Joel Sadavoy

Barriers to Access to Mental Health Services for Ethnic Seniors: The Toronto Study

Objective: To identify and describe barriers to access to mental health services encountered by ethnoracial seniors. Method: A multiracial, multicultural, and multidisciplinary team including a community workgroup worked in partnership with seniors, families, and service providers in urban Toronto Chinese and Tamil communities to develop a broad, stratified sample of participants and to guide the study. This participatory, action-research project used qualitative methodology based on grounded theory to generate areas of inquiry. Each of 17 focus groups applied the same semistructured format and sequence of inquiry. Results: Key barriers to adequate care include inadequate numbers of trained and acceptable mental health workers, especially psychiatrists; limited awareness of mental disorders among all participants; limited understanding and capacity to negotiate the current system because of systemic barriers and lack of information; disturbance of family support structures; decline in individual self-worth; reliance on ethnospecific social agencies that are not designed or funded for formal mental health care; lack of services that combine ethnoracial, geriatric, and psychiatric care; inadequacy and unacceptability of interpreter services; reluctance of seniors and families to acknowledge mental health problems for fear of rejection and stigma; lack of appropriate professional responses; and inappropriate referral patterns. Conclusions: There is a clear need for more mental health workers from ethnic backgrounds, especially appropriately trained psychiatrists, and for upgrading the mental health service capacity of frontline agencies through training and core funding. Active community education programs are necessary to counter stigma and improve knowledge of mental disorders and available services. Mainstream services require acceptable and appropriate entry points. Mental health services need to be flexible enough to serve changing populations and to include services specific to ethnic groups, such as providing comprehensive care for seniors.

Survivors: A Review of the Late-Life Effects of Prior Psychological Trauma

The author reviews the literature on the epidemiology, symptom picture, and treatment of elderly patients who have encountered serious psychological trauma earlier in life. Data are predominantly derived from studies of aging Holocaust survivors and combat veterans from World War II, the Korean Conflict, and Vietnam, Survivor syndromes persist into old age, but patterns of expression vary. Holocaust survivors appear to have adapted well to instrumental aspects of life, whereas combat warriors may show less functional life-adaptation. Persisting symptoms in all groups include marked disruptions of sleep and dreaming, intrusive memories, impairment of trust, avoidance of stressors, and heightened vulnerability to various types of age-associated retraumatization. There is a deficiency of controlled treatment studies of traumatized elderly patients, but successful group, individual, and family clinical interventions have been described.

Multi-family psycho-education group for assertive community treatment clients and families of culturally diverse background: a pilot study.

This study evaluates the incorporation of Multi-Family Psycho-education Group (MFPG) to an Assertive Community Treatment Team developed to serve culturally diverse clients who suffers from severe mental illness. Participants included Chinese and Tamil clients and their family members. Family members’ well-being, perceived burden, and acceptance of clients were assessed before and after the intervention. Focus group interviews with clinicians were conducted to qualitatively examine MFPG. Family members’ acceptance increased after MFPG. Regular attendance was associated with reduction in perceived family burden. Culturally competent delivery of MFPG enhanced family members’ understanding of mental illness and reduced stress levels and negative feelings towards clients.

A Men's Group: Psychotherapy of Elderly Men

ABSTRACTThe group psychotherapy of a population of cognitively intact men, aged 70–95 years, resident in a home for the aged is described. Although this age group is often thought to be nonresponsive to psychotherapeutic intervention, it appears that group psychotherapy is a valuable modality in addressing the common clinical picture of social isolation, depression, and demoralization. The paper describes certain technical modifications in the conduct of the group by the leader—high activity and support, therapeutic transparency, translation, and integration—that facilitate this process. Psychodynamic aspects of aging and of living in an institution are also elaborated, with particular reference to the role of the life review, current theories of narcissism, and the consequences of the mens efforts to maintain their self-esteem and sense of self in the face of recurrent narcissistic injuries and losses.

Psychogeriatric care in the general hospital.

