back
People who have come to Australia as refugees or asylum seekers are at increased risk of developing mental distress.
Slide 3: Front
Mental health service use
Slide 3: Back
People from CALD background success mental health services less frequently than the Australian-born population.
Slide 4: Front
Reaching a crisis point
Slide 4: Back
People from CALD backgrounds are more likely to reach crisis point before accessing mental health services and are over-represented in acute mental health units as involuntary inpatients.

Some contributing factors to mental distress in CALD populations include:
Migration and acculturation

After a person migrates, adjusting to a new culture can present emotional and social challenges. For some people, acculturation can be stressful and can place the individual at risk of mental distress. Factors that contribute to this include personal factors such as the individual's own personality and experiences, the reason for migration and the perceived gap between the host and home culture. It can also be influenced by external factors including the attitudes and beliefs of a person's new community.

Racial discrimination and equity

People who experience racism and discrimination are more vulnerable to higher levels of mental distress than people who do not have these experiences. Mental distress may include depression and psychosis. Racism that is perceived at a systemic level also directly impacts individuals and can result in people disengaging from employment, services and community. Exclusion from these types of activities further isolates individuals and can result in compounding mental distress.

Language acquisition

Language poses a significant barrier for people from non-English speaking backgrounds when accessing mental health services. People with limited English have higher levels of stress, and self-report increased levels of poor mental health.

Language can also pose a barrier for people seeking employment, education and community engagement. Lack of engagement with such activities is known to lead to poorer mental health outcomes.

The refugee experience

Refugees have often experienced significant trauma including violence, imprisonment, torture, hardship and the loss of, or separation from, family and loved ones.

Such significant life events may be experienced by both adults and children, and may put them at risk of developing mental ill health. It should be noted that these traumatic experiences do not automatically lead to the development of a mental illness.

Picture of mother and child
Some key challenges for people from CALD backgrounds include:

Slide 1: Front
Housing
Slide 1: Back
Difficulty navigating the private rental market can arise through language barriers and a lack of experience/understanding of rights and responsibilities. This can interfere with securing and maintaining housing and can also lead to individuals being exploited by some landlords.
CALD families on low incomes may have limited accommodation options due to a lack of affordable housing. They may be forced to live in isolated areas or in overcrowded homes.
Lack of previous Australian rental history can lead to difficulty in securing housing.
Slide 2: Front
Transport
Slide 2: Back
Not having a driver’s license or access to a car can pose a barrier for people. The ability to apply for a driver’s license may be inhibited by language and financial difficulties.
A lack of understanding of the local area and its transport systems can also make getting around difficult. This is often exacerbated for people living in rural areas.
Slide 3: Front
Employment
Slide 3: Back
Language can pose a significant barrier to obtaining employment in Australia. People with lower English literacy (both written and verbal) are frequently underemployed and underpaid.
A lack of Australian work history can impact a person’s ability to secure employment and work experience.
A lack of transport or affordable housing close to main areas of employment can result in CALD families living further away from main employment hubs. Not having a driver’s license or access to a personal vehicle can further inhibit ability to maintain employment.
Discrimination in job interviews or in the workplace can reduce the chances of obtaining and sustaining employment.
Skills, qualifications and experience obtained overseas may not be recognised by Australian employers, making it more difficult to find ongoing work.
Slide 4: Front
Financial issues
Slide 4: Back
Financial issues can pose a significant barrier to a person’s recovery. People who are newly arrived to Australia may have few financial resources. They also can be vulnerable in contractual settings (eg. signing a lease agreement) due to language and cultural barriers.
Slide 5: Front
Navigation of and access to services
Slide 5: Back
Language difficulties can pose a barrier for people when identifying and accessing services, especially if there is a lack of translated information including visual information.
Understanding the mental health system can be challenging for people who may not have accessed services in Australia before, or who had very different types of service experience in their home country.
Mental health and medical language can differ between different cultures and can pose additional barriers to people trying to access services.
Slide 6: Front
Low English literacy
Slide 6: Back
Low literacy in English can impact on interactions with services and providers.
Slide 7: Front
Differences in cultural norms and beliefs
Slide 7: Back
Differences in cultural norms and beliefs can impart upon conceptions of mental and physical health and wellbeing, and openness to certain treatment options.
Slide 8: Front
Exposure to discrimination and racism
Slide 8: Back
Exposure to discrimination and racism can negatively impact on people’s health and wellbeing. These impacts can be largely invisible. Services and providers must use person-centred and trauma-informed approaches.
Slide 9: Front
Lack of information about services
Slide 9: Back
A lack of information about services, or awareness of available services, can present a barrier.
Slide 10: Front
Low level of understanding about rights and responsibilities
Slide 10: Back
A low level of understanding about rights and responsibilities can impact on a person’s ability and willingness to seek and interact with disability services.
Slide 11: Front
Fear of stigma
Slide 11: Back
A fear of stigma from within and outside their communities is often a component of mental health for people from CALD backgrounds.
Slide 12: Front
Lack of role clarity in the community
Slide 12: Back
People from CALD backgrounds may lack role clarity in their new community (they may feel they can’t or are unable to perform their prior roles), which can impact upon their wellbeing.
Slide 13: Front
Lack of access to technology
Slide 13: Back
A lack of access to technology, such as computers/laptops, the internet and mobile phones, can impact people’s ability to interact with health and disability services. This can be compounded by lack of English.
Picture of person wearing “Happy music for sad days” T-shirt
CALD-sensitive practice involves:
Recognition of cultural explanatory models

