Evaluation of the Cultural Consultation Service of the Jewish General Hospital
Laurence J. Kirmayer, Caminee Blake, Danielle Groleau, Jaswant Guzder, Eric Jarvis & Suzanne Taillefer
The Cultural Consultation Service (CCS) at 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 report presents the systematic evaluation of the service. The CCS was located adjacent to the Culture and Mental Health Research Unit, which served, as the coordinating center for the overall research project.
This report provides a quantitative analysis of the implementation and effectiveness of the CCS. A qualitative analysis of cases and the consultation process itself is presented in a second accompanying report. The structure and function of the service are described in the Handbook in Appendix G.
Methods
The CCS began operation in mid 1999, The initial development involved the recruitment of staff(two research coordinators/assistants, a clinical coordinator, two post-doctoral fellows, and an information officer) and the development of links with clinicians and culture brokers who acted as core consultants for the service.
A series of cases were discussed in depth at the inception of the project with a large number of consultants present. This served to train the staff and to help the team to cohere as a work group. Weekly clinical meetings were organized for case presentations and formal cultural consultations and were attended by core staff as well as trainees. These meetings were tape-recorded and transcribed for later process evaluation.
Case Accrual and Consultation Procedure
A brochure announcing the service was prepared and distributed to the mailing lists of the Quebec Corporation of Psychologists and the Quebec Psychiatric Association. Promotional literature describing the service stated: "a cultural consultation is best reserved for cases where there are difficulties in understanding, diagnosing and treating patients that may be due to cultural differences between clinician and patient. Such differences can occur even when patient and clinician are from similar background because of wide variation within social and cultural groups."
Initial inquiries about the CCS as well as intake and triage of all cases was dealt with by the CCS clinical coordinator (a clinical psychologist), or by the medical director (a psychiatrist). The goal of the initial intake was both to document the nature of the request and to assess whether it qualified as an appropriate referral to the service.
A standardized procedure was followed to collect information and triage all cases (see CCS Handbook, Appendix G):
1. Consultee (individual or organization requesting the consultation) was identified and basic information collected on the referring clinician: their position, institution, profession and contact information.
2. The actual reason for the consultation request was asked. The question was asked in an open-ended way, with additional questions to clarify and complete information regarding the circumstances of the patient and referral.
3. Clarification about who the primary case manager or practitioner following the patient in treatment was determined as a way of knowing who the recommendations would be directed at and to ensure that the CCS would be able to function strictly in a consultative role.
4. Consultees were then asked to specify the cultural reasons for which they were seeking consultation. Consultees were read a list of options (see Intake form, Appendix G) from which they could choose. It was emphasized that they should choose as many categories that applied to their request.
5. Consultees were asked what their expectations were with respect to how our service could assist them. Again, consultees were read a list of options (see Intake form) from which they could choose. If they chose the option requesting that we take over treatment of the patient, it was then clarified what our role could be and how we might assist from a consultation perspective only.
6. If the referral request seemed appropriate, the clinical coordinator would clarify whether the patient was aware that this request was being made and whether the consultee felt that the patient understood what a cultural consultation would involve. This question was particularly important to address cases where the patient was likely to be seen directly. When needed, the coordinator discussed the need to reassure the patient about confidentiality. Finally, a description of the consultation process was provided, as well as an indication of the length of time needed to arrange the consultation.
7. In cases where the request for a consultation was not appropriate, clarification of our possible role was described, the consultee was redirected to other resources, or brief interventions and recommendations were made at the time of intake.
A Handbook was prepared for consultants working with the CCS team which outlined basic procedures and provided guidelines for the cultural formulation and other resource materials. A copy is provided in Appendix G.
Cultural consultations took one of two forms:
- A direct assessment of patient by a cultural consultant and or culture broker preferably with the participation of the referring person. A complete assessment usually involved 1 to 3 meetings with patient, a brief written report, transmitting initial recommendations, followed by a clinical presentation to the team for discussion, and a longer cultural formulation report.
- 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 presented the case and their concerns during a clinical meeting in which the CCS team members and the invited consultant discussed the case and make conceptual and intervention- related suggestions.
Evaluation of Services
One of the main goals of the project was to evaluate the effectiveness of the cultural consultation service. This goal was met in two ways: (1) by obtaining feedback from the consultee about their level of satisfaction with the cultural consultation as well as their suggestions for how the consultation could have been improved and (2) by evaluating whether recommendations provided by the consultation were implemented.
A literature review was conducted in the general domains of patient satisfaction with mental health and medical services, utilization concordance and consultation as an intervention in order to find appropriate measures. Existing measures referred to in the literature did not adequately meet the needs of the project. As a result, we developed new questionnaires (Appended to this report).
