Implications of study for policy and practice

The evaluation of the Cultural Consultation Services has implications for access to service, quality of care, and the integration of services, and transferability. It was not possible to assess the impact on health outcomes of the population or the cost-effectiveness of the intervention because of the nature of consultative practice.

Access to services

Our data confirm that there are important gaps in the delivery of mental health care to refugees, immigrants and First Nations peoples.

Our results clearly indicate that the limitations of length of treatment and availability of psychiatry and psychology create problems of access to services for asylum seekers, refugees, immigrants and members of cultural communities. The consultations found that these problems go beyond those experienced by others in the health care system for several reasons:

1. These cases required more time and more resources (interpreters, culture brokers, meeting with extended family, linkage with community organizations) than comparable cases from Canadian-born patients to accomplish basic clinical tasks of diagnostic assessment and treatment planning.
2. Given this greater demand, and the technical and logistical complexity of conducting and formulating an adequate assessment, in many cases we saw such a basic assessment had never been attempted even though people had been in the treatment system for many years.
3. The complexity of the cultural formulation and the strategies for working with cultural difference are not widely known by clinicians and, up to now, have not been an adequate part of their training or ongoing education.

The specialized teams in transcultural psychiatry facilitated access to services in several ways:

1. they provided service for under-served populations who usually do not receive interpreters, culture-brokers and community organizations with knowledge and expertise in working with specific ethnocultural groups;
2. for patients already receiving mental health care, they providing links to clinicians,
3. by providing access to specialized consultation that increases the knowledge and skill ("know how") of clinicians in diverse milieus, the service immediately improved the quality of care of patients;
4. by creating a place for clinical training of professionals from different disciplines who can use transcultural perspectives in their subsequent practice milieus the services contribute to the development of new resources.

The development of a specialized resource also brought with it certain problems:

1. the development of a sensitivity to cultural questions leads to an increase in demands, exceeding the capacity of the team;
2. the subsequent tightening of criteria for admission reduced accessibility to the services the team while increasing the bureaucratic quality of the process which harms the alliance with a vulnerable population.

The CCS increasingly recognized the need to offer time-limited treatment interventions and long-term follow-up to meet the needs of referring clinicians and patients to have access to basic care. On the other hand, the Transcultural Clinic at the MCH, which offered comprehensive treatment and longer-term therapy from the start, found that it quickly became backlogged and was unable to respond to its unique populations (including refugee children). As a result, the MCH considered a move toward more consultative services based on supporting care providers in other parts of the hospital and other institutions or community settings. Thus, both services, although starting out with different models converged on a mix of consultation-liaison (mainly diagnostic assessment and treatment planning) and direct treatment provision (including various forms of individual and family therapy and aspects of case management, coordinating care form many providers).

Quality of care

The Transcultural team allowed the development of innovative interventions, that allow space for plurality of models to understand and respond to mental health problems.

One way in which the teams improved the quality of care was by giving a space and time where the voice of patients and clinicians could be heard to identify their most pressing needs and concerns. This was accomplished by several basic strategies:

1. an ethical stance that granted the primacy and validity of patient's stories; and insisted on the necessity for full and adequate communication as the basis for the clinician's assessment and intervention;
2. an epistemological view insisted on the fluidity and multiplicity of narratives so that, contrary to the juridical view of the refugee review board and other systems, no one narrative was privileged as the "final" truth. This multiplicity was not only present in discourse but reflect in the composition of the teams and their collaborators.
3. a pragmatic approach that emphasized the use of interpreters and culture brokers. Interpreters were integrated into the teams as partners in the assessment and treatment process. While recognizing that they could not provide an unbiased or perfect window onto patients' experience, they were nevertheless absolutely essential to go beyond the imprecision and error found when there were significant linguistic barriers to communication.

Integration with other services

The Transcultural teams worked in collaboration with other services and institutions. The MCH team, in particular, developed the concept of institutional mediation for immigrant and refugee children and families in settings of schools, the Department of Youth Protection, and immigration (including the Commission of Immigration for Refugee Status).

