Mental Health’s Address to the Challenging Cultural Reality of Malta

Appreciation of society as being the whole made up of so many different parts in terms of groups with various interests, skills and needs is what cultural diversity is about. Culture is defined as the distinctive customs, values, beliefs, knowledge, art and language of a society. Multiculturalism has always been embedded with the Maltese reality. However, a steep increase in the country’s population since 2011 may be presenting new realities that can translate into hefty and challenging demands. This review therefore presents the following research-based evidence on how mental health can address this phenomenon, particularly in the case of Malta and similar small countries. In particular, the following aspects were highlighted, namely: cultural safety, holistic health services, multicultural awareness, sensitive lingual expression, community integrity and cultural partnership. Practical recommendations are presented.

Culture has been understood in varied ways, from different farming techniques to sharing meanings and knowledge (Kirmayer, 2018).Anything related to human behavior is somehow related to cultural factors, some of which are subtle, and some not so much.Appreciation of society as being the whole made up of so many different parts in terms of groups with various interests, skills and needs is what cultural diversity is about.Group members making part of such a society are thereby respected for their unique faiths and sexual orientation.
According to the APA Dictionary of Psychology, culture is defined as the distinctive customs, values, beliefs, knowledge, art and language of a society.These values are passed from one generation to the next and they influence people's behavior, attitudes and perspectives (2023).Moreover, the European Commission defines multiculturalism as the 'acceptance of immigrants and minority groups as distinct communities whose languages and social behaviors…distinguish them from the majority…(it) advocates that members of such groups should be granted rights equal to each other and to…members of majority groups' (Xuereb, 2009, p.33).
Although cultural psychiatry in the past was found by many different labels, including ethno-psychiatry, migrant psychiatry, transcultural psychiatry, anthropological psychiatry, and comparative psychiatry, the present term 'cultural psychiatry' describes how culture affects the holistic wellbeing and functioning of people, and how individuals express stress and seek help (Bhugra et al., 2021).
For the purpose of this paper, we are using the term of culture as ethnic identity which in itself is a multi-layered concept that is influenced multi-factorially, including gender, class, faith, language and nationality, amongst others (Tribe, 2005).
Culture can show its influence on a diversity of human experiences.For example, it affects ways in which individuals express their prognostics and whether they emphasize physical or emotional symptoms.Asian patients seem more likely to report somatic symptoms first.Emotional challenges are only reported if there is further questioning on how they feel.According to Andrade (2017), the report 'Mental Health: Culture, Race, and Ethnicity: a Supplement to Mental Health: A Report of the Surgeon General' states that cultures differ in the meaning and importance given to mental conditions.Differences occur on whether mental illness is real or imagined, a condition afflicting the mind, the body, or both, on who is at risk, its causing factors, and stigma around mental health.Although mental conditions can be seen as more prevalent in some cultures than in others, Andrade (2017) reiterates that it remains a fact that some disorders may be more genetic (like schizophrenia), while others more social and cultural (such as burnout and suicide).In fact, the same author lists differences and varied expressions to personal problems and how individuals handle stress.For example, when facing mental Published by IDEAS SPREAD health problems, Asian groups prefer avoidance of upsetting thoughts, whereas African Americans are more selfresourceful and more likely to turn to their spirituality for support, than whites.
Research has consistently shown that culture continues to greatly affect mental wellbeing as experienced by minorities.In fact, in the US, ethnic minorities are less likely to seek help than whites (Andrade, 2017).Contributing factors such as mistrust due to a history of discrimination naturally demand serious consideration.
According to the Canadian Mental Health Association (2022), newcomers to Canada normally face the added stress of fitting in a new community, whereby different perspectives of health and language barriers may complicate this process.Past trauma history, together with loss of status are issues that continue to entangle their journey to wellbeing towards acculturation or the process to adapt to a new culture.