Quantitative evaluation. The quantitative evaluation of the service assessed the outcome of consultations in terms of (i) consultee satisfaction, and (ii) recommendation concordance using questionnaires that are appended to this section of the report. Although our original plan was to evaluate patient outcomes as well, this proved impossible for two main reasons: the great heterogeneity of cases; and the intrusiveness of the consultation process.
Four instruments were used for the quantitative evaluation:
- an intake form and consultation progress tracking database;
- consultation recommendation form;
- consultee satisfaction form;
- recommendation concordance form.
Consultee's Satisfaction with the Consultation
In the literature reviewed, satisfaction with a consultation was typically assessed using open-ended questions which covered three main domains: (1) satisfaction with feedback and support provided; (2) likelihood of making future referrals to the service; and (3) impact of the consultation on the consultees knowledge base (e.g. increased psychiatric knowledge, clinical confidence, diagnostic/treatment confidence)(Carr, Faehrmann, Lewin, Walton, & Reid, 1997; Brown & Weston, 1992). The "Client Satisfaction Questionnaire" (Attkinsson, 1989) (CSQ) was used as a general guide in developing our own measure, although we significantly modified the questions to meet our specific needs and objectives. Consistent with the general domains assessed in the medical consultation literature, our consultee satisfaction questionnaire assessed consultee level of satisfaction with the feedback and support provided, the likelihood of making future referrals, the extent to which the consultation increased their knowledge base as well as their input about what aspects of the consult they found helpful or difficult as well suggestions for the improvement of our services (questionnaires are appended to this report).
Although itwas hoped that the satisfaction questionnaire could be administered at a standard period of time following the consultation, it proved difficult to standardize the time because the length of the consultation process was not fixed and feedback often was provided to consultees over the course of several sessions. We decided that consultee satisfaction would be obtained 2-3 weeks after the brief report (which included the immediate treatment plan and recommendations) was provided.
Recommendation Concordance: Follow-Up Questionnaire
Another common way in which the outcome of a consultation has been measured in the literature is through recommendation concordance, i.e. whether or not medical staff followed through with recommendations made as a result of the consultation process. Researchers typically assess whether there was concordance, partial concordance or non-concordance with the recommendations (Huyse, Strain, & Hammer, 1990; Huyse, Strain, Hengeveld, Hammer & Zwaan, 1988; Salvador-Carulla, 1999). Concordance is determined by first categorizing the nature of the recommendations such as whether it involved psychosocial management, psychosocial diagnostic treatment (i.e. obtain additional information from the primary care physician or family), discharge management, biological diagnostic action (i.e., lab tests, medical consultation), medication, or aftercare (Huyse, Lyons & Strain, 1992; Huyse. Lyons & Strain, 1993). Additional variables measured to assess consultation outcome includes such variables as: (1) the amount of time involved for a consultation (in hours); (2) utilization reductions in medical inpatient or outpatient department; (3) length and number of visits with each patient; (4) number and types of contacts with others performed as part of consultation; and (5) frequency of referrals to consultant (Levenson, Hamer, & Rossiter, 1992; Cole, Fenton, Engelsmann, & Mansouri, 1991; Knapp, & Harris, 1997).
For the purpose of the present study, recommendation concordance was measured by a brief follow-up interview with consultees after the cultural consultation report with specific recommendations was sent. Consultees were asked to rate the clarity and feasibility of the recommendations on 4-point Likert scales (from "not all" to "completely"), and to indicate which recommendations they had carried out. For recommendations not implemented, consultees were asked to describe the obstacles that prevented implementation and to suggest what would have facilitated the implementation of that recommendation. Additional questions asked about the possible influence of the cultural consultation on the patient's utilization of various heath and social services.
Summary of Data Collection Procedure
- Patient is referred to the CCS. Basic information is collected from the referring person at the time of triage. After the initial meeting/consultation with the patient, the CCS Consultant asks the patient the intake questions.
- Immediately following the consultation, clinical recommendations are written and sent to the consultee.
- Consultee satisfaction was obtained by the Clinical Coordinator approximately 2-3 weeks following the end of the consultation.
- Three months following the end of the consultation, the Clinical Coordinator recontacted the consultee to complete the recommendation follow-up questionnaire.
Qualitative Evaluation
The qualitative component of the evaluation used a semi-structured protocol for summarizing case conferences, as well as interviewing consultees and consultants who attended the case conferences, 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.
Results
Here we present the preliminary results from the quantitative evaluation of the service. The results of the qualitative evaluation are presented in a separate report that follows this one (Appendix B2).
Description of Consultation Requests
A total of 102 consultation request were received by the service from December 1999 to November 2000. Of these, 69 (68%) were for individuals, 29 (28%) for couples or families, and 4 (4%) involved requests for consultation from organizations concerning dilemmas they faced in working with specific ethnocultural communities or groups (e.g. refugees from Kosovo).
