Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697809161515.pdf (Malta)
CR EAT IN G A “B ET TE R FUT URE” FOR MIGRANT AN D R E FUGE E W O M E N I N M A LTA : COMPE TE NCE HAN DBOOK p .

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p C RE AT I NG A “ BET T ER FUT URE” FOR MIGRA NT AND RE FUG EE W O M E N I N M A LTA : CULTURAL CO MP ETEN CE HA N DBO O K Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook © Authors of the handbook are: Maria Jones, Alana Christopher, Diana Tudorancea, Elizabeth Branscombe, Ruta Solomon, Raquel Medialdea Editors: Richard Theuma, Maria Jones, Alexandra Palos Graphic Design: Giada Di Biase Supported By: U.S. Embassy Valletta, Malta p .

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p ABSTRACT This handbook was designed and written by Migrant Women Association Malta (MWAM) as the final requirement for the “Julia Taft” Refugee grant provided by the US Department of State.

The Julia Taft grant provided funding for Malta’s first mental health service dedicated to female refugees and migrants: the “Better Future” service.

The name was chosen to reflect the service’s efforts to empower women to secure a better future for themselves.
By writing this Handbook, we at MWAM aim to provide a framework for mental health practitioners and others working or interested in the field, firmly based on the intersection between gender-based violence and migration in Malta.

The Handbook is comprised of policy and legal research and the learned realities of providing a mental health service to migrant and refugee women.
The first three chapters of the handbook give general information about gender-based violence, asylum processes and migration, and includes testimonies from two former asylum seekers that tell their own stories of migration.

In the final three chapters, the Handbook delves into understanding how cultural dynamics can affect women’s interaction with services in Malta.
It takes a service-centric approach, and tries to offer experiential input and practical advice to service providers working with potential survivors of sexual and gender-based violence.

The Handbook is by no means comprehensive, but rather attempts to shed light on what we at MWAM have learned from aiming to provide a culturally competent service, so that the Handbook may, in turn, serve as inspiration and a tool for improving other services in the field of mental health.
Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook p .

6 TABLE OF CONTENTS 7 .

p INTRODUCTION WHY CULTURAL COMPETENCE?
LIST OF ACRONYMS USED IN THIS REPORT MIGRANTS AND ETHNIC MINORITIES IN MALTA MIGRATION ON A GLOBAL SCALE MIGRANT AND REFUGEE WOMEN SEXUAL AND GENDER-BASED VIOLENCE MIGRATION IN THE MEDITERRANEAN AND TO MALTA MIGRANT AND REFUGEE PROFILES IN MALTA MIGRATION PERSPECTIVES: TWO CASES FROM ERITREA SEXUAL AND GENDER-BASED VIOLENCE: KEY DEFINITIONS AND LEGAL FRAMEWORK BETTER FUTURE: A YEAR ON WHY THE SERVICE WAS NEEDED AND GAPS IN AVAILABLE SERVICES IN MALTA DESCRIPTION OF MOST COMMON MENTAL HEALTH SYMPTOMS SERVICE OBJECTIVES IN THE MALTESE CONTEXT SERVICE USER ANALYSIS MWAM GUIDELINES AND LESSONS LEARNED VIGNETTE: UNDERSTANDING DIFFERENT CULTURAL PERSPECTIVES VIGNETTE: CULTURAL APPROACHES FROM A SERVICE PERSPECTIVE HOW TO APPROACH MIGRANTS AND MIGRANT COMMUNITIES: SUCCESSFUL OUTREACH STRATEGIES WORKING WITH INTERPRETERS HOW TO ESTABLISH A WORKING RELATIONSHIP THE FUTURE OF “BETTER FUTURE” GLOSSARY OF TERMS 8 9 11 12 12 17 17 18 20 22 24 32 32 33 37 38 40 40 41 44 46 50 52 53 Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook INTRODUCTION In order to provide a more efficient service to migrant communities looking to integrate, MWAM has conducted an exercise aimed at harmonising service provision in distinct sectors serving female migrants and refugees.
The current situation in Malta provides sub-optimal outcomes due to a number of factors, one of these underlying factors is that frontline staff are coming from a different professional and cultural background which erects barriers between the migrant community and the workers.

To help bridge this gap, MWAM has since its inception, used its staff and volunteer hive mind and this specific fieldwork, to issue this handbook.
The handbook has been designed with several stakeholders in mind, with the aim to serve as a guide for frontline professionals within the sector, including among others: • Medical and Mental Health Professionals who are tasked with diagnosing and treating the migrants’ physical and mental condition, which may involve monitoring on an ongoing basis;.
• Public Servants including asylum caseworkers seekers’ for screening and who are responsible respective processing asylum applications, as well as detention services personnel who are the responsible administration of detention centers; • Social and support workers, who are tasked for with assisting migrants integrate effectively with the Maltese community; • Law Enforcement officials the Executive Police and the Armed Forces of Malta and legal practitioners who are routinely involved with how the migrants are treated at law; including While these stakeholders are often equipped to handle sector-specific tasks associated with their roles, they may lack a holistic view of the process.
It is this gap which this handbook has p .

8 been designed to fill.

The upcoming sections address each part of the process both from the context of Malta’s sociocultural climate and from the typical background of the various migrants and refugees that enter Malta’s shores.

This Handbook intends to initiate an effort in developing cultural competence specifically in relation to migrant women at risk of S/ GBV.
It is hopefully a first of many steps in developing culturally competent practices across the country.

As a result, it has no specific focus in any sector, and attempts to provide a basic understanding and a practical guide for service providers engaging with women from different cultures.

First and foremost it must be read as a practical guideline created from the experience of Migrant Women Association Malta’s “Better Future” project team, and its time spent researching the topic if S/GBV.
The main instruments for data collection were the team members themselves, and this handbook represents the summary of their experiences and lessons throughout its developments.

As a result, it favors in some of its chapters the mental health aspect of service provision, but nevertheless, it is dedicated to all frontline staff charged with services.

However, it does not represent an exhaustive list nor the culmination of what these efforts should be.
It should be read like a practical guideline which provides basic information that would assist with developing basic rapport and establishing one essential element: trust.

Trust is an important factor for service compliance, and service compliance is then a paramount element to delivering assistance to those in need.

As a result, this Handbook is a breakdown of the reasons behind migration, delves into specific cases and life stories and approaches, as well as includes a detailed description of S/GBV.
WHY CULTURAL COMPETENCE?

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p Multiculturalism is an inevitable side effect of globalization.

Migration - be it in the form of seeking asylum, forced displacement, or to seek better opportunities - is a contemporary reality.

As such, population structures will change.

Cultural diversity is now inherent to most, if not all countries, and it represents a paradigm shift that requires the introduction of a new skill set for all new professions, as no sector is now completely homogenous.
Cultural diversity may offer, in the context of immigration, a broader range of behaviours, conceptions and world views, which can enrich the existing culture.

Multiculturalism and integration are two very commonly used ‘buzz words’, which reflect a greater picture of social functioning.
Whilst human rights are granted as such to allow all individuals to move, seek asylum, or otherwise reside in other countries, and efforts are made that those rights are accessible to everyone securing and protecting freedom of movement is necessary but not sufficient in terms of concrete integration1.

Governments that serve a multi-ethnic population must be prepared for accommodating the needs of the incoming migrants of any origin2.
According to the Universal Declaration of Human Rights, everyone has the right to public services in the country of residence3, which suggests that all services should be culturally sensitive and accessible for all.

Irrespective of age, ethnic origin, religion, socioeconomic conditions, gender, nationality, disability, sexual orientation, the state must provide adequate access to health goods, services and facilities in order to ensure equity4.
However, access to health care can easily become subject to biases of the dominating groups and often comprise of cross cultural encounters.

Unfortunately, due to the gaps it creates culture can become the source of conflict that would significantly affect the individual’s access to these services.

Not addressing or at the very least minding these differences from the practitioner’s part may be debilitating and interfering with the good functioning of the service5.
1 Ilana Redstone Akresh, Douglas S. Massey, Reanne Frank, Beyond English proficiency: Rethinking immigrant integration, Social Science Research, Volume 45, May 2014, 200-210 2 CESCR.

2000.

‘The right to the highest attainable standard of health (article 12 of the International Covenant on Economic, Social and Cultural Rights).’ General Comment No.

14.

E/C.12/ 2000/4.


Committee on Economic Social and Cultural Rights 3 UN General Assembly, Universal Declaration of Human Rights, 10 December 1948, 217 A (III), Art 25, available at: https://www.

refworld.org/docid/3ae6b3712c.html 4 World Health Organization (WHO), Global Health Observatory (GHO) data.
Available at: http://www.who.int/gho/health_equity/ about/en/ 5 Reyneri, E., & Fullin, G. 2011, ‘Labour Market Penalties of New Immigrants in New and Old Receiving West European Countries.’ International Migration, 49(1), 31-57 Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook The US Department of Health and Social Services define culture as the process by which individuals and systems respond respectfully and effectively to people of all cultures, languages, classes, races, ethnic backgrounds, religions, and other diversity factors in a manner that recognizes, affirms, and values the worth of individuals, families,and communities and protects and preserves the dignity of each.
In addition, cultural competence requires an understanding and appreciation for how skin colour, national origin, gender identity, sexual orientation, religion, age, class, mental and physical ability, immigration status, education, geographic location, and other identifiers influence how an individual navigates and experiences the world6.

Having such an understanding of the blueprint that affects the individual can facilitate the service provider’s effectiveness and reduce frustration on both ends.
Most importantly, it can foster integration and trust building with service providers ( s am h s a ) , c u l t u r a l c o m p e t e n c e .

A v a i l a b l e a t : h t t p s : / / w w w .

S a m h s a .

G o v / c a p t / a p p l y i n g - s t r a t e g i c - p r e v e n t i o n / cu l t u r a l - c o m p e t e n c e p .

1 0 LIST OF ACRONYMS USED IN THIS REPORT 1 1 .
p AIDA Asylum Information Database CEDAW Convention on the Elimination of All Forms of Discrimination Against Women COI Country of Origin DV Domestic Violence EIGE European Institute for Gender Equality FGM/C Female Genital Mutilation/Cutting GBV Gender-Based Violence GDP Gross Domestic Product GREVIO Group of Experts on Action against Violence against Women and Domestic Violence IDP Internally Displaced Person(s) IOM International Organization for Migration LGBTI Lesbian, Gay, Bisexual, Transgender or Intersex MWAM Migrant Women Association in Malta NCPE National Commission for the Promotion of Equality NGO Non-governmental organization PQ Preliminary Questionnaire form PTSD Post-Traumatic Stress Disorder RAB Refugee Appeals Board SGBV Sexual and Gender-Based Violence THB Trafficking of Human Beings UDHR Universal Declaration of Human Rights UN United Nations UN DESA United Nations Department of Economic and Social Affairs UNHCR United Nations High Commission for Refugees UNICEF United Nations Children’s Fund VAW(G) Violence Against Women (and Girls) WAVE Women Against Violence Europe WHO World Health Organization Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook MIGRANTS AND ETHNIC MINORITIES IN MALTA MIGRATION ON A GLOBAL SCALE According to the United Nations Department of Economic and Social Affairs (UN DESA), in 2015 there were approximately 244 million international migrants in the world, making up about 3.3 per cent of the global population, This figure does not include internal migrants who stay within the borders of their own countries, which was estimated to be 740 million in 2009.
Today the world is experiencing the highest levels of displacement ever recorded.

UNHCR reports that by the end of 2017, 68.5 million people around the world had been forced from their homes7.

Despite popular belief, the majority of these forcibly displaced migrants are not arriving in Europe and North America.

While the dominant discourse often describes the majority of migration as south-north, much of global migration occurs between states in the Global South8.
According to UNHCR, developing regions host 85 per cent of the world’s refugees under UNHCR’s mandate (approximately 16.9 million people).

The least developed countries provide asylum to approximately one-third of the global total (6.7 million refugees).

Globally, every two seconds one person is forcibly displaced.

It has been estimated that the global forced migration crisis will project to about 300 million in 20309.
As a result of this, UNHCR and all concerned humanitarian bodies are calling for regional and international collaboration in developing mitigation strategies.

WHAT IS MIXED MIGRATION?

Migration may occur due to a variety of push factors, and individuals migrating have unique profiles, vulnerabilities and needs.
Mixed migration flows can include a variety of migrant profiles, including refugees, asylum seekers, victims of trafficking and migrants that are motivated to seek better lives and economic opportunities.

7 UNHCR, 2017, Global Trends: Forced Displacement in 2017, 2.

Available at: https://www.unhcr.org/5b27be547.pdf 8 Broadly, the Global ‘South’ and the Global ‘North’ are used terms to categorize nations into two different region statuses.
The Global South roughly refers to the regions of Africa, Asia, Latin America and Oceania, areas that are mostly low-income and culturally marginalized.

While related to other terms such as “Third World” or “Periphery,” the term Global South seeks to emphasize global power relations as opposed to development or cultural difference.

As these terms are two very broad categories, they often cannot capture the nuances related to development and migration.
For more information regarding the term Global South, see https://journals.sagepub.com/doi/pdf/10.1177/1536504212436479.

For more information regarding migration within and between the Global North and the Global South, see https://www.thecairoreview.com/essays/migration-myths-and-the-global-south/ 9 Center for Strategic & International Studies (CSIS), 2018, Confronting the Global Forced Migration Crisis, 5.
Available at: https://csis-prod.s3.amazonaws.com/s3fs-public/publication/180529_Ridge_ForcedMigrationCrisi.

pdf?xG6zs9dOHsV2fr2oCxYTT6oar049iLfA p .