People from CALD backgrounds may have differing views and beliefs around mental health and wellbeing. Some cultures may associate mental ill health with shame, and attempt to hide it from their community. This can put pressure on family members to take on significant caring roles, isolating them from friends and other supports.

Fear of stigma can delay people from seeking help before the onset of a crisis. Cultural beliefs can also affect the type of treatment that a person is willing to engage in (traditional healing versus Western medicine).

Symptoms of mental ill health may be described through somatic experiences, such as backaches, headaches or stomachaches.

Guided by a recovery orientation, it is important to listen to the individual story behind a person’s mental distress and the meaning they attach to the cause and effect of mental ill health. Different cultures will have different understandings or beliefs around these causes and effects, which can impact on the way that they experience recovery.

Consideration of cultural factors/taboos

For some people from CALD backgrounds, it may be important to work with health practitioners of the same gender. People from some cultural groups may feel uncomfortable saying 'no' to questions, and may therefore answer 'yes' inappropriately.

It is also important to recognise that cultural groups are not homogenous and there are other factors that contribute to a person's mental health and their interaction with services. To ensure that you are working in a culturally appropriate manner, be curious and discuss the specific cultural considerations that people would like you to be aware of when working with them.

Inclusion of family, carers, loved ones or community

People from CALD backgrounds or those newly arrived in Australia may be separated from family and loved ones, and may feel isolated in their new community. It is important to maximise any family support that is available to ensure that the natural support network is nurtured. Linking the person with their local community can also address social isolation and promote ongoing health and wellbeing.

Some cultures may consider family to be wider than the immediate family unit recognised in Western culture. It is important to talk with each person about who they see as their support network / family and who they would like involved in the work you do together.

A person-centred approach

A person-centred approach represents the best way to work with a person. It values their cultural, religious and linguistic identity. Within a person-centred approach, a person’s preferences, values, and beliefs are valued and considered. Approaches are then tailored to each person.

A trauma-informed approach

A trauma-informed approach is especially important when working with people from CALD and refugee backgrounds, as they may have experienced various forms of trauma over the life-course. A trauma-informed approach allows practitioners to work sensitively and appropriately with people, and lessens the risk of re-traumatisation.