The sources of requests by institution and profession of the referring clinician are summarized in Tables 1 and 2. Almost two-thirds of consultations came form hospitals (primarily the JGH where the service was situated) including the ER, emergency psychiatry, inpatient and outpatient wards. Of these, half came from psychiatric settings and half from other medical clinics or services. The next most frequent sources of consultation requests were CLSCs (comprehensive community clinics) and community organizations.
The three most frequent types of professionals requesting consults were social workers, psychiatrists and nurses. Nurses came from both psychiatry and primary care (CLSC) settings. Almost half of all requests were from mental health practitioners (psychiatrist, psychologist or psychoeducator) (n=47); a further 20 cases came from trainees in psychiatry and psychology (residents and interns). About 1/4 of requests for consultation came from social service providers (social workers, community workers, or lawyers, n=22). About 10% came from primary care providers (family physician, family medicine resident, or pediatrician, n=11).
During the early stages of the project, we did not insist that the consultee (primary clinician or case manager) be present during the cultural consultation. However, it quickly became evident that having the consultee present greatly facilitated the consultation and its goals. First, having the consultee present allowed for the transfer of knowledge about the patient to occur directly. It provided a means for the consultee to learn about possible lines of inquiry and issues to explore, particularly concerning the potential effects of migration. This approach was consistent with the goal of enhancing the cultural knowledge and skills of the consultee, rather than acting as "experts" whose methods and knowledge remain mysterious or opaque. Having the consultee present also allowed for an immediate reframing of the problem by the consultee as well as a better understanding what was guiding patient behavior. Finally, the presence of the consultee improved continuity of care because it fostered the clinician's interest in the patient and kept the consultee at the center of the patient's future care.
Table 1. Institutional Sources of Consultation Requests (n=102)
| n | % | |
|---|---|---|
| Hospital | 60 | 58.8 |
| ER, ER Psychiatry | 9 | 8.8 |
| Inpatient (Medical & Psychiatric) | 11 | 10.8 |
| Outpatient Psychiatry | 19 | 18.6 |
| Other outpatient clinics | 20 | 19.6 |
| CLSC | 23 | 22.4 |
| Community Organizations | 11 | 10.8 |
| Private Practitioner | 2 | 2.0 |
| Schools | 3 | 2.9 |
| Other* | 3 | 2.9 |
* Law firm, family member
Table 2. Profession of Clinicians Requesting Consultation (N= 102)
| n | % | |
|---|---|---|
| Social Worker | 18 | 17.6 |
| Psychiatrist | 17 | 16.6 |
| Psychiatry Resident | 12 | 11.8 |
| Nurse* | 16 | 15.7 |
| Psychologist | 10 | 9.8 |
| Psychology Intern | 6 | 5.9 |
| Family Physician or GP | 8 | 7.8 |
| Family Medicine Resident | 2 | 2.0 |
| Medical specialist | 1 | .98 |
| Pediatrician | 1 | .98 |
| Community Worker | 2 | 2.0 |
| Psychoeducator | 2 | 2.0 |
| Lawyer | 2 | 2.0 |
| Other | 5 | 4.9 |
* Nurses came from both psychiatry and primary care settings
For a subsample of 33 consecutive cases, consultees were asked how they came to know about the service. The most frequent response was from a third party who knew about the service (n=16, 48%), followed by knowing a member of the CCS team (n=9, 27%), reading the CCS brochure (n=6, 18%), working at Jewish General Hospital (n=2, 6%), past use of the service (n=2, 6%), and miscellaneous other sources (n=4, 12%). Thus, for 27 cases (81%) word of mouth was the most important way consultees learned of the service.
Of the 102 cases, sociodemographic information was available for 118 individuals (69 individuals and 49/58 partners in couples). These 118 individuals came from 42 different countries; the most frequent countries of origin were India (n=15, 12.7%) and Pakistan (n=10, 8.5%) and Canada (n=6, 5.1%).
Of 85 cases for whom the mother tongue was known, 70 (82%) had a mother tongue that was neither English nor French, but one of 28 other languages. The four most frequent non-English and non-French mother tongues were Punjabi (n=17), and Arabic (n=12).
Of 71 cases for which languages spoken was directly assessed, 64 had some English or French. However, this was not always sufficient to allow adequate diagnosis and treatment and consultation was often sought due to the effects of language barriers.
Of the 98 individual or couple cases, 49 (50%) needed an interpreter involved at some stage. Interpreters needed covered 19 languages: 8 Asian languages, 6 European, 3 Middle Eastern, 1 African, and 1 Aboriginal. The three most frequently needed languages were Punjabi (6 cases), Spanish (4 cases), and Turkish (4 cases).
The sociodemographic characteristics of the individual and couple consultation requests are summarized in Tables 3 and 4. For individual cases the mean age was 36.6 years (SD=15.4), range 11 to 84); almost 2/3 were female and less than half were married. The level of formal education was relatively low with almost half having only elementary school education. Fully 2/3 were unemployed. In terms of immigration status, the largest group of referrals were refugees or refugee claimants (many of the latter were referred from the regional refugee medical clinic (the Clinique Santé Accueil) located in the CLSC Côtes-des-Neiges adjacent to the JGH.
