German outpatient psychotherapists are culturally and linguistically diverse. Nevertheless, psychotherapists with a migration background are underrepresented in outpatient mental healthcare services. Patients with a migration background are also underrepresented in the German outpatient mental healthcare system. Because mental healthcare services must be sensitive and respectful towards patients' cultural and linguistic needs, the mental healthcare outpatient service must be more accessible to therapists who speak languages other than German and English. Psychotherapeutic treatment of patients with a migration background can be tremendously challenging because of other cultures' differing value systems. Prospective, advanced training in cross-cultural sensitivity and cross-cultural supervision should be provided.

It was evaluated in an inpatient rehabilitation setting whether patients with mental or psychosomatic disorders people with a migration background are treated less frequently, profit less from the treatment, and have a higher risk for a negative outcome. On the basis of a prospective sample (n=25,066), the healthcare utilization of inpatient rehabilitation institutions, the level of mental stress, the quality of treatment, and the influence of risk factors were reviewed. Patients with a migration background show a lower level of health care utilization and a higher level of overall mental stress. Turkish patients and patients from the former Yugoslavia show the poorest treatment results. The regression analysis underlines clinical and sociodemographic factors as independent, negative predictors for good treatment results. Treatment concepts should be more strongly oriented to the needs of patients with a migration background and socioeconomically deprived patients.

There are inequalities in health among migrants and local populations in Europe. Due to migration, Germany, Norway and Sweden have become ethnic culturally diverse nations. There are barriers to mental health care access for refugees, migrants and minorities, and problems with quality of culturally sensitive care in the three countries. This is despite tax-funded health care systems based on equity in service provision. There is a need to develop culturally sensitive mental health services that respond to the increasing diversity of the populations. In this chapter, we will take a closer look at cultural diversity in the countries in question, discuss challenges and give examples of current work to open up mental health services to cultural diversity. The German example will focus on the movement of Interkulturelle Öffnung (cross-cultural opening of the health care system) and work on creating national guidelines and quality standards. From Norway, the work of the National Centre for Mental Health for the indigenous Sámi population will be presented. The Swedish example will focus on the work carried out by the Transcultural Centre. The latter is a competence centre supporting development of culturally sensitive care as an integrated part of the regional health and mental health care system in Stockholm. Finally, the relevance of mental health care for a culturally diverse population, as a part of the larger social project of building tolerant multicultural societies, will be discussed.

Globalization and cultural diversity challenge mental health care in Europe. Sensitivity to culture in mental health care benefits effective delivery of care to the individual patient and can be a contribution to the larger project of building a tolerant multicultural society. Pivotal for improving cultural sensitivity in mental health care is knowledge in cross-cultural psychiatry, psychology, nursing and related fields among professionals and accordingly training of students and mental health professionals. This paper will give an overview, and a critical examination, of current conceptualisation of cross-cultural mental health training. From German and Swedish experiences the need for crosscultural training and clinical research on evaluation will be presented.