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A. Institutional histories of the three services

Appendix A

Institutional History of Transcultural Psychiatry Services at Jewish General, Montreal Children's and Jean-Talon Hospitals

Patricia Foxen

Three clinical services in Montreal took part in the evaluation project: the Cultural Consultation Service (CCS) of the Sir Mortimer B. Davis Jewish General Hospital (JGH), the Transcultural Child Psychiatry Service at the Montreal Children's Hospital (MCH) and the Transcultural Clinic at the Hôpital Jean-Talon (JTC). For each of these services, the sections of this report review the origins, organization and intervention models, clinical ideologies or philosophies, links with other health and social services and community organizations, and perceived barriers to implementation and service provision. These capsule histories are based on interviews with the directors of the clinics and a review of available historical material. Since all of the services are relatively new and in evolution, this exercise was intended to identify main trends in the development of the services and provide background for consideration of the potential transfer of these service models to other settings.

Origins

A review of the institutional histories of the three services shows that all three developed in response to demographic changes over the past 10-20 years in Montreal, which has seen a large increase in the cultural diversity of both the general and patient populations in the city. The Côte des Neiges area, where the JGH is situated, is the most ethnically diverse area in the entire greater Montreal metropolitan area with more than half the population being foreign born. The MCH and JTC responded to an increased diversity among the specific populations served (e.g. 50 % of children are allophone (MCH) and 33% of the Jean Talon area are allophone (JTC)). As such, the services are rooted in a broader political imperative to engage and implement the multicultural mandate assigned to the health sector in Canada, and more specifically to meet the specific, and unmet, mental health needs of immigrants, refugees and cultural minorities.

Each clinic was originated by a psychiatrist with extensive previous experience in the area of transcultural psychiatry, and whose particular perspective and experience in the field has shaped the development and orientation of services through time, along with input from other professionals working with each group. All three clinics consider themselves to be fairly young institutions, with the JTC originating in 1992, the MCH in 1995 and the CCS in 1999. While all see the relatively recent and evolving nature of their services as contributing, in part, to present continuing efforts and concerns to strengthen their institutional structures (see below), the CCS in particular points to the "pilot" nature of its project over the past year and a half. In examining the evolution and barriers experienced by the three clinics, I shall note several common elements and processes as described by their directors. At the same time, I show how the services differ in terms of their institutional roots and guiding philosophies, the populations they serve, their overall mandate, structure and objectives, and the types of interventions and psychiatric and cultural therapeutic models utilized.

The CCS at the Jewish General Hospital was organized under the leadership of Dr. Laurence Kirmayer, a research psychiatrist with training in anthropology and a background in consultation-liaison psychiatry who is also the Director of the McGill division of Social and Transcultural Psychiatry. Dr. Kirmayer's interest in developing this service stemmed in part from his previous involvement in the U.S. National Institute of Mental Health Work Group on Culture and Diagnosis in DSM-IV from 1991-1994 (Mezzich et al, 1999). Appointed to the steering committee of this group near its end, Dr. Kirmayer was enjoined to develop and disseminate the cultural formulation outlined in Appendix I of DSM-IV (American Psychiatric Association, 1994) in psychiatric training and clinical practice. This project was also influenced by Dr. Kirmayer's site review of the Australian National Transcultural Mental Health Network in 1998 (Kirmayer 1998; Kirmayer & Rahimi, 1998; Minas et al., 1993, 1995). More locally, a 1995 epidemiological study by Dr. Kirmayer and colleagues that examined help-seeking patterns among immigrant populations in the Côte-des-Neiges district of Montreal found a high degree of unmet need for mental health services in these populations (Kirmayer, et al, 1996). All of these factors sparked the idea for establishing a cultural consultation service which would enable existing clinicians and institutions in Montreal to better understand, manage and help their immigrant and refugee patient populations.