For the 29 cases involving couples or families the mean age of the husband was 41.1 years (SD=8.2, range 31 to 55) and for the wife 36.3 years (SD=8.8, range 21 to 47).
Information on religious affiliation or background was available for 78 cases. The most frequent was Moslem (n=31), followed by Christian (23). Sikh (9), Jewish (7), Hindu, (4) and Buddhist (4).
Table 3. Sociodemographic Characteristics of Cases Involving Individuals (N=68)*
| n | % | |
|---|---|---|
| Gender (Female) | 40 | 59 |
| Marital Status (n=62) | ||
| Married | 26 | 42 |
| Separated/Divorced | 9 | 15 |
| Widowed | 2 | 3 |
| Never Married | 25 | 40 |
| Education Level (n=43) | ||
| Elementary School | 19 | 44 |
| High School | 4 | 9 |
| College | 9 | 21 |
| University | 11 | 26 |
| Employment Status (n=52) | ||
| Employed | 10 | 19 |
| Unemployed | 34 | 65 |
| Student | 7 | 13 |
| Homemaker | 1 | 2 |
| Immigration Status (n=49) | ||
| Citizen | 13 | 27 |
| Landed immigrant | 12 | 24 |
| Refugee/Refugee Claimant | 20 | 41 |
| Aboriginal | 3 | 6 |
| Student visa | 1 | 2 |
* Sociodemographic information is incomplete because in many cases the patient was never met but only discussed with the referring clinician. The number of cases for which information is available is given after each variable name and the percentages for each category calculated with this denominator.
Table 4. Sociodemographic Characteristics of Cases Involving Couples or Families (N=29)*
| Husband | Wife | |
|---|---|---|
| Education Level (n=10 husbands, 12 wives) | ||
| Elementary School | 1 | 3 |
| High School | 3 | 3 |
| College | 5 | 5 |
| University | 1 | 1 |
| Employment Status (n=15 husbands, 12 wives) | ||
| Employed | 10 | 4 |
| Unemployed | 5 | 4 |
| Homemaker | 0 | 4 |
| Immigration Status (n=15 husbands, 20 wives) | ||
| Citizen | 3 | 4 |
| Landed immigrant | 6 | 8 |
| Refugee/Refugee Claimant | 3 | 7 |
| Diplomatic status | 1 | 1 |
| Not in Canada | 2 | 0 |
* Sociodemographic information is incomplete because in many cases the patient was never met but only discussed with the referring clinician. The number of cases for which information is available is given after each variable name and the percentages for each category calculated with this denominator.
Table 5 summarizes the main initial reasons for consultation. The most common request was help in clarifying a diagnosis, obtaining psychological assessment, or interpreting the cultural meaning of symptoms and behaviours. Almost as often, there was a request for advice on appropriate treatment. In about 25% of cases there was a request for information or help linking to an appropriate professional or community resource (e.g. refugee aid organization, cultural community organization).
Although 50% of cases (51/102) had one main reason for consultation, more than a third (35/102) had two reasons, 16 gave three reasons and 3 (3%) had four reasons for seeking the consultation. The most common reasons were for diagnostic assessment, treatment planning, or a combination of the two.
Table 5. Initial Reasons for Consultation (n = 102)
| n | % | |
|---|---|---|
| Diagnostic Assessment | 59 | 57.8 |
| Treatment Planning | 46 | 45.1 |
| Need for Interpreter or Culture-broker | 18 | 17.6 |
| Information or Link to Resources | 26 | 25.4 |
| Cultural Community or Group Issues | 4 | 3.9 |
| Other* | 4 | 3.9 |
* Other includes: forensic issues; ethical questions; and query about potential usefulness of cultural consultation.
CCS Resources, Responses and Interventions
Of 102 initial contacts, about half were handled with only telephone contact which involved directing the clinician to other resources (e.g. community clinics, organizations, professionals, or the emergency room), arranging for an interpreter, or provided generic advice on intervention strategies (Table 6). In 17 cases, the triage decision was that there was no need for a consultation. Of the 52 cases for which a consultation was recommended, 70% involved seeing the patient and 21% the patient was not seen; in the remaining 6 cases, the consult was incomplete or the patient lost to follow-up.