Picture of person gazing to right of screen
Protective factors for mental health for CALD individuals and communities include:
•	Religious beliefs
•	Negative views of suicide and/or substance abuse
•	Family and community cohesiveness
•	The opportunity for a new beginning through migration
•	Increased resilience from past experiences
•	Being married (for men)
•	Being a parent
Risk factors for mental health for CALD individuals and communities include:
•	Experience of trauma or negative incidents in the country of origin, during the migration process, or in the new country
•	Stress associated with integrating into a new culture
•	Isolation from family members and support networks who remain living in the home country
•	Change in socioeconomic status and income instability through loss of, or change in, occupation
•	Lack of access to health and support services due to language or cultural barriers
•	Discrimination and lack of social acceptance of CALD people within the mainstream/Anglo-Australian population

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Engaging with and working with people from CALD backgrounds with disability
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Considering the influence of culture and religion
Take the time to research your client's culture and religion to ensure you are aware of key cultural nuances and considerations.
When in doubt, it is best practice to ask the person what is important to them from a cultural and/or religious perspective.
Using interpreters
The risk of confusion and misunderstanding when conversing formally and informally can be higher among people who do not speak English as their first language. It is important to use professional interpreters to ensure people can understand and make themselves understood at all times.
Find a suitable, registered and qualified interpreter in a person's correct language and dialect. Avoid using family and friends as interpreters as they may not understand mental health terminology and their involvement may compromise confidentiality and the family hierarchy.
Face-to-face interpreting is preferable wherever possible as this will help to establish rapport and allow for non-verbal cues to be considered. There may be some instances where people may prefer a phone interpreter for the sake of anonymity.
When conducting face-to-face sessions involving an interpreter, set up chairs in a triangle or semi-circle if the participant is bringing a support person, to be inclusive of all individuals present. Maintain eye contact with the participant (not the interpreter) to establish rapport. Be patient when communicating to convey respect, and seek clarification when unsure about information. When working with people who speak languages other than English, it is important to ask questions in a way that the person understands, which may mean asking questions in a different way until you find the way that is best suited to them. Take time to develop trust and rapport, remembering this may take longer due to the presence of an interpreter.
Participants from CALD backgrounds can access free interpreter services when using the services of NDIS registered providers. More information on the use of interpreters is available via Australian Government Translating and Interpreting Service.
CONTINUE

Recovery model and CALD communities
Image of person gazing downwards
Working from a recovery orientation with people from CALD backgrounds can be effective as this approach is person-centred.
Different cultures often have different understandings and beliefs around mental health, which often vary from Western understandings. This makes it particularly important to take time to build rapport with people and listen to their own stories of mental health and wellbeing.
There may be more aspects contributing towards a person's recovery than you realise, including cultural, familial, spiritual/religious and community considerations. These should be considered and addressed as appropriate.
For some individuals, the idea of a service being person-driven rather than practitioner-driven can be a new concept and may take time to adjust to.
For some cultural groups, recovery may be familial or community-focused rather than individual-focused. In this case, the approach taken by the support worker may differ to the approach that would usually be taken when working with other participants.

Ideas for cultural inclusivity for organisations:

Cultural awareness training for staff
It is important that all staff have the opportunity to partake in cultural awareness training, to challenge assumptions and reflect upon their own biases.

Translating information for participants
It is imperative that information be appropriately translated for participants in varying formats (e.g. written and visual).

Employing bilingual staff and/or using interpreters
It is key to employ bilingual staff and/or use interpreters where appropriate and necessary, to ensure you are understood, and people can appropriately express themselves and their needs.

Celebrating cultural holidays and events
Celebrating holidays and events can demonstrate to people from CALD backgrounds that organisations and staff value their culture, language and religion. The Harmony Day website contains a list of cultural holidays observed by various CALD communities.

Employing a holistic approach
A holistic approach involves considering physical, psychological, social, cultural and spiritual aspects to wellbeing.

Using a person-centred approach
A person-centred approach recognises that planning and decisions are driven by the person and their needs, interests and goals and an understanding of the intrinsic role that family, extended family, community, and cultural context play in the recovery journey for many people from CALD communities.

Using a trauma-informed approach
Employing a trauma-informed lens and providing support that incorporates an understanding of the impact of trauma on the lives of people from CALD communities (particularly refugees) helps to avoid more trauma, and to ensure interactions are culturally safe.

