The Cultural Consultation Service of the Jewish General Hospital

(Appendix B)

The Cultural Consultation Service (CCS) of the Sir Mortimer B. Davis– Jewish General Hospital was designed and implemented expressly for the current research project. The function of the CCS was to provide specific cultural information, links to community resources or formal cultural psychiatric or psychological assessment and recommendations for treatment. This section presents the systematic evaluation of the service.

Cultural consultations took one of two forms:

1. A direct assessment of patient by a cultural consultant and or culture broker preferably with the participation of the referring person (complete assessment usually involved 1 to 3 meetings with patient, a brief written report, transmitting recommendations, and usually a clinical presentation at the end of the process to give the entire team an opportunity to discuss the case).
2. The second major form of consultation occurred strictly between the referring person and the cultural consultant, without the patient being seen directly. Typically, the consultee to presented the case and their concerns during a clinical meeting in which the CCS team members and the invited consultant discussed the issues and made recommendations.

Objectives

The specific goals of this evaluation were:

1. to document the process of developing the service to identify the types of problems seen, types of resources needed, recommendations made, as well as facilitating factors and barriers to implementation;
2. to identify gaps and barriers to care in the general health care system through analysis of cases referred to the CCS;
3. to identify the types of cultural formulation used by consultants;
4. to evaluate the client (consultee) satisfaction, recommendation concordance and clinical outcomes of the intervention.

Methods

Quantitative evaluation. The quantitative evaluation of the service involved assessing the outcome of consultations in terms of: (i) types of cases referred and evaluated; (ii) use of specific professional and community resources; (iii) types of interventions and recommendations; (iv) consultee satisfaction, and (v) recommendation concordance using questionnaires that are appended to this section of the report. Although the original plan was to evaluate patient outcomes and cost effectiveness, this proved impossible for two major reasons: (i) the great heterogeneity of cases, which spanned the gamut of psychiatric conditions, sociodemographic characteristics and social predicaments; and (ii) the intrusiveness of the consultation process, which did not always involve direct contact with the patient, or else involved a series of elaborate group meetings in which the priority was making structural or strategic therapeutic interventions. (Details of the methods are presented in Appendix B1).

Qualitative evaluation. The qualitative component of the evaluation used a model of participatory research with participant-observation by a research anthropologist working in close collaboration with the team. A protocol was used to summarize case conferences and interview consultees and consultants, to document: (i) the type of intercultural problems referred to the CCS; (ii) types of persons and institutions who utilize the CCS (iii) types of cultural formulations and their influence on interventions; (iv) types of clinical and community recommendations proposed; (v) barriers to service implementation (e.g., legal and ethical barriers for refugees) and how they are overcome; and (vi) intrinsic and extrinsic factors that facilitate or hinder the implementation of the CCS recommendations. (Details of the methods are presented in Appendix B2).

Findings

Over the 12-month period of formal data collection, the CCS service received 102 requests for consultation. These came from the whole range of health and social service professionals based at hospitals and community clinics (CLSCs). The majority of consultation requests concerned individuals but almost 1/3 involved couples. Four cases involved requests from organizations to discuss issues related to their work with a whole ethnocultural group or community.

Most clinicians requesting consultations had heard about the service through word of mouth, and the rate of referrals gradually increased over the course of the project as consultees who had found the service useful spoke of it to others or asked for help with a new case. Presentations to clinical services by CCS team members also increased awareness of the service and its usefulness.

The cases represented an enormous diversity of countries of origin, languages, ethnocultural groups and religions. This demanded a wide range of consultants, interpreters and culture brokers. It precluded developing ethnospecific services. Indeed, we were aware of some ethnocultural communities that did not make a significant number of referrals simply because they were aware that we did not have consultants who spoke the appropriate language available; contrariwise, certain ethnocultural communities are probably over-represented in our sample because our team had multilingual, multicultural clinicians from that group available.

The most common reasons for consultation were requests for help with clarifying a diagnosis or the meaning of specific symptoms or behaviours (58%), treatment planning (45%), and request for information or a link to organizations and resources related to a specific ethnocultural group or issue (e.g. refugee status (25%). Half of all cases had multiple reasons for requesting consultation giving some indication of the complexity and inter-relatedness of issues.