Multiculturalism is not an option, neither is it something you are for or against.Stuart Hall argues that the term 'multicultural' (used adjectivally): '…describes the social characteristics and problems of governance posed by any society in which different cultural communities live together and attempt to build a common life while retaining some of their 'original' identity.'(Hall 2000, 209) A clear challenge to this reality remains the bias in studies on this topic.In a meta-analysis study on cross-cultural major studies in the last decade, Goodwin et al. (2020) found that the field of cross-cultural studies remains dominated by Western approaches, with a particular focus on US and Western European studies.Thus, an expansion and integrity to local studies in cultures not normally represented in such research is clearly called for.

The Malta Challenge
Multiculturalism has always been embedded with the Maltese reality.A key reason is the geophysical position of this little island, being as it is in the middle of the Mediterranean Sea.With such a diverse cultural past, Malta seems to have always been at the crossroad of cultures.From the megalithic temple era, dating back to 7000 BC (Trump, 2002), to more recent times, Malta has welcomed diverse nations, occupiers and people, a trademark still noted to this day.This has dramatically increased since Malta joined the EU (Azzopardi, 2019).
One notices a steep incline in the country's population since 2011.In this period, it grew almost by a quarter.According to the Malta National Statistics Office (NSO), this population increase has mostly to do with immigration.In fact, there were over 22% of the population who were foreign, more than one in five persons (The Malta Independent, 2022).Certain areas of the country house most of these foreigners.For example, 15% of all non-Maltese residents live in the St Paul's Bay area, followed by Sliema and Msida.Among the non-Maltese, almost 60% were male, with an average age of around 40 years, which is 9 years younger than the average Maltese residents.Since 2011, the average age of non-Maltese has grown even younger, standing at around 40.6 years.
Malta is the 10th smallest country in the world, with just a total area of 316 sqm.However, it is the most densely populated EU Member state, with around 1,649 persons per square kilometer, and the ninth most densely populated in the world (The Malta Independent, 2022).Bartolo (2022), a former Maltese education minister, stated that inclusive multiculturalism should be the aim that the whole country needs to work for.Learning to live together should not be understood as living side by side, in clusters hostile to each other, as is often the case with plural multiculturalism.Bartolo (2022) mentioned the famous speech by King Harald V of Norway, 6 years ago, where he outlined that nationality may not always be clearly defined because what we call home is where our heart is -which may go beyond physical boundaries.This is what inclusive multiculturalism is about.
Thus, an issue very pertinent that occurred with multiculturalism in Malta is the short time by which it has grown (an increase of 24.5% from 2011.).This sentiment was rightly reflected recently by Alfred Sant, a Maltese MEP, who captured this very succinctly: 'the problem with the foreign population in Malta is that it has grown too fast.There has not been enough time for local society to adjust to the changing reality.Becoming multicultural is not a transformation that can be successfully achieved overnight ' (2023).This sharp increase did not occur without side effects.Debono (2012) believes that the Maltese see migrants as a burden or even a threat to their prospects for their future.In fact, research has found that participants reported feeling challenged when working with culturally diverse clients with abilities, needs and explanatory models different from their own (Doublesin, 2013).The greatest challenges seem to relate to the increase in complexity of issues pertaining to family, gender and youth.The same author recommended more research in this area in Malta, a topic which still is well under-researched.Published by IDEAS SPREAD

Challenging Issues Around Multiculturalism
According to the intercultural trends and social change in the Euro-Mediterranean Region of the Anna Lidh Foundation for the Dialogue between Cultures, Ms Aubarell stated that diversity, knowledge and the approach to 'the other' have been key factors throughout recent developments (2022).A number of decisive moments have clearly played a huge role in these developments, including the 9/11 events which highlighted a binomial reality more than ever before, the global East-West dialogue, while raising the scepter of the risks of fundamentalism and xenophobia; the Arab Springs and others.According to Aubarell (2022), similar values including equality, diversity and participation move such dialogue to more fruition.
However, the reality is far from simple.A number of conflicting issues require further discussion and evolvement.For example, although religion and cultural diversity do matter, are they perceived as contributing factors or rather as risk factors?
Aubarell (2022) highlights the fact that although the positive label of the Mediterranean as a hospitable geographic area, full of rich history, still persists, even among affected citizens, the conflictive reality is also maintained.Risks that need attention to are mistaken assumptions that may derail the process for intercultural dialogue.To this end, ethical issues could well present another sensitive area -it is a major ethical challenge with an important ethical imperative to slow social divisions.