This study examines treatment outcome in 52 psychogeriatric patients to help determine the role of the general hospital in psychiatric care of the elderly. The author reviewed the charts of all patients 65 years of age and over admitted to the psychiatric ward from 1974 to 1978. Approximately 80% of this group showed symptom remission. Treatment failures correlated closely with the presence of major organic brain syndrome. Despite an average age of 73.4 years and a high proportion of widowed patients only 10 patients needed new placements on discharge. The author discusses the reluctance of general hospitals to treat the psychogeriatric patient despite the high success rate, the merits of such an active treatment approach and the effect of short-term therapy programs on the treatment of this group.

Psychotherapy and the Cognitively Impaired Elderly

Cognitive decline is often a devastating event, whatever the cause. It assaults the very core of the individual — his or her capacity for reflection and memory, emotional intimacy, love and warmth, giving and receiving advice and respect, and tolerating or taking pleasure in the daily passage of life. Those who care for the slowly disappearing self of their mother, father, sister, or brother, are left puzzled, helpless and, most importantly, progressively less able to communicate. Relationships that have a past of vital interaction gradually evolve into the isolated and painful solitudes of two people deeply connected by history but irrevocably separated by this disease.

The characterologically difficult patient: a hospital treatment model.

A treatment model for the hospitalized borderline patient has evolved from the long-term, intensive treatment of these patients in a psychodynamically oriented setting. Four stages are identified and described. Each has a therapeutic goal and strategy, and repeatedly observable patient responses and staff counter-responses. Although patients vary in the lengths of time in each stage and there is much back and forth between stages, the regularity with which this pattern occurs greatly increases the capacity of the treating personnel to understand and guide the treatment process. The model clarifies perplexing, discouraging, or stale-mating affects and behaviours in the patients, and misleading counter-therapeutic affects and behaviours in the staff. Further, it can predict certain features and, to some extent, probable outcome in any particular course of treatment.

Adapting ACT to serve culturally diverse communities: a comparison of a Japanese and a Canadian ACT team.

OBJECTIVE The assertive community treatment (ACT) teams of Mount Sinai Hospital in Toronto and the KUINA Center, Hitachinaka, Japan, were compared with regard to ACT fidelity, organizational structure, populations served, and treatment outcomes. Ethnocultural adaptations to the ACT model made by both teams included enhanced family support and intervention, culturally and linguistically matched staff and patients when possible, culturally informed therapy, routine cultural assessments, culturally matched housing and community support, and flexible funding models. METHODS Data were gathered by chart reviews (66 patients in Toronto and 40 patients in Japan), a satisfaction measure, a standard measure of ACT fidelity, and a pre-post measure of treatment outcomes (the Brief Psychiatric Rating Scale), and hospitalization days. RESULTS Both teams achieved good fidelity to ACT and reductions in hospitalization and symptom severity. Family satisfaction scores were high. CONCLUSIONS With culturally informed adaptations, ACT can be effective in a Canadian mixed ethnocultural population and a homogeneous Japanese population.

P01-446 - Working with cultural diverse persons involved in law and mental health - cultural competency training manual

The goal of this presentation is to introduce a new “Cultural Competency Training/Manual (CCTP) for Law and Mental Health professionals Working with persons involved with law and mental health” sponsored by a grant from the Law Foundation of Ontario and department of psychiatry of Mount Sinai Hospital. The manual is qualitative which includes conducting a literature review, facilitation of multi-stakeholder focus groups, and interviewed key stakeholders, consultation with clinical staff from the Mount Sinai Hospital and other Court Support programs, to address the key challenges in working with culturally diverse persons involved with law and mental health. In the oral presentation, we will present key themes on the challenges in dealing with culturally-diverse persons involved in law and mental health. The themes were consistent with the literature, evidence-based research, and validated by actual provider experience. They include language and communication, mistrust of mainstream services, racism and discrimination, resistance from persons involved with law and mental health and their families, and the need for cultural competency practices, such as interpretation, cultural understanding, community and systemic support. With these themes in mind, we will demonstrate the application of practical skills and cultural competencies using vignettes. A cultural competency model of working with culturally diverse persons involved in law and mental health and the five key responsibilities will be introduced. They include the following domains: language and communication, system support and navigation, education and advocacy, and collaboration.