1 2 According to IOM, the main characteristics of mixed migration flows are “complex population movements including refugees, asylum seekers, economic migrants and other migrants’.

Unaccompanied minors, environmental migrants, smuggled persons, victims of trafficking and stranded migrants, among others, may also form part of a mixed flow.” 3 1 .
p Migrants and refugees often enter the same migration “flows” by using of the same means of transport and transnational routes to reach their destination – usually travelling irregularly and facilitated either entirely, or in part, by human smugglers, regardless of the different factors contributing to their reasons for migrating10.

These migrant profiles are not static, however, as individuals can, and do often, cycle between them.
For example, internal migrants originally driven by conflict or in search of better opportunities, may eventually cross international borders and become international migrants11.

PUSH FACTORS FOR MIGRATION Globally, economic migration is the main reason for an individual migrating to another country.

The most recent estimates from 2013 data indicate that just under two thirds of all international migrants are migrant workers12.
However, these numbers are likely to be underestimates due to difficulties in collecting this type of data13.

Economic migrants may be high-skilled or low-skilled workers, and they may migrate to study, or for temporary or longer-term work.

Lower-skilled workers, who often migrate to high-income countries for the opportunity to make higher wages in their destination country, may or may not have irregular status.
Many of these migrant workers send home remittances, or part of their earnings, to support their families or communities.

Forced displacement caused by armed conflict, generalized violence, climate change and other factors is also increasing, and occurs both internally and across borders.

In 2017, there were 40.0 million internally displaced persons (IDPs) and 25.4 million refugees worldwide14.
Ongoing and large-scale conflicts are a major factor in this type of movement, along with violence and instability.

The core and significant strategies with the increasing humanitarian crisis of migration that need to be addressed are as follows.

First and most important is that countries should develop methods of integration and cultural assimilation within host country.
Creating conducive environment for migrants to work, to be able to communicate, learn and form their representative community will enable them to be productive as well as building long term solutions.

Secondly, ways of tackling the inequalities within 10 Mixed Migration Hub, 2019.

What is Mixed Migration?

Available at: http://www.mixedmigrationhub.org/member-agencies/ what-mixed-migration-is/ 11 The Migration Observatory, 2011.

Mixed Migration: Policy Challenges.


Available at: https://migrationobservatory.ox.ac.uk/ resources/primers/mixed-migration-policy-challenges/ 12 IOM, 2018, World Migration Report 2018, 28.

Available at: https://publications.iom.int/system/files/pdf/wmr_2018_en.pdf 13 ibid.

28.

14 The terms “refugee” and “IDP” are both used to describe individuals that were forcibly displaced from their homes for reasons of persecution, conflict, or other reasons.
However the difference between the terms hinges on the location of the individual.

A refugee has crossed an international border and is outside their country of origin.

An IDP does not cross an international border and moves inside their own country.

According to UNHCR, IDPs are forcibly displaced because of a variety of causes such as violence or natural or human-made disasters.
While these two categories of individuals may face similar challenges or persecution, their legal status affects the rights they have and benefits they are able to receive.

Figures taken from UNHCR, 2017 Global Trends: Forced Displacement in 2017, 2.

Available at https://www.unhcr.org/5b27be547.pdf Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook the host country.

This will enable to tackle conflicts arising based on religious or racial minority groups.
Even women and girl empowerment and mainstreaming are critical steps that must be considered to tackle such issues.

The third and usually neglected issue is preparing cities for ecological changes.

As weather related natural disasters and environmental changes are driving people to migrate, policy makers and urban designers should consider given space to internally displaced population so that they don’t end up in slums.
Resettlement and relocation programs should be well integrated priorities of urban planning15.

In 2017, 68 per cent of refugees worldwide were from five countries: the Syrian Arab Republic, Afghanistan, South Sudan, Myanmar and Somalia.

WHAT IS THE DIFFERENCE BETWEEN A MIGRANT, REFUGEE AND ASYLUM SEEKER?

Although all individuals migrating may be considered migrants, not all migrants are refugees.

In particular, migrants and refugees are treated fundamentally different under international law.
Whereas migrants - particularly economic migrants - might choose to migrate due to poverty, or to improve their and their family’s lives, refugees are forced to flee their country for fear of persecution in order to save their lives or freedom, making them entitled to international protection16.
According to the 1951 Convention Relating to the Status of Refugees, a refugee is a person whom, “...is unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion.” When an individual has registered in a country for international protection, they are an asylum seeker.
International protection begins with admission into the country of asylum and registration and documentation by national authorities or UNHCR.

The State has the primary responsibility for providing protection and rights to refugees17.

An asylum seeker is a person whose refugee status has not yet been determined by the authorities but whose asylum application entitles them to protection on the basis that they could be a refugee.

15 World Economic Forum, 2016.


The biggest issues facing migrants today and what we can do to solve them.

Available at: https:// www.weforum.org/agenda/2016/11/the-biggest-issues-facing-migrants-today/ p .

1 4 16 UNHCR, Mixed Migration.

Available at: https://www.unhcr.org/uk/mixed-migration.html 17 UNHCR, 2019, Registration.
Available at: https://www.unhcr.org/registration.html Refugee status confers a number of important protections and rights on the individual, including the principle of non-refoulement, or the obligation of a state to not return a refugee to a territory where their life or freedom would be threatened18.

This principle also applies to asylum seekers, whose refugee status has not yet been determined19.

5 1 .
5 1 .

p The principle of non-refoulement is one of the most important principles of international law, and one of the most essential rights given to individuals with legal refugee status.

Article 33 of the 1951 Convention ensures that refugees and asylum seekers cannot be returned or extradited to their country of origin if they fear for their life or freedom, and therefore ensures they have the right to stay in their host country.

What is the principle of non-refoulement?


Article 33 of the 1951 Convention Relating to the Status of Refugees states that “No Contracting State shall expel or return (“refouler”) a refugee in any manner whatsoever to the frontiers of territories where his life or freedom would be threatened on account of his race, religion, nationality, membership of a particular social group or political opinion” However, refugee status protections are only available for a small proportion of forcibly displaced migrants.
While many migrants are also forced to leave their homes and communities for reasons beyond their control, they are limited in the protection that other states can, or are willing to, provide.

18 UN General Assembly, 1951, available at: https://www.refworld.org/docid/3be01b964.htm 19 “The principle of non-refoulement is of particular relevance to asylum-seekers.
As such persons may be refugees, it is an established principle of international refugee law that they should not be returned or expelled pending a final determination of their status.” Advisory Opinion on the Extraterritorial Application of Non-Refoulement Obligations under the 1951 Convention relating to the Status of Refugees and its 1967 Protocol, para 6 available at: https://www.unhcr.org/4d9486929.pdf Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook Human trafficking, which is different from migrant smuggling20, is another type of forced migration.
While data is often underreported and difficult to collect, it is estimated that between 2012 and 2014, 63,251 victims were detected in 106 countries and territories.

Individuals may be trafficked for a number of reasons, including forced labour and forced marriage, however sexual exploitation is the dominant reason21.

What is the difference between migrant smuggling and trafficking?
Human trafficking is comprised of three constituent elements, the act (what is done), the means (how it is done), and the purpose (why it is done).

Human trafficking is done for the purpose of ongoing exploita- tion, including sexual exploitation, labour exploitation, the removal of organs, or others.

The act of migrant smuggling is not explicitly for the purpose of exploi- tation, and the smuggling often ends with the migrants’ arrival at their destination.
Migrants who have been smuggled can also be vulnerable to exploitation, however.

While both human trafficking and migrant smuggling are considered criminal acts, there are a few key differences between the two acts.

The first is consent.

Migrants who are smuggled have given their con- sent to the smuggler, whereas victims of trafficking have either never consented or their consent has been abused by the traffickers.

Another key difference is transnationality.


Migrant smuggling is always across international borders, whereas human trafficking can occur both when victims are taken to another State or moved internally within a State.
20 Human trafficking is defined in the ‘Protocol to Prevent, Suppress and Punish Trafficking in Persons Especially Women and Children’ as “the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation.” Migrant smuggling is a crime, and involves aiding another to illegally enter a State to which they are not a national or resident.
Source: UN General Assembly, Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, Supplementing the United Nations Convention against Transnational Organized Crime, 15 November 2000, available at: p .

1 6 https://www.refworld.org/docid/4720706c0.html 21 IOM, 2018, World Migration Report 2018, 308-9.

Available at: https://publications.iom.int/system/files/pdf/wmr_2018_en.pdf MIGRANT AND REFUGEE WOMEN 7 1 .

p The role of women in migration is constantly evolving.
While economic migration is often perceived to be mostly male-dominated, recent trends show that increasing numbers of women are migrating internationally to work.

Men still make up over half of migrant workers, but various sectors, such as the care and service sectors, have increasing demands for female migrant workers.

These trends also vary regionally, and there are many countries, such as Thailand and the Philippines, where the emigrants are mostly women22.
Female migrant workers are increasingly playing an important role in sending remittances and supporting families in their countries of origin.

While many women may migrate from countries that have strict gender roles and ideologies, their independence in their destination country can change how they perceive decision-making and social dynamics.

In 2017, 68 per cent of refugees worldwide were from five countries: the Syrian Arab Republic, Afghanistan, South Sudan, Myanmar and Somalia.
All female migrants also face particular challenges in migration.

Migrants often face long difficult journeys and lack secure, legal channels to their destination countries.

Women, who are usually the primary caregivers for children, can face additional difficulties in raising funds for travel, accessing smugglers’ networks, and other concerns, particularly in instances of forced migration.
SEXUAL AND GENDER-BASED VIOLENCE Women of migrant and refugee backgrounds are particularly vulnerable to sexual and gender-based violence (SGBV) on all stages of their journey, from country of origin to destination country.

While in transit, migrant women may face sexual exploitation or abuse by their smugglers.

These cases are often under-reported, for a number of reasons.

Cultural factors may lead to a social stigma for survivors of SGBV.
Other factors include isolation, the lack of a support network or trusted healthcare provider, or the fear of consequences to their immigration status can also discourage survivors from reporting23.

Human trafficking also disproportionately affects female migrants.

In 2014, 71 percent of all human trafficking victims were women and girls, trafficked for sexual, marriage or labour exploitation, as well as other reasons24.
Trafficking and SGBV often overlap, and victims of trafficking may also be exploited sexually by their traffickers25.

22 IOM, 2018, World Migration Report 2018, 185.

Available at: https://publications.iom.int/system/files/pdf/wmr_2018_en.pdf 23 MWAM, 2017, Creating a “Better Future” for Migrant and Refugee Women in Malta, 19-21.

Available at: http:// migrantwomenmalta.org/wp-content/uploads/2018/04/MWAM_Mental_Health_Svce_SGBV_Refugee_Migrants_V1-1-1.pdf 24 IOM, 2018, World Migration Report 2018, 308-9.
Available at: https://publications.iom.int/system/files/pdf/wmr_2018_en.pdf 25 mnesty International, Refugees and migrants fleeing sexual violence, abuse and exploitation in Libya, 1 July 2016.
Available at:https://www.amnesty.org/en/press-releases/2016/07/refugees-and-migrants-fleeing-sexual-violence-abuse-and-exploitation-in- libya/ Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook Migrants and refugee women also face an increased risk of SGBV in their host societies, due to lack of integration, isolation, language barriers and restricted access to education and unemployment.
Other barriers to reporting exist because survivors may be reliant on their partner financially or on their partner’s legal status.

Migrant and refugee women also may face discrimination in their host societies, which can limit their access to healthcare providers and facilities.

This is a serious problem, because women that have experienced violence or trauma often experience physical or mental health problems, and may not be able or willing to access facilities to receive support or protection26.
MIGRATION IN THE MEDITERRANEAN AND TO MALTA In 2018, 81 per cent of migrants crossing the Mediterranean to enter Europe.

Mediterranean migration flows follow three primary routes: the Eastern Mediterranean route (Cyprus, Bulgaria and Greece), the Western Mediterranean route (most often from Morocco Spain, either via the Alboran Sea or overland via Ceuta and Melilla) and the Central Mediterranean route (mostly via Italy and Malta).
The Central Mediterranean route, which was the most active route used in 2017, was surpassed by both the Western (most active) and Eastern (second most active) in 201827.

S o u r c e : I O M , ‘ ’ D e c e m b e r 2 0 1 8 26 MWAM, 2017, Creating a “Better Future” for Migrant and Refugee Women in Malta, 19-21.
Available at: http:// migrantwomenmalta.org/wp-content/uploads/2018/04/MWAM_Mental_Health_Svce_SGBV_Refugee_Migrants_V1-1-1.pdf 27 IOM, 2018, Mixed Migration Flows in the Mediterranean December 2018, 4.

Available at: https://rovienna.iom.int/sites/default/ p .
1 8 files/publications/Flows_Compilation_Report_December_2018.pdf Historically a country of mass emigration, Malta’s positioning in the Central Mediterranean, with a large surrounding search and rescue zone, has meant that, since 2002, the country has been dealing with significant numbers of people arriving as a result of irregular migration: asylum-seekers and migrants attempting to reach Europe from North Africa by boat have averaged at 1,650 persons per year28.
Many undocumented migrants arrive in Malta by boat, due to its location on the Central Mediterranean route.

These groups cross the Mediterranean for a number of reasons, but many have been driven out of their countries of origin because of conflict or persecution.

The majority of these migrants submit applications for international protection once they arrive in Malta29.

