Purpose of the project
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 findings of this study will be useful to clinicians, planners and educators involved in developing models for the delivery of culturally appropriate and effective mental health services.
The project had three main activities corresponding to our major goals:
- Development and evaluation of cultural consultation services
A new Cultural Consultation service was established at the Sir Mortimer B. Davis–Jewish General Hospital (JGH). This service was assessed along with already existing Transcultural Clinics at the Montreal Children's Hospital (MCH) and Hôpital Jean-Talon (HJT). This allowed us to identify gaps in services and to compare different models of service.
- Development of information resources for cultural consultations
We created databases of community organizations, professionals and resource persons with expertise in culture and mental health and a website for access to this data and related information in cultural psychiatry.
- Training mental health professionals for intercultural work
We reviewed training models and developed a series of teaching materials and in-service training activities for health and social service professionals. In collaboration with the Regional Board of Health and Social Services, this program also aimed to improve the capacity of clinicians and interpreters to work together in mental health and to develop a cadre of culture-brokers.
The quantitative evaluation of the JGH and MCH services 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. Efforts to assess patient outcomes and cost-effectiveness were stymied by the great heterogeneity of the cases seen and the need to minimize intrusiveness in the consultation context, which sometimes did not involve seeing the patient but only meeting with the referring clinician.
The qualitative component of the evaluation used a model of participatory research with participant-observation by research anthropologists working in close collaboration with the teams. At the Jewish General Hospital, a protocol was used to summarize case conferences and interview consultees and consultants, to document: the process of consultation and its outcomes. At the MCH series of cases of refugees with histories of severe trauma (related to organized violence) and adolescents with first episode psychoses were intensively analyzed by interviewing the clinicians involved in their long term care, reviewing records and analyzing case conference discussions. At the HJT, a series of patients were followed up with a semi-structured interview protocol to assess the impact of the large group intervention.
The analysis of cases seen in the cultural consultation services and transcultural clinics indicates that access to mental health care varies by linguistic and cultural background and that racism diminishes access to mental health care or undermines the relevance and reception of conventional care. In a significant number of cases, language barriers and the cultural complexity of the cases had prevented adequate assessment in conventional mental health care settings.
The cultural consultation services were able to respond to these needs in a substantial proportion of cases and their interventions were well received by referring clinicians. They required substantial resources in terms of specific expertise in cultural psychiatry as well as interpreters and culture brokers. Evaluations often involved teams of 2-3 or more interviewers and multiple or lengthy contacts with patients and their families. However, the result of the intensive process was often a change in diagnosis and treatment plan with significant immediate and long-term consequences for patients' functioning, use of services, as well as clinician satisfaction.
The review of training models and programs indicates that there is insufficient development and integration of transcultural training in most professional programs as well as little or no training in working with interpreters and culture brokers.
Recommendations and 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 both by developing additional services and through ongoing training and support of clinical institutions and personnel.
- There is a clear need for specialized multidisciplinary teams or services that bring together clinical expertise with cultural knowledge and language skills essential to work with patients from diverse cultural backgrounds.
- Specialized cultural consultation services can play a major role in education of clinicians and in developing innovative strategies for intervention, which can later be transferred to practitioners in primary care settings.
- There is a need to increase awareness of cultural issues in mental health and corresponding clinical skills at the level of primary care and social service institutions through in-service training.
- There is a need to support community services and improve liaison with professional mental health care to develop the role of culture brokers who can work closely with clinicians to mediate during clinical encounters and identify appropriate resources to assist with the social care of patients.
- 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 clinicians' own linguistic and cultural background knowledge as added skills.
- There is a specific need to train mental health practitioners to work with interpreters. This should become a standard part of graduate training programs in psychology, psychiatry and family medicine residencies, and the education of other mental health and social service professionals.
- There is a need for additional training of interpreters to increase their expertise in mental health. Interpreters also need ongoing supervision and support to work with potentially distressing or traumatizing situations.
- Quality assurance and accreditation standards for cultural competence must be further developed and applied to both training and service programs.
- Finally, there is a need for a national network in transcultural mental health that can act as a clearinghouse for models of intervention, clinical resources and training materials.