The transcultural psychiatry division of the MCH is led by Dr. Cecile Rousseau, whose long involvement and contacts with community organizations working with refugees at multiple levels (including, but not restricted to health issues, e.g. RIVO and the TCRI), situates this service within a broad grass-roots network and partnership. Key staff and collaborators with the team thus work within this broader context. In addition, Dr. Rousseau has a history of participation in community research projects examining issues such as racism, access to institutional support, and the social inclusion or exclusion of immigrants and cultural minorities. As a child psychiatrist, Dr. Rousseau perceived the need for specialized services designed to meet the mental health needs of refugee and immigrant children and their families, in particular (but not limited to) those having lived through organized violence. The most salient aspects of this service are thus its focus on children and families, and its commitment to viewing refugee mental health within a broader political and structural context, integrating issues of socioeconomic realities and broader power dynamics with subjective suffering and mental health.

The Jean Talon Clinic originated under the leadership of Dr. Carlo Sterlin, who has worked in the area of transcultural psychiatry since the 1960s, starting with the McGill team headed by Murphy and Cowell. The origins of this clinic stem from the large numbers of Haitian patients attending the outpatient clinic of HJT who spoke only Creole and whose clinical manifestations fell outside conventional psychiatric frameworks. Despite early perceptions of the clinic as focused solely on the Haitian population, the clinic has grown into a well-established transcultural psychiatry service working with a broad diversity of immigrant and refugee patients. The clinic's model is based on the French ethnopsychiatric or ethnopsychoanalytic perspective which proposes interventions that re-anchor cultural others in their traditional culture rather than imposing an occidental psychiatric perspective (Streit, 1997; Nathan, 1994).

Intervention models

The directors of the three clinics indicate that from their inception, and despite the "specialized" nature of services, the goal has been to work within and collaborate with the broader existing psychiatric structure. They do not wish to be seen as segregated services with special privileges or a separate status. This aspect is built into the consultation services of the CCS and the JTC, which emphasize working with and training outside clinicians and care-givers; at the JTC and MCH, it is also part of clinical service models, which have fine-tuned their intake criteria over time and do not take cases that can be seen elsewhere. All three directors note that while the conceptualization of services was initially broad, tentative and open, the services have evolved significantly over time through dynamic processes of change, learning and adaptation to their various milieus, collaborators and patient populations. Given the innovative and non-conventional services and approaches proposed by these projects, an adaptive and flexible institutional framework has been required due to a number of elements including the pragmatic aspects of working with other established institutions, factors such as changing rates of patient referrals, as well as a constant re-evaluation and self-critique of approaches and interventions. In tandem with this dynamic and flexible process, institutional adjustments and maturation have also been geared toward strengthening and solidifying bonds with both the internal hospital sector and outside institutions.

The first phase of the CCS involved both setting up the consultation service and conducting on-going research to evaluate its effectiveness. The main goal of the CCS project has been to address existing gaps in research and service-provision regarding psychiatric care for adult cultural minorities. This out-patient consultation model seeks to use existing structures, acting as consultant and liaison for mental health care providers in order to mainstream cross-cultural mental health care. The CCS developed a roster of organizations (e.g. CLSCs, community refugee organizations) and persons (clinicians, cultural brokers, interpreters) who can be contacted on an as-needed basis for consultations or who to whom they can refer specific cases. In addition, the CCS team includes a number of cross-cultural clinicians who also function as consultants (and, more recently, as therapists on the team).

Consultations organized through the CCS have been conducted with individual clinicians as well as with institutions (e.g. Jewish family services, CLSCs) where case conferences and in-service training workshops on cultural issues have been conducted. The goal of these consultations is to draw out and make explicit both the psychiatric and cultural knowledge expertise of consultants, in order to enable a transfer of skills to clinicians. As such the service operates more as a teaching setting, a medium for transferring expertise rather as a specialized clinic. Another major goal of the CCS is to help train cultural consultants; to this end, it has prepared a cultural formulation booklet to be used as a teaching tool and guideline for cultural consultants. Trainees in psychiatry, psychology, social work and other disciplines take part in the weekly CCS case conferences. Due to an some caregivers response to the limitations of the consultation model (see Barriers section below), the CCS has considered expanding its consultative orientation to include ongoing treatment services.