Mediation, between the institutions of the host country and families or communities allowed an integration of services that were otherwise extremely particularly fragmented for refugees and migrants. This mediation is based on several principles that have emerged from our practice:

1. the recognition of the vulnerability of families due to barriers of communication, and inequalities power and influence with host country institutions;
2. equally, the recognition of the fragility of institutions, which may be more hidden than that of families, but no less important. This fragility tends to be underestimated due to the image of power given by the legal mandate of the institution. Often intervenors within the institutions were found to live with considerable anxiety and feelings of powerlessness that paralyzed them or leads them to adopt rigid positions.
3. The necessity, therefore, to reinforce the anchoring of the family in their familiar frames of reference, but also to support institutions before beginning the mediation
4. The anchoring that constitutes the first phase of engagement in mediation subsequently allows the two parties to begin to de-center from their conventional frames. This de-centering creates the possibility of meeting around an initial mutual understanding to begin to negotiate new collaborative strategies for problem resolution.

Health impacts and cost effectiveness

Due to the extremely heterogeneous nature of the cases, the relatively brief intervention, and the lack of direct patient contact in many cases, it was not feasible to measure or reasonable to expect direct health impacts on the patients seen by the service. Nor was it possible to define a delimited population that would be affected by the intervention, since the service aimed to address gaps in services for many different types of patient.

However, there were significant changes in service use, diagnosis and treatment in individual cases that will have dramatic impact both on their long term wellbeing and functioning and on the ultimate costs of their care to the health and social service systems.

Some of the cases we saw were clearly costing the system more because of neglect that they would if effective treatment were provided (not to mention the ethical and humanitarian issues) also there is a long-term cost. Problems that may be amenable to a relatively brief intense intervention, like having an interpreter available to make a proper diagnosis at the start, become complicated and refractory to treatment as errors pileup, relationships of trust deteriorated, and the functioning of the individual deteriorates.

In several cases patients who had not been receiving any effective treatment for their conditions were accurately diagnosed and enrolled in appropriate treatment. In some cases, this involved children who had been incorrectly diagnosed due to a lack of use of interpreters and cultural expertise and who had treated for years with inappropriate medications and other interventions.

The existence of the service raised awareness about of issues related to culture and the use of interpreters throughout the health care system. Among the unanticipated effects of the service was a great increase in interest in training in cultural psychiatry among students in medicine, psychiatry, social work and nursing. It attracted a number of trainees to McGill postgraduate pgorams. The availability of this type of clinical experience may have a major impact on the skills and orientation of future generations of mental health practitioners.

Transferability

Similar services could be developed in other cities based on the needs of the local population. The requirements for transfer of the model include:

1. An explicit and long term commitment on the part of regional health and social service authorities and health care institutions to the ideals of cultural competence in health care and to a meaningful response to improving the quality of services for a culturally diverse population.
2. A willingness to work closely with representatives of ethnocultural communities and community organizations to identify unmet needs and potential resources for the delivery of cultural appropriate mental health care. This requires understanding the internal diversity of cultural communities and provides the opportunity to build up a network of resources that can be deployed in the assessment and management of specific cases. This process can also contribute to reducing psychiatric stigma and educate the community to be more effective consumers of available services. This work must scrupulously respect issues of confidentiality, which are particularly delicate in small ethnocultural communities
3. The process of implementation involves identifying core staff with the requisite skills and obtaining infrastructure support (offices, secretarial support, telecommunications, computers). It is important to locate the service in a place within the health care system that makes it acceptable both to patients and clinicians (preferably a non-psychiatric setting easily accessible to the cultural communities and clinicians who are being served.)
4. An individual or small group of clinicians with expertise in cultural psychiatry including familiarity with the elements of cultural formulation and the techniques of consultation-liaison work, obtained by training at major sites and by systematic efforts to reflect on their own ethnocultural background and clinical experiences with diverse populations.
5. A multidisciplinary, culturally diverse team of professionals open to rethinking standard practices to incorporate the use of interpreters, culture brokers and community consultants to generate cultural formulations
6. The ready availability of a stable pool of professional interpreters (for evaluations and long-term interventions), which allows the clinical team to develop a mutual collaboration. Ideally, these interpreters should have specific training in mental health.
7. The ability to fund professionals and non-professionals with cultural expertise (culture brokers) provided by the Health Transitions grant dramatically increased the capacity of the service to provide appropriate interventions. Other services have had rely on volunteer time and this makes it difficulty to insure availability, a high level of expertise, and benefit from cumulative experience.
8. Given the innovative services and approaches involved, there is a need for a flexible institutional framework that can adapt to the pragmatic aspects of cultural consultation including:
   
