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Spring 2008 | Vol 11 No 3

Focus

Challenging borders and barriers

Cultural competence must embrace anti-oppression frameworks

By Avril Roberts

There is an ever increasing body of research linking racism and mental health problems. “Racism has many different impacts on people’s health,” says Dr. Kwame McKenzie, senior scientist in the Social, Equity and Health Research Section at the Centre for Addiction and Mental Health (CAMH) in Toronto. “It is linked to factors such as poverty that increase the risk of developing illness. Some consider racist attack and abuse to directly lead to health problems.”

Add to that micro-aggressions, the kinds of incidents described in a 2005 study of the strategies black Caribbean students attending Montreal community colleges use to achieve academic success: “I was with a group in the metro and we were waiting for someone who was going to meet us there,” recounted one student. “Automatically it was assumed that we were troublemakers and we were told to leave.” Repeated experiences grind people down: “It eats you up morally,” reported another student. “It’s very hard to get through.”

“The students felt that systemic racism is an issue and that they have to use the anger that is engendered by racism as a motivation to succeed,” says Dr. Myrna Lashley, lead author of the study and a psychology professor at John Abbott College in Montreal. “We are creating a generation of very angry young people.” In her private practice where she does psychological assessments for the courts and social services, Lashley deals with these young people. “I notice that quite a few have mental health difficulties. They have social issues that make them feel they don’t belong.”

Lashley says that clinicians must consider broader social issues when working with such clients. “Society, not just clinicians, has been unable to accept what systemic discrimination does to people. It changes how you view the world and yourself. It attacks your self-esteem and makes you more cautious.”

This systemic discrimination is often mirrored in the mental health system, which may not acknowledge racism, discrimination and oppression and their impact on mental health. “Some institutions welcome this discourse, but others forbid it,” says Dr. Jaswant Guzder, head of child psychiatry at Jewish General Hospital in Montreal.

Guzder says that mental health and addiction clients often have to contend with “a collusion of professional blind spots, beginning with our institutional stance that is unwelcoming or that denies cultural axis issues. If an institution doesn’t facilitate the building of a therapeutic alliance that takes into account both a person’s experiential cultural map and previous racism encounters, this clinical setting is taking an approach that reflects either overt racism or an implicit racism related to ignorance, lack of acknowledgement or sheet oversight, a situation that constitutes institutional racism,” she says.

Related challenges include:

Limited access to language interpretation services. “These services are considered a luxury, not a necessity,” says Guzder. Too often, nonprofessional staff are enlisted to provide on-the-spot interpretation, setting the stage for misinterpretation, misdiagnoses and mismanagement of mental health issues.

Cultural misinterpretation. For example, there is a generalization that people from some ethnocultural backgrounds are non-verbal or somatizers and are therefore unsuited to psychotherapy, when, in fact, they may come from cultures where direct confrontation or disclosure of feelings is discouraged.

Clinician neutrality. Or, as Guzder calls it, the “delusion of neutrality – the notion that we, in the healing professions, are so neutral that we view all human suffering in the same way and don’t bring prejudices of our own.”

Inadequate training. Do health care education and training discuss the fact that ethnicity might make a difference to health-seeking and care? Is social exclusion as a determinant of health examined?

Over-reliance on Eurocentric therapies and models of care. Adherence to limited notions of health and wellness fails to consider more culturally appropriate types of care.

Emphasis on evidence-based practice. “If we decide we want to use this mantra, then if services are going to be equitable, the evidence needs to be equitable,” says McKenzie. “There are two problems with this. One is that we need more information and research on different ethnocultural groups. The second is that we may need new methodologies that allow us to make sense of the data we get from research on small ethnocultural groups. At the moment, our system of care is built on knowledge that is mainly monocultural. This is unlikely to meet the needs of a multicultural population.”

Scarcity of funding for ethnoracial services. “Mainstream money feeds into mainstream organizations for care, but for the groups that have the highest need, money is often diverted into community organizations that mean well but that may be less able to offer comprehensive care,” says McKenzie.
Factoring in the structures, philosophies and impacts of the organizations that intersect with the mental health system such as schools, child welfare services, settlement agencies, police and the criminal justice system, it becomes glaringly evident that cultural competence must expand beyond its traditional focus on individual clinical competence.

“If we want to be serious about producing non-discriminatory, balanced services, we must take a systemic approach,” says McKenzie. “We must be advocates. We have to put money into the right places, think of the big picture and unfreeze services so they can be innovative and fast-moving to adapt to the needs of cultural communities.”

