Cécile Rousseau

Common mental health problems in immigrants and refugees: general approach in primary care

Background: Recognizing and appropriately treating mental health problems among new immigrants and refugees in primary care poses a challenge because of differences in language and culture and because of specific stressors associated with migration and resettlement. We aimed to identify risk factors and strategies in the approach to mental health assessment and to prevention and treatment of common mental health problems for immigrants in primary care. Methods: We searched and compiled literature on prevalence and risk factors for common mental health problems related to migration, the effect of cultural influences on health and illness, and clinical strategies to improve mental health care for immigrants and refugees. Publications were selected on the basis of relevance, use of recent data and quality in consultation with experts in immigrant and refugee mental health. Results: The migration trajectory can be divided into three components: premigration, migration and postmigration resettlement. Each phase is associated with specific risks and exposures. The prevalence of specific types of mental health problems is influenced by the nature of the migration experience, in terms of adversity experienced before, during and after resettlement. Specific challenges in migrant mental health include communication difficulties because of language and cultural differences; the effect of cultural shaping of symptoms and illness behaviour on diagnosis, coping and treatment; differences in family structure and process affecting adaptation, acculturation and intergenerational conflict; and aspects of acceptance by the receiving society that affect employment, social status and integration. These issues can be addressed through specific inquiry, the use of trained interpreters and culture brokers, meetings with families, and consultation with community organizations. Interpretation: Systematic inquiry into patients’ migration trajectory and subsequent follow-up on culturally appropriate indicators of social, vocational and family functioning over time will allow clinicians to recognize problems in adaptation and undertake mental health promotion, disease prevention or treatment interventions in a timely way.

Addressing Cultural Diversity Through Collaborative Care

This chapter describes principles of collaborative care in mental health and how this model, based on strong partnership between primary care and mental health professionals, can be adapted to provide culturally sensitive services. The patient-centred model of collaborative care aims at decreasing barriers to accessing mental health care, which are particularly tangible for ethnocultural minorities and marginalized groups. It recognizes the major role played by primary care professionals in delivering mental health services and the benefit of comprehensive networks of professionals and community partners. The chapter discusses necessary conditions for implementing such initiatives, describes the benefits of multidisciplinarity, which goes beyond a medically centred model, and addresses issues of power. It then considers the adaptation of collaborative care to address the cultural specificities of communities. It reviews the recommendations of the Canadian Collaborative Mental Health Initiative (CCMHI) Toolkit for Ethnoculturally Diverse Populations and of the Canadian Collaboration for Immigrant and Refugee Health (CCIRH), and then focuses on two key areas identified by these recommendations: partnership with communities and awareness of historical and cultural specificities. The chapter then describes a youth mental health care project in a multiethnic neighbourhood to illustrate how collaborative care can be adapted to local constraints, while fostering attention to cultural diversity in mental health. Finally, the chapter addresses training methods appropriate to support collaborative care and proposes a continuing education program based on the synergy of seminars, supervisions, and didactic teaching.

Cultural Consultation for Refugees

Refugees and refugee claimants are faced with the task of rebuilding their lives in an unfamiliar environment, while having to deal with past trauma and multiple ongoing stressors. As part of the clinical intervention with this population, it is important to understand and act on the social determinants of health, which may maintain or exacerbate mental health problems and impede integration. In this chapter, we summarize the legal rights of refugees and refugee claimants, with a strong focus on the criteria that a refugee claimant must meet in order to be accepted as a refugee according to international and Canadian law. We then examine some of the main stressors that refugees and refugee claimants may face during the premigratory, transit and postmigration phase, and discuss in greater depth the impact of immigration detention in the host country and of family separation and reunification. This is followed by a discussion of the clinical assessment and treatment of refugees who have experienced trauma and forced migration. Finally, we provide guidance on writing reports assessing refugee claimants’ mental health in the context of refugee status determination proceedings. To conclude, we briefly examine the relevance for clinicians to engage in advocacy on behalf of this population.

Cultural Consultation in Child Psychiatry

This chapter addresses cultural consultation in child psychiatry. The mental health needs of immigrant and refugee youth are outlined, and different models of mental health services for immigrant and refugee children and their families are described. The work of two transcultural child psychiatric teams, one in Canada and one in France, are presented in order to illustrate the practice of transcultural child psychiatry. The aim is to outline practical strategies for consultation and intervention, and also to show how specific institutional, social and political contexts influence how clinicians address issues associated with minority status and culture in their cultural consultation work. The chapter concludes with some reflections on how sociocultural context influences the practice of transcultural child psychiatry in these two models of care.

Gender, Power and Ethnicity in Cultural Consultation

Issues of gender, ethnicity, power and position not only influence the identity and social suffering of the patient, but shape the clinical encounter influencing therapeutic alliance, transference, countertransference and the process of assessment and treatment. This chapter uses case material from the work of South Asian cultural consultants to illustrate how the identity of the consultant influences clinical encounters with patients from the Indian subcontinent, with particular attention to gender and power issues. The cultural or racial similarities or differences in the identity of consultant and patient, or referring clinicians, raise complex issues encompassing institutional, familial, and individual dynamics. These issues may have positive effects on the clinical alliance, or create excessive ambivalence and negative responses that undermine therapeutic work. Mirroring of gender and power attributes can position the therapist as someone who shares vulnerabilities and strengths with minority patients. This can cause impediments to clinical work, with resistance, scotomas or excessive identifications. The intrapsychic, intra-familial and socio-political implications are explored using a case examples as well as reference to current literature on gender, migration and identity. As the cultural consultation strives to promote cultural safety as the primary basis of engagement, therapist and patient identity issues must be acknowledged and conflicting agendas of gender, power, ethnicity, as well as cultural dissonance and prejudice must be negotiated by consultants and clinical teams.

Conclusion: The Future of Cultural Consultation

In the final chapter, we reflect on the lessons learned from over a decade of work by the cultural consultation service. We consider the challenges of implementation and evaluation, the evidence for impact on the health care system, and the implications for mental health policy, the design of health care systems, the training of professionals, and everyday clinical practice. The findings from CCS project are important because they indicate significant unmet need for mental health services for indigenous peoples, immigrants, refugees and asylum seekers. At the same time, the CCS project suggests that outpatient consultation provides an effective means of responding to some of these needs. A service like the CCS can support mainstream health care, provide ongoing training within clinical institutions and create a context that allows professionals from diverse backgrounds to make systematic use of their linguistic and cultural expertise. Beyond issues of access, equity and quality of health care, multicultural mental health services provide an important arena for building pluralistic civil society.