The goal of culture-sensitive working in mental health care is reducing major health inequalities. People with little education generally have poorer health. In health care, there is equality but not equity. Personal cultural-sensitive care can provide equity.

Every culture looks at mental health problems from a certain way of thinking and acting. Every culture has its own symptom pool. This influences people’s interpretation of mental illness (1), the expression of distress (2), the help-seeking attitudes (3) and prevention (4).

The explanatory models of mental illness differ per culture. It is important to know the explanatory model of the patient as discordance between client and counsellor can lead to disruption of the therapeutic relationship (1), poor communication (2) and poor therapy compliance (3). Health care workers have expectations of clients an people with a migration background cannot always live up to these expectations.

Non-Dutch parents make less use of mental health care services compared to Dutch parents. They experience less need for help and are worse at problem recognition. Moroccan adolescents are worse at problem recognition than Dutch adolescents. The differences in reported mental health use are mediated by emotional problem identification. It is possible that there are differences in emotional problem identification because it of cultural differences in what is normal and abnormal.

The therapist should investigate the ideas of the client about the cause, meaning and solution of the problems (1), should communicate the therapist’s vision (2) and should communicate the potential benefits of therapy (3).

Culture refers to the set of lifestyles that certain groups of people develop and share over a long historical period. Most cultural differences are not immediately visible. Culture is taught during upbringing. However, people are mostly not aware of the cultural values. This causes that cultural differences often lead to misunderstandings. Culture partially determines how complaints and illnesses are explained and presented. A high context culture makes use of indirect communication. A low context culture makes use of direct communication.

There are several cultural competences that are important for a therapist:

• The therapist should not address the client as a representative of the culture but should view the client as an individual.
• The therapist should consider all cultural information as hypotheses that need to be tested with each client.
• The therapist should get to know own culture-specific norms and values.
• The therapist should demonstrate real empathy, commitment, attention and should take the time with the client.
• The therapist should use methods that are in line with the client’s learning and problem-solving abilities.

A good method of checking whether a message has been successfully transferred is the teach-back method which asks the client to repeat the message in the client’s own words. There are several phases in the life of a refugee:

1. Disruption and structural violence
2. Flight
3. Arrival and screening
4. Housing
5. Integration and acculturation

Being a refugee influences loss (1), family reunification (2), discrimination (3), social-economic status (4), future prospects (5) and access to care and education (6). There are several background aspects of refugees:

• The family members often lived apart from each other for a long period of time.
• The refugees are often from countries where children were raised by the whole family.
• The refugee children often miss the other family members.
• The refugees often experience a loss of people who supported and loved them.
• The refugees need to get used to the new family composition.

Refugee parents are often not familiar with the Dutch education and health care system. This leads to a reversed dependence, where the child who is growing up in the new country understands the systems but the parents do not. This leads to revised parent roles which lead to a loss of status.

Refugee families often experience poverty and financial constraints. In refugee asylums, they often experience a lack of privacy and have an uncertainty of the duration of the stay. They often have relationship problems (1), shared traumatic experiences (2) and reduced emotional availability (3). The family factors are an important predictor of psychosocial problems for children.

Developing in a stressful environment leads to the brain developing differently. Long-term stress leads to the brain specializing in alertness and danger at the expense of other functions (e.g. social interaction, regulating emotions).

Resilience is influenced by a complex set of risk and protective factors in the child (1), family (2), culture (3), school (4) and society (5). It is important to focus on reducing stress rather than reducing problem behaviour.

Traumatic events (1), separation (2), insecurity (3) and acculturation problems (4) are risk factors. Education (1), knowledge of the language (2), hope (3), financial stability (4), bicultural connection (5) and feeling of belonging (6) are protective factors.