Cultural Consultation: A Model of Mental Health Service for Multicultural Societies
At the time of initial contact, the most commonly stated reasons for consultation were as follows: requests for help in clarifying a diagnosis or the meaning of specific symptoms or behaviours (58%), requests for help in treatment planning (45%), and requests for information or a link to organizations and resources related to a specific ethnocultural group or issue (for example, refugee status) (25%). One-half of all cases had multiple reasons for requesting consultation, which gives some indication of the complexity and interrelatedness of the issues.
The cases represented enormous cultural diversity, with 42 countries of origin, 28 languages, over 50 ethnocultural groups, 6 major religious traditions, and numerous distinct sects. This demanded a wide range of consultants, interpreters, and culture brokers. The bank of culture brokers and consultants included 73 professionals, who were predominately psychologists, psychiatrists, and social workers. A few consultants were used repeatedly, both because of the specific background of the referred cases and because of their high level of skill.
Almost one-half of all requests to the CCS (50 cases) were resolved with telephone contact and either informal exchange of information or linking to specific resources. In about 20% of the cases, the clinical coordinator felt that there was no need for a cultural consultation. Some of these cases represented inappropriate referrals for which basic medical and social services had not yet been arranged; others involved an effort to refer a difficult case with no apparent cultural component, in the hope of obtaining additional services. In 10 of the 52 cases for which a consultation was recommended, the consultation occurred entirely through discussion with the referring clinician, and the patient was not seen.
Interpreters were needed for about one-half of all consultations. In many cases, we met this need with a clinician who spoke the requisite language. In two-thirds of the cases, it was necessary to match the consultants’ background in some way with that of the patient (for example, in language, ethnicity, or religion). In one-third of the cases, some specific clinical skills were needed (for example, psychiatric expertise; family therapy training; or experience working with trauma, refugees, or somatization).
While it was possible to find appropriate consultation resources in most cases, ethnic matching was very approximate. Often, it was not possible to find a clinician with the requisite language skills and cultural knowledge to address specific cultural and mental health issues. In such cases, we used an interpreter or cultural broker and a clinician with generic expertise in cultural consultation. However, it was difficult to find well-trained interpreters or appropriate culture brokers to work with patients or families from some of the smaller ethnocultural communities or with more recent immigrants. Further, ethnic matching was sometimes contraindicated. For example, patients were sometimes reluctant to meet with a culture broker or consultant from their own background when the small size or internal milieu of the local community made confidentiality a concern.
In cultural consultations, we raised a wide range of issues to provide the social, cultural, and political context for patient symptoms and behaviour and to guide diagnostic assessment, treatment planning, and service delivery. Attention was given to the patients’ cultures of origin and to their social circumstances (for example, poverty, unemployment, and experience of racism). When formulating cultural issues, we avoided sweeping generalizations or cultural stereotypes and focused on detailed histories and local cultural issues that could be explicitly linked with the patients’ symptoms and distress. We also emphasized the culture of psychiatry and the health care system in general—the values, models, assumptions, and institutional practices that may diverge from patient expectations and create misunderstandings, interactional problems, or conflicts that are sometimes mistakenly attributed to a patient’s cultural or personal background.
The most frequently raised issues were as follows:
variations in family systems, including structure, roles, and value systems (for example, patriarchal families) (24,25)
identity issues related to age and gender roles and life- cycle transitions (for example, the significance for identity and social status of marriage, divorce, child-bearing, adolescence, or being an elder) (26–30)
the impact of exposure to torture, war, and organized violence in political and historical context (31,32)
for asylum seekers, the profoundly stressful impact of the refugee claimant process, with its prolonged period of uncertainty and review board hearing (33,34)
the intergenerational impact of migration (for example, issues of identity, the fracturing of extended families, changing gender roles, the loss of communal supports and mediators, and the creation of tensions between generations) (35,36)
the effects of subtle or covert racism or other biases on provision of services to patients (5,37–41)
the prevalence of dissociative and somatoform symptoms, leading to misdiagnoses of psychosis, personality disorder, or malingering (42,43)
previous experiences with health care and healing practices in the country of origin, including biomedicine and traditional systems of medicine (44,45)
the importance of religious practices for coping and social support, particularly in the psychological containment of grief and anxiety (46,47)
Interestingly, explanatory models of illness, which form a large part of the literature in medical anthropology, were not central to most of the case formulations. It appeared that many individuals had pluralistic models that enabled them to make use of both biomedical and traditional resources. Difficulties arose because of conflicts with clinicians who were intent on pursuing a single course of action, with little tolerance for patients’ medical pluralism. Of course, it is possible that distressed individuals who understood their problems exclusively in terms of traditional explanatory models were less likely to make use of biomedical health care services and hence, less likely to be referred to the CCS.