At the transcultural psychiatry clinic of the MCH, interventions revolve around clinical assessments and on-going therapy for refugee and immigrant children and their families. This model utilizes a team approach toward clinical intervention (see Philosophy below). While the team started out very small, it has progressively integrated a number of caregivers who are present at the initial assessment and serve as principal or co-therapists throughout the course of therapy. In addition, the team trains a small number of students and residents from Montreal universities (McGill, Université de Québec à Montréal, Concordia University) as well as other Canadian and European universities.

The MCH team began with a very open mandate and initially received referrals for a wide range of problems. The team was confronted with numerous complex cases that they were not equipped to manage but which included cultural issues (for example developmental disorders among immigrant children). Because the team soon became overloaded, the MCH revised and limited its mandate to cover a delimited patient population, in order to reduce patient load and increase efficiency. Referrals to the MCH now come primarily from schools, lawyers, a CLSC or another clinician. A priority is placed on refugee families, particularly those who have lived through organized or other forms of violence, though a large number of children with potential developmental and behavior problems (e.g. ADD) are also seen. In addition, the team works closely with the psychiatric emergency ward and sees a number of patients with acute psychoses. Although the relevance of "cultural" aspects in cases of psychosis was initially more difficult for clinicians to appreciate, the team has been able to work well as consultants to the inpatient ward at the MCH to develop interventions with these families.

The evolution of the MCH service from broader grass-roots accessibility to institutional integration within the hospital has also meant changing its practices to adapt to the norms and criteria of the hospital. For example, given the hospital's referral and triaging policies, the transcultural division had to shift from an informal word-of-mouth referral system from the community to the more formal process required by the psychiatry unit's triage system. Because of reluctance among patients to speak initially with someone from outside the team, an administrative coordinator was hired on the team to take referrals and triage cases. In addition to clinical services the, MCH Transcultural Team is involved in a number of other institutional activities, including providing training for outside institutions (e.g. Department of Youth Protection), as well as working on prevention programs in Montreal-area schools.

The JTC intervention model includes both consultation and clinical services. During its first two years, the JTC was devoted only to training and structuring the service and team-members. Due to the multiplicity of care-givers involved, it was felt that an important initial phase was to create cohesion at the level of proposed interventions and approaches. During this period, team members received training from French ethnopsychiatrists, who conducted a series of workshops. This stage was followed by a process of self-training and peer supervision within the clinic.

The JTC consultation service is designed to accompany outside caregivers in the application of an ethnopsychiatric dimension to clinical cases, through a concrete demonstration of specialized intervention. Different intervention models are used depending on the case and its referral; these may involve several outside caregivers who come with the family, several internal co-therapists, as well as interpreters (see attached). Initially these consultation groups were very large; because they became difficult to manage, smaller intervention groups were created. Currently, group interventions often involve approximately 8-10 care-givers from different institutions (including the JTC).

The JTC team also offers a complementary clinical service, accepting primarily cases that are referred from within the hospital. Within the outpatient psychiatry unit of the hospital (which has a designated geographic sector or catchment area), a separate group composed of psychiatrists, psychologists, nurses, social workers and an art therapist have been given the mandate to help develop the transcultural team; this group refers cases to the transcultural team, who then decides whether to set up a consultation or take on the case. When referrals come from outside the hospital, the team insists that the patient's care-giver participate in a consultation, rather than taking on clinical cases from the outside. In addition to clinical and consulting interventions, the team is also involved in working on primary prevention interventions in schools.

Philosophy

All three directors describe the ideology behind their transcultural services as one that is flexible and based in multiple theoretical frames. Due to the multidisciplinary nature of the caregivers and teams, the somewhat "in-between" institutional and philosophical spaces within which they work, and the relative newness of institutionalized transcultural mental health programs in general, they reject the imposition of, or strict adherence to, one particular theoretical or intervention model. As mentioned, a key component to these services is a constant process of self-criticism and dynamic evaluation. However, different core approaches are evident for the three teams, which incorporate psychiatric and cultural perspectives in different ways and to different degrees.

