Increasing Transcultural Competence in Clinical Psychologists Through a Web-Based Training: Study Protocol for a Randomized Controlled Trial

Background In mental health care, the number of patients with diverse cultural backgrounds is growing. Nevertheless, evaluated training programs for transcultural competence are missing. Barriers for engaging in transcultural therapy can be identified in patients as well as in therapists. Besides language barriers, clinical psychologists report insecurities, for example, fear of additional expenses when involving a language mediator, ethical concerns such as power imbalances, or fear of lack of knowledge or incorrect handling when working with patients from other cultures. Divergent values and concepts of disease, prejudices, and stereotyping are also among the issues discussed as barriers to optimal psychotherapy care. The planned study aims to empower clinical psychologists to handle both their own as well as patients’ barriers through a web-based training on transcultural competence. Methods The training includes 6 modules, which are unlocked weekly. A total of N = 174 clinical psychologists are randomly assigned to two groups: the training group (TG) works through the complete training over 6 weeks, which includes a variety of practical exercises and self-refections. In addition, participants receive weekly written feedback from a trained psychologist. The waitlist control group (WL) completes the training after the end of the waiting period (2 months after the end of the TG’s training). The primary outcome is transcultural competence. Secondary outcomes consist of experiences in treating people from other cultures (number of patients, satisfaction and experience of competence in treatment, etc.). Data will be collected before and after the training as well as 2 and 6 months after the end of the training. Discussion This randomized controlled trial tests the efficacy of and satisfaction with a web-based training on transcultural competence for German-speaking clinical psychologists. If validated successfully, the training can represent a time- and place-flexible training opportunity that could be integrated into the continuing education of clinical psychologists in the long term. Trial registration DRKS00031105. Registered on 21 February 2023

evidence for a moderator effect

Background: While ethnic discrimination emphasizes boundaries between different cultures, the concept of transculturality focuses on the fact that cultures can merge and that individuals integrate novel cultural elements into their identity. This is an exploratory study that investigates the interplay between perceived ethnic discrimination, psychological adjustment and transcultural identity. Methods: Structured interviews were conducted using a sample of 46 adolescents with a Turkish migratory background and 45 adolescents who were native born Germans. Results: Correlational and multiple regression analyses revealed that perceived discrimination was clearly associated with a poorer psychological adjustment among adolescents with a migratory background. Transcultural identity moderated this relationship. That is, adolescents who showed higher levels of transcultural identity displayed a better psychological adjustment when compared to adolescents who showed lower levels of transcultural identity—provided that they did not feel discriminated against. This is congruent with the idea that transcultural identity can involve considerable benefits for personality. However, when adolescents perceived higher rates of discrimination, higher levels of transcultural identity came attached to a poorer psychological adjustment. Conclusions: The findings suggest that perceived discrimination has negative effects on the well-being of immigrant adolescents—particularly for those who describe their identity as transcultural. The findings are discussed considering specific characteristics of transcultural identity, and how they stand in opposition to discrimination

Causal attribution for mental illness in Cuba: A thematic analysis

Explanatory models (EMs) for illness are highly relevant for patients, and they are also important for clinical diagnoses and treatment. EMs serve to capture patients' personal illness narratives and can help reveal how culture influences these narratives. While much research has aimed to understand EMs in the Western hemisphere, less research has been done on other cultures. Therefore, we investigated local causal attributions for mental illness in Cuba because of its particular history and political system. Although Cuban culture shares many values with Latin American cultures because of Spanish colonization, it is unique because of its socialist political and economic context, which might influence causal attributions. Thus, we developed a qualitative interview outline based on the Clinical Ethnographic Interview and administered interviews to 14 psychiatric patients in Havana. We conducted a thematic analysis to identify repeated patterns of meaning. Six patterns of causal attribution for mental illness were identified: (1) Personal shortcomings, (2) Family influences, (3) Excessive demands, (4) Cultural, economic, and political environment in Cuba, (5) Physical causes, and (6) Symptom-related explanations. In our sample, we found general and Cuba-specific patterns of causal attributions, whereby the Cuba-specific themes mainly locate the causes of mental illness outside the individual. These findings might be related to Cubans' socio-centric personal orientation, the cultural value of familismo and common daily experiences within socialist Cuban society. We discuss how the findings may be related to social stigma and help-seeking behavior.Peer Reviewe

