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 Humanities and Social Science Research; Vol. 6, No. 1; 2023 
ISSN 2576-3024   E-ISSN 2576-3032 

https://doi.org/10.30560/hssr.v6n1p22 

 22 Published by IDEAS SPREAD 
 

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

Michael Galea1 & Frankline Zammit Galea1 
1 University of Malta, Malta 

Correspondence: Michael Galea, Department of Mental Health, Faculty of Health Sciences, University of 
Malta, Malta. E-mail: michael.galea@um.edu.mt, frankline.zammit.galea@ilearn.edu.mt 

 

Received: February 21, 2023; Accepted: March 20, 2023; Published: March 21, 2023 

 

Abstract 

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. 

Keywords: culture, cultural diversity, multiculturalism, mental health, holistic wellbeing 

1. Towards a Clearer Definition of Culture and Multiculturalism 

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 



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health problems, Asian groups prefer avoidance of upsetting thoughts, whereas African Americans are more self-
resourceful 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. 

2. 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. 

 



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3. 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. 

4. 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 



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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 



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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. 

5. 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. 

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