The CCS positions itself primarily within cognitive-behavioral therapy models, favoring a pragmatic approach toward therapy that gives people the tools to empower themselves. The team works within the framework of the cultural formulation of DSM-IV, seeking to examine the ways in which cultural information interacts with a more standard psychiatric evaluation. At the same time, the senior clinicians on the team espouse a systems and interactional model that emphasizes social factors, gender and the dynamics of racism. The team generally tries to formulate problems in terms of social networks, looking at how cultural factors are implicit in communities and systems rather than emphasizing an individual-oriented therapy. Overall, while the team works within established psychiatric categorizations, it tends to view the meaning of symptoms as indeterminate, with no single or correct interpretation, focusing rather on the most useful interventions for specific patients. As such, both psychiatric and cultural expertise are seen as separate dimensions that are as useful in their own right, that must be assessed and integrated for comprehensive patient care.

Perhaps because interventions at the JTC and MCH include direct clinical services, their approaches tend to steer further from conventional psychiatric frames. Clinical interventions at the JTC and the MCH are based around a system of team evaluations. Here, initial patient assessments are conducted by a principal therapist but usually with input from the rest of the team; long-term therapy is often conducted with co-therapists, who may include a clinician and cultural broker/interpreter or other participants. In both cases the team represents a multi-disciplinary and multi-cultural group of caregivers. (For example, the MCH team includes psychiatrists, psychologists, art-therapists, students, an anthropologist, with members originating from Canada, Asia, Africa, the Middle East, Latin America and the Caribbean). In both cases, most of the team is usually present for the initial evaluation and often an outside person as well (either a culture broker, translator, and/or social or community worker familiar with the patient). Although the team approach has been criticized for imposing an unequal power dynamic, both the MCH and JTC directors view this approach, on the contrary, as a way of diffusing or shifting the entrenched power relations of individual therapy. This system is designed to provide a multiplicity of cultural and disciplinary representations unlike more conventional models whereby a single clinician (often of the host culture) is present. Rather than providing an intimidating or unequal relation with the family, it is thus felt that the team's diversity and multiplicity opens space for rich cultural and clinical communication with the patient, and encourages a dynamic exchange among the therapists concerning different perceptions, interactions and interpretations of the patients and their problems, which then become useful in proposing therapeutic interventions.

The MCH model utilizes an eclectic and flexible clinical model that incorporates various theoretical streams. The team uses a hybrid "bricolage" of therapeutic approaches that borrow from European (Tobie Nathan and Rose-Marie Moro), North American (Harvard) and Latin American psychiatric models, in particular the latter's emphasis on the political dimensions of collective and individual suffering. Dr. Rousseau emphasizes that the team does not accept patients based on strict ethnopsychiatric criteria because there is a dynamic interaction between culture and suffering among refugee patients, such that the complexity of their stories, situations and distress cannot be approached by looking at cultural aspects only.

In the MCH model, decisions regarding treatment are based on an assessment of whether or not the team can efficiently intervene (rather than on the urgency or gravity of the case). This decision is rooted in a philosophy of non-aggression that is, the realization that an imposed intervention at particular times and in particular cases may be, for fragile refugee families, experienced as aggressive and harmful rather than helpful. This decision corresponds to the team's humanist approach toward working with victims of violence and trauma. From this perspective, a key element of intervention (or non-intervention) is to incorporate non-psychological aspects, such as issues of weakness and power people's interactions, in the clinical work with families. Here, it becomes particularly important to fully respect the process of silence and disclosure according to the family's norms, beliefs and pace rather than to impose the disclosure of suffering as in certain trauma models.

This humanist perspective avoids looking at particular clinical strategies as universally positive or negative; from this view, disclosure, trust and "making sense" are not necessarily positive, and silence, denial, loneliness and absurdity are not always "negative" impediments to mental health. Instead, enabling families to move slowly around trauma, to shift and find an equilibrium between these various aspects of healing, is seen as preferable strategy. The therapist's main role thus becomes not only to help the family to "make sense" of their suffering by proposing stories, ideas, key words and actions that may help rebuild their worlds but also to hold the tremendous uncertainty and confusion surrounding their experiences and feelings.