McKenzie is optimistic that Canada can be a leader in delivering equitable care: “There is a chance for Canada to develop service models that could be the envy of the world because there is so much diversity here and it is a relatively new country. However, this means challenging old ways of thinking and people will have to start thinking differently.”

One service model that pushes the traditional boundaries of cultural competence and puts systemic issues of racism and oppression at the centre of care operates through Across Boundaries, an ethnoracial community mental health centre in Toronto. The agency opened its doors in 1995, as the only community mental health agency in Ontario, possibly in Canada, to build its foundation on an anti-racism, anti-oppression approach that drives the organizational structure, hiring, training and education and service delivery.

Walk into the agency and you will notice that everyone – staff and clients – is a person of colour. If you are a current or prospective client you will be invited to sit in the open area or, if you like, in a separate room. The program co-ordinator will come out and greet you, introduce you to everyone and offer you coffee while you wait to attend your program or interview. While you sit there, you may notice that some of the artwork on the walls reflects systemic issues like racism.

“Mental health already has too much stigma,” says Sulekha Jama, who has worked on the agency’s front lines. “When you come into a place where everybody looks like you, where you don’t know who is staff and who is client until they introduce themselves, that helps a lot. We also name racism. The minute you name it, it opens the door for people to actually talk about it. It’s a comfort for people when they come through the door, knowing that they can just be who they are. That’s what they tell us.”

All of the clients in Across Boundaries’ programs are people of colour with severe mental illness. During the intake process, if a client mentions experiencing racism, the case worker assigned to the client at the first meeting asks if the client would like to talk about it. If the client hasn’t raised any race issues, the case worker explains that Across Boundaries operates from an anti-racism framework and is open to discussing related issues whenever the client would like.

According to Jama, immigration is a major topic. “Clients talk about what they went through at the airport when they claimed refugee status, being separated from the other passengers, being searched, having customs officers make fun of them, laughing at them because of their English,” she says. “We’re able to tell them that other people have gone through the same thing. They are relieved to find out it’s not just them. It gives people the sense that this is a place where they can talk about it.” So many clients from Afghanistan, Iran and Iraq have had such humiliating or traumatic experience that they have formed a support group facilitated by a case manager who speaks Persian. The group of about 14 people has been meeting weekly for the past five years.

A Tamil support group that started shortly after the tsunami hit Sri Lanka in 2004 is still going strong under the direction of a Tamil-speaking staff member. About 16 people meet weekly in Scarborough, an area of eastern Toronto that is home to more than 7,000 Tamils who fled Sri Lanka’s civil war.

At the Jane-Finch Mall, in the heart of a diverse neighbourhood in northwestern Toronto facing many social issues, youth aged 16 and older in the Y-Connect program drop in for two hours every Tuesday evening for Real Talk, a freewheeling session where they meet with two youth workers and chat about what is going on in their lives.

Across Boundaries provides space for two psychiatrists to offer services on site – one is the only Somali psychiatrist licensed to practice in Ontario. A doctor of traditional Chinese medicine offers acupuncture at the mental health centre once a week and a doctor of Ayurvedic medicine (a medical system from India) visits once a month.

The agency’s staff have completed formal and informal anti-racism training that informs their attitudes and behaviours with clients. Many have deep roots and connections in the cultural communities they serve, so their awareness of cultural beliefs and practices helps them advocate on their clients’ behalf when dealing with mainstream agencies, for example, helping a depressed Somali mother find community day care for her four rambunctious preschoolers so that as a single mother with a mental illness she would not get caught up in the Children’s Aid system.

Beyond clinical care, Across Boundaries conducts community-based research about pressing issues such as the experience of trauma from war, abuse or migration and its impact on mental health.

Martha Ocampo, co-director and one of the founders of Across Boundaries, says, “The whole idea behind Across Boundaries was to develop a model, have the mental health system look at our model and see how effective it is, then use it to appropriately serve a very large population so that at some point we would disappear.”

But Across Boundaries has not disappeared. Far from it. The agency served 480 clients in 2007 and still seems to be unique in its approach to mental health services. “Perhaps some organizations are not ready yet to operate in an anti-oppression framework,” says Ocampo. “If they haven’t had the anti-racism education and training, people don’t understand why there is a need for a paradigm shift or a change in the way they have been doing business. It is important that organizations go through a process of organizational change, starting with governance.”

Ocampo raises these key questions: Who is governing the organization? What needs to change? What kind of policies have to be developed? How will the policies be implemented? What programs or services will be appropriate for people coming into the programs? What kind of outreach can you offer? Who needs the help most? Who are your partners? With these questions in mind, mental health and addiction agencies can begin to work toward developing models of cultural competence that recognize systemic issues like racism and oppression.