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Intercultural training of mental health professionals

We established a multidisciplinary group to assess the education needs of different professionals and develop specific training activities in: (i) primary care; (ii) interpreter and culture-broker programs; and (iii) graduate training programs. These groups met regularly to coordinate their activities. Group members were active in intercultural training.

The primary care work group comprised physicians, social workers, and frontline workers who identified cultural training needs in their respective disciplines. They organized workshops to increase the competence of clinicians in the domain of culture and mental health, particularly for refugee services, and to know how to make appropriate use of specialized services.

The interpreter training subgroup included Isabelle Hemlin from the Regional Board of Health and Social Services, who is responsible for the training and deployment of interpreters throughout the health care system. This group made recommendations for improving the training of interpreters in the domain of mental health. It also interfaced with the primary care group to help train practitioners to make appropriate use of interpreters, since there was evidence of under-utilization of interpreters.

The third subgroup was concerned with post-graduate training for psychiatrists and mental health professionals as well as with philosophy and methods of training and education at a more global level. This group organized a conference on Models of Training in Culture and Mental Health to be held May 2001 as an Advanced Study Institute with the McGill Summer Program in Social and Cultural Psychiatry.

We initiated monthly seminars at both the JGH and the MCH open to mental health professionals in the community. The MCH series ("Culture & Clinic Rounds") addressed clinical assessment issues including: trauma; family reunification; psychotherapy with South Asian women; and boundary issues in transcultural psychiatry. The JGH series ("Culture & Community Mental Health") focussed on issues in community psychiatry. Topics included: minority origin professionals in health and social services; women, racism and the mental health system; rape as a crime of war; linkage between community organisations and mental health professionals; dilemmas of ethnic match; and the asylum-seeking process.

An integral aspect of this project was to establish dialogue and liaison with existing community resources in culture and mental health. We met with representatives concerned with training from many community organizations including: (i) Réseau d'Intervention auprès des personnes victimes de violence organisée (RIVO); (ii) Table de Concertation des organismes de Montréal au service des réfugiés et immigrantes (TCRI) (iii), Institut Interculturel de Montréal (IIM); (iv) l'Association Canadienne Pour la Santé Mentale; (v) Alliance des Communautés Culturelles pour L'égalité dans la Santé et des Services Sociaux (ACCES); and (vi) Centre Sociale d'aide aux immigrants. We identified areas of possible exchange including: training mental health professionals in intercultural awareness and skills; information and resource sharing; and the development of a mechanism for providing ongoing clinical consultations for mental health professionals working in an intercultural context. We participated in organizing a conference on the role of religion and spirituality in mental health. A complete list of training activities is provided in Appendix F3.

Review of programs and practices (Appendix F1)

The research gathered and evaluated the state of the art in training practices in cross-cultural mental health. The focus was on instructional or learning activities that aimed to increase the effectiveness of mental health practices within and across cultural milieus. Training practices were defined as any explicit theoretical approach, didactic method, or program; we also considered implicit training ideologies or practices in clinical, academic, or community mental health. The mental health professions covered included psychiatry, psychology, counselling and to lesser degrees social work and nursing. Training practices, and models, from university, hospital, and community settings were gathered and compared. The research was conducted at the local, national, and international levels.

Method

The review involved three strategies: (1) a systematic review of available literature on training, course syllabi, and program descriptions using PsychLit, Medline and Internet search engines (Appendix F2); (2) a brief survey questionnaire and subsequent dialogue with international leaders in the field addressing pedagogical philosophy, methods, models, trends and gaps in cross-cultural training in mental health; and (3) on-site visits to local, national and international programs.

Findings

Literature Review: A growing body of theoretical literature in the area of cross-cultural training in mental health in the last ten years; supports the need for renewed effort to define cross-cultural training and clinical practices in mental health. There is general agreement that the notions of race, ethnicity and culture have been conflated and inappropriately applied in clinical settings. There is divergence of opinion on the emphasis of various training models, i.e. anti-racism, cultural awareness, cultural competence, and culture specific vs. culture general approaches.

Training programs and manuals: Although several training manuals have been developed, it is not, clear, whether these programs have been implemented or what they outcomes have been. Many of these are designed as manuals that meant to be used in clinical settings. Most follow a modular formats, and can be presented as sections over six to eighteen hours to address a spectrum of issues related to cultural awareness and skill development. Interpreter Training Programs: are somewhat more developed and offered as a specific area of study in colleges. There is a lack of research evidence to support the effectiveness of most training programs either in terms of cognitive and attitudinal changes or ultimate impact on clinical skills and practice.

Cross-cultural university curricula have been developed and implemented in clinical domains of study but largely in piece-meal, ad hoc fashion. On a global level, there is little evidence of systematic approaches to cross-cultural training in mental health. The United States, Australia and England are leaders in integrating cross-cultural curricula in clinical university programs but these program cannot be considered standard practice within those countries. Other noteworthy initiatives are listed in the full report (Appendix F1). Within the United States, for example, there is a lack of consensus on how to view the cultural mosaic and consequently the basic goals of cross-cultural care. Managed care is sometimes viewed as an engine which drives a politically correct version of the cultural competence model, which in some circles translates mainly into providing services for the four major under-represented, under-served minority groups defined by census categories. Canada has very little in the way of organized cross-cultural curricula in the clinical health or mental health domains.

The role of the Community is ill-defined in major institutional structures and yet "cultural experts" often work in their own community milieu. As such, parallel training structures and initiatives seem to be in place in a number of instances. Often groups working on intercultural mental health care were unaware of the contributions of other groups locally, nationally and internationally.