Encouraging individual empowerment
It is important to empower people by encouraging them to take control of their lives and health.

Avoiding cultural/religious stereotyping
To avoid stereotyping, listen, ask and clarify each person's responses, and build trust by being respectful, reliable and honest.
Engaging with CALD communities
There may be opportunity to provide outreach to a local centre where people from various CALD communities meet, or a need for cultural awareness training amongst local service and medical providers. Where certain groups or individuals are important to communities (e.g. elders, or religious leaders), it may be important for these individuals to acquire skills in mental health first aid.

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When providing support to people from CALD backgrounds, consider:

Different expectations about family involvement in decisions
Different cultures have different expectations about family involvement in decision making. Some cultures are more collectivist, and family members may be very involved in helping to make decisions for eachother. Be respectful of different family dynamics and the people that participants want to include in their care. Approaches to working with people differ when recovery is conceptualised as familial or community focused - for example, there may be more scope to work with the wider family unit.

The impact of gender from a cultural/religious perspective
Gender norms and roles impact different cultures to differing degrees. It is important to be aware of the impact of gender for different people, as it may impact ways of engaging appropriately and sensitively. Some people from CALD backgrounds may have preferences around the gender of a worker, to make them feel more comfortable and culturally safe.

Potential fear of authority figures
Some people and cultural groups have had difficult, negative or stigmatising interactions with authority figures, and may feel uncomfortable with people percieved to be in positions of authority. It may take time to earn their trust.

The impact of stigma, discrimination and trauma
Many people and cultures are impacted by stigma, discrimination and trauma over their lifetime. The impacts of this can be both visible or invisible. Approaches must be culturally safe and trauma-informed, to avoid re-traumatising people. NSW Gov has more info around trauma-informed care.

Preferences for the language/culture/religion of a worker
Some people may prefer a worker who speaks their language and understands their culture and religion, while others will prefer someone from outside their own community, so they can remain more anonymous.
CONTINUE

Further resources to assist in working with CALD communities
The Embrace Project, run by Mental Health Australia, and funded by the Department of Health, provides advice and support on mental health and suicide prevention for people from CALD backgrounds. The website contains resources including links to mental health services, community organisations and online training.
In consultation with key partners, The Embrace Project has also established the Framework for Mental Health in Multicultural Australia: Towards culturally inclusive service delivery. This framework is designed to assist both individual workers and organisations to evaluate their cultural responsiveness and enhance service delivery for CALD communities.
More information and resources for CALD communities can be found at Mental Health in Multicultural Australia. The following video outlines tips for communication when working with people from CALD communities. This video outlines tips and advice for working with people from CALD backgrounds.


Lesson 4 of 6
People from CALD backgrounds and the NDIS

CALD participants in the NDIS
People from non-English speaking backgrounds with disabilities face multiple barriers and are less likely to access government-funded disability support services than others with disabilities. It is unsurprising that Australians from CALD backgrounds have a lower participation rate in the NDIS.
An estimated 83,000 people from CALD backgrounds living with a disability are eligible for the NDIS (representing around 20% of all eligible Australians). Recent figures show that people from CALD backgrounds account for far less people with an approved NDIS plan. As of 30 June 2019, there were 24,023 participants from CALD backgrounds in the NDIS, making up 8.4 per cent of all Scheme participants.
In additon to this:
- CALD participants in the NDIS reported poorer health outcomes at baseline compared to non-CALD participants, and were also slightly less likely to participate in education or have paid employment. The families and carers of CALD participants had poorer outcomes at baseline compared to the families and carers of non-CALD participants, including being less likely to have a paid job or to be able to advocate for their child or family member.
- A larger proportion of CALD participants have cancelled access requests arising from “evidence not provided” compared to non-CALD participants.
- A smaller proportion of CALD participants have Supported Independent Living (SIL) arrangements in their plans (3%) compared to non-CALD participants (8%). For participants aged 25 and over only, SIL arrangements are included in the plans of 5% of CALD participants, compared to 16% for non-CALD participants.
- The complaint rate for CALD participants has been consistently lower than non-CALD participants over the last ten quarters.
- Culturally, people in some communities feel shame or guilt that their child is born with a disability. Others do not acknowledge the disability due to stigma. This presents additional layers of difficulty in accessing the NDIS.
Read more in the NDIS culturally and linguistically diverse report.