9 1 .

p What is the Asylum Process in Malta?


An individual claiming asylum in Malta must first place an application with the national Office of the Refugee Commissioner, who is the authority that processes all applications for international protection in Malta.

To register the individual’s desire to apply for international protection, they submit a Preliminary Questionnaire (PQ) form.
After completing this, the individual has a recorded interview and completes an additional application form, which then is their official application for international protection.

At the end of the interview, the applicant is told they will be notified of the decision of the Refugee Commissioner in due course.

After receiving the determina- tion of their status, the applicant has 2 weeks to appeal the decision to the Refugee Appeals Board (RAB).
While waiting for the decision of the Refugee Commissioner, asylum se- ekers in Malta are guaranteed a number of rights to protect them.

Accor- ding to UNHCR Malta, once an asylum seeker has filed an application they then have “the right to remain in Malta pending the examination of the case.” They also have the right to receive information about the asylum procedure, have an interpreter, and to seek legal assistance.
Asylum se- ekers also have the right to confidentiality while waiting for their status determination.

UNHCR states that “every person arriving in Malta has the right to apply for asylum.

However, that does not mean that every person will be granted protection.” Asylum seekers may receive two types of international pro- tection, refugee status or subsidiary protection.
Subsidiary protection is granted to individuals who are at risk of serious harm to their lives in their countries of origin but do not meet the full definition of refugee status, which accords them various rights and legal benefits.

28 MWAM, 2017, Creating a “Better Future” for Migrant and Refugee Women in Malta, 13.

Available at: http://migrantwomenmalta.

org/wp-content/uploads/2018/04/MWAM_Mental_Health_Svce_SGBV_Refugee_Migrants_V1-1-1.pdf 29 IOM, 2015, Migration in Malta: Country Profile 2015, 30.
Available at: https://publications.iom.int/books/migration-malta- country-profile-2015 Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook The majority of asylum seekers in Malta receive subsidiary protection.

According to UNHCR Malta, only about 10 per cent of applicants in Malta receive refugee status.

1,445 migrants and refugees arrived by sea in Malta in 2018.

This number is significant, as it is the highest number of arrivals to the country since 201330.
This number has fluctuated throughout the past decade, due to changing governmental policies and agreements within countries of origin and destination countries, developments in organized smuggling networks and the role of search and rescue operations in the region31.

The majority of migrants arriving by boat in Malta are male, however this trend is changing.
From 2003- 2014, the percentage of women and girls arriving by boat has generally increased from 4.78 per cent in 2003 to 17.55 per cent in 2014, with the maximum in 2012, at 22 per cent.

Additionally, the majority of asylum seekers arriving in Malta are male32.

MIGRANT AND REFUGEE PROFILES IN MALTA Migrants arriving in Malta have diverse nationalities and countries of origin.
According to UNHCR Malta, the top 10 countries of origin of non-Maltese living in Malta are: United Kingdom, Somalia, Italy, Bulgaria, Germany, Russia, Eritrea, Serbia, Sweden, and Libya.

In 2017, the top asylum application countries of origin were Syria, Libya, Somalia, Eritrea and Iraq33.

Many refugees have not stayed in Malta due to resettlement programmes, agreements with other EU countries or choosing to leave of their own initiative34.
However, many of them are still living in open centers or directly in communities While much of the attention on migration in Malta centres on asylum-seekers and irregular migration, it’s important to note the majority of immigrants to Malta are European Union nationals.

In 2013, over half of all migrants to Malta were citizens of EU countries.

In 2013, out of the 22,466 migrants in Malta, 12,840 were European Union nationals in Malta for reasons of work, study or family unity.
Migrants and refugees from these groups fled their countries of origins for a number of reasons.

Political unrest, instability, violence, and environmental disasters are a few factors that push groups of people to migrate internationally.

30 IOM, 2018, Mixed Migration Flows in the Mediterranean December 2018, 22.

Available at: https://rovienna.iom.int/sites/default/ files/publications/Flows_Compilation_Report_December_2018.pdf 31 IOM, 2015, Migration in Malta: Country Profile 2015, 23.
Available at: https://publications.iom.int/books/migration-malta- country-profile-2015 32 ibid.

23. p .

2 0 33 UNHCR, Malta Asylum Trends.

Available at: https://www.unhcr.org/mt/charts/ 34 UNHCR, 2015 Malta Asylum Trends 2005-2015.

Available at: https://www.unhcr.org/mt/wp-content/uploads/ sites/54/2018/05/8_2005-2015_fs.pdf.pdf 1 2 .

p Asylum seekers and migrants from Libya are often fleeing political instability and violence.
Libya is a transit country for many migrants, and IOM reports there may be up to 1 million migrants currently in Libya35.

Migrants in Libya are currently facing extreme insecurity and serious human rights abuses, which leads many to decide to cross the Mediterranean.

Another high risk country for people, and a high exporter of refugees, is Syria.

The ongoing conflict and violence in Syria created forcibly displaced over half of all Syrians.
While many remained in Syria, there are 6.3 million Syrian refugees, which is the highest number in the world.

The conflict in Syria is currently a level 3 emergency, and many Syrians are unable to meet their basic needs36.

Somalia has also experienced decades of conflict, as well as environmental and natural hazards.

Many Somalis have been internally displaced throughout the country and region because of the recurring droughts and violence37.
While the majority of migrants, asylum seekers and refugees in Malta are from the previously mentioned countries, migrants also come from many other countries of origin.

They may have fled their countries for similar reasons.

Conflict, armed violence, environmental disasters and insecurity are common in many contexts around the world.

Thousands of refugees and migrants flee Eritrea because of human rights violations and arbitrary detention.
Eritrea also requires military service, which can be extended indefinitely and for some, has lasted as long as 20 years.

Many Eritreans flee the country because they are unable to meet their basic needs and escape the human rights abuses38.
35 To learn more about Libya, see IOM’s profile on Libya: https://www.iom.int/countries/libya, the US State Department report on human rights in Libya: https://www.state.gov/documents/organization/277499.pdf or the Human Rights Watch updates on Libya: https://www.hrw.org/world-report/2019/country-chapters/libya 36 For further reading about Syria, see UNHCR’s reports on the country: https://www.unhcr.org/figures-at-a-glance.html and https://www.unhcr.org/syria-emergency.html, and the EASO COI Meeting Report on Syria: https://coi.easo.europa.eu/ administration/easo/PLib/Syria_COI_Meeting_Report_Nov-Dec_2017_Published_March_2018.pdf 37 For further reading about Somalia, see UNHCR’s country profile: https://www.unhcr.org/somalia.html, and the EASO Country of Origin Information Somalia Report: https://www.easo.europa.eu/sites/default/files/publications/coi-somalia-dec2017lr.pdf 38 For further reading about Eritrea, see Amnesty International’s profile on Eritrea: https://www.amnesty.org/en/countries/ africa/eritrea/report-eritrea/ or the EASO Country of Origin Information Report: https://www.easo.europa.eu/sites/default/files/ publications/coi-%20eritrea-dec2016_lr.pdf Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook MIGRATION PERSPECTIVES: TWO CASES FROM ERITREA The Better Future team has had the chance to make contact with the Eritrean community relatively late, compared to other communities, due to difficulties in securing an outreach worker / interpreter.
The case studies below were brought forth by her efforts.

Their cases reign in people’s personal encounters with some of the most salient reasons people leave.

While the reasons behind migration and the struggles along the way are documented in academia, this handbook aims to introduce personal experiences behind migration, as well as the lessons their experiences can teach.
THE RUNAWAY CONSCRIPT Hayat39 is now a married father of two who has granted the Better Future team the opportunity to speak closely, and share his experience.

horrible, but living in Eritrea is awfully precarious and thus difficult to cope with.

After contacting smugglers and paying them large sums of money, he crossed again to Sudan where he finally planned to use the Libya and the Mediterranean Sea as a means to reach Europe.
Like all Eritrean refugees, Hayat is fortunate enough to have reached safety and stability in his life.

His story begins against a backdrop of compulsory military service for all adult men, a service that is often abusive and difficult, spanning many years.

After four years of military conscription, Hayat had had enough.

He arranged to escape and cross the border with some fellow soldiers from his unit.
Unfortunately, within two days of their journey to Sudan, they were caught by secret agents of the Eritrean government.

This was is the point where Hayat endured the worst form of abuse: he was interrogated, assaulted and eventually incarcerated.

During his in the prison, he had witnessed enduring maltreatment, humiliation and callous handling of prisoners.
Having spent one year in confinement without any trial, he was subsequently returned to military service in Eritrea where he was treated as a traitor by his unit leaders.

imprisonment After several months of unrelenting abuse which was tantamount to slave labour, he managed to escape again to neighboring Ethiopia by putting his life at the risk of the Eritrean government’s “Shoot to kill” policy at border areas.

He confessed that having to consider to escape his country is p .
2 2 39 Name altered for anonymity During Hayat’s journey through several migration routes across the Mediterranean, he admitted to being subject to mistreatment and exploitation on a worse scale than to what he had endured in Eritrea, with traffickers and demanding ransom money that was beyond his means to provide to let him cross the Mediterranean Sea, payments which he succeeded to give in exchange for intense physical labor.
However, lack of independent judiciary systems able to safeguard persons against torture and other cruel, inhuman or degrading acts of punishment still represented a high incentive to leave, and in his experience he is still content with having left Eritrea.

Hayat’s example is but one of the typical plights of Eritrean persons, and one of the many reasons they chose to flee.
Other reasons can be extrajudicial executions, or fear of arbitrary detention of all persons in dissent towards the government, in demonstrations and protests, journalists, teachers and religious group leaders.

This is but one of many examples why persons leave their home countries.

Dictatorial governments, guerilla or sectarian forced conscription, exploitation and extra-judicial detention and torture are plaguing residents of war torn countries and highly unstable economies.
including those participating 3 2 .

p A WOMAN’S LIBERATION STRUGGLE This story is one of Better Future’s most representative cases, and has been brought forth through outreach and self-referral.

Through its psychological counselling sessions, Better Future team confirmed that she had experienced severe trauma and is as a result still trying to recount her entire experience.

Sophia40* is a 20 years old Eritrean woman, she is among the surviving victims of traffickers in Libya, currently living in Malta.
Her difficulties started when she illegally crossed the highly militarized border of Eritrea to Ethiopia.

Sophia was only a teenager, when her journey began.

Having been raised in a remote village, born to illiterate parents in a highly patriarchal society with rigid gender roles, she had no chance to be enrolled in school until her departure from Eritrea.

Her incentive to leave, was offered by her older brother who had been living in another neighboring country and offered to help her to leave.
During her recount, she weepingly described her life in Ethiopia as a hellish and very hard to cope with, without being able to speak without knowing the country’s language and without any external support apart from the financial With the aid of smugglers, she crossed again to Sudan in order to plan her journey to Libya.

Shortly after, she started off together with other fellow Eritreans and reached Libya.
There, the smugglers transported them to a hangar off the coast of Libya, and detained them there until they agreed to pay extra money, and thereafter to be sent by boat across the Mediterranean.

After the migrants acquiesced to the smuggler’s demands and made the payment, it became apparent that after the payment, the smugglers had underhandedly agreed to substitute themselves with a group of human traffickers against a fee, which in effect meant that they had been sold like a commodity.
40 Name altered for anonymity Over the course of her recount, Sophia was overcome with anguish when she spoke about her life in the Libyan prison, so much so that at one point she dampened her scarf from being unable to contain herself from crying.

She was told that the price for her freedom was another ransom of money which she couldn’t afford.

“...they made me call my brother to ask him to send €7,000 worth of money immediately”.
“My brother was so tired of sending me money and that time he asked me to be patient until he gets some loan from friends and relatives.”.

She disclosed that she had been sexually assaulted and abused repeatedly by smugglers and prison guards, even after she would have been knocked unconscious.

She had experienced abuse and assault at their hands repeatedly, for a period of over a year.

As a result of it, she lost her sense of living, thinking and suffered from apparent dissociative amnesia.
Sophia had been exposed to multiple acts of S/GBV that are tantamount to complex PTSD.

However, she had never been officially diagnosed; and due to her inability to recount many elements of her story due to potential PTSD, she is currently facing a difficult legal situation in Malta.

Her interviewers might not have been aware of the underlying complexities of her condition and are likely to have treated her application unfavorably as a result.
Her case is also one of many who would have been escaping not only a difficult situation in her home country, but running away from traumatic instances along her journey.

Malta is unquestionably to receive a vast number of migrants from a very different country, and regardless of the changes and population trends, will become an increasingly multicultural country.
As a result, service providers are under increasingly confronted with the realities of migration, and experience first hand some of the difficulties migrants have to experience.

In order to maintain its workforce, and respond to service beneficiary needs, and particularly remain sensitive to issues related to S/GBV.
Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook SEXUAL AND GENDER-BASED VIOLENCE: KEY DEFINITIONS AND LEGAL FRAMEWORK DEFINITIONS ‘Sexual violence’, ‘gender-based violence’, and ‘violence against women’ are terms that are often used interchangeably, by advocates, practitioners and in literature alike.
Each of these terms refer to the perpetuation of sex-stereotyped roles and violations of fundamental human rights; they deny self- determination of the individual, hamper human development and deny human dignity41.

Sexual and gender-based violence (SGBV) refers to any act perpetrated against a per- son’s will based on gender norms and unequal power relationships.

It encompasses threats of violence and coercion.

It inflicts harm on women, girls, men and boys.


