Issues and trends

Partnering with ethnoracial communities to take culture seriously

By Carolyn Morris

The first thing clients of Punjabi Community Health Services in Brampton, Ontario, are asked to sign is a consent form that allows counsellors to talk with the client’s family. Because extended families are central to Punjabi culture, it is often necessary to convince a client’s father of the need for mental health treatment, or to counsel wives or siblings who might not know how to deal with a family member’s addiction. The agency will still provide services if the client refuses to sign, but manager Amandeep Kaur says treatment in that case often isn’t as effective as when the family is involved.

In a recent example, six sisters who were worried about their brother’s drinking got counselling, as did their husbands, about how to stop enabling their brother’s problem. Counsellors began the brother’s treatment by focusing first on his family.

Achieving this type of culturally appropriate care in mental health and addiction services was the focus of a recently completed five-year provincial project, Taking Culture Seriously in Community Mental Health. Led by the Centre for Community Based Research (CCBR) in Waterloo, the participatory action research project – research “with” and not “on” people – brought together multi-disciplinary researchers, mental health practitioners and members of five different cultural communities in Toronto and Waterloo – Spanish-speaking Latin American, Mandarin-speaking Chinese, Polish, Punjabi Sikh and Somali.

The project went beyond merely identifying problems and brainstorming solutions to applying its findings through various demonstration projects. It was carried out in three phases – data collection through interviews and focus groups, development and applications for funding of demonstration projects and project evaluation.

The project serves a growing need. While immigration grows steadily in Canada, especially in large urban areas, many newcomers do not have access to effective mental health services. “The old way of doing business is not working too well,” says Joanna Ochocka, executive director of the CCBR. The study’s main finding, as its name suggests, is that the mental health system must take culture seriously by not only seeking advice from members of diverse ethnoracial groups, but by also allowing them to become stakeholders. “Diverse cultural groups, policy makers and practitioners need to work differently and collaboratively,” says Ochocka. “There are many things that cultural groups need to do to feel stronger and define their needs, but they should also be recognized partners.”

The mental health system must take culture seriously by not only seeking advice from members of diverse ethnoracial groups, but by also allowing them to become stakeholders.

Punjabi Community Health Services developed one of the study’s six demonstration projects. The agency obtained resources to provide mental health services and an addiction program for the Punjabi Sikh population in Toronto’s Peel region. The project provides therapy tailored to the needs of the community and combats stigma around mental health problems through a weekly TV call-in show in Punjabi. The project has had a lot of success in increasing comfort with what is traditionally a taboo subject for this community and adapting to clients’ culture. Involving extended families in treatment, as in the case of the six sisters and their brother, is one example.

A common theme emerging from the study is that adaptation needs to be reciprocal; cultural groups and mental health providers learn from one another. One demonstration project led by the Kitchener Downtown Community Health Centre hired seven point people, or “navigators,” from different ethnoracial groups to link members of their communities with services and educate service providers about cultural sensibilities. “It’s a lot about breaking the stigma,” says Alida Abbott, the project co-ordinator. But navigators also play an important role in educating service providers about particular needs of their community members, and they often act as interpreters.

Language barriers can be challenging, but they aren’t the only obstacle to good mental health care, says Amandeep Kaur. If service providers speak someone’s language but know little else about the culture, they can easily obtain basic information, but when it comes to counselling, it becomes more complicated. The differences in cultural values run a lot deeper than vocabulary. For example, in some cultures, including Punjab, the literal translation of “mental health” is a derogatory word. Mandarin has no word for mental health. If service providers use the term, they could scare people away from treatment. Navigators help service providers understand the client’s cultural framework.

But understanding cultural frameworks doesn’t mean adhering to stereotypes, says Ana Luz Martinez, a settlement worker at the Kitchener-Waterloo Multicultural Centre, who was hired as one of 10 community researchers for Taking Culture Seriously. “You cannot say that Latin Americans behave in a certain way, because everybody’s different,” she says. Martinez stresses the need for service providers to be open and adaptable, to be able to adjust to a client’s needs. She would also like to see more service providers from different cultural backgrounds – she knows of just two Spanish-speaking counsellors in her area.

But for practitioners who may not speak the language or be familiar with a client’s culture, there are still ways of providing better care. One theme that came up often in focus groups and from navigators was that people felt they were not given time to express themselves and that service providers didn’t listen to them. Martinez says this is often the case when counsellors give more attention to the interpreter than to the client. “If there is no empathy with the client, the service isn’t provided to the client, it’s provided to the interpreter,” she says. She has also seen clients become nervous when an intake person asks personal questions over the phone. Some people get intimidated and simply hang up.

Several of these concerns were captured in front of an audience of service providers and policy makers in Other End of the Line, a play commissioned by the project and produced by the Multicultural Theatre Space. To a frenetic drumbeat, a man wearing a white lab coat looks down at his clipboard and asks mechanically, “Can I have your name, please?” The woman beside him answers nervously, “Um, my name is …” Without letting her finish, the man bombards her with more questions, as he scribbles away: “Can I have your family name, and that’s perfect, can I have your address, your postal code …?” The scene feels inhumane, and especially alienating for someone who might already be vulnerable and confused.

Encounters with an unfamiliar medical system aside, the immigration experience itself can put newcomers at increased risk of developing mental health issues. “People struggle with employment, with life adjustments, with parenting,” says Ochocka. Sometimes they have experienced trauma. Martinez herself was a refugee from Guatemala, who lived in a refugee camp in Mexico before coming to Canada. She says that the immigration system should be more proactive in pointing newcomers toward counselling services they may need.

But people will not seek help if they don’t think the system can provide it. Many communities are distrustful of Western mental health practices. “In Canada, some doctors just rush you to medication,” one focus group participant said. “That is what most people are afraid of.” Many cultures have a more holistic approach to mental health, and fear they will be labeled mentally ill and given prescriptions. By creating more space for ethnic diversity and by adapting professional training programs to embrace various cultural perspectives, the mental health system could become more responsive to the needs of ethnoracial communities.

With the study’s focus on translating theory into practice, strategies have emerged that community mental health and addiction agencies across the country can apply to make their services more culturally appropriate. As funding dries up for some of the demonstration projects, such as the cultural navigator initiative, participants hope to secure sustained financing to keep them going. They hope to see more ethnoracial groups become involved as stakeholders in Canada’s mental health system. “This is not only about the research project, with its start and end dates and its budget,” says Ochocka. “This type of community-university research partnership is part of a bigger agenda, a movement.”