Stigma of Mental Illness in Germans and Turkish Immigrants in Germany: The Effect of Causal Beliefs

Background: Stigma poses an additional burden for people suffering from mental illness, one that often impairs their social participation and can prevent them from seeking adequate help. It is therefore crucial to understand how stigma develops in order to counteract it by setting up effective evidence-based anti-stigma interventions. The present study examines the effect of causal beliefs on stigmatizing behavioral intentions, namely people's desire to distance themselves from persons with mental illness. In addition, we draw cross-cultural comparisons between native Germans and Turkish immigrants to investigate the influence of culture on stigma and causal beliefs and to broaden knowledge on the biggest immigrant group in Germany and on immigrants in Western countries in general.Methods:n = 302 native Germans and n = 173 Turkish immigrants were presented either a depression or a schizophrenia vignette. Then, causal beliefs, emotional reaction and desire for social distance were assessed with questionnaires. Path analyses were carried out to investigate the influence of causal beliefs on the desire for social distance and their mediation by emotional reactions for Germans and Turkish immigrants, respectively.Results: We found an influence of causal beliefs on the desire for social distance. Emotional reactions partly mediated this relationship. Causal attribution patterns as well as the relationship between causal attributions and stigma varied across both subsamples and mental illnesses. In the German subsample, the ascription of unfavorable personal traits resulted in more stigma. In the Turkish immigrant subsample, supernatural causal beliefs increased stigma while attribution to current stress reduced stigma.Conclusion: Our study has implications for future anti-stigma interventions that intend to reduce stigmatization of mentally ill people. Targeting the ascription of unfavorable personal traits and supernatural causal attributions as well as promoting current stress as the cause for mental illness appears to be of particular importance. Also, the mediating influence of emotional responses to causal beliefs needs to be addressed. Furthermore, differential interventions across cultural groups and specific mental illnesses may be appropriate

Mental health of refugees following state-sponsored repatriation from Germany

von Lersner U, Elbert T, Neuner F. Mental health of refugees following state-sponsored repatriation from Germany. BMC Psychiatry. 2008;8(1): 88.BACKGROUND: In recent years, Voluntary Assisted Return Programmes (VARPs) have received increasing funding as a potential way of reducing the number of refugees in EU member states. A number of factors may affect the mental well-being of returnees. These include adjustment to the home country following return, difficult living conditions, and long-term effects resulting from the severe traumatic stress that had originally driven the affected out of their homes. Little is known about the extent to which these and other factors may promote or inhibit the willingness of refugees to return to their country of origin. The present pilot study investigated refugees who returned to their country of origin after having lived in exile in Germany for some 13 years. METHODS: Forty-seven VARP participants were interviewed concerning their present living conditions, their views of their native country, and their attitudes towards a potential return prior to actually returning. 33 participants were interviewed nine months after returning to their country of origin. Mental health and well-being were assessed using the questionnaires Posttraumatic Stress Diagnostic Scale (PDS) and EUROHIS and the structured Mini International Neuropsychiatric Interview (M.I.N.I.).Our objectives were to examine the mental health status of refugees returning to their home country following an extended period of exile. We also aimed to assess the circumstances under which people decided to return, the current living conditions in their home country, and retrospective returnee evaluations of their decision to accept assisted return. RESULTS: Prior to returning to their home country, participants showed a prevalence rate of 53% for psychiatric disorders. After returning, this rate increased to a sizeable 88%. Substantial correlations were found between the living situation in Germany, the disposition to return, and mental health. For two thirds of the participants, the decision to return was not voluntary. CONCLUSION: Psychological strain among study participants was of a considerable magnitude. As a result of traumatic stress experienced during war and refuge, victims were vulnerable and not well equipped to cope with either post-migration stressors in exile or with a return to their country of origin. It is noteworthy that the majority returned under pressure from immigration authorities. Living conditions after return (such as housing, work, and health care) were poor and unstable. Participants also had great difficulty readapting to the cultural environment after having lived abroad for an average of 13 years. Current VARPs do not take these factors into account and are therefore not able to assist in a humanitarian reintegration of voluntary returnees