The most common recommendations emerging from the cultural consultation involved reassessing or changing treatment (70%) or using an additional treatment (for example, medication or psychotherapy) (48%). A change in diagnosis was recommended in 23% of cases. In 9 cases, it was suggested that treatment be reorganized to enable ethnic match at the level of clinician, service, or specific type of treatment intervention.
In all, 29 referring clinicians (representing 47 cases) completed service evaluation questionnaires. Of these, 86% reported that they were satisfied with the consultation and that it had helped them manage their patients. Useful aspects of the consultation included increased knowledge of the social, cultural, or religious aspects of their cases (41%); increased knowledge of the psychiatric or psychological aspects of their cases (21%); improved treatment (48%); improved communication, empathy, understanding, or therapeutic alliance (31%); and increased confidence in diagnosis or treatment (14%). The major difficulties or dissatisfactions with the cultural consultation were the lack of treatment or more intensive follow-up (14%), unavailability or inappropriateness of recommended resources (14%), concerns about the competence of the culture broker (10%), and the impression that there was too much focus on social context, rather than on psychiatric issues (10%). All said they would use the service again and would recommend that their colleagues use it. They reported high rates of concordance with recommendations. In 21 cases, some aspect of the CCS recommendations was not implemented. Reasons for this included patient noncompliance (n = 13), lack of staff or other resources (n = 9), and spontaneous improvement (n = 7).
The cases referred to the CCS revealed that language barriers and the cultural complexity of assessing symptoms prevented adequate diagnosis and treatment for a significant number of patients, including refugees, new immigrants, and members of established ethnocultural communities. The CCS was able to respond to these needs in most cases, and the subsequent assessments, treatment plans, and interventions were well received by referring clinicians.
Consultations required substantial resources in terms of specific expertise in cultural psychiatry, interpreters, and culture brokers. Evaluations often involved teams of 2 to 3 clinicians, interpreters, and culture brokers, as well as multiple or lengthy contacts with patients and their families. However, the result of this intensive process was often a change in diagnosis and treatment plan, with significant immediate and long-term consequences for patient functioning, decreased use of services, and increased clinician satisfaction.
Cultural consultation often facilitated the therapeutic alliance between the referring person and the patient. This positive change frequently started to express itself when the consulting clinician was present during the clinical interview carried out by the culture broker. Perhaps the clinician’s effort to seek a consultation demonstrated to the patient an interest in understanding the patient in his or her own cultural framework. The cultural formulation produced by the consultation placed the patient’s puzzling or disturbing symptoms and behaviours in a social and cultural context and thus made sense of them. By clarifying the patient’s predicament, the consultation increased the clinician’s empathy. In recognition of this, the CCS team on most occasions invited all consulting clinicians to be present during the cultural broker’s clinical interview, to facilitate knowledge transfer and strengthen the clinical alliance.
Cultural consultation also revealed a case’s complexity and often transformed the clinician’s frustration or feeling of being overwhelmed into an appreciation of the intellectual and professional challenge presented, leading to increased clinician interest and motivation to remain actively involved. Even when patients were not seen, the advice and reinterpretation of events provided by the CCS team worked to improve and maintain the referring clinician’s treatment alliance and refine the diagnostic and treatment approach.
Evaluation of the cases referred to the CCS identified important systemic barriers to the use of interpreters within medical institutions. Clinicians were untrained in their use and not compensated for the added time and effort required. Because clinicians did not know that interpreters were both important and available, there was a lack of demand for interpreter services. Administrators, too, were unaware that a pool of available interpreters had been established by the regional health authority (48).
Challenges to Service Implementation
We faced several challenges in the process of conducting cultural consultations, which raises important considerations for the future development of this type of service.
While some clients welcomed the opportunity to be seen by a clinician or culture broker from a similar cultural background, other clients expressed reservations or concerns that being seen by someone from their own community might compromise their privacy. These concerns were realistic for patients from some small cultural communities with high degrees of stigmatization of mental health problems. Reassuring patients about rules of confidentiality was necessary but not always sufficient. The concerns about confidentiality also applied to the use of interpreters during the consultation. Similarly, some clients who were seeking asylum expressed concern about how information gathered during a cultural consultation might affect their application for refugee status.
A shared body of knowledge and experience is crucial to clinicians’ ability to understand and empathize with their patients’ predicaments. For clinicians to appreciate these patients’ problems and begin to think more clearly about assessment and intervention, it was essential to introduce some of the rich and complex social and cultural context of their lives. At times, however, the complexity of the formulation had the potential to undermine the referring clinician’s competence and confidence. It was crucial to the success of the consultation that clinicians came to view the cultural dimensions as understandable and within their sphere of competence. Accordingly, it was essential to devise formulations that did not simply elaborate the complexity and ambiguity of the case but yielded pragmatic guidelines for intervention. Models drawn from family therapy and cognitive-behavioural therapy provided useful bridges from specific social and cultural formulations to clinicians’ existing domains of expertise.
Clinicians often made demands of the CCS that went beyond consultation to include requests for emergency intervention, for comprehensive primary care