Table 6. Types of Triage Responses and Interventions (n=102)
| n | % | |
|---|---|---|
| Consultation Recommended (n=52) | ||
| Patient seen directly | 36 | 35.3 |
| Patient not seen | 11 | 10.8 |
| Partial or incomplete consultation | 5 | 4.9 |
| Telephone Consultation at Triage (n=50) | ||
| Consultee directed to other resources | 12 | 11.8 |
| Arranged for an Interpreter | 7 | 6.9 |
| Provided advice on intervention | 11 | 10.8 |
| No Consultation Needed | 17 | 16.7 |
| Patients lost to follow-up | 3 | 4.9 |
A total of 72 consultants were available to the CCS in its database and three specialized transcultural teams (at the Montreal Children's Hospital, Jewish General Hospital and Hôpital Jean Talon). Not all of these consultants were used in the present case series. Table 7 summarizes the professional backgrounds of the consultants in the CCS bank and also lists the frequency with which consultants from a particular background were actually used.
Table 7. Types of Professionals Available in Bank and Used by CSS
| Available in Bank | Used (N=52) | ||
|---|---|---|---|
| n | % | ||
| Psychologist | 21 | 50 | 96 |
| Psychiatrist | 18 | 41 | 75 |
| Social Worker | 14 | 17 | 31 |
| Multidisciplinary Team | 3 | 9 | 16 |
| Interpreter | 7 | 9 | 16 |
| Anthropologist | 5 | 4 | 7 |
| Other Culture Brokers* | 7 | 4 | 7 |
* students, community members
When selecting an appropriate consultant for a cultural consultation, the ideal selection was conceptualized as being a mental health professional who possessed the needed cultural knowledge and who spoke the patient's language. Often, however, these criteria were not possible to meet. As a result, several individuals or consultants would be asked to act as a team combining their knowledge or expertise for the consultation. For examples, culture brokers were sometimes teamed with a mental health practitioner for a cultural consult. In a number of cases, it was only through the process of acting as a consultant for the service that a relationship with the CCS would develop and an appreciation of their knowledge and areas of expertise would be known.
Table 8 displays the specific types of consultation resources needed for the 102 cases referred to the CCS. In all cases some form of matching of the clinician or consultants background was desirable and this was achieved (very roughly) in 80% of cases. Specific clinical skills were needed in 34 cases and again this was possible in almost 80% of cases. The most difficult match involved finding a psychiatrist, which was not possible in about 1/3 of cases (in part this may have reflected the use of psychologists on the team), and finding a non-clinical consultant (an interpreter or culture-broker) for certain small ethnocultural groups. In 49 cases, there was a need for an interpreter; often however this was fulfilled by using a multilingual clinician. In 4 cases the need was only for an interpreter.
In all, there were 241 specific resources identified as needed in response to the 102 cases for an average of 2.36 needs per case. When they could be found in one person (e.g. a Tamil speaking child psychologist) then a single consultant sufficed. More commonly, 2 to 3 consultants were required to provide the requisite linguistic, cultural and medico-psychological expertise to assess a case and plan treatment.
Table 8. Types of Consultation Resources Requested & Actually Used
| Requested | Fulfilled Requests | |||
|---|---|---|---|---|
| n | % All Cases | n | % of Requested | |
| Cultural Consultant | 69 | 68 | 60 | 87 |
| Clinician | 60 | 59 | 55 | 92 |
| Non-clinician | 9 | 9 | 5 | 56 |
| Matching | 100 | 98 | 80 | 80 |
| Ethnocultural group | 54 | 53 | 43 | 80 |
| Language | 34 | 33 | 29 | 85 |
| Religion | 9 | 9 | 6 | 67 |
| Other | 3 | 3 | 2 | 67 |
| Specific skills or expertise | 34 | 34 | 27 | 79 |
| Psychiatrist | 9 | 9 | 6 | 67 |
| Child psychiatrist | 7 | 7 | 5 | 71 |
| Family therapist | 5 | 5 | 4 | 80 |
| Trauma | 4 | 4 | 4 | 100 |
| Refugees | 3 | 3 | 3 | 100 |
| Somatization | 2 | 2 | 2 | 100 |
| Other* | 4 | 4 | 3 | 75 |
| Interpreter Only | 4 | 4 | 3 | 75 |
* Specific expertise with disability, substance abuse, sexual identity, CBT
Table 9 summarizes the types of recommendations made in the cultural consultation for the 52 cases where a consultation was provided. The most common type of recommendations were to re-assess or change the treatment (2/3 cases) or institute a new or additional treatment (1/2 cases). Treatments recommended include medication, cognitive behavioral and supportive psychotherapy, family therapy, and social system interventions. In 1/5 of cases, referral to a new professional was recommended to provide needed treatment or follow-up.
The consultation resulted in a modification or change of diagnosis in 23% of cases. Most often this was a qualification of the existing diagnosis. In several cases, the consultation indicated that a patient had been wrongly diagnosed. This occurred when, due to lack of familiarity with the patients language or culture, dissociative symptoms were misdiagnosed as psychosis, and affective disorders were misdiagnosed as personality disorders. The presence of severe trauma related to organized violence (e.g. torture) was sometimes minimized or over-looked by clinicians unfamiliar with conditions in the patient's country of origin.
