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-reflections. 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.

Public attitudes towards depression and schizophrenia in an urban Turkish sample.

Stigma towards mental illness influences help-seeking behavior and prevents individuals with a mental illness from seeking the appropriate treatment for their condition. In Turkey, a shift from inpatient psychiatric mental health care towards a community-based, low-threshold system highlights the importance of understanding public attitudes towards the mentally ill. This study aims to underpin developments in mental health care through culturally sensitive research. Public stigma towards schizophrenia and depression is examined for the first time simultaneously in a community sample. Unlabeled case vignettes of either schizophrenia or depression as well as an assessment of mental illness attribution and the desire for social distance (SDS) were presented to an urban Turkish sample (N = 295). Analysis of variance revealed that attribution to mental illness determines significant levels of stigma for schizophrenia, however not for depression. Furthermore, desire for social distance (SDS) was significantly higher for the schizophrenia condition compared to depression. Depression and schizophrenia evoke different reactions within the Turkish population, specifically the attribution to mental illness increases stigma. This finding is discussed in light of the contact hypothesis, and furthermore contextualized within literature on familiarity with depression symptoms on the one hand, and perceived dangerousness and symptom severity of schizophrenia on the other hand. Implementation of timely and culturally sensitive adapted interventions within the ongoing reform of the Turkish mental health care system is recommended.

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.

Attitude toward psychiatrists and psychiatric medication: A survey from five metropolitan cities in India.

BACKGROUND: Stigmatization and overall scarcity of psychiatrists and other mental health-care professionals remain a huge public health challenge in low- and middle-income countries, more specifically in India. Most patients seek help from faith healers, and awareness about psychiatrists and treatment methods is often lacking. Our study aims to explore public attitudes toward psychiatrists and psychiatric medication in five Indian metropolitan cities and to identify factors that could influence these attitudes. MATERIALS AND METHODS: Explorative surveys in the context of public attitudes toward psychiatrists and psychiatric medication were conducted using five convenience samples from the general population in Chennai (n = 166), Kolkata (n = 158), Hyderabad (n = 139), Lucknow (n = 183), and Mumbai (n = 278). We used a quota sample with respect to age, gender, and religion using the census data from India as a reference. RESULTS: Mean scores indicate that attitudes toward psychiatrists and psychiatric medication are overall negative in urban India. Negative attitudes toward psychiatrists were associated with lower age, lower education, and strong religious beliefs. Negative attitudes toward psychotropic medication were associated with lower age, male gender, lower education, and religion. CONCLUSION: In line with the National Mental Health Policy of India, our results support the perception that stigma is widespread. Innovative public health strategies are needed to improve the image of psychiatrists and psychiatric treatment in society and ultimately fill the treatment gap in mental health.

[Guidelines for Trainings in Inter-/Transcultural Competence for Psychotherapists]. / Leitlinien für Trainings inter-/transkultureller Kompetenz in der Aus-, Fort- und Weiterbildung von Psychotherapeuten.

BACKGROUND: The ongoing globalization leads to the fact that intercultural aspects are becoming more important in recent years. Unfortunately, the psychosocial sector in general as well as psychotherapists in particular are not sufficiently trained for those issues. In the German speaking countries so far there were no guidelines for the conceptualization of intercultural trainings for psychotherapists. In the present study guidelines for trainings of inter-/transcultural competence of medical and psychological psychotherapists have been developed. METHODS: An extensive data base was collected including a systematic international literature research, qualitative expert interviews, a quantitative survey among therapists and 8 focus groups with clients as well as therapists from different cultural backgrounds. The guidelines for trainings were then extracted in a 2-step consensus procedure. RESULTS: The guidelines define learning objectives which should be achieved in a training. They also describe the structural as well as substantive requirements which should be met in such a training. In addition to knowledge on cultural issues that should be acquired in a training the guidelines put high emphasis on the self reflection of training participants on their own cultural embededness as well as on the aquisition of culturally sensitive skills. DISCUSSION: Regarding demographic trends in Germany trainings for intercultural competence should become an obligatory element in the training of psychotherapists. The guidelines represent a high-quality base for the conceptualization as well as the evaluation of such trainings. CONCLUSION: The guidelines developed here represent an instrument for the improvement of the training of therapists in Germany in the field of transcultural psychology. In the long term they could contribute to the intercultural opening of the German mental health system and improve the quality of psychotherapeutical treatment of migrants in Germany.

The impact of perceived ethnic discrimination on mental health depends on transcultural identity: 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.

[Conceptions of "transcultural competence" and their relevance for the psychiatric-psychotherapeutic care. Results of an interdisciplinary literature review]. / Konzeptionen von "transkultureller Kompetenz" und ihre Relevanz für die psychiatrisch-psychotherapeutische Versorgung. Ergebnisse eines disziplinübergreifenden Literaturreviews.

The concept of transcultural competence is increasingly discussed in Germany as a requirement for providing adequate psychiatric-psychotherapeutic care for persons with a migration background. To this day, understanding of this concept is heterogeneous. This overview aims at systemizing existing definitions of transcultural competence in psychology, medicine and related fields to improve understanding of the term in practice. 130 German and English language scientific papers were analyzed and were evaluated qualitatively with grounded theory method. The analysis produced 3 approaches: a technological approach, a component approach and a positioning-and-attitude approach. The suggested categorization of the understandings of the term transcultural competence allows for a detailed overview of the current definitions of this term and thus provides criteria for a better evaluation of implemented transcultural competence in fields of psychiatric-psychotherapeutic care.

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 non-bereaved 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 health and dysfunction in young adulthood in addition to exposure to other war-related traumatic events. Furthermore, the syndrome of PGD can help to identify those with the greatest degree of distress and dysfunction.

Mental health of refugees following state-sponsored repatriation from Germany.

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.

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.