Mental health of returnees: refugees in Germany prior to their state-sponsored repatriation

von Lersner U, Wiens U, Elbert T, Neuner F. Mental health of returnees: refugees in Germany prior to their state-sponsored repatriation. BMC International Health and Human Rights. 2008;8(1): 8

War and Bereavement: Consequences for Mental and Physical Distress

Background: Little is known about the long-term impact of the killing of a parent in childhood or adolescence during war on distress and disability in young adulthood. This study assessed current prevalence rates of mental disorders and levels of dysfunction among young adults who had lost their father due to war-related violence in childhood or adolescence. Methods: 179 bereaved young adults and 175 non-bereaved young adults were interviewed a decade after experiencing the war in Kosovo. Prevalence rates of Major Depressive Episode (MDE), anxiety, and substance use disorders, and current suicide risk were assessed using the Mini–International Neuropsychiatric Interview. The syndrome of Prolonged Grief Disorder (PGD) was assessed with the Prolonged Grief Disorder Interview (PG-13). Somatic symptoms were measured with the Patient Health Questionnaire. General health distress was assessed with the General Health Questionnaire. Findings: Bereaved participants were significantly more likely to suffer from either MDE or any anxiety disorder than nonbereaved participants (58.7 % vs. 40%). Among bereaved participants, 39.7 % met criteria for Post-Traumatic Stress Disorder, 34.6 % for PGD, and 22.3 % for MDE. Bereaved participants with PGD were more likely to suffer from MDE, any anxiety disorder, or current suicide risk than bereaved participants without PGD. Furthermore, these participants reported significantly greater physical distress than bereaved participants without PGD. Conclusion: War-related loss during middle childhood and adolescence presents significant risk for adverse mental healt

Refugees in Germany: A psychological analysis of voluntary return

In recent years, Voluntary Assisted Return Programmes (VARPs) have receivedincreasing funding as a potential way of reducing the number of refugees in EU member states. A number of factors may affect the mental well-being of returnees. These include adjustment to the home country following return, difficult living conditions, and long-term effects resulting fromthe severe traumatic stress that had originally driven the affected out of their homes. Little is known about the extent to which these and other factors may promote or inhibit the willingness of refugees to return to their country of origin. The present pilot study investigated refugees who returned to their country of origin after having lived in exile in Germany for some 13 years.The objectives of the present study were to examine the mental health status of refugees returning to their home country following an extended period of exile. We also aimed to assess the circumstances under which people decided to return, the current living conditions in their home country, and retrospective returnee evaluations of their decision to accept assisted return.47 VARP participants were interviewed concerning their present living conditions, their views of their native country, and their attitudes towards apotential return prior to actually returning as well as nine months after returning to their country of origin. I also interviewed a group of refugees (n = 50), which were also living in Germany but explicitly did not intend to return. In the study I included refugees and returnees, respectively, who returned to countries of the Former Yugoslavia, Turkey and Iraq. Mental health and well-being were assessed using the questionnaires PDS and EUROHIS and the structured interview M.I.N.I. Prior to returning to their home country, participants showed a prevalence rate of 53% for psychiatric disorders. After returning, this rate doubled to a sizeable 88%. Substantial correlations were found between the living situation in Germany, the disposition to return, and mental health. For two thirds of the participants, the decision to return was not voluntary. In the group of stayers we found a prevalence rate of 78% psychiatric disorders, a factor, which prevented return to the country of origin. In this group we also recorded substantial correlations between the living situation in Germany, disposition to return and mental health.The results show that psychological strain among study participants was of a considerable magnitude. As a result of traumatic stress experienced during war and refuge, victims were vulnerable and not well equipped to cope with either post-migration stressors in exile or with a return to their country of origin. It is noteworthy that the majority returned under pressure from immigration authorities. Living conditions after return (such as housing, work, and health care) were poor and unstable. Participants also had great difficulty readapting to the cultural environment after having lived abroad for an average of 13 years. Current VARPs do not take these factors into account and are therefore not able to assist in a humanitarian reintegration of voluntary returnees