According to Mental Health FirstAid (2022), there are four ways culture can impact mental health: 1. Cultural stigma.Each culture has its unique way of viewing, understanding and responding to mental health.For those cultures where mental health is overshadowed by stigma, where it is understood as some kind of unwanted vulnerability to be hidden, it thus presents as a bigger challenge in terms of help and treatment.
2. Understanding symptoms.Research indicates that culture plays a major role in how individuals express their feelings and symptoms.Thus, a person is influenced on whether to focus entirely on physical symptoms only, on emotional symptoms only, or both.
3. Community Support.Culture can greatly influence and affect whether a person with mental health issues finds much needed support and assistance from family and community, or is left by themselves to seek help due to stigma.
4. Resources.Mental health treatment needs to be tailor-made according to the patient's unique experiences and concerns.This may present an added challenge to the health authorities providing such support.Every culture and person is different, thus recovery may entail a different route.

Mental Health's Holistic Response to Multiculturalism
Multiculturalism is here to stay.In fact, as recent experience shows, it is most probably bound to increase more, worldwide, for diverse reasons and factors (Kirmayer, 2018).To respond to this emergence, instead of a simple list of culture-bound syndromes, the DSM-5 (APA, 2013) has updated the criteria to reflect more the cross-cultural variations and their connotations, particularly to address a more person-centered assessment.Thus, mental health's response to this phenomenon of multiculturalism needs to be holistic in scope.A number of perspectives pertinent to this view are therefore in place.
Cultural safety: seems the first response.According to the Canadian Mental Health Association, cultural safety includes a) cultural competence, b) mutual respect at work, which includes attitudes, behaviors, skills and policies used; c) providing helpful, specific information in different languages; d) recognizing cultural, medical or health practices; e) assuring that policies respect community needs (family or religious roles); f) providing culturally sensitive health screening tools; and g) being holistic in scope, thus addressing the whole person (beyond cultural limitations).The same Association also cautions against the assumptions of generalizations, where people assume that all are on the same level or somehow enjoy the same needs and demands (2022).
Hechanova and Waeldle (2017) suggested five key elements to mental health professionals on where culture meets mental health.First element is emotional expression.Although in the West, this is widely used therapeutically, this may not be the case in other places.For example, in Africa and Asia certain beliefs exist where talking or expressing self about painful issues may further those feelings.Shame is the second issue, which seems to be a key stumbling block among Asians in particular.Because of the importance that the Asian family plays in an individual's life in general, challenges such as mental health issues may place that family in a dark light of shame, thus necessitating keeping that reality a secret.Third element is the power differences and issues between therapist and clients.The resilience and power perceived as arising from collectivism (tribe) is the fourth factor.Finally, the presence of spirituality and faith may be used both as an attribution and also as a coping mechanism.
Holistic health services: According to Gopalkrishnan (2018), increasingly research is pointing to the need for holistic health services.Some suggestions even integrate mental health services with primary health care, which may get past some of the stigma and discrimination issues (USDHHS, 2001).
Multicultural Awareness: Culture blindness is one area that may play a huge part in the progression or otherwise of multiculturalism.Basically, it is the inability to mutually understand certain issues, normally because of rigid compliance to the views, attitudes, and values of one's own culture.Such disagreement could arise also when one's own culture impedes and interferes to value different opinions or views.
Sensitive Lingual expression: Mental health professionals need to be culturally sensitive and understand how clients, especially from diverse cultural backgrounds, express themselves (Haley & Combs, 2010).
Understanding the historical realities presents a more urgent need for collaboration between mental health and communities representing different cultures.An area closely related to culture is language, which can lead to cultural understanding and communication as a whole.This requires professional interpreters to ease and facilitate the therapeutic relationship -a fact that very often is thought of in Western countries policies.However, problems exist, first with the non-utilization of such services, and secondly, with problems of resources in other areas of the world (FECCA, 2011).The Maltese language is the only Semitic language written in a Latin script that may ease difficulties in the understanding and comprehension of some African languages.However, it still necessitates the appropriate usage of professional interpreters for better communication.Zammit (2021) found that an interculturally capable person does not require knowledge of one's own and other's cultural aspect only, but demands mutual respect and acceptance between both cultures.