Gender-based violence (GBV) refers to violence directed at a person due to their gender, as well as due to the expectations within their culture and society because of that gender.

The term gender-based violence therefore spotlights the gendered nature of violence, and how, for example, a woman or girl’s lower status in a society or culture increases their vulnerability to sexual, psychological or physical violence and perpetuates male power and control.
Gender-ba- sed violence and violence against women are forms of discrimination based on sex or gender.
Violence against women (VAW) as defined by the United Nations, is “any act of gen- der-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life.” Thus, unlike VAW, SGBV can also refers to male vulnerability in society and culture.
However, women are disproportionately affected by violence on the basis of their gender, and therefore, in this study SGBV will primarily refer to violence directed against women and girls.

SGBV can occur during all life stages, including pre-birth, infancy, childhood, adolescence, reproductive age, and old age.

41 UNHCR, 2003, Sexual and Gender Based Violence against Refugees, Returnees and Internally Displaced Persons.
Available at: http://www.unhcr.org/protection/women/3f696bcc4/sexual-gender-based-violence-against-refugees-returnees-internally-displaced.

p .

2 4 html 5 2 .

p STAGE OF LIFE EXAMPLES OF SGBV Pre-birth Forced abortion, battering during pregnancy, sex-selective abortion, and coerced pregnancy (e.g.

in the context of genocide).

Infancy Physical abuse, emotional abuse, female infanticide (killing an infant based on her sex), and differential access to food and medical care between boys and girls.
Childhood Sexual abuse, Female Genital Mutilation/ Cutting (FGM/C); early marriage/ child marriage, trafficking of human beings (THB), and differential access to education.

Adolescence So-called ‘honour’ crimes, child and/or forced marriage, sexual exploitation (such as sex for school fees), sexual harassment, sexual abuse in the workplace, violence by boyfriend/girlfriend, rape, violence due to sexual orientation, THB, survival sex, commercial sexual exploitation, and sexualized torture in detention.
Reproductive age Domestic violence, so-called ‘honour’ crimes, rape and sexual assault, violence due to sexual orientation, survival sex, forced confinement, commercial sexual exploitation, and abuse of widows.

Old age Elder abuse or sexual abuse (abuse by intimate partner, younger family members or caretaker), abuse of widows (including property-grabbing, accusations of wi- tchcraft, forced confinement), and forced marriage (e.g.

wife inheritance).
wife inheritance).

Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook INTERNATIONAL LEGAL FRAMEWORK AND DEFINITIONS OF SEXUAL AND GENDER-BASED VIOLENCE The principles of non-discrimination and equality traverse all human rights instruments42.
The International Bill of Rights43 speaks clearly of every human’s equal rights, ‘without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status44.’ The Committee on the Elimination of Discrimination Against Women (CEDAW) is the foremost international instrument guaranteeing women’s rights to equality and non-discrimination against women in public and private life, by public authorities, any person or organization in civil, political, economic, social and cultural areas45.
Importantly, it also considers the potential negative roles of culture and tradition in shaping gender stereotypes.

CEDAW recognises GBV as a form of discrimination that impairs or nullifies women’s enjoyment of human rights and fundamental freedoms, including: the right to life; not to be subject to torture or to cruel, inhuman or degrading treatment or punishment; to liberty and security of person; to equal protection under the law; and to the highest standard attainable of physical and mental health.
Several international instruments specifically address and define sexual and gender-based violence against women and girls.
In the Declaration on the Elimination of Violence against Women (1993), there is a broad and gender-based definition of violence against women and girls encompassing all forms of violence outlined in article 2 as: (a) Physical, sexual and psychological violence occurring in the family, including battering, sexual abuse of female children in the household, dowry-related violence, marital rape, female genital mutilation and other traditional practices harmful to women, non-spousal violence and violence related to exploitation; (b) Physical, sexual and psychological violence occurring within the general community, including rape, sexual abuse, sexual harassment and intimidation at work, in educational institutions and elsewhere, trafficking in women and forced prostitution; (c) Physical, sexual and psychological violence perpetrated or condoned by the State, wherever it occurs.
42 Fareda Banda, 2008, ‘Project on a Mechanism to Address Laws that Discriminate against Women’, OHCHR 5 43 Comprising of: the UN Charter, Universal Declaration of Human Rights (UDHR) the International Covenant on Civil and Political Rights (ICCPR), and the International Covenant on Economic Social and Cultural Rights (ICESCR).
See United Nations, Charter of the United Nations (adopted 24 October 1945) 1 UNTS XVI available at http://www.un.org/en/documents/charter/; Universal Declaration of Human Rights (adopted 10 December 1948) UNGA Res 217 A(III) (UDHR) available at http://www.un.org/en/ documents/udhr/; International Covenant on Civil and Political Rights (adopted 16 December 1966, entered into force 23 March 1976) 999 UNTS 171 (ICCPR); International Covenant on Economic, Social and Cultural Rights (adopted 16 December 1996, entered into force 3 January 1976) 993 UNTS 3 (ICESCR) 44 UDHR art 2(emphasis added) 45 Ferdous A. Begum, ‘Interpretation of the Islamic Jurisprudence in the Spirit of the International Human Rights Norms and the Convention on the Elimination of all Forms of Discrimination against Women’ Rabat Round Table Discussion on Women Leading Change in the Muslim World (WUNRN May 16-17 2011) available at:http://www.wunrn.com/news/2011/07_11/07_11/071111_ islamic.htm p .
2 6 7 2 .

p International law provides for special protection of children (defined as anyone under 18 years of age, unless under the law applicable to the child, majority is attained earlier).

46The UNICEF Convention on the Rights of the Children47 (1989) is the most important treaty in this matter, often completed by national laws.
This convention includes protection from all forms of violence, abuse and neglect by parents and child-carer (article 19), with special protection to be granted to refugee children (article 22).

Articles 34 and 35 on children’s right to be protected against sexual exploitation, namely sale, prostitution and child pornography, along with abduction, sale and trafficking are covered in further details in the Optional Protocol on the sale of children, child prostitution and child pornography.
Lastly, article 39 emphasizes on the right to rehabilitation of child victims, specifying that special attention should be paid to help both physical and psychological recovery, in order to restore the children’s heath, self- respect and dignity, and promote their reintegration into society.
EUROPEAN LEGAL FRAMEWORK AND DEFINITIONS OF SEXUAL AND GENDER-BASED VIOLENCE Considering that gender-based violence is a violation of basic human rights that prevents the achievement of real equality between women and men, the Council of Europe Convention on Preventing and Combating Violence against Women and Domestic Violence (the ‘Istanbul Convention’) aims at creating a legal framework at pan-European level to protect women against all forms of violence and prevent, prosecute and eliminate such type of violence.
It states that48: [G]ender‐based violence against women” shall mean violence that is directed against a woman because she is a woman or that affects women disproportionately49.
“[V]iolence against women” is understood as a violation of human rights and a form of discrimination against women and shall mean all acts of gender‐based violence that result in, or are likely to result in, physical, sexual, psychological or economic harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life50.
46 UN General Assembly, Convention on the Rights of the Child (CRC), 20 November 1989, United Nations, Treaty Series, vol.

1577, p.3, Art 1.

Available at: https://www.refworld.org/docid/3ae6b38f0.html 47 UNICEF, The Convention on the Rights of the Child, Protection rights: keeping safe from harm.

Available at: https://www.unicef.

org/crc/files/Protection_list.pdf 48 Council of Europe Portal, Istanbul Convention: Action against violence against women and domestic violence.
Available at: http://www.coe.int/en/web/istanbul-convention/home 49 Council of Europe, Council of Europe Convention on preventing and combating violence against women and domestic violence, 11 May 2011, Istanbul, 11.V.2011, Art.

3 d, available at: https://www.coe.int/fr/web/conventions/full-list/-/conventions/ rms/090000168008482e 50 ibid.

Art.
Art.

3 a Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook Based on these international and European standards, the following five types of sexual and gender- based violence can be discerned51: 1.

Sexual violence.

2.

Physical violence.

3.

Emotional and psychological violence.

4.

Harmful traditional practices.

5.

Socio-economic violence.


Different forms of violence include intimate partner violence, stalking, sexual harassment, sexual violence (including rape), physical and psychological violence, forced marriage, forced abortions, forced sterilization, female genital mutilation, trafficking in human beings and femicide.
Chapter VII - Articles 59, 60 and 61 of the Istanbul Convention include specific provisions for migrants and asylum-seekers: • Article 59 - “Residence status”- specifies the conditions in which autonomous residence permits shall be applied for and issued for gender-based violence survivors, • Article 60 - “Gender-based asylum claims” - introduces the recognition of gender-based violence as a form of persecution and serious harm, thus entitling the gender-based violence survivors to complementary/subsidiary protection.
It also highlights the need for gender-sensitive reception procedures, refugee status determination, asylum processes and support services.

• Article 61 - “non-refoulement”- reinforces the principle of non-refoulement for gender-based violence survivors.
The ‘Istanbul Convention’ also put in place a specific monitoring instance named GREVIO, in order to monitor and ensure the effective implementation of the Convention’s provisions by all its parties WAVE reports that in 2011, the estimated annual cost of gender-based violence against women amounted approximately to 1.8% of the EU GDP, i.e.

EUR 228 billion in lost economic outputs, services utilization and personal costs.

This represents an annual cost of EUR 450 per European citizen per year.
Investing even only 10% of this cost in prevention would significantly reduce this economic burden on national budgets.

MALTESE LEGAL FRAMEWORK AND DEFINITIONS OF SEXUAL AND GENDER-BASED VIOLENCE At the time of the writing of this report, and following its ratification of the ‘Istanbul Convention’, the Maltese government is examining a new “Gender-based Violence and Domestic Violence” bill in order to add provisions and amend existing laws to translate the Istanbul Convention into Maltese law.
The first readings of this bill took place in October and November 2017.

This bill is meant to repeal both the Domestic Violence Act and the Council of Europe Convention on Prevention and Combating of Violence against Women and Domestic Violence (Ratification) Act.

p .

2 8 51 UNHCR, 2003, Sexual and Gender Based Violence against Refugees, Returnees and Internally Displaced Persons, 15.
Available at: http://www.unhcr.org/protection/women/3f696bcc4/sexual-gender-based-violence-against-refugees-returnees-internally- displaced.html Within the bill, “Gender-based violence” is defined as such: “gender-based violence” means all acts or omissions that are directed against a person because of their gender, that result in, or are likely to result in, physical, sexual, psychological or economic harm or suffering, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life52”.
9 2 .

p The bill includes the creation of a Commission for Gender-based Violence and Domestic Violence, in charge of defining and coordinating the implementation of a dedicated action plan on Domestic violence, in coordination with the Civil society.

Until this bill passes, the currently applicable law in terms of gender-based violence is to be found in different Codes and Acts.

The Criminal Code includes provisions for domestic violence, rape (article 198) and sexual assault in section 2017.
Sexual harassment is covered through different laws and codes: Equality for Men and Women Act (chapter 456, article 9 sub-section 1), Employment and Industrial Relations Act (chapter 452, article 9) and Criminal Code (Chapter 9, Subtitle IX: Of Threats, Private Violence and Harassment Section 249-251 d).

Stalking is not mentioned /defined per se but is still covered by the Criminal Code.

Legal provisions on protection orders are provided in the Criminal code, article 412c.
The term “domestic violence” was introduced and defined in the Maltese Criminal Code by Act XX of 2005.

Previous to this act, the Maltese Criminal Code recognised crimes against the family and punished.

more severely crimes committed by family members on other family members, but without any mention of ‘domestic violence’ as such.
The Domestic Violence Act of 2005 defines domestic violence as “any act of violence, even if only verbal, perpetrated by a household member upon another household member and includes any omission which causes physical or moral harm to the other.
Domestic violence can be of physical, verbal and moral nature.” In this act, the phrase “household member” includes: (i) persons married or formerly married to each other; (ii) persons living in the same household as the offender or who had lived with the offender within a period of one year preceding the offence; (iii) persons whose marriage has been dissolved or declared null; (iv) parents and their children; (v) other adults sharing the same household; (vi) persons who are, or have been, formally or informally engaged with a view to get married; (vii) persons who are related to each other either by consanguinity or affinity up to the third degree inclusively; (viii) persons having or having had a child in common; (ix) the child conceived but yet unborn of any one of the persons mentioned in paragraphs (i) to (viii), both inclusive.
52 Gender-Based Violence and Domestic Violence Act, 2017.

Department of Information (doi.gov.mt).

available at: http:// justiceservices.gov.mt/DownloadDocument.aspx?app=lp&itemid=28728&l=1 Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook CONTRIBUTING FACTORS The ecological framework53 below demonstrates that no single factor can explain why some individuals or groups are at higher risk of interpersonal violence than others who are more protected from it.
The framework shows that interpersonal violence is the outcome many factors interacting at four levels: the individual, the relationship, the community, and the societal.

Ecological model for understanding violence societal community relationship individual Source: Heise et al., 1999; Krug et al., 2002; CDC, 2004 At the individual level, a person’s history and biological factors influence how they behave.

This increases their likelihood of becoming a victim or a perpetrator of violence.
Examples of this include: • being a victim of child abuse • psychological or personality disorders • alcohol and/or substance abuse • a history of behaving aggressively Personal relationships such as family, friends, intimate partners and peers may influence the risks of becoming a victim or perpetrator of violence.

Examples of this include: • having violent friends or family Community contexts in which social relationships occur including schools, workplaces, and neighbourhoods also influence violence.
Examples may include: level of unemployment • • population density • mobility • local drug or gun trade Societal factors influence whether violence is encouraged or inhibited.