Another key element of this approach is to understand the complex relationship between collective, structural violence and the individual, subjective spaces of violence; for example, the relation between organized violence and domestic violence, which is found in a number of cases, cannot be addressed without seeking to understand, and enable the family to understand, the connections between political and interpersonal aggression and suffering. The team's philosophy is thus to integrate a broad view of suffering its political and subjective aspects, its uncertainties, confusions and contradictions in clinical work, and to both empathize with and hold the patient/family through this process.

In addition, rather than looking at "culture" as something that can be clearly delineated in terms of "tradition", "modern", "home culture" and "host culture", the team approaches the cultural aspect of therapy, and of the patient/family, in terms of a play between numerous interacting and dynamic representations. In other words, rather than seeking to either focus on or impose an essential "home culture", on the one hand, or view a rejection of the host culture as an "acculturation" problem, the team looks at the culture as a process of approximation and distancing, in which therapy may create an intimate and playful space where individual and collective representations those of family members and of the therapists can circulate and be bridged. Often, therapy sessions (with the child, the parents, or both) are conducted with two therapists, one of whom represents the home culture. While the team tries to assess the particular vulnerability or possible pathology, it also seeks to bring out as well the strengths, capacities and networks that the families have, including the particular combination of social and personal resources and cultural belief systems. The family is helped to develop its own knowledge and resources for coping with distress or illness.

The MCH team tends to approach psychiatric diagnosis as a tool to be used with specific cases in contexts of power (i.e. in interactions with other institutions such as the IRB or schools that require a diagnosis for specific reasons). In such contexts, it makes selective use of "medicalized" psychiatry. When families or institutions request a more traditional psychiatric response to a problem (e.g. medication for Attention Deficit Disorder or psychosis), and when the team's clinicians view it as appropriate, they combine medication with other types of therapy. Given the attention to issues of social power, medication is viewed, as a means of alleviating suffering rather than "normalizing" social behavior.

Although the clinical ideology of the JTC borrows heavily from French ethnopsychiatric models (i.e.Tobie Nathan) thus trying to bridge traditional/cultural interpretations with a Western psychoanalytic dimension they emphasize the fact that, because their main purpose is to try to translate theoretical notions into clinical application, they have remained highly flexible and do not adhere to an imposed model. While they do not disqualify psychiatric knowledge, they are less prone to use conventional diagnostic categories; the psychiatric perspective is seen as one among others that may be useful to clients. Within their clinical model, primary importance is placed rather on presenting a traditional space and cultural concepts that make sense to the patient, using only those definitions of "mental health" that make sense from the client's perspective. The JTC team thus tries to incorporate psychodynamic intervention models with an anthropological approach that draws on the client's cultural interpretation of the problem, thus creating a space for the interaction of discourses. As such, clinical interventions are also geared toward creating an atmosphere that enables the client to incorporate and rework elements from various cultures.

Links with other institutions

For all three services, working closely with other institutions, as well as within a larger hospital setting, has meant a process of both continuity and constant change oriented by the different teams' relationships with these outside institutions. The process of developing both personal and institutional relations has been a critical, and complex one for all, and has included a slow process of learning the strengths and weaknesses of other organizations, key actors, and how to work with them. Overall, the inter-institutional aspect of these services has involved constant work to sensitize other institutions to a transcultural approach, one that has, in turn, affected the evolution of the services themselves.

This process of mutual accommodation has taken place in relation to the larger medical institution (hospital) within which the service exists as well as with the outside institutions with whom the transcultural teams interact on a service or mediation basis. Because these other institutions are prone to their own changing dynamics (governed by political and structural decisions), and given the non-traditional aspects of the transcultural services (see Barriers below), this process has not always been smooth. For example, both JTC and CCS mention that because conventional psychiatric care is based on sectorization according to different geographic regions, it has been difficult or for their host institutions to accept the non-sectorized, nature of their services. In addition, when other institutions undergo administrative or organizational changes, partnerships can become diffused and collaboration becomes more difficult.

Nevertheless, each of the services has built strong ties to a wide range of health care, social service and community institutions and organizations. The CCS has worked with numerous community organizations including CLSCs, SARIMM, the Clinique Santé Accueil, the Herzl Family Practice Center, Jewish Family Services, and the Module du Nord, as well as Aboriginal and Filipino Community organizations.

