Objectives and rationale
This project involved the development and evaluation of cultural consultation as a specialized service in mental health. The principle objective of the service was to improve the accessibility and cultural appropriateness of mental health services for the multicultural population of Montreal, including immigrants, refugees, and ethnocultural groups, as well as Aboriginal peoples. This new program can serve as a model for similar services in other Canadian cities.
The specific objectives of the project were:
- to identify gaps in existing services to ethnocultural minorities, immigrants refugees and Aboriginal peoples;
- to develop and evaluate a multidisciplinary cultural consultation service which specializes in mental health evaluation and treatment;
- to facilitate access to cultural expertise in mental health by developing a network of clinicians, databases and internet resources.
- to offer ongoing professional training and to promote the development of competency in intercultural intervention among mental health practitioners, particularly those who offer front line or primary care services;
The reports of the Federal Task Force on Mental Health Issues Affecting Immigrants and Refugees and of the Comité de Santé du Québec indicated the need to develop culturally sensitive health care for all citizens . Despite the policy of equal access to care for everyone, significant barriers to care continue to exist across Canada for Aboriginal peoples, immigrants, refugees and ethnocultural minorities by reason of language, culture and ethnicity.
Culture shapes the experience and expression of emotional distress and social problems in myriad ways (Kirmayer, 1989). In order to accurately diagnose and treat patients from diverse backgrounds, therefore, it is essential to consider the cultural meaning of somatic symptoms, and explore the social context of distress (Kleinman, 1988; Mezzich et al., 1996; Rogler, 1993, 1996). A variety of models have been developed to meet this clinical challenge. These range from ethnospecific mental health services or clinics (e.g. an Indochinese Refugee Mental Health Clinic; Kinzie et al., 1980), to the use of culture brokers and specially trained mental health translators, to the training of clinicians in generic cultural competence. Despite the apparent utility of many of these approaches, to date there have been no studies to demonstrate their efficacy and cost-effectiveness. In a climate of constrained resources for health care and steadily increasing cultural diversity, the development and evaluation of models of care has become an urgent priority.
Beyond the need for basic research on models of care for culturally appropriate and accessible mental health services, there is a need to improve the process of diagnosis and treatment in cross-cultural psychiatry (Rogler, 1996). This is not simply a matter of devising a cultural formulation of a case, but requires the development of assessment instruments, new strategies and techniques of intervention and research to better understand the interactional processes of interviewing, interpreting, assessment and treatment in the larger context of the changing demography of our society.
Models of care
A variety of models have been developed to meet the challenge of culturally appropriate care:
- The simplest approach is to insure access to standard care for all patients. At a minimum this requires readily available interpreter services. However, since many individuals from culturally diverse backgrounds are unaware of mental health services or experience significant barriers, access must include elements of community outreach education. Our own research in the Côte des Neiges area (Kirmayer, et al., 1996), clearly documented under-utilization of existing resources by immigrants from certain ethnocultural communities. In many cases this was attributed to the perception that they would be stigmatized by their community, or would face barriers due to language, culture and racism in conventional mental care settings.
- A second model involves the use of helping resources and people within cultural communities. In most communities of any size, there are professionals, indigenous healers, elders and other ‘natural' helpers who have traditionally dealt with mental health problems. These people have intimate knowledge of the social norms and cultural history of their community. Their modes of intervention are culturally consonant, and may enjoy greater legitimacy and authority that biomedicine or formal social services in responding to mental health problems. Conventional health care services may refer people to such practitioners or work in close collaboration within them, each providing complementary aspects of patient's care. However, for complex cases and major psychiatric disorders, they may not have the requisite expertise and institutional resources to provide all aspects of care.
- A third model involves the development of specialized services. These has followed different directions in different countries (Kirmayer & Minas, 2000,) In the United States, this has taken the form of ethnospecific services, e.g. Indochinese, Hispanic or African-American Mental Health Clinics (Cheung & Snowden, 1990; Kinzie et al., 1980; Mason, et al. 1996; Primm, et al., 1996; Sue et al., 1991). A similar model has been tried in Toronto with the Hong Fook Mental Health Clinic. In Britain, an attempt has been made to provide psychodynamic psychotherapy in an "anti-racist clinic" for people from visible minorities (Fernando, 1995; Kareem & Littlewood, 1992). In contrast, in Australia, efforts to provide improve access and provide culturally sensitive care have been integrated into the mainstream with an emphasis on the ready availability of interpreters (Minas, Silove & Kunst, 1993; Gardner, 1997; Kirmayer, 1998).
Clearly, these models are not mutually exclusive. Each has a potential role to play. In particular, there is indirect evidence form cultural psychiatric research and client satisfaction studies to suggest that specialized services have an important function in improving the quality and accessibility of mental health care for ethnocultural minorities (Sue, 1992). These services are intended to provide support for mental health work in primary care as well as social service and psychiatric settings. In this way, they can be a useful adjunct to the overall effort to shift psychiatric care to the primary care sector.
Up to the time of the present study, there have been no comparative evaluation studies of the merits and limitations of any of these models, so that it is difficult for planners to justify investment in the development and maintenance of specialized services. The CCS Project was designed to evaluate the impact of cultural consultation, to clarify its role and effectiveness, and to compare different models of implementation.