These may include the following contributors: • economic and social policies that maintain socioeconomic inequalities • availability of weapons • social and cultural norms (including male dominance over women / parental dominance over children and/or cultural norms that endorse violence) p .
3 0 53 For more information see: https://www.who.int/violenceprevention/approach/ecology/en/ SGBV DURING DISPLACEMENT STAGES OF FLIGHT EXAMPLES OF SGBV 1 3 .

p Prior to flight Sexual violence and torture of women, girls, boys and men is widespread during conflict and often is a reason for flight.

Other common forms of SGBV include abduction, sexual slavery, and forced pregnancy.

During flight SGBV can occur at the hands of traffickers or border guards and other individuals in positions of authority.
During displacement Common types of SGBV: domestic violence, sexual assault and rape, forced marriage, survival sex, sexual exploitation and abuse by humani- tarian workers, and sexual abuse in schools, and sexual and gender-ba- sed violence by host community as retribution over depletion of natural resources.
In order to tackle S/GBV in the post migration phase, wherein the government has little control over the incidents and traumas that occured to survivors prior to arrival, services must consider a number of durable solutions: • Often cultural norms, language, education and lack of time to attend mass information sessions, prevent women from participating fully in discussions.
Families are represented by the husband and father who might make a choice that he has never discussed with his wife or female children.

•• Survivors of rape may fear going to a place where they were abused in the past, without recourse or support for their psycho-social or mental health needs.

•• Sometimes community and family members pressure a survivor not to report domestic violence due to the perceived adverse effects this may have on their resettlement case.
•• Questions about nationality, succession (inheritance) laws and boundary or land disputes may mean that some vulnerable persons or minorities are denied access to their property upon return to their country of origin.

• Married girls living with the family of their spouse may prefer to integrate, to repatriate or to resettle with their own family but may not be able to express their wishes freely.
•• Sometimes, at the end of a cessation exercise (for refugees) or a solutions strategy, those who experienced trauma including SGBV prior to flight do not opt to return.

It is often members of groups without significant social or structural support (elderly or single women, or adolescents) who stay behind on their own.

These people are at risk of social isolation, poverty and exploitation, including sexual exploitation.
•• Someone who has a certain disability may feel compelled to base choices related to durable solution on the choice of a caregiver.

•• Child marriage may increase as families fear not finding appropriate spouses for their children in resettlement countries.
•• Persons who are lesbian, gay, bisexual, transgender or intersex (LGBTI) may face security concerns in the country of origin, but if they have not disclosed their sexual orientation, may feel pressured to return with other family and community members.

in some cases, rise before •• FGM/C can, resettlement, as that such procedures are illegal and could not be performed in resettlement countries.

refugees know •• During integration in a host community, SGBV may occur for a number of reasons.
If refugees do not obtain the right to work, they may be vulnerable to exploitation and abuse.
Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook BETTER FUTURE: A YEAR ON This chapter represents an outline for the argument of why such a service is needed and how mental health and other important struggles that migrant women face fail to be addressed, partially due to cultural variations in the way in which symptoms are understood and communicated, and due to barriers (legal, linguistic or cultural) that women face in attempting to access certain services.
WHY THE SERVICE WAS NEEDED IN MALTA In order to design a service capable of addressing community needs, a mapping exercise had been conducted across several sectors in Malta - including health, mental health and migrant related services.
The Preliminary Mapping Report, published by MWAM in March 2017 contains a few key findings carried forward as an argument in favor of the creation of Better Future: • In the EU-28 (at the time) EIGE reports show that half the women who have experienced physical and sexual violence in their previous 12 months would not have disclosed it to any institution or individual.
Extrapolating from that, one can assume that the figure is much higher in asylum seeker women • Data recorded is fragmented, pointing to a lack of coordination among involved stakeholders with different mandates.

This can also point to lack of continuity of care.

• Mental Health is a challenge among male refugee/asylum seeker populations, as revealed by information provided by Mount Carmel Hospital.
Considering population epidemiology, it is a safe extrapolation to make in assuming that the numbers of women suffering from mental health conditions is equal if not higher.

The difference is that women’s help seeking behaviours are different due to a number of challenges.

Additionally, from the NGO’s collective experience, there is an understanding that there were unaddressed needs of women and men at risk of S/GBV.
While significant progress has been achieved for combatting and preventing DV and trafficking, in terms of catering for other forms of S/GBV, much of the efforts remain at research level.

As was highlighted in the previous chapters, Malta has made efforts to combat S/GBV at a legislative level.

However, taking the case example of FGM as a type of discrimination against women according to NCPE54, very little is done towards addressing it with at risk communities and as a result, in combating it.
Part of the reason is that the human resources needed to address it, in terms of experts in the field, community liaison and cultural mediation - are missing.
Nevertheless, post migration risk of FGM remains high in Malta due to imported practices55.. 54 National Commission for the Promotion of Equality (NCPE), 2015 ‘Female Genital Mutilation in Malta: a Research Study’ Available at: https://ncpe.gov.mt/en/Documents/Projects_and_Specific_Initiatives/Forms%20of%20Violence/Report%20-%20FGM.PDF 55 Carabott, Sarah, Risk of female genital mutilation in Malta ‘high.’ Times of Malta, 19 October 2018.

Available at: https://www.

p .


3 2 timesofmalta.com/articles/view/20181019/local/risk-of-female-genital-mutilation-in-malta-high.691946 Other forms of S/GBV, such as forced marriage, denial of resources, marital rape and labor trafficking, can be more difficult to identify, partially due to women’s difficulty to trust authority, differences in cultural sanctions and community structure.

As the Better Future team noted, communities tend to have preferential access to different services(?
), largely based on word of mouth and where help seekers can find interpreted services ready to cater for them.

This results in issues not being addressed inter-alia, but rather in an encapsulated manner by whichever service finds itself available to the person seeking help.

Moreover, it is mainly cases that already present some form of immediate threat are being prioritised because many of the beneficiaries only access them when they are in crisis.

3 3 .
3 3 .

p The existing psychosocial services are already under a heavy demand, which means that much of the difficulties that are encountered by potential clients accessing them, are compounded by a waiting list that services inevitably have to encounter.

Moreover, the extent to which service providers are trained to work in multicultural settings is unknown, and is not represented in any formal training as of yet.
As a result, many of the services that could help to tackle S/GBV for migrant women do not undergo a systematic approach to asylum seeking women.

Better Future presents as a mobile team that tries to tackle issues with their beneficiaries where it is most comfortable for them, especially in the initial phases of rapport establishing.
Mobility has proven a highly effective tool in reaching many other services and attempts to start working where the potential service users are, and an essential tool for reaching out to services and offering the support they need in order for them to tackle cases of S/GBV.

More importantly, due to the high volume of needs against the capacity of service providers, outreach capabilities have always been put at the bottom of the priority list.
One of the items of Better Future agenda at its inception, was to start the effort of creating a multi-agency response system that puts the client at the centre of all efforts.
In conclusion, the main gaps in service provision are represented by: Lack of access to interpreted services, and/or lack of timely cultural mediation • Low outreach capacity due to pre-existing high demand • • Differentiated preference of community • Difficulty in tackling intersectional issues • Low capacity due to high volume of needs DESCRIPTION OF MOST COMMON MENTAL HEALTH SYMPTOMS One major factor that has been observed during the year spent conducting outreach and counselling was that some cultures do not necessarily differentiate between physical and psychogenic pain, making it difficult for a professional to differentiate between medical and psychiatric symptoms.
Much of the literature does show that certain cultures have a higher chance at developing psychosomatic symptoms than others do, on account of the fact that mental health and physical health are regarded as one.

This factor is compounded by the difficulty of many languages to reflect inner realities, thus reducing the ability to verbalize inner realities.
Even in the presence of an interpreter, some clients had Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook difficulty in expressing how they were feeling and how they were reacting to their own symptoms.
In the initial contact phase, it would not be unusual to hear phrases such as: I have headaches / My head always hurts” • • My mind is always racing” I feel pain in my chest” • I feel my arms heavy” • I can’t sleep” • I feel like I’m boiling inside” • While physical symptoms in such presentations are a high risk, considering a number of factors such as improper nutrition; physical trauma; and lack of access to medicines for minor symptoms56, practitioners should always consider the possibility that such expressions might be pointing to a psychological issue.
Another item that needs consideration is the person’s help-seeking behaviours.

As such, the migration route and people’s past experiences could affect the way they regard figures of authority and attending staff of any sort.

Women, particularly those who had been exposed to violence perpetrated by authorities (i.e.

being brought back to their abuser by police, being forced into marriage by older members of family) tend to have a greater difficulty to establish trust with a person of authority.
As a result, displaying any form of distress or psychological discomfort may be completely obscured by physical symptoms or hidden altogether.

Taking into consideration that acts of S/GBV expand much further than the immediate family, authorities must expect to first work on trust-building rather than on expecting women to be forthcoming with their problems.

This proves that there are a number of factors that impact help-seeking behaviours: A.
Cultural sanctions surrounding pain: Community-based experience reveals that, as an example, Somali women take pride in their resistance to pain.

This is a fact that is observed in literature and based on personal accounts - where restraining from displays of pain during obviously painful experiences such as childbirth is viewed favourably.

Conversely, expressions of pain are interpreted as a sign of weakness.
That would entail that displaying symptoms of any form of illness may happen only in extreme cases57.

Displays of pain vary, and so do manifestations of other issues worth counselling - such as grief, shame, fear, anxiety, etc.

B.

Cultural sanctions on help-seeking behaviours: Similarly, help-seeking behaviours, particularly when it comes to non-medical issues, can be viewed from a strongly cultural perspective.
“Airing out dirty laundry” is an idiom with an interpretation in almost every language, however, the strength of its significance may vary.

Seeking out counselling and psychotherapy, and reaching out to a professional on such issues is seen as going to a stranger to complain about one’s family.

This is especially true, as observed before, in cases of domestic violence, where the victim may feel pressure from his/her community to try to deal with their issues internally rather than seeking out an outsider.
Such may be the case that, even if survivors of S/GBV do receive care from a local 56 Hodges-Wu, Joan and Zajicek-Farber, Michaela, ‘Addressing the Needs of Survivors of Torture: A Pilot Test of the Psychosocial Well-Being Index.’ Journal of Immigrant & Refugee Studies 15:1, 71-89. p .
3 4 57 This should not be interpreted as a blanket statement - in every culture there are strong individual variations system, such as Mount Carmel or a DV shelter, they may not be forthcoming with the root cause of their distress but rather disclose their immediate issues (i.e.

not having work, feeling always tired, feeling sad).

Survivors of S/GBV may not recognise the type of support being offered, whether they are entitled to it, or its benefits.

5 3 .
5 3 .

p C. Past experiences: Whether disclosure of S/GBV acts that could have an impact on health or mental health may easily be tied into their past experiences.

Whether this is due to patriarchal societies, that automatically distrust a woman’s disclosure, or due to abuses experienced at the hands of staff either in countries of origin or in transit, survivors of S/GBV may feel reluctant to recount their experiences and distress to personnel involved in their care.
This statement holds true to an extent to the Maltese persons who may have felt disappointed or failed by the system, professionals should always account for the fact that the severity of such incidents varies drastically.

D. Cultural sanctions against acts of S/GBV: The Better Future team noted throughout its experiences drastic variations in how different acts of S/GBV are perceived.
By and large, physical abuse within an intimate relationship or by staff is widely recognised as ‘wrong’, other forms of S/ GBV may not be as immediately noticed.

While DV and human trafficking is currently at the forefront of concerns in Malta, frontline staff should always consider that there are many other forms that on the surface may be considered ‘acceptable’.

As a result, the impact on health and mental health may not be recognised as immediately by survivors.
All of this is not to say that there is no expression of symptoms, or that it is always undetectable.

The clearest indicators are complaints of sleep disturbance, either in the form of sleep / wake patterns, or through spontaneous awakenings during the night.

Particularly in cases where the person has a physically demanding job, such disturbances are a clear indicator that there are mental health issues at play.

Often times, respondents may complain of having ‘too many thoughts’.
Some of the clients that have been treated had an easier time verbalising their thoughts, rather than their emotions.

As such, many of the clients accessing “Better Future” services - even in the form of short term interventions and support, had complained of having too many thoughts, nightmares, too many ideas, or the opposite - being unable to think, experiencing mental blocks, and experiencing difficulty to concentrate.
Irritability and anger can also find an easier way onto someone’s list of concerns, and while there are gender norms sanctioning expression of anger in women, questioning certain worries while carefully highlighting that there will be no judgment and information will remain confidential may elicit further responses.
Women appearing to be overtly aggressive or extremely resistant, isolating and irritable may have experience mental health struggles that cannot be as readily communicated (or accepted) as women from the host community which are accustomed to mental health practices.

Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook Another barrier that requires consideration is the manner in which people prioritise their needs.

According to Maslow’s pyramid of needs (fig.


1), people concerned with their immediate issues may not be able to verbalise issues pointing to psychological issues while they are in need of basic security (i.e.

food, employment).

Several suggestions in side-stepping such barriers in conducting a mental health assessment will be presented in other sections within this handbook.

The need for self-actualisation Experience purpose, meaning and realising all inner potentials.
Esteem Need The need to be a unique individual with self-respect and to enjoy general esteem from others.

Love and belonging needs The need for belonging, to receive and give love, appreciation, friendship.

Security need The basic need for social security in a family and a society that pro- tects against hunger and violence.