The community-oriented foundations of the MCH services have developed into important partnerships during the institution building process. The MCH team works in close partnership and alliance with community organizations such as the Equipe Santé Accueil of the Côte-des-Neiges CLSC, SARIMM, TCRI, CSAI. These institutions are seen to provide a trans-institutional network of support and knowledge vital to the clinic's work. In addition, the MCH also works with important partners such as schools, the DYP, and the IRB. With these institutions, the team sees its relationship as often one of mediation whereby the team acts as mediators between the family and the other institution, or between institutions. This has involved for example reaching out to schools (to open the doors toward a greater cultural sensitivity in understanding diverse family norms and behaviors) and to the IRB (to increase awareness of suffering and distress and counter the perception of refugees as manipulators). Some of these relationships have evolved over time, particularly those with whom the team has had major differences or conflicts in the past such as the IRB and DYP. Rather than seeing these institutions as monolithic and all powerful, the team has forged alliances within them. Over time, it has become clearer that the institutions are, in some ways, fragile and those working within sometimes feel vulnerable, limited and threatened by a lack of comprehension concerning their work with refugee and other cultural different populations. At the same time, the perception of the MCH team on the part of these institutions has also evolved, as evidenced, for example, by the fact that the DYP recently asked the MCH team to meet and discuss a trans-institutional seminar that would enable sharing models and practices.

From its inception, the JTC team has also had a strong relation with outside institutions. Indeed, the director notes that the clinic was initially better known on the outside, and received more external referrals, than it did from within the Jean Talon hospital. Although it continues to receive references from community organizations such as CLSC, Centres Jeunesses, CSAI, SARIMM and others, the JTC has noted tensions with certain other community organizations, possibly due to a perception that they receive more funding. Overall however, inter-institutional collaboration has been positive. The director states that increased collaboration, interest from and alliances with outside institutions has strengthened relations within the hospital sector, which has increased referrals to the clinic.

Barriers to implementation and service provision

Despite the ambiguous politics within Quebec concerning support for multiculturalism and multilingualism, all three of these services are situated within hospitals committed to issues of community, culture and diversity. This positioning within institutions that support, and are conducive to, transcultural work has facilitated their ability to operate within the broader health sector.

Dr. Rousseau notes that the MCH has traditionally been open and sensitive to multicultural issues. The hospital is well organized and staffed in this respect, and provides for the ready availability of interpreters (for evaluations and long-term interventions) as well as maintaining a multicultural clinic from which the team receives many referrals). The fact that the MCH team received an award from the Multiculturalism bureau reinforced this positive institutional profile as well as the team's relationship with the hospital.

Dr. Sterlin states that the JTC hospital's favorable attitude toward the idea of a transcultural clinic is evidenced by the immediate provision infrastructure resources (such as secretaries, photocopiers, space), as well as the fact that the larger institution has been an important source of support both within the hospital as well as within broader field (with Régie Régionale).

Finally, Dr. Kirmayer notes the Montreal Jewish General Hospital's origins which emphasized issues of equity and community in the face of anti-Semitism in the medical sector. The JGH has made responding to diversity (in its staff and patient population) a central theme in its recent long range planning efforts. In addition, the CCS and MCH also note that their location within teaching hospitals has strengthened their relations to the university research environment.

Despite this favorable positioning, all three services face ambivalence in the broader medical sector (including their respective hospitals), which at once welcomes the effort to promote transcultural mental health services but simultaneously finds it difficult to understand or appreciate the clinical exigencies or therapeutic models used, which fall outside of the realm of conventional practices and routines.