Mental health of returnees: refugees in Germany prior to their state-sponsored repatriation

Abstract Background Many refugees live for years in exile. The combination of stress in the host country, together with long-term effects resulting from traumatic stress usually experienced in the home country may affect mental health. Little is known, to what extent these and other factors promote or stall the willingness to return to the country of origin. Here, we investigate, as an example, refugees who will return to their country of origin after having lived in exile in Germany for some 11 years. Objective What is the mental health status of returnees before the actual return who have been living in exile for an extended period? We also asked, what are the current living conditions in Germany and what are the motives for and reasons against a voluntary return to the country of origin? Methods Forty-seven participants of programs for assisted voluntarreturn were interviewed about their present living situation, their view regarding their home country and voluntary return. These findings were compared to a group of 53 refugees who had decided to remain in Germany (stayers). Participants were recruited by means of advertisements posted in refugee centres, language schools, at doctors' offices and in organisations involved in the management of voluntary return in Germany. The prevalence of psychiatric disorders among respondents was tested using the structured interview M.I.N.I. The Posttraumatic Stress Diagnostic Scale (PDS) was used to assess PTSD in more detail and EUROHIS was applied to measure the subjective quality of life of participants. Results We found a prevalence rate of 44% psychiatric disorders in the group of returnees and a rate of 78% in the group of stayers. We also recorded substantial correlations between the living situation in Germany, disposition to return and mental health. In almost two thirds of the participants the decision to return was not voluntary but strongly influenced by immigration authorities. The most important reason for participants to opt for a stay in Germany were their children, who have been born and raised in Germany. Conclusion Psychological strains among the study participants were very high. Traumatic stress, experienced during war and refuge, has left the victims vulnerable and not well equipped to cope with post-migration stressors in exile. It is noteworthy that the majority returned under pressure of the immigration authorities. The fear of an uncertain future after the return was substantial. These factors should be taken into account in programs designed to assist returnees, including those that offer support after return to the country of origin.</p

Psychische Gesundheit und Rückkehrvorstellungen am Beispiel von Flüchtlingen aus dem ehemaligen Jugoslawien

Theoretischer Hintergrund: Viele Flüchtlinge aus dem ehemaligen Jugoslawien leben seit ca. 11 Jahren in Deutschland. Es fehlt bislang an Daten zu den Langzeitfolgen der traumatischen Kriegsereignisse und der Einflüsse von Exilfaktoren auf die psychische Gesundheit in dieser Population. Auch sind Zusammenhänge zwischen diesen Faktoren sowie die Einstellung zur Rückkehr nicht ausreichend untersucht.Fragestellung: Wie ist die psychische Gesundheit dieser Flüchtlinge nach durchschnittlich 11 Jahren im Exilland Deutschland einzuschätzen? Welche Motive sprechen aus Sicht der Betroffenen für und gegen eine freiwillige Rückkehr ins Herkunftsland?Methoden: n = 50 Flüchtlinge wurden zu ihrer aktuellen Lebenssituation, ihrer Einstellung zum Heimatland und zu freiwilliger Rückkehr befragt, sowie zu ihrer psychischen Gesundheit mit dem strukturierten Interview M.I.N.I. und den Fragebögen PDS und EUROHIS untersucht.Ergebnisse: Bei 78.0% liegt mindestens eine psychische Störung vor, es zeigen sich Zusammenhänge zwischen Lebenssituation in Deutschland, Rückkehrbereitschaft und psychischer Gesundheit.Schlussfolgerungen: Die psychische Belastung der Befragten ist sehr hoch, Ursachen hierfür sind sowohl die erhöhte Vulnerabilität auf Grund der Kriegsereignisse als auch die Belastung durch Postmigrationsfaktoren im Exil. Diese Faktoren sollten im Umgang mit Flüchtlingen in Deutschland berücksichtigt werden und haben auch Implikationen für die Planung von Rückkehrhilfeprogrammen