The physiological needs The need for food, water, shelter and clothing.
In conclusion: • • • • • • Search for signs of physical complaints that have no medical explanation Consider that people might try to minimise or obscure their physical and psychological suffering Search for cognitive signs for an emotional disorder If available, account for the person’s history Search for signs of irritability Inquire about sleep patterns and other personal issues.

p .

3 6 SERVICE OBJECTIVES IN THE MALTESE CONTEXT 7 3 .
p The Better future project has been pioneering in addressing gaps in the system which were previously raised.

Once the preliminary mapping report had been concluded, it provided service developers with a basic understanding of which issues Better Future can assist with, as well as initial network of stakeholders.
As such, the service has been set out with three fundamental goals in mind: • To promote mental health support for women at risk of S/GBV, through female interpreter services • To identify cases of S/GBV and tackle them through counselling or referral to counselling?

Other services?
Other services?

• To strengthen and develop the necessary multi-agency response to cases of S/GBV More importantly, Better Future presented a pilot project for a new type of service - one that was able to evolve and lend itself to women’s needs, which included moving the team to a different location, where they were needed, rather than expecting women to travel and access the service by themselves.
From an operational perspective, this essentially developed Better Future into a small unit of professionals: mental health and cultural mediators, which were mobile across the country, and striving to be present in as many parts of migrant women and their families’ journey as possible.
Due to its intended flexibility and adaptability to necessities, the Better Future team took on multiple roles throughout the year, which then multiplied to several other objectives: • Provide consultation to other services where needed; • Offer information and outreach on gender and health issues for women residing in open centres; • Liaise with other entities in view of the provision of specialised information to women in open centres; • Facilitate collaboration and referrals between different entities; • Establish itself as a focal point within the centres; • Network in light of the strengthening inter-agency collaboration and information sharing; • Mediation between staff and service users; • Provide cultural mediation services wherever necessary; Better Future had always chosen to try and be as responsive as possible to women’s needs, as well as establish itself as a project / entity to be trusted by the community and service providers alike.
Often, this meant stepping outside of its S/GBV mandate, in order to address more immediate issues that were affecting service providers - such as conflict management and offering a platform for interpretation services.
Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook SERVICE USER ANALYSIS MWAM SERVICE USERS BY GENDER/AGE/NATIONALITY, NO OF SESSIONS HELD, LENGTH OF CASES The service succeeded in facilitating connections with a number of local partners, most notably those involved in similar migrant related services.
This is reflected in the information below: Total number of users: 31 Referrals among Service Users: s r e s U f o r e b m u N 30 25 20 15 10 5 0 Referral No Referral Referral organization Number of Percent (%) users (n) AWAS 10 JRS Community Self - referral Mount Carmel Hospital Break the Cycle IOM University of Malta Xchange 9 3 3 2 1 1 1 1 32.26 29.03 9.68 9.68 6.45 3.23 3.23 3.23 3.23 ReferralsOrganizations among Service Users: s r e s U f o r e b m u N 10 8 6 4 2 0 p .
3 8 A W A S JR S C o m S elf-R eferral M o u nt C ar m el H ospital m u nity Breack th e C ycle Xchan g e M IO U niversity of M alta Need of interpreter among Service users: Number of sessions among Service users: 9 3 .
p 18 15 12 9 6 3 s r e s U f o r e b m u N 0 Interpreter n e e d e d N o interpreter Number of sessions Number of users (n) Percent (%) 1 2 3 4 10 12 15 17 25 30 Total 2 10 10 2 1 2 1 1 1 1 30 6,45 32,26 32,26 6,45 3,23 6,45 3.23 3.23 3.23 3,23 100 Gender Based Violence (GBV) among Service users 15/31 cases of GBV known from the start 4/31 (%) cases of GBV discovered through counselling Service Users by Country of Origin: s r e s U f o r e b m u N 6 5 4 3 2 1 0 C ote d’Ivoire Libya S o m alia S u d an Eritrea P akistan Siria B an gla d esh C a m ero o n Ethio pia Country of Origin Number of users Percent Libya Somalia Cote d’Ivoire Sudan Eritrea Pakistan Syria Bangladesh Cameroon Ethiopia Iraq Malta Mexico 6 6 4 3 2 2 2 1 1 1 1 1 1 Total 31 19.35 19.35 12.9 9.68 6.45 6.45 6.45 3.23 3.23 3.23 3.23 3.23 3.23 100 Ira q M exico M alta Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook GUIDELINES AND LESSONS LEARNED VIGNETTE: UNDERSTANDING DIFFERENT CULTURAL PERSPECTIVES Scenario Outline: Sarah is an American English teacher who works abroad away from her country.
At the public high school where she teaches, she forms part of a minority of female teachers.

The teachers meet before classes start every morning.

Upon arrival, each male teacher shakes hands with all the other male teachers at the gathering.

They usually greet Sarah, but do not shake her hand or approach her.

Sarah feels excluded by her colleagues because they refuse to greet her in the same way as the other male teachers.
She feels disrespected and unaccepted by the other teachers because of her gender.

Examining the situation from a cross-cultural perspective: 1.

Consider relevant cultural aspects that may be influencing behavior.

While the situation seemed disrespectful from Sarah’s cultural perspective, she realized there were local cultural factors affecting her colleagues’ behavior.
Because of the community’s conservative religious beliefs and cultural practices affecting the interactions between men and women, the men were acting respectfully and appropriately according to their cultural tradition.

2.

Try to determine the motivation behind the issue.

While an interaction may be perceived as disrespectful from one cultural perspective, it may not have been intended in that way.
After examining the relevant cultural factors, Sarah realized that her colleagues’ behavior wasn’t motivated by bad intentions.

She observed that, in spite of treating her differently, they continued to respect her work.

3.

Speak to someone familiar with the cultural context who can provide insight into the situation.

Sarah explained the interaction and her response to a close female colleague, while being clear about her own cultural context.
The colleague was able to share some perspective about the situation, including the relevant cultural factors and the reasoning behind the behavior.

4.

Determine whether or not the behavior is getting in the way of successfully performing the job.

After gaining more understanding of the interaction, Sarah realized that it was not interfering in her ability to complete her work.

While her colleagues greeted her differently than the other teachers, her ideas and her work were respected.
She decided against publicly complaining about the issue and continued to build on her professional relationships with her colleagues.

p .

4 0 VIGNETTE: CULTURAL APPROACHES FROM A SERVICE PERSPECTIVE 1 4 .

p Case example: The Better Future team is about to conduct their first group session in one of Malta’s open centres.

It had prepared itself with two interpreters and two facilitators, and was ready to explore the topic of gender and womanhood with a group of 10 women.
The team was hoping to steer the conversation towards the topic of gender-based violence and use the group as a platform to screen for potential signs of distress.

As soon as several group members sit down in the common room, the team decide to hold off from beginning the session until a larger group of women assemble.

As time wears on, the team decide to make small conversation about everyday life, before breaching the bigger topic of gender and violence against women.
However, as soon as they start describing themselves as helpers, they are met with a number of questions - Why are they there?

What is their role?

Why should the team be trusted?

Why are they unlike other organisations that promised but failed to deliver?

Soon enough, the team is roped into a heavy discussion about everyday needs and are feeling pressured into having to define their role by what they are doing or not doing.
Having to repeat what they are not able to do is increasing the frustration on both sides.

Once the team does manage to communicate that they are there to cater for women, and specifically for their mental health problems, they are met with an even sterner barrage of questions.

Can they not see what the problems are?

Can they not understand that the women do not have other problems apart from material struggles?
The team emerge from the session overwhelmed, without having addressed what they had originally intended to, but rather with a long list of issues to attempt to solve.

What happened?

This initial session represented a hard earned lesson for the team.

They had decided to tackle the open centre as a structured service, with the expectation of a similar understanding from women attending the session.
While the Better Future team had its best intentions for the first sessions, it had failed to take into account a number of issues.

: Needs are based on a hierarchy: A very basic element of this encounter which the team had not taken into account, was that the topic they were attempting to bring into the session was not addressing immediate concerns that were indeed pressing to the women attending .
As a result, attendees could not recognise the purpose of the team raising the topic of gender and mental health as a valid one.

The same may be emphatically said about any service with a long term type of approach, including certain types of education services (i.e.

language classes, skills builders, etc.)

and even police services.


Gender dynamics have a noteworthy impact as well, since mothers would most certainly prioritise their children’s needs above their own and therefore be less receptive to services targeting them, or struggle to access those services due to lack of childcare.
[ Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook Overpromising should be avoided: In par with the previous point, when confronted by a number of issues - ranging from complaints about staff, material scarcity, questions about rights and responsibility, people have the natural tendency to try and promise action on behalf of their clients as a way to appease frustrations and try to showcase their trustworthiness.
However, if staff are presented with a problem that doesn’t have an immediate solution (and most do not), or if the problem falls outside the scope of the service; it is counterproductive to attempt to promise an attempt at a solution as it may result in trust being frailed even further, and it may reinforce a sense of helplessness.

This is what could easily have happened even before the Better Future team set foot in the centre as a result of other entities’ tendencies to overpromise.
Trust is not a given: The main challenge for the team was the assumption that, on account of being humanitarian workers with good intentions, they would be automatically trusted.

However they did not take into account that women would have met with a number of personnel with varying degrees of professionalism, trustworthiness and ability to respond appropriately.
Such encounters could have left women feeling jaded towards yet another wave of helpers, and thus not necessarily willing to open up and listen to what the team might have had to say.

Moving a step further, many women would have had extremely negative or traumatic experiences with authority / NGO workers / police forces and therefore would have little reason to trust the service presented.

Roles should be communicated: Attendees had entered the session with a number of expectations of their own.
Without knowing who the persons standing before them were, or what the scope of their role was, they were able to quickly fill in the blanks with what they thought NGO workers should do.

The team had not communicated their roles immediately, but rather chose to begin conversing about everyday needs, and described themselves in non-specific terms (“we’re here to help”).

This led the group to believe that their goal was to collect doleances.
As a result, the team’s inability to respond to questions created an atmosphere of frustration and disappointment that was difficult to overcome in one hour.
What could have been done better: Familiarising the staff and team with people’s everyday life: Prior to the initial information session, the team should have spent time familiarising itself with everyday life in the open centre and its people, gathered first hand information about its micro-culture, and treated it as any first time community encounter.
In the absence of the expectation of a structured session, the team would have then had the chance to establish initial rapport with at least some of the centre residents.

Additionally, it would have served them to understand how residents would receive potentially controversial information about gender and mental health.
Communicating roles with clarity: The facilitator should have introduced themselves as a counsellor, and describe their role as a mental health professional - from the start, without trying to avoid the topic of mental health out of fear of negative responses.

Being frank about one’s purpose and goal may have caused one or more women to leave but it would have clarified from the very start what the team does.
Acknowledge more pressing needs: The team could have also acknowledged that needs are also prioritized according to urgency - while mental health issues do tend to have a negative impact on everyday function, they are less likely to be acknowledged as a separate problem but rather understood p .

4 2 holistically.

However, systemic issues require a long term approach which needs strategizing and planning, rather than taking in complaints.
Mediating between what the service offers in practical terms and the gap of needs requires a lot of transparency and clear communication.

Taking the case in point, granting women the right to open up about what is pressing them on a daily basis, whilst establishing whether there is any course of action for them, would have helped them feel better understood and would have carried the message that the service is not blind to daily struggles.
The initial contact should be seen as a trust-building exercise rather than an information delivery session, and in order to build trust, honest conversations about the scope and function must be considered.

The team should have ensured to acknowledge that there are needs that may be more pressing, and that those can be taken into account, but without taking the role of centralising complaints.

3 4 .
3 4 .

p Familiarize outreach workers with salient aspects of the community: Not all service providers need to consider such an effort - nevertheless, community outreach workers do need to have guiding steps prepared in order to be able to familiarise themselves with the culture at the stage of initial exposure.

Additionally, however, all service providers are encouraged to communicate their role mandate as clearly as possible.
In the eventuality of having received a referral, the professional point of contact for that referral should always explain why a woman was referred, the role of the referee agency, and the limits of their service.

Communicating and reinforcing such information beforehand ensures transparency and fosters collaboration.
While frontline staff who are conducting an intake may presume that certain elements of their profession should have been communicated beforehand, they should nevertheless retake the same steps.

Communication should be in a medium understood by service recipient: this may include appropriate sign language, braille and language support.

Therefore, before initiating contact with a new client group the service provider must consider the possibility to include an interpreter.
Even if recipients may have a conversational command of Maltese/English, ensuring full comprehension should be kept at the forefront of their priorities.

The onus of being understood lies with the service.
Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook HOW TO APPROACH MIGRANTS AND MIGRANT COMMUNITIES: SUCCESSFUL OUTREACH STRATEGIES While every migrant community is different and will require different approaches to effective outreach, we’ve identified a few key strategies for successful outreach and effective communication through outreach with migrant communities in Malta.

1.

DON’T make assumptions about what people do (or don’t) know about mental health.
Never make assumptions about people’s understanding of mental health.

While you should never assume that people will automatically have a baseline understanding of what mental health is, you should also never assume that everyone is unfamiliar with the notion of mental health.

Using terminology that is too simple may seem patronizing or even insulting, especially if you’re working with medical professionals.
If you’re in a group outreach situation, get a feel of the room by asking about the background of the group.

Then relay your information in a way that allows you to respect everyone’s previous knowledge, while also reaching those who may not know.

Start your basic definitions with “for those of you who may not know” to introduce what is being presented, and ensure that no one in the group feels patronized or left behind.