This ambivalence affects not only the nature of collaboration with the specialized services, but in evident particularly in the lack of commitment to resources and funding for specialized services. For example, Dr. Rousseau notes the difficulties in the first two years of the service to justify the existence of a transcultural psychiatry division to the hospital. Despite the team's alliances with key staff in other departments, the hospital's formal recognition by the outside sector through the granting of an award received by the transcultural team, and a general appreciation for the team and its strengths, there still seems to be a perceived lack of legitimacy, and the team still remains relatively marginal and precarious within the hospital's institutional structure. Dr. Sterlin, also points to tensions within the JT hospital caused by the team's alternative ideological stance toward mental health, which does not wish to frame itself within a psychiatric mode. For example, he notes that in the past a major conflict was created when the department head refused to name the service "Transcultural Clinic," insisting that it must incorporate Psychiatry into its name. Dr. Sterlin argued that this would not be conducive to access in the community, where the stigma of psychiatry for immigrants and refugees is felt as particularly negative or simply does not make sense within their culture.

Ideological differences aside, a number of pragmatic problems have also arisen due to the fact that these services, to some extent, do not conform to conventional medical models. Both the MCH and CCS, for example, have been frustrated by the broader institution's requests to speed up services, and the constant questioning regarding why patients or cases cannot be seen immediately. The CCS is trying to cope with this time-lag problem within the hospital by instituting a liaison position who can work with the in-patient unit in identifying systemic problems and issues. An additional difficulty that affects the speed of response by the CCS is finding resources (consultants, cultural brokers, interpreters, clinicians) of particular cultural backgrounds when the local immigrant community in question is small.

Both the CCS and MCH state that another major problem has been the perception by the hospital that all cases that include a "cultural" or linguistic barrier are to be referred to the specialized services. Because it is impossible to satisfy this load, and is not within the objective of the either service, this external perception has created problems. The MCH, for example, has been asked to take on increasing numbers of cases from Northern Quebec involving Aboriginal families, at times referred through court orders. Because the team feels that many of the problems of this population are highly specific and result from large structural issues, the request for "medical" expertise from the team has been frustrating.

In the case of the consultation services provided by the CCS and the JTC, both have run into similar barriers. As Dr. Sterlin notes, initial problems with consulting clinicians revolved around fears that a specialized clinic would increase work load, and that a different intervention model would mean a questioning of the usual clinical practice. The transcultural clinic evoked both the fear of change and the threat of calling into question professional knowledge and authority. For its part, the CCS has encountered a fair amount of institutional resistance and hurdles on the part of the hospital as well as individual clinicians toward whom the consultation service is targeted as reflected in relatively small number of referrals received. Barriers in engaging individual psychiatrists have included the fact that some do not identify social, cultural, racial and economic issues as an important dimensions in psychiatry, while others do not view consultation particularly the more time-consuming and complex consultations promoted by the service as useful in difficult cases. Many feel that such consultations increase the work load, are too lengthy, take too long to set up, and therefore do not respond to the need for rapid problem-resolution necessitated by acute psychiatric treatment. They would prefer to hand over these cases altogether rather than go through the consultation process and have to continue with difficult management issues. This problem has led the CCS team to re-evaluate its focus on consultation and to consider providing direct clinical services.

Finally, funding remains a particularly salient problem for these teams. Although the CCS has been well funded for the first phase of its project by the Health Transitions Fund of Santé Canada, with the end of this grant there is no definite commitment on the part of the Hospital, Regional Health Council or other agencies to maintain funding of the service. The JGH has committed 40% of the time of a psychiatrist to the service but funding for other professionals (i.e. psychologist, nurse-practitioner, social worker, secretary) needed for an interdisciplinary team is not available. The most pressing need remains for a fulltime clinical coordinator to provide telephone consultation and triage, as well as for funds to compensate the cultural consultants and culture-brokers drawn from the ethnocultural communities.

For the MCH and JTC teams, funding has been highly precarious. While two-and-a-half positions on the team (including Dr. Rousseau's) are paid through the hospital, other team members rely on funding from small projects, research grants and fund-raising for particular projects (e.g. the school prevention project). The JTC receives a minimal amount of funding through grants from private organizations, amounting to $15,000 over two years; in addition the hospital pays for half a salary and a small amount for training. Given that both teams function through the input and work of numerous persons of various professional backgrounds, there is a need for basic clinical and non-medical staff with special skills and expertise (psychologists, social workers) crucial to the running of the services, but an inability to procure stable funding for such positions or to compensate non-professional culture brokers. To date, much of the work provided by collaborators has been non-remunerated.

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