   
   • changes in the flow of patients,
   • the need for more time and longer sessions to complete assessments involving many participants as well as interpreters.
   • the need to work closely in collaboration with other established institutions
   • the need to involve extended families and community organizations in decision making processes.

Obstacles to implementation

The research identified important obstacles to the implementation of cultural consultation services, and culturally sensitive care more generally.Some of the obstacles to implementation of the program reflected ambivalence in the broader medical sector (including their respective hospitals), which at once welcomed the effort to promote transcultural mental health services but simultaneously found it difficult to understand or appreciate the clinical exigencies or therapeutic models used, which fell outside of the realm of conventional practices and routines.

1. There was pressure to replace the consultation-liaison model with an outpatient treatment team approach to provide additional services that would simply take some of the load off conventional serves. There was also pressure to respond to emergencies (imminent deportation) or provide quick consultations when time was needed to bring together the requisite expertise.
2. Finding resources (consultants, cultural brokers, interpreters, clinicians) of particular cultural backgrounds was sometimes difficult, especially when the local immigrant community in question was small.
3. One barrier to addressing these structural problems is the prevalent ethnocentrism of health care providers and planners. For example, many hospitals under-utilize existing interpreter resources because practitioners are satisfied with a minimal level of communication with their patients, or find it too difficult logistically to obtain the requisite help.
4. There was also a tendency to reframe social structural and economic problems in cultural terms and so divert attention from larger issues that demand political action. For example, the MCH has been asked to take on increasing numbers of cases from Northern Quebec involving Aboriginal families, at times referred through court orders. Many of the problems of this population result from larger structural issues, the request for "medical" expertise from the team raised systemic issues that exceed clinical knowledge.
5. The Transcultural clinic evoked both fear of change and resistance to calling into question one's professional knowledge and authority. Adopting a consultation-liaison model that emphasized the transfer of skills reduced this. In many cases, it was possible to put cultural notions in the framework of family interventions, which reinforced clinician's existing competence and made the new ideas easier to integrate.
6. Barriers to engaging individual psychiatrists included the fact that some did not identify social, cultural, racial and economic issues as an important dimensions in psychiatry, while others did not view consultation – particularly the more time-consuming and complex consultations promoted by the service – as useful in difficult cases. Concerns voiced by clinicians who had not used the service included the impression that such consultations would increase their workload, were too lengthy, take too long to arrange, and therefore not respond to the need for rapid problem-resolution necessitated by acute psychiatric treatment. Such clinicians would prefer to hand over these cases altogether rather than go through the consultation process.
7. Finally, funding remained a particularly salient problem for these teams. In the Medicare system funding for psychiatrists can be readily arranged but support for other professionals (i.e. psychologist, nurse-practitioner, social worker, etc.) needed for an interdisciplinary team is less available. The most pressing needs are for a fulltime clinical coordinator to provide telephone consultation and triage, and funds to compensate the cultural consultants and culture-brokers drawn from the ethnocultural communities.

Policy implications

The findings from this project are important because (a) they indicate significant unmet need for mental health services for Aboriginal peoples, immigrants, refugees and asylum seekers and (b) because they suggest some effective means of responding to these needs by developing additional services, providing ongoing training within clinical institutions, and by training and supporting professionals to make systematic use of their linguistic and cultural expertise.