2.
2.

DO establish baselines on the level of understanding of the outreach topic when possible.

Understanding what people know about the subject and their backgrounds can help you to be clearer and more effective in outreach.

However, this may not be feasible depending on the size of the group and the specifics of the outreach.

In small groups or with individuals, gauge the level of understanding in the group and use this to determine how you approach the topic of outreach.
It’s also helpful to assess several factors in the group you’re working with, such as levels of education and self-expression.

If you are working through an interpreter and the level of self- expression is unclear, ask them to assess the individual based on their language and expression and to determine, to the best of their knowledge, if the person sounds highly expressive or uses more simple language.

This can allow you to target the information to this specific audience.

3.
3.

DO explain your role and the topic of outreach from the beginning.

From the start of the outreach, clarify your role and purpose.

Use clear and concise terms, both for the sake of the participants and the interpreter.

Make sure that you are open with the group or individual about who you are and what the topic of outreach is, in order to establish trust and ensure participants understand what you will be discussing from the beginning.

4.
4.

DO communicate effectively and clearly when working with an interpreter.

When working with communities that speak a different language, an interpreter is essential to ensuring your outreach is effective.

The success of your communication with the interpreter will directly impact the effectiveness of the outreach itself.

If you are working with an interpreter, make sure to collaborate them so they are able to communicate your message effectively.
Use clear and concise terms and speak in small sentences.

Also, always give the interpreter enough time to translate fully and precisely.

When working with specific groups or discussing sensitive that your issues, also make sure interpreter is appropriate to the context.

For p .

4 4 example, many migrant communities are sensitive to gender, and having a male interpreter when working with female migrants on sensitive issues may cause discomfort and an unwillingness to participate.

5.
5.

DON’T assume that people take for granted the same systems and services that you do.

Mental health understanding and prioritizing varies greatly across cultures and individuals.

The same is true for the ability to access and the availability of facilities and services in other countries.

Regardless of their educational background, never assume that people are taking for granted the same services, systems and procedures that you are.
While a procedure or system may seem like common sense or standard practice to you, never assume that it is a standard practice to everyone.

When promoting a service be sure to detail all important information and make its characteristics clear.

6.

DON’T assume your information will be well received and immediately acted upon.

Individuals may have had a wide range of previous experiences with different services, both positive and negative.
They may also have previously tried to access services but were unable to.

Consider the various barriers that might be limiting individuals from accessing services, including language barriers, gender, nationality, legal status, lack of information, and others.

These barriers may restrict or completely stop these individuals from accessing services and leave them frustrated and unwilling to pursue these services in the future.
Before presenting your outreach or promoting a service, learn the room beforehand and consider the various barriers to those individuals.

Take into account the factors that may be considerations to pursue access to services and incorporate those into your presentation.

7.

DON’T assume that women will receive the service well.

When doing outreach with women, make sure to consider the various factors that affect gender issues and roles within their community.
Cultural expectations and individualism and collectivism may cause women to perceive issues around certain services as a rupture from their community values and expectations.

This includes things like child protective services, protection orders, and even emergency shelters and mental health programmes.

They may receive these services poorly or even reject them outright.

5 4 .

p Consider cultural factors that may affect the reception of these services beforehand.
When presenting these services, make sure to explain when and how these services would be used.

8.

DO use feedback to constantly improve outreach.

Feedback is an important tool to learn about outreach effectiveness and work towards improvement.

It is also an important way to demonstrate that you value the opinion of the communities that you are trying to serve.

Reach out to the communities you are working with and a range of individuals in order to collect feedback and information about outreach.
Take care to ensure that feedback isn’t just received from the loudest voices in the community, but also vulnerable groups that may be more difficult to reach.

Various feedback mechanisms can be used in order to assess what is and isn’t achieving the outcomes you are seeking.

Generally having more than one method of feedback will allow you to reach different audiences and gain a variety of responses.
Honest and open feedback is the most valuable both to you and the community that you are working with, and this can be achieved by allowing anonymity.

Ultimately, feedback is there to help ensure outreach is effective, and also ensure communities and individuals have a voice as well.

9.

DO recognize that every migrant community is different.

Understanding and acceptance of the various topics of outreach may be vastly different across cultures and groups.
Additionally, every individual and group will have different needs and expectations.

There is no one-size-fits-all approach to outreach.

The way you engage every community may need to be different.
Never assume that what was done previously will work for any future group, Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook WORKING WITH INTERPRETERS THE NEED FOR INTERPRETATION CULTURAL MEDIATION IN MENTAL HEALTH SETTINGS As there are many culturally diverse people living in Malta who require access to health and social services, there is great need for the services of language interpreters.
Language allows us to understand the world we are living in, explain our own world, and connect with others.

Language represents an entire system of thought.

For mental health professionals, it is the only tool which allows a therapeutic relationship to form between the client and practitioner, allowing them to create a space of understanding and work towards change and healing.
In contexts of physical health, language enables the medical professional to fully understand a patient’s symptoms, the mechanism of injury and whether the treatment is effective.

Because it is impossible to provide a high quality service without effective communication between a health practitioner and the client, it is the practitioner’s responsibility to consider the use of an interpreter during treatment.
Whenever the client prefers to speak, or is more fluent, in a language other than the practitioner’s primary language, or when consultation is impaired due to inadequate communication, an interpreter should be used.

It is also important to remember that a person’s second language competency may decrease during times of stress or in the presence of a thought disorder, delirium, dementia, anxiety or depression, making the need for an interpreter even more important.
The failure to use an interpreter when one is warranted can lead to misdiagnosis, inaccurate assessments, ineffective treatments, adverse effects of intervention and additional costs in the long-term.

Health providers should consider undertaking a language needs analysis for the service for the service population and consider how to best meet identified needs.
There is some debate as to whether interpreters should merely translate the spoken word or play a role in interpreting cultural and contextual variables that may be relevant to mental health issues.

It is important to remember that the modern disciplines of mental health, psychology and psychiatry were developed through the lens of western ideology, making it difficult for people from other cultures to grasp certain concepts.
For example, views on the body and the mind as separate things, notions of the self, views of the family structure, treatment options, notions of individualism and collectivism may differ from culture to culture, and an interpreter may need to ensure that the practitioner understand the client’s understanding of these notions.

It is a health practitioner’s responsibility to familiarise themselves with culturally appropriate ways of supporting clients from culturally diverse communities.
THE ROLE OF THE INTERPRETER involving precise, effective and The ability to speak both the working language and the language of the service user does not qualify someone to take on the role of interpreter.

Interpreting is a highly specialised timely skill translation of information from one language to another.

Interpreters must ensure that they have adequate training in their roles and work with impartiality, confidentiality, accountability and strive for accuracy.
Frequently, the interpreter has an advantage over the practitioner in terms of developing rapport with the client, and it is vital that the interpreter prioritize and protect the therapeutic relationship between the client and practitioner.

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4 6 1.

Consecutive Interpretation In this common type of interpretation, the interpreter listens to a segment of speech, then repeats what they have heard in the language of the listener.
The speaker then resumes his/ her statement, before pausing again to allow the interpreter to translate.

In this way the interpreter alternates with the speaker.

The length of what can be retained before rendering the translation will depend upon the complexity of the statement being made, and upon the interpreter’s own experience.

A new interpreter will need to keep the segments short (no more than a sentence or two).

A more experienced interpreter will be able to take in longer segments58.
Some interpreters use the first person when interpreting (saying ‘I’ when responding with the service user’s words).

This is often preferable because this wording can give a more accurate rendition of the words and emotions being expressed and convey a better sense of immediacy59.

However, it is important that interpreters who find this uncomfortable be allowed to use the third person.
Most interpreters move between the first and third person, or will become more comfortable using the first person as they know and understand the client better.

2.

Understanding Pauses As an interpreter, it is important to respect pauses in mental health therapy, as they are one of the most important therapeutic tools.

Silences carry as much meaning with them as words do.
Silences are filled with texture and feeling, and can have therapeutic, neutral, or destructive effects on the therapeutic relationship.

While there are silences that feel awkward, indifferent, or even hostile, there are also silences that feel comforting, affirming, and safe.

They resonate with the ease of a patient and clinician exchanging feelings and thoughts that do not quite make it into language60.

7 4 .
7 4 .

p The difference between an invitational silence and an awkward one is the professional’s intention.

The clinician deliberately creates a silence meant to convey empathy, allow a patient time to think or feel, or to invite the patient into the conversation in some way.

Therapists generally think of themselves as actively creating this kind of silence.
While we recognize that these silences are tremendously valuable61, we also note that these silences are often described as a kind of holding, which has a stage-setting, expectant quality62.

3.

Transference and Countertransference As an interpreter, the person is equally exposed to both transference and countertransference.

Even though the interpreter’s role is to facilitate communication, it is always possible that their own emotions and perceptions can bias the way they translate.
A lot of meaning can be lost if the interpreter carries an unrecognized bias63.

It is important to recognize countertransference – and discuss this with the practitioner.

Examples: • The interpreter recognizes herself in her client’s actions, or thoughts, and mistakenly discusses her own issues instead of those of the client’s.

• The interpreter feels that the client is making wrong choices, or does not approve of a personal characteristic of the client but does not realize it.
She is then adding a lot of negative meaning to the client’s words instead of ensuring a neutral translation.

the clinician-patient relationship.’ Ann Fam Med ;7:80–83 61 Rushton CH.

2009, ‘Ethical discernment and action: The art of pause.’ AACN Adv Crit Care.
;20:108–111 62 Back, A. L., Bauer-Wu, S. M., Rushton, C. H., & Halifax, J., 2009, ‘Compassionate Silence in the Patient–Clinician Encounter: A Contemplative Approach.’ Journal of Palliative 58 UNHCR, 1993, ‘Interpreting in a Refugee Context’ Available Medicine, 12(12), 1113–1117.
http://doi.org/10.1089/ at: http://www.unhcr.org/publications/legal/3ae6bd5f0/training- jpm.2009.0175 module-rld3-interpreting-refugee-context.html 63 Bias - a person prefers an idea and possibly does not give 59 Pérez-Foster, R. 1998 ‘The power of language in the clinical equal chance to a different idea.

Bias can be influenced by a process.’ Maryland: Rowman Littlefield Publishers Inc. number of factors, such as popularity, emotional connection, 60 Buetow SA.
2009, ‘Something in nothing: Negative space in familiarity, etc.

Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook THE ROLE OF PRACTITIONERS WORKING WITH INTERPRETERS literacy, Practitioners need to be trained both to work with interpreters and to feel confident in so doing.
All in practitioners should consider participating training courses, or, if working with an interpreter unexpectedly, allocate time to consider the issues or discuss them with a more experienced colleague prior to their first session with an interpreter.

When selecting an interpreter, consideration must be given to the client’s ethnicity, religion, education, language and preference for gender or country of interpreter.
It should not be assumed that someone who speaks a language can speak/understand it in all the dialects64, It is necessary to work collaboratively with the interpreter and commit to a working relationship based on trust and mutual respect across all parties.

Create an atmosphere where each member of the group feels able to ask for clarification if anything is unclear.
If the service user will be seen for a number of sessions, the practitioner should try to use and book the same interpreter throughout to encourage rapport and build trust between service user, interpreter and practitioner.

This will make the process flow better, contain anxiety for all participants and is likely to lead to better outcomes65.

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Managing the Shift in Dynamics of an Interpreted Session Attention must be paid to the shift in dynamics that the inclusion of an interpreter may bring to 64 Tribe, R. with Sanders, M.; 2003, ‘Training issues for interpreters.’ In R. Tribe & H. Raval (Eds.)
Working with interpreters in mental health London & New York: Brunner- Routledge, 54–68 65 The British Psychological Society, 2017, ‘Working with interpreters: Guidelines for psychologists’ Available at: https:// www.bps.org.uk/sites/bps.org.uk/files/Policy/Policy%20-%20 Files/Working%20with%20interpreters%20-%20guidelines%20 for%20psychologists.pdf p .

4 8 the therapeutic setting and how this might be managed.
Especially in contexts where there is a closely-knit ethnic community, it is possible that the client may have a pre-existing non- professional relationship with the interpreter.

It is necessary that the practitioner warn the In such cases, it may help the client to feel comfortable and share information freely; however, the practitioner may be confronted with additional challenges in developing a therapeutic relationship.
Conversely, the client may be more wary of speaking freely, as they may be anxious about being identifiable within the community and their information being shared.

It is best to address this issue directly.

The practitioner and interpreter must avoid dialogue which is external to the interpretation, as this side conversation will likely make the client uncomfortable and untrusting.

2.
2.

Managing the Content of an Interpreted Session Consideration must be given to ways in which a practitioner might adjust their use of language and communication style when working with an interpreter.

• Avoid using complicated technical language.

• Words and signs often do not have precise equivalents across different languages, and a short sentence in English may take several sentences to explain in another language or vice versa.
It is important for the practitioner to be patient if the interpreter takes longer to interpret than expected • Avoid using proverbs and sayings, which may be culturally specific and impossible to interpret.

If something does not make literal sense, it is usually best avoided.

• Because the pace of the session becomes slower and perhaps disjointed when using an interpreter, practitioners should be aware that it can become easy to lose concentration or to lose the thread of the session 3.
The Physical Space of an Interpreted Session It is important to consider the appropriate seating arrangement for the type of consultation you will be conducting with the client and interpreter.

For example, if the session is therapeutic in nature, the psychologist should ensure that the seating is arranged such that a triangle is formed between the client, the psychologist and the interpreter.