The Cultural and Linguistic Diversity Strategy

In July 2021, the NDIA released a progress update on the Cultural and Linguistic Diversity Strategy. It details progress against the priorities identified in the Strategy and actions to further drive the implementation of the Strategy over the next 18 months. The NDIA will commence engagement in late 2021 with CALD stakeholders, including participants, families, carers and the sector to develop a refreshed Strategy, to be completed in 2022.

“Some individuals, from countries where there is no social welfare, are just grateful for being in Australia. They’re hesitant to seek help because they don't want to rock the boat by asking for disability support.” - Sylvana Mahmic, Chief Executive Officer, Plumtree



Systemic limitations in the NDIS model
Systemic limitations in the NDIS model pose significant and complex challenges for CALD clients with disabilities. For example:
- CALD participants often have low awareness of where to find NDIS information and available services, and understanding the NDIS model and access points.
- There is a reported lack of consideration given to cultural concerns in NDIS planning.
- Many CALD clients are not fluent in English and require greater support in planning and purchasing of services. The planning process can be emotionally draining and stressful for CALD families with minimal information and resources.
- Many CALD clients do not meet scheme expectations of client capacity for self-advocacy. Additional funding for support coordination is needed for CALD clients who face cultural and systemic barriers to self-advocacy. The reliance on self-activation  may not be appropriate for many people from CALD backgrounds. There is greater likelihood that already marginalised groups will not initiate their packages and fail to adequately advocate for their needs, hence underutilizing available services. CALD participants are utilising 66 percent of their plans on average compared to 68 percent for non-CALD participants. Self-activation sits with an individual-focussed framework. Many people from CALD backgrounds are accustomed to more collectivist ideals.
- The family is often seen as the primary care provider to CALD people with disabilities. The emphasis of CALD communities on inter-dependence and the role of family in the care of people with disabilities influences care preferences and needs to be accommodated.
- There is a significant need for translation services to be incorporated into existing plans for CALD clients to assist with delivery of funded supports. The need for translation services varies amongst CALD communities and individuals. Tailored responses are needed. Written information, especially individual support plans, needs to be presented in people's first languages or converted to Easyread format.
- Supported accommodation for CALD family members with disability may not be perceived as culturally appropriate. Similarly, respite support is predominantly interpreted as being care provided outside of the family home and may be rejected by some CALD participants.
 Particular groups of people with disability may be disadvantaged in the planning process, with planning even ‘entrenching disadvantage’.
"This scheme is turning into a dual-track system, where people who have advocates or families in their corner, or who are more well-resourced and more educated, can get one set of outcomes . . . while people who don’t have those things, who perhaps come from a CALD background, who have more complex needs, who maybe come from an Aboriginal or Torres Strait Islander background, who don’t have families in their corner to go in to bat for them, are getting a . . . poorer set of outcomes. If we don’t do something to address this issue . . . we’re going to end up entrenching disadvantage instead of working to counter it".
- Peter Tully, Every Australian Counts

CONTINUE
CALD participants and psychosocial disability
Compared to non-CALD participants, a smaller proportion of CALD participants have a primary disability type of intellectual disability or autism, and a higher proportion have a primary disability type of psychosocial disability. Compared to non-CALD participants, a smaller proportion of CALD participants have a high or medium level of function, and a larger proportion have a low level of overall function.
Varying degrees of stigma attached to disability are evident amongst CALD communities, but stigma surrounding mental illness or psychosocial disability is often the most difficult to overcome. Cultural norms and beliefs about disability impact on willingness to seek and receive services and support. Raising awareness of and access to available disability services amongst CALD people with disability, plus establishing rapport with trusted providers and support workers can assist.


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