Unmet need

1. The analysis of cases seen in the cultural consultation services and transcultural clinics indicates that language, cultural background and racism all diminish access to mental health care or undermine the relevance and reception of conventional care. The cases seen in our clinics had inadequate treatment for mental health problems, in some cases despite having being "in the system" for years. In a significant number of cases, the absence of interpreters or culture brokers and the cultural complexity of the cases prevented adequate assessment in conventional mental health care settings.
2. Given the great diversity of immigration to Canada, ethnospecific clinics are not practical for most groups, in most regions. For small communities, specialized clinics are undesirable because they cannot provide the requisite privacy and anonymity for patients, since everyone in the community knows everyone else. The antiracist focus favored in Britain is not appropriate both because of less endemic racism and because it tends to ignore the more positive and pervasive significance of culture and ethnic identity. The Australian approach is most relevant to the Canadian context, but it often stops with simply providing interpreter services and does not incorporate the broader perspectives and tools of cultural psychiatry.
3. While there are grassroots community initiatives that address the mental health needs of immigrants and refugees, there remains a significant lack of co-ordination of resources as well as a lack of a coherent structure to manage the needs of an increasingly diverse population. As well, there are too few clinical consultants available to support primary care and frontline workers in the community.

Model of service

Our results suggest that there is a need to balance three sources of help for culturally diverse populations: (i) to increase awareness and skills at the level of primary care; (ii) to support community services and improve liaison with professional mental health care; and, (iii) to provide specialized teams with cultural knowledge and language skills essential to work with patients who require a high level of expertise to diagnose and treat their problems.

1. The model we advocate involves the development of specific cultural consultation services which can provide assessment and treatment planning as well as networking with community resources for clinicians in primary care, psychiatry, social services and other mental health disciplines. This service can also contribute directly to the training of interpreters and culture brokers as well as developing links with helping resources within the cultural communities.
2. Given the need for similar resources (clinicians from specific backgrounds, interpreters, culture brokers) for both consultation and treatment, the most useful services will allow a combination of consultation with the availability of intervention and follow-up for complex cases or those requiring specialized resources.
3. There is a need to support community services and improve their liaison with professional mental health care as well as to develop culture brokers who can work closely with clinicians to mediate clinical encounters and identify appropriate resources to assist with the social care of patients. This includes seeking means to remunerate culture brokers for their time and expertise.
4. Health care and social services institutions must make it easier for practitioners to access and use interpreters and culture brokers. This requires supporting the additional time and personnel needed to work interculturally and across languages as well as recognizing (and recruiting) clinicians with diverse backgrounds and linguistic skills.

Training

Cross-cultural training is a necessary component of clinical training for all mental health professionals. However, in most educational and practice settings it remains largely undeveloped. What does exist is mostly informal and poorly defined. In particular, most mental health professionals receive no training on how to work with interpreters and culture brokers and no systematic education in cross-cultural assessment or intervention.

1. There is a need to strengthen training of mental health practitioners in concepts of culture and strategies of intercultural care. This should include recognition of the value of clinician's own linguistic and cultural background knowledge as added skills. Professional training should provide explicit models for integrating tacit cultural knowledge and current best practices in mental health care. Trainees should be given opportunities to reflect on and make use of their own cultural backgrounds and to employ their linguistic skills in working with patients.
2. There is a need to train mental health practitioners to work with interpreters. This should become a standard part of graduate training programs in psychology, psychiatric residencies, and the education of other mental health and social service professionals. In-service training and continuing education programs should be provided for practitioners.
3. Interpreting in the context of mental health care is especially demanding because of the technical need to transmit not only the gist of what someone is saying but its precise form and quality (set against a backdrop of cultural norms) in order for the clinician to assess the patients mental status. Mental health interpreting also involves emotionally intense and challenging situations that may affect all participants. Interpreters need additional training in mental health as well as, supervision and support to work with potentially distressing or traumatizing situations.
4. There is a need to define and train interpreters and other knowledgeable community members or clinicians for an expanded role as culture brokers. This requires addressing specific ethical issues that challenge the narrow role currently assigned to interpreters.
5. Quality assurance and accreditation standards for specific and generic cultural competence must be further developed and applied to both training and service programs.

Networking

Finally, there is a need for a national network in transcultural mental health that can act as a national clearinghouse for models of intervention, clinical resources and training materials. This network could also sponsor interdisciplinary training activities and collaborative research across centers. Through the internet this may be readily extended to an international network to provide an added level of support and exchange of ideas.