Finally, family systems problems were often attributed to personality difficulties or other psychiatric conditions by clinicians unfamiliar with the culture-specific dynamics and politics of family life (e.g. the structure of patriarchal families) or with the impact of migration on extended family systems and vulnerable individuals. More detail on the salient aspects of the cultural formulation is provided in the companion report on the process evaluation of the CCS.
Table 9. Recommendations of Consultation (n=52)
| n | % | |
|---|---|---|
| Reassess or Change Diagnosis | 12 | 23.1 |
| Reassess or Change Treatment | 36 | 69.2 |
| Refer to New Professional | 11 | 21.2 |
| Advise Additional Treatment | 25 | 48.1 |
| Advise Interpreter/Culture-broker* | 3 | 5.8 |
| Ethnic Match | ||
| Clinician | 3 | 5.8 |
| Service | 5 | 9.6 |
| Treatment | 1 | 1.9 |
| Referral to Community Resource | 7 | 13.5 |
* These recommendations involved the use of an interpreter or culture broker alone where there was no need for a clinician.
Satisfaction
A Consultee Satisfaction Survey was completed by 29 clinicians who received consultations by the CCS service. Fully 86% (25/29) reported that the service had met most or all of their needs; 21/29 = 72% found the service helped them to effectively with their clients quite a bit or a great deal, and only 1/29 = 3% found it did not help at all. All clinicians would recommend the service to a colleague and 100% would come back to the service.
Clinicians also responded to an open-ended question asking what they found useful about the cultural consultation. The most frequent benefit was increased knowledge regarding either the social, cultural or religious aspects of the cases or specifically psychiatric and psychological aspects. About half of consultees found that the consultation had improved the patient's treatment and almost 1/3 found that it had improved their communication, empathy and understanding of the patient or strengthened the therapeutic alliance.
Table 10. Aspects of Clinical Case the CCS Consultation Helped (N=29)
| Cases Relevant | Cases Where Consultation Helped | ||
|---|---|---|---|
| n | n | % | |
| Diagnosis | 25 | 18 | 72 |
| Treatment | 29 | 28 | 97 |
| Compliance | 19 | 13 | 68 |
| Migration Issues | 15 | 10 | 67 |
| Cultural | 29 | 25 | 86 |
| Psychiatric | 27 | 23 | 85 |
| Trauma | 16 | 11 | 69 |
| Racism | 16 | 11 | 69 |
| Identify Resources | 22 | 17 | 77 |
Table 11. What Consultees Found Useful about the Consultation (N=29)
| n | % | |
|---|---|---|
| Increased Knowledge | 18 | 62 |
| of social, cultural or religious aspects | 12 | |
| of psychiatric or psychological aspects | 6 | |
| Improved Treatment | 14 | 48 |
| Improved communication, empathy, understanding, or therapeutic alliance | 9 | 31 |
| Increased Confidence in Diagnosis or Treatment | 4 | 14 |
| Useful to have ethnic match of consultant and patient | 4 | 14 |
| Increased Skill | 3 | 10 |
| Helpful to alliance with family | 3 | 10 |
In response to an open-ended question about what they found useful about the consultation, consultees' most frequent responses were that the consultation increased their knowledge particularly about the social, cultural and contextual aspects of the case as well as psychiatric and psychological aspects. Almost half of the respondents felt the consultation had affected their treatment of the case by providing new therapeutic strategies (8 cases) or confirming their ongoing treatment approach (4 cases). About 1/3 felt the consultation had improved their relationship with the patient in terms of better communication, increased empathy and understanding or a stronger therapeutic alliance. Three consultees also noted that the consultation had helped improve their collaboration with the patient's family. Four respondents noted that it increased their own confidence in the diagnosis or treatment plan. Four consultants felt that having a consultant from the same background as the patient was particularly helpful. Only three consultees reported that the consultation had improved their own skills for conducting assessments themselves or identifying appropriate resources.
Among the other aspects of the service that some consultees found useful were the thoroughness of the team's evaluation, the multidisciplinary nature of the team, and practical assistance with writing official letters (i.e. to the Refugee Review Board).
Table 12. Difficulties or dissatisfactions with cultural consultation (N=29)
| n | % | |
|---|---|---|
| Wanted treatment or more follow-up | 4 | 14 |
| Resources suggested were not appropriate | 4 | 14 |
| Concerns about competence of culture broker | 3 | 10 |
| More focus on psychiatric issues rather than social context | 3 | 10 |
| Concerned that they would lose client due to consult | 1 | 4 |
| Need more concrete strategies | 1 | 4 |
| Quicker response | 1 | 4 |
| Concern that cultural elements were missed | 1 | 4 |
The most common concerns with the need for more treatment or follow-up from the team and with the difficulty in locating appropriate treatment resources for clients with specific language or ethnocultural needs. A few consultees expressed concerns about competence of culture broker assigned to their case. In one case, they expected someone with greater psychiatric expertise; in another, they felt that culture broker/consultant was not well prepared as he had not read documentation provided to familiarize himself with the client beforehand. In a third case, the consultee felt there was insufficient collaboration with the consultant and he did not agree with consultant's intervention. Three consultees felt that there was insufficient input on the psychiatric level in their case due to the emphasis on contextual factors; e.g. there was a greater emphasis on the patient's experience of victimization and other issues were not dealt with. One consultee expressed dissatisfaction with the discussion during the CCS clinical meeting because he would have liked the presentation to be more interactive and less focused on reading a report. Another consultee would have liked more concrete clinical intervention strategies to deal with the issues raised by the consultation. They felt there was a need to translate the cultural formulation into clinical interventions.