About half of all requests to the CCS could be resolved with telephone contact and informal exchange of information or linking to specific resources. In about 1/5 cases the clinical coordinator felt that there was no need for a cultural consultation. Some of these cases represented inappropriate referrals in which basic medical and social services had not yet been arranged or employed, others involved an effort to refer a difficult case that had no indication of a cultural component in the hope of obtaining additional services. Of the 52 cases where a consultation was recommended, in 1/5 the consultation occurred entirely through discussion with the referring clinician and the patient was not seen.

The specific resources needed for consultation involved interpreters for about half of all consultations. Some form of matching of the consultants' background (language, ethnicity or religion) with that of the patient was needed in 2/3 of cases, and some specific clinical skills (psychiatric expertise, family therapy training, experience working with trauma, refugees, somatization) was needed in 1/3 cases.

Building on the existing network developed by the MCH, the CCS established a bank of 73 consultants (see Appendix E), predominately psychologists, psychiatrists and social workers. In fact, a small number of consultants were used repeatedly, both because of the specific background of referred cases and because of the high level of skill and they evinced. Consultants integrated directly into the team (as staff at the JGH, postdoctoral fellows or trainees) were used most frequently.

Because it was not usually possible to find a skilled clinician with the requisite language skills and cultural background knowledge, it was often necessary to use 2 to 3 consultants to address the specific cultural and mental health issues raised by a case.

It was possible to find appropriate resources to conduct the consultation in most cases. However, ethnic matching was very approximate and it was particularly difficult to find psychiatrists and child psychiatrists with skills needed to work with specific patients. As well, for smaller ethnocultural communities or more recent immigrants, it was sometimes difficult to find a well-trained interpreter or appropriate culture broker to work with a patient or family. Patients were sometimes reluctant to meet with a culture-broker or consultant from their own background because the small size of the local community made confidentiality impossible to maintain.

Most clinicians (86%) reported they were satisfied with the consultation and that it had helped in the management of their patients. All who had used the service said they would use it again and would recommend that their colleagues use it.

More detailed information on the reasons for consultations comes from the qualitative process evaluation (Appendix B2). This went beyond the statements made during the initial telephone contact to consider all of the available evidence as to the consultee's explicit needs as well as hidden or implicit requests in the case. The latter were determined through observation of the case conferences where the consultee would often present, as well as by taking into account the perspectives of all the consultants involved with the case and the clinicians, culture brokers and social scientists on the CCS team. This process also lead to the identification of new problems that had not been part of the clinician's reasons for referral, or identified at the time of triage, but which constituted additional valid reasons for cultural consultation.

Based on the process evaluation, the most frequent explicit reason for consultation was for help in planning, reformulating or obtaining appropriate treatment for the patient (92% of cases). The next most common reasons for consultation involved interactional problems between the consultee and the patient or other care providers (67%). This involved explicit acknowledgement by the care provider that the problem resided between the patient and himself/herself. The remaining explicit reasons for consultation were: diagnostic questions (50%); problems with patient treatment compliance (40%); difficulties of consultee's themselves (e.g. feeling lack of skill or competence to deal with problem or emotionally overwhelmed by patient's trauma history) (35%); systemic problems (e.g. with gaps in services, continuity of care, expectations of other professionals, or administration of health care and social service institutions) (23%), and specific issues with interpreters (e.g. lack of availability, misunderstandings, misalliances) (12%).

For 63% of cases no new reasons were identified during the consultation, suggesting that the triage process often was sufficient to help the referring clinician accurately identify and articulate the basic needs for consultation. New reasons for consultation – of which neither the referring clinician nor the triaging psychologist had been aware – were identified through the consultation process in the remaining 37% of cases. The most common type of new problem was systemic (10/19 cases), involving availability of services, continuity of care, or dilemmas created by specific institutional practices. The systems involved included health and social services, education, legal and immigration. The relative lack of recognition of systemic problems may have to do with the tendency to attribute difficulties to characteristics of the patient rather than the system, and to become habituated to or normalize everyday difficulties with system. In 5 cases, new diagnostic issues were raised, including the need for specialized medical or neuropsychological evaluation to rule out organicity or intellectual impairment. Multiple new reasons (2 to 4) were identified for 12 cases (23%), indicating the complexity of issues that might have gone unrecognized without cultural consultation.

Implicit reasons for consultation were identified in 15/52 (29%) of cases. The most common implicit reasons involved problems that concerned consultees themselves (10/15) or systemic issues (8/15). Implicit reasons for consultation related to the consultee, involved the consultee's own lack of confidence or or feeling of incompetence in dealing with the patient. In some cases, the consultee's implicit concern was with the competence of another professional, and the cultural consultation was seen as a way to document inadequate care and mobilize an alternative. Subtler cases involved challenges to clinicians' implicit assumptions about including cultural differences in gender roles, religious values, and issues of racism.