The psychologist and the interpreter should ideally be equidistant and sitting facing the client.
The psychologist will maintain eye contact with the client, not deflecting their gaze to the interpreter.

If a carer or family member is present, the chairs could be arranged in a semi-circle; this will ensure that the clinician can speak directly to all parties involved.

However, if the purpose of the session is cognitive assessment with formal tests, the client and practitioner should sit opposite each other, with the interpreter sitting at the side of the client.

4.
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Debriefing and Ensuring the Well-Being of the Interpreter It is imperative that the practitioner keep in mind the well-being of the interpreter and the fact that the interpreter does not necessarily have the training required to deal with the emotional content of the session.

Be mindful of the risk of vicarious traumatisation and consider what support the interpreter might require.
The practitioner and interpreter should plan to meet for 15 minutes following the session to give the interpreter the opportunity to process feelings and reactions that they couldn’t exhibit during the session.

A debriefing meeting imperative not only is to ensure that the interpreter will not carry an emotional burden from the session, but also to clarify any content of the session which was unclear or unspoken.
The interpreter should be encouraged to reflect on the client’s phrasings or body language that may give added meaning to the actual translated content.

It may be useful for the practitioner to hear about any hunches that the interpreter had during the session, or about any moments when it felt that the client had something to say but didn’t share.
The debriefing discussion serves as a review of the session, allowing for both counsellor and interpreter to exchange opinions, identify points to clarify in subsequent sessions and add any potential points to the treatment plan.

QUICK TIPS FOR THE INTERPRETED SESSIONS 9 4 .

p • Because meetings conducted with an interpreter may take longer, account for this when booking appointments.
• Allocate 10–15 minutes in advance of the session to brief the interpreter about the purpose of the meeting and to enable them to explain any cultural issues that may have bearing on the session.

• Ensure that the seating is arranged such that a triangle is formed between the client, interpreter.

The the practitioner and the practitioner and the interpreter should ideally be equidistant and sitting facing the client.
• The practitioner will maintain eye contact with the client, not deflecting their gaze to the interpreter.

• Allocate 10–15 minutes at the end of the session to debrief the interpreter about the session and offer support and supervision as appropriate.

RECOMMENDATION It is our recommendation that all people living in Malta have the right to access available services and ensure that these services are effective, irrespective of the service user’s ethnic background and first language preference.
As such, a centralized system should be devised for interpreters in Malta.

Having a shared pool of interpreters who have been vetted and received adequate training will provide improved accessibility for entities such as clinics, hospitals, open centers, shelters, schools, and NGO’s, making it more likely that the patient receives the services that they need.
As well, having an agency for interpreters will hopefully ensure that they are receiving the support and compensation that they need in order to remain engaged and professional in their work.
Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook HOW TO ESTABLISH A WORKING RELATIONSHIP Perhaps all practitioners wonder about similar issues: how to ask the right questions, how to interpret the signs of distress, how to provide the best support, and how to manage difficult clients, or those who don’t appear to want the practitioner’s help.
At the core of any effective therapy is the therapeutic rapport which must be built between the practitioner and the client.

A working relationship can be defined as a good relationship which allows two parties to work towards their common goals.
A working relationship can be applied to any type of helper - client dynamic including centre support worker - resident, social worker - service user, doctor - patient, counsellor - client, and is established by a positive interaction between a person and their service provider.

Regardless of the nature of the relationship, any staff engaging with their client needs to be founded on building the essential element of trust.
The Better Future team has noted how trust can change the way messages are received, and how it then impacts outcomes in the long term.

Whilst in the middle of mediating between two parties, or conveying a set of rules and regulations, the team noticed that established trust ensured that beneficiaries were more open to treatment and more willing to accept any suggestions and rules.
Workers who were closer and in a more trusting relationship with their beneficiaries usually had the ability to provide input that would be better accepted than that of a specialist, for the simple reason that they have the key of any healthy working relationship.

The following non-exhaustive list represents how to best establish a good working relationship with a client, based on our experiences: Avoid prejudice A.
While staff may have dealt with persons from a certain country in the past, one must bear in mind that culture only predicts a small part of an individual’s way of responding to their context.

It may seem counterintuitive to suggest that culture should not be accounted for, given the scope of this Handbook, but culture does not represent the totality of an individual.
As a result, experience of having dealt with a number of other individuals from the same country mustn’t be taken as a blueprint of how a particular service user will behave.

Another common misconception and assumption is that the asylum process has been easy, and facilitated a way into Malta.

That is often not true.


Asylum applicants are faced with compounded issues which are not easily overcome due to language barriers, issues around discrimination, difficulties accessing appropriate services or being refused services.

Due to all of these challenges that people face, they may feel extremely reluctant to ask for help, to express themselves freely in fear of reprisals, or even to regard assistance offered p .

5 0 as a form of help.


Obviously, opposing prejudices initiated by staff will only heighten the barrier.

Approach a person with benevolence, and without assumptions.

different Approach cultures with B. curiosity It has been noted that often service providers are compelled to resort to assumptions.

This is often due to a service provider’s caution around being perceived as harassing a client by asking too many questions about cultures.
Asking friendly, open ended questions about what made people feel unsafe in their countries of origin, questions about norms and habits, and questions about their day to day life in their country of origin can be effective if used with the right intention.

Genuine care and interest about COI is an effective tool in acknowledging the cultural differences in a healthy way, as well as showing desire to establish a common ground.

The key aspect to consider is the tone and context of the question.
Many women with whom Better Future came in contact reported feeling harassed on the 1 5 .

p street by strangers asking why are they in Malta, because the subtext had been “you should not be here”.

While frontline staff cannot control acts of harassment and discrimination, they can be aware that tone of voice and openness have an impact on how the trust is established.

The same women who would report harassment on the streets would welcome genuine questions about COI realities.
In the case of mental health workers, this is a particularly important element because it will give insight not only into the culture, but what it was like for the client to experience that culture.

Any encounter with a new culture should be taken as an opportunity to develop one’s skill set.

Trust the cultural mediator C. While ideally the first person to ask about their culture is the client themselves, cultural mediators are also a valuable resource.
If the cultural mediator is not ad-hoc (brought in by the client or found amongst hospital cleaning staff, etc.)

but comes from a reliable source (NGO/government/ UNHCR worker), reaching out for their opinions may help enhance a working relationship.

Therapists, psychologists and psychiatrists are particularly encouraged to allocate time after a session to ask for feedback.
More often than not, the cultural mediator should be able to offer valuable input on how to manage a professional relationship, and how to interpret behavioural and social cues from the client (See “Working with Interpreters” for more information).

D. Break down all concepts to their simplest Multiculturalism is an exercise of different belief systems coexisting in the same context.
One must assume that not everyone is on the same page, not everyone operates by the same notions, and not everyone has the same history.

That means that, in particular for S/GBV survivors, it is essential for staff to try to make everything as transparent as possible.

Particularly in cases where multiple agencies need to be involved in order to tackle different aspects of the case, it is important to explain the role of every actor.
Simply stating what profession is reached out to - or worse - involving them without asking for consent can result in negative outcomes.

The approach that has always been effective for Better Future was its complete transparency with service beneficiaries.
In the case of any intake that necessitated the involvement of external personnel, Better Future staff has been explicit regarding consent for sharing specific information, the reason for involving external personnel, and their role and level of involvement in the case.

As a result, women felt more trusting towards the service, and towards any agency Better Future has referred.
Moreover, The same notion applies to medical treatments, particularly psychiatric medications, which tend to be perceived as an unknown.

Talking clients through the therapeutic process, what they might be expected to do, how they might be experiencing as a result of treatment, and where to ask for help in case of side effects, was proven to reduce the rates of non-compliance with treatment.
Being honest and explicit about the client’s personal support, explaining their situation and the plan to assist them in terms as non-non-technical as possible convey the message that they are at the centre of the plan.

While conveying complex medical or legislative notions in a simple and understandable way may not be easy, this may be the only way to ensure that trust is being built.

In turn, the client will likely feel more empowered and in control of their own life.
This shifts the relationship from that of authority, to one of collaboration.

E. Offer support and information regarding other services This advice, as a general rule, applies to all service beneficiaries, as the “Better Future” team has noted that certain agencies wouldn’t even be known to all Maltese women, or not always.
However, this is even more true considering the fact that many women have language barriers, information gaps, accessibility problems that prevent them from learning and/or accessing other related services.

For example, a woman going to a psychologist in Mount Carmel, experiencing a disability that might make her eligible for Agenzija Sapport or with a socioeconomic problem making her eligible for Agenzija Appogg must be guided accordingly by the psychologist.
The service provider already in contact with a service recipient should take charge in referring and informing them about other services.

This goes hand in hand with their openness and honesty about what they can or cannot do in terms of help towards the woman asking for help.

Reducing expectations and working to increase trust in other parallel social welfare or health services will improve overall quality - as one professional would be aware of the actions of their colleagues from other sectors.
Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook In conclusion, a healthy working relationship is founded in openness and honesty.

It must also be recognised that the onus of overcoming barriers lies mostly with the service provider, whose role is to assist in whichever way they are mandated.

Survivors of S/GBV are a particular vulnerable group, and can have a difficulty in trusting helpers, which is why a welcoming, honest encounter is the most preferable.
Much of the psychological damage caused by acts of S/GBV revolves around power imbalance, and subsequent partial or complete loss of self-determination from the survivor’s part.

Whether it was as a result of a single traumatic incident, or protracted trauma, professionals should always be sensible to the dynamics that may arise with an S/GBV survivor.
Whilst establishing a working relationship, staff must always uphold a client centric approach, that acknowledges that no one is infallible in their knowledge.

Working outside of one’s own assumptions and cultural norms can be challenging, but it may be useful to remember that the survivor is the expert on their own experience.
Ultimately, no professional is infallible in their knowledge, however, any encounter with a new culture should be taken as an opportunity to develop one’s skill set, and an opportunity to develop a stronger inter-agency collaboration.

THE FUTURE OF “BETTER FUTURE” Better Future was always a response to reality, a response to needs that was always given the chance to evolve.
With the creation of this cultural handbook, and with the piloting of its procedures completed, the service is now grounded in the Maltese context and established as a reliable source for support and consultation.

However the future of the service remains much to be determined also by the ever-changing socio- economic realities of the country.

Adaptability and flexibility still remain its main tenants, and the most important efforts.
Nevertheless, “Better Future” remains committed to keeping its beneficiaries at the centre of operations, at the centre of decision making and at the centre of its goals.

While a service expansion may be in order - to ensure that the numbers and lessons presented in this handbook are going to increase, the quality and determination of developing further will still be maintained under the mandates of this.

p .

5 2 GLOSSARY OF TERMS 3 5 .


p Asylum Seeker - Person who has traveled outside of their country of origin, has applied for refugee status and international protection, and is waiting on the determination of their status.

Migrant Smuggling - A crime in which a person or group aids a migrant in illegally entering a State to which they are not a national or resident.
Gender-Based Violence - Violence directed at a person due to their gender, as well as due to the expectations within their culture and society because of that gender.

Gender-based violence and violence against women are forms of discrimination based on sex or gender.
Female Genital Mutilation/Cutting “All procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons66.” - Forced Displacement - Migration that occurs because an individual is forced to leave their home, often because of generalized violence, armed conflict, climate change, environmental disasters, or other factors.
Forced displacement may occur internationally when an individual crosses international borders, or within a country when an individual remains in their country of origin.

Human Trafficking - The act, means and purpose of moving persons for reasons of exploitation, including sexual exploitation, labour exploitation, and others.

A victim of human trafficking has not given consent to be trafficked, or their consent has been abused by the traffickers.
Human trafficking can occur both internationally and within a country.

Internally Displaced Person - Person who is forcibly displaced and has not crossed an international border.

IDPs remain within their country of origin, and may live in IDP camps or other communities.

Irregular Migration - Migration that occurs “outside the regulatory norms of the sending, transit and receiving countries67”.
Mixed Migration - Migration flows (use of the same means of transport and transnational routes) that are complex and include a variety of migrant profiles, including refugees, asylum seekers, victims of trafficking and migrants that are motivated to seek better lives and economic opportunities.
Refugee - The 1951 Refugee Convention defines a refugee as a person who has a “well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country68.” The legal status of refugee can only be conferred on an individual that matches this description and has applied for asylum outside of their country of origin.
Sexual and Gender-Based Violence - Any act perpetrated against a person’s will based on gender norms and unequal power relationships.

It encompasses threats of violence and coercion.

It inflicts harm on women, girls, men and boys.

Subsidiary Protection - A form of international protection granted to asylum seekers that do not meet the full definition of refugee status, but cannot return to their country of origin because they risk serious harm to their lives.
Violence Against Women - “Any act of gender- based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life69.” 68 UN General Assembly, Convention Relating to the Status of Refugees, 28 July 1951, United Nations, Treaty Series, vol.

66 WHO, 2019, Female genital mutilation.


Available at: https:// 189, p. 137, art 2(A) available at: https://www.refworld.org/ www.who.int/news-room/fact-sheets/detail/female-genital- docid/3be01b964.html mutilation 69 UN General Assembly, Declaration on the Elimination of 67 IOM, 2019, Key Migration Terms.

Available at: https://www.


Violence against Women, 20 December 1993, A/RES/48/104, iom.int/key-migration-terms available at: https://www.refworld.org/docid/3b00f25d2c.html Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook p .

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p Creating a “Better Future” for Migrant and Refugee Women in Malta: Cultural Competence Handbook