There were only a few suggestions from consultees on how the service could be improved. The most frequent suggestion (n=4) was that the service should be better advertised and promoted so that detailed information was readily available. Two consultees felt the service should provide more training opportunities, as well as written materials and references; one felt that a resource bank with short recent histories on the countries of origin of their clients would be helpful. Two consultees thought that providing short to mid-treatment for cases would make the service more useful. Two suggested changing the format of the consultation. One felt that performing such long and in-depth evaluations creating unrealistic expectations for subsequent treatment on the part of patients. A second respondent suggested that setting up formal meetings with the consultant before and after they met with the patient would help them to obtain more feedback and useful information. One consultee pointed to the need to further train and improve the skill levels of culture brokers and to carefully screen the pool of culture brokers to insure their competence.
Recommendation Follow-up
A total of 21 respondents provided detailed information on which of the cases recommendations they had follow-up. Of 21 respondents, 19 found the consultees recommendations mostly or completely clear, 16 found them mostly or completely feasible to carry out.
For each recommendation that had not been carried out, respondents were asked to describe why they were not implemented (Table 13). There were three main reasons specific recommendations were not carried out: (i) patient noncompliance (13 cases), (ii) lack of or inefficiency of resources (5 cases) and (iii) lack of staff follow-through (4 cases). In 7 cases the situation had spontaneously improved so that certain recommendations were no longer deemed necessary or appropriate.
Table 13. Reasons Why CCS Recommendations were Not Implemented
| Recommendations n | Cases (N=21) | ||
|---|---|---|---|
| n | % | ||
| Patient Non-compliance | 13 | 8 | 38 |
| Due to poverty | 3 | 3 | 14 |
| Recommendations too complex | 3 | 3 | 14 |
| Symptoms too severe | 1 | 1 | 5 |
| Situation Spontaneously Improved | 7 | 5 | 25 |
| Lack of Staff Follow-Through | 4 | 4 | 20 |
| Lack/Inefficiency of Resources | 5 | 5 | 25 |
| Unknown | 2 | 1 | 5 |
Respondents were also asked what cold have made the recommendations work. The reasons offered were: (i) better transition from CCS to community follow-up (n=6); (ii) improved availability of resources (n=6); (iii) better assessment of patient (n=3); and (iv) greater professionalism on the part of the staff (n=1).
It was not possible to track the health care utilization of patients seen by the CCS directly. To obtain a crude estimate of the potential impact of the CCS intervention on patient's use of clinical services, the referring clinicians were also asked to the best of their knowledge, whether the CCS consultation had affected their patient's use of specific health services. Table 14 summarizes the results. The greatest impact was on the services provided by the referring clinician, followed by other primary care settings, mental health and emergency room use.
Table 13. Impact of Consultation on Services
| Information Available | Cases Where Consultation Affected Use of Services | ||
|---|---|---|---|
| n | n | % | |
| Your own services | 19 | 13 | 68 |
| Primary Care | 18 | 8 | 44 |
| Mental Health | 18 | 6 | 33 |
| ER | 15 | 3 | 20 |
| Other | 20 | 5 | 25 |
In response to an open-ended question about the reasons why the CCS influenced patients' use of services, clinicians offered the following explanations: the CCS consult (i) facilitated contact with medical and mental health professionals (n=10); (ii) improved the therapeutic alliance (n=7); (iii) improved patient's compliance (n=6); (iv) facilitated access to community resources; and (v) other (n=10).
Discussion
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 increase 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 developed 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 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 21% 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 75 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. In general, it was 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 immigrant groups, 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.
According to consultees, the CCS consultation had its greatest impact on treatment and on the cultural and psychiatric aspects of the case. What clinicians found most useful about the consultation was that it increased their knowledge of social, cultural or religious aspects of the cases, or of the psychiatrist or psychological aspects. Almost as frequent was an effect on improved communication, empathy or understanding of the case.
Benefits of the Cultural Consultation Model
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.
Cultural consultation often facilitated the therapeutic alliance between the referring person and the patient. The act of the consultee seeking a cultural consultation may demonstrate to the patient an interest in better understanding the patient within their own cultural framework which can have the effect of facilitating treatment and increasing empathy on the part of the referring person.