Implicit problems related to systemic factors (found in 8/52 or % of cases) differed from those we identified as new problems in that there was some reason for the clinician to downplay or hide them. Generally, this was because the consultee was hoping to transfer the patient or obtain services for the patient that the CCS was not set up to provide, i.e. psychotherapy, long-term treatment or case management. These cases are clear indicators both of poor accessibility to services or gaps in the system and the limitations of the consultation model to resolve them.

Cultural consultation often facilitated the therapeutic alliance between the referring person and the patient. The consultee's effort to seek a consultation may have demonstrated to the patient an interest in understanding the patient in his or her own cultural framework. The cultural formulation produced by the consultation made sense the patient's puzzling or disturbing symptoms and behaviours by placing them in social and cultural context. This clarified the patient's predicament and thus, increased the clinician's empathy for the patient.

Cultural consultation also revealed the complexity of the case, transforming clinician's frustration into an appreciation of the intellectual and professional challenge presented by the case, and so increasing clinician's interest and motivation to remain actively involved.

A wide range of issues were raised in cultural consultations to provide the social, cultural and political context for patient's symptoms and behaviour and guide diagnostic assessment, treatment planning and service delivery. The most frequent issues raised concerned:

• variations in family systems and structures (e.g. patriarchal families)
• variations in age and gender roles (e.g. significance of marriage, divorce, adolescence or elder status for identity and social status of men and women)
• notions of honor and shame as regulatory principles in family dynamics
• the impact of migration (e.g. issues of identity, fracturing extended families, changing gender roles, eliminating communal supports and mediators, and creating tensions between generations)
• the impact of exposure to violence (CCS consultants often faced incredulity from clinicians on the level of violence that patients had been exposed to in their home countries)
• the stressful impact of the application process, waiting period, and review board hearing for asylum seekers
• the effects of subtle racism or other biases on provision of services to patients
• prevalence of dissociative symptoms leading to misdiagnosis of psychosis, personality disorder or malingering
• experiences with health care and healing practices in country of origin
• the value of religious practices in self-soothing and psychological containment of grief and anxiety.

Even where patients were not seen, the advice and re-interpretation of events provided by the CCS team worked to improve and maintain the referring clinician's treatment alliance, and refine their diagnostic and treatment approach.

A number of important challenges and potential obstacles were faced in the process of conducting cultural consultations:

1. While some clients welcomed the opportunity to be seen by a clinician or culture broker from a similar cultural background other clients expressed reservations or concerns that being seen by someone from their own community might compromise the privacy of their problems. Some cultural communities are very small and mental health problems highly stigmatized so that their concerns were realistic. Reassuring patients about rules of confidentiality may be necessary but not sufficient.
2. The same concerns about confidentiality applied to the use of interpreters during the consult. Given that the CCS strictly used interpreters from the Régie régionale, the rules of confidentiality were clearly in place. Patients needed to be reassured about what this would mean.
3. Similarly, sometimes clients who were seeking asylum expressed concern about how information gathered during a cultural consultation might affect their application for a refugee status. Again, clarification of the CCS's role to these patients was essential.
4. We needed to clarify repeatedly with consultees that we functioned strictly as a consultation service and not a treatment service. Clinicians often made demands of the CCS that went beyond consultation, requesting emergency intervention, comprehensive primary care, or transfer of the case for long-term treatment or case management. We had several consultations in which, once the process began, the consultee became inaccessible or discontinued treatment with the patient, presumably on the assumption that the CCS would become responsible for the patient's subsequent care.
5. The cultural consultant was sometimes placed in a difficult position, called upon to balance the demands of developing an alliance with the patient based on cultural understanding while still negotiating the rules, norms and standards of traditional psychiatric care. The demands of these two positions were sometimes in complete opposition. As a result, the skill level of the consultant and their relative comfort in negotiating this position was important in any consultation.
6. The CCS was very active in promoting the use of professional interpreters in hospital and other mental health settings. The recommendation to use an interpreter was frequently made as part of a consultation but also as a phone intervention even when a consultation was not pursued. Despite the increased use of professional interpreters in the hospitals, difficulties and resistance to their use was still noted particularly in the case of hospitals that still tend to rely on staff members to act as interpreters.