Community aspect: Tribe clearly explains that most of our theory and practice of mental health is mostly biased in favor of Western culture, heavily influenced by notions of Cartesian dualism of body and mind, positivism and reductionism.'Very little concern is therefore given to community or familial processes' (Tribe, 2005, p8).
According to Helman (2007), cultural meanings of health and illness vary greatly -and this needs to be well understood, in order to present an integrated view of mental health and culture.To begin with, perceptions of etiology of disease vary a lot, from the natural world to the social realm or even beyond.Seeking treatment is another complex reality, where some cultures emphasize somatic concerns while others cognitive or emotional symptoms.This is further impeded with discrimination (for example the major barriers Aboriginal Peoples face in receiving mental health services (Boksa et al., 2015), stigma due to low socio-economic status of the family.
It is to be reiterated that globalization is not a recent phenomenon (Held, 2007).However the last 100 years has seen an enormous and speedy increase, with materialism, social dissolution and individualism increasingly threatening the social fabrics that for long served as protective factors to humans (Melluish, 2014).An aspect that may help mitigate the negative effects of such a phenomenon could be the religious aspect of the Maltese.Marsella (2011) speaks of the society as a patient, to remind us that not all problems originate within the individual.One's presence or absence of wellness may be subject to external factors.Marsella thus emphasizes that community-based ethno-cultural services are a positive resource that needs to be tapped into for a stronger mental health wellbeing within a multicultural setting.
Cultural Partnerships: According to Gopalkrishnan (2018), the way forward is to move beyond the cultural competence framework toward developing cultural partnerships.Three reasons are given for this shift requirement, namely a) work across cultures is hardly ever value-neutral (particularly in view of the historical context); b) the 'competence' approach is biased in favor of the 'giver', while ignoring the client; and c) the competence model is based on a static understanding of culture, rather than an ever-evolving one.Cultural partnerships provides a more level-play scenario, while distances itself from traditional concepts of power relationships.Cultural partnerships can be envisaged between mental health providers and different cultural communities, refugee groups and traditional healers or community elders (Isaacs et al. 2010).Gopalkrishnan views this partnership also to cover the therapist -client relationship, engaging the client as an active agent in their own healing process, which is in line with the recovery approach (2018).
Inherent to this partnership, one can also add a cultural consultation service.According to Kirmayer et al. (2014), cultural consultation can rely on close collaboration with mental health interpreters and culture brokers.An area included in this consultation is cultural formulations which normally means the understanding of problems in social contexts.This may demand systemic thinking.A word of caution is to be raised because the presence of a clinician with 'an identifiable ethnic minority…raises complex issues of transference and countertransference'(p.vii).Primary care is a key setting for cultural consultation, in line with collaborative care.Other settings include refugee work, family separation and reunification, general hospital psychiatry, people applying for asylum, and others (Kirmayer et al., 2014).Moreover, Minbaeva et al. (2021) emphasize that relevant studies are moving beyond the double-edged sword metaphor towards unfolding complexity.They argue at expanding diversity categories beyond culture and mechanisms beyond information.

Conclusion
In this paper, we discussed the variations in the definition of culture and multiculturalism.Culture affects a diversity of human experiences.It affects human expression of their own personal experience.Indeed it is culture that is normally behind one's emphasis on physical or emotional symptoms.Considering that most of our theory and practice of mental health is mostly biased in favor of Western culture, together with the recent increase in globalization, also witnessed well in Malta, with the challenges that these changes present, it is pertinent to keep abreast and focused on the way forward, in order to attend to holistic mental wellbeing without doing injustice to cultural integration.Among the perspectives that require on-going investigation and attention where mental health and culture intersect, research points at the following: a) cultural safety; b) holistic health services, c) multicultural awareness, d) sensitive lingual expression, e) and a consistent movement toward cultural partnerships.