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.
Challenges, Obstacles and Limitations to Cultural Consultations
A number of important challenges and potential obstacles were faced in the process of conducting cultural consultations:
- When responding to a request for a cultural consultation, it was necessary that the patient's permission to be seen by a cultural consultant was secured. While some clients welcomed the opportunity to be seen by a clinician or culture broker from a similar cultural background or with relevant cultural knowledge, other clients expressed reservation or worry that being seen by someone from their own community might compromise the privacy of their problems. Some cultural communities are very small and certain problems highly stigmatized so that their concerns may be realistic. Reassuring patients about rules of confidentiality may be necessary but not sufficient.
- 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.
- 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.
- We often needed to clarify repeatedly with consultees that we functioned strictly as a consultation service and not a treatment service. We had several experiences with 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.
- The cultural consultation service was sometimes asked to respond to emergencies or crises (e.g. crises related to the imminent deportation of a patient). The CCS did not have sufficient resources and staff to respond quickly to these requests; nor was it designed to provide emergency care.
- During the process of developing a cultural consultation service, an appreciation for the difficult position that a cultural consultant can be placed in was developed. The role of the cultural consultant is often to act as a bridge between the patient and the referring person. They are also often expected 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 or psychological care. The demands of these two positions do not always coincide and can sometimes be in complete opposition to one another. As a result, the skill level of the consultant and their relative comfort in negotiating this position is important in any consultation.
- 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, resistance to their use was still common, particularly in the case of hospitals that tended to rely on staff members to act as interpreters. Despite the intervention of the CCS, the JGH continued to under-utilize the interpreter pool and the most of the funds assigned by the Régie Régionale to the hospital for this purpose went unused.
References
Atkinson, C. (1996). Client Satisfaction Questionnaire. In L.I. Sederer & B. Dickey (Eds.), Outcomes Assessment in Clinical Practice (p. 278), Baltimore, Maryland: Williams & Wilkins
Bland, R.C., Orn H., & Newman, S.C. (1988). Lifetime prevalence of psychiatric disorders in Edmonton. Acta Psychiatrica Scandinavica, 77 (Suppl. 338), 24-32.
Brown, JB, & Weston, WW. (1992). A survey of residency-trained family physicians and their referral of psychosocial problems. Family Medicine, 24
Carr, V., Faehrmann, C., Lewin, T., Walton, J., Reid, A. (1997). Determining the effect that consultation-liaison psychiatry in primary care has on family physicians psychiatric knowledge and practice. Psychosomatics, 38 (3), p.217-229
Cole, M., Fenton, F.R., Engelsmann, F., & Mansouri, I. (1991). Effectiveness of geriatric psychiatry consultation in an acute care hospital: a randomized clinical trial, American Geriatrics Society, 39, p. 1183-1188.
Huyse, F., Lyons, J.S., & Strain, J. (1993). The sequencing of psychiatric recommendations-concordance during the process of a psychiatric consultation. Psychosomatics, 34 (4), p.307-313.
Huyse, F., Lyons, J.S., & Strain, J. (1992). Evaluating Psychiatric Consultations in the General Hospital — Multivariate predictions of concordance. General Hospital Psychiatry, 14, 363-369.
Huyse, F., Strain, J., & Hammer, J.S. (1990). Interventions in Consultation/Liaison Psychiatry. Part I: Patterns of Recommendations. General Hospital Psychiatry, 12, 213-220.
Huyse, F., Strain, J., Hengeveld, M. W., Hammer, J., & Zwaan, T. (1988). Interventions in Consultation-Liaison Psychiatry: The development of a schema and a checklist for operationalized interventions. General Hospital Psychiatry, 10, 88-101.
Knapp, P.K., & Harris, E.S. (1998). Consultation-Liaison in Child Psychiatry: a review of the past 10 years. Part II: Research on treatment approaches and outcomes. Journal of the American Academy of Child and Adolescent Psychiatry, 37: 139-146.
Levenson, J.L., Hamer, R.M., Rossiter. L.F. (1992). A randomized controlled study of psychiatric consultation guided by screening in general medical inpatients, American Journal of Psychiatry, 149(5):.631-637.
Lin, E., Goering, P. (1992). The Ontario Health supplement: content and method. Paper presented at the Ontario Psychiatric Association 72nd Annual Meeting, Toronto, Ontario.
Salvador-Carulla, L. (1999). Routine outcome assessment in mental health research, Current Opinion in Psychiatry, 12: 207-210.
Takeuchi, D.T., Young, K.N.J. (1994). Overview of Asian and Pacific Islander Americans. In N.W.S. Zane, D.T. Takeuchi and K.N.J. Young (Eds.), Confronting Critical Health Issues of Asian and Pacific Islander Americans (p. 3-21). Thousand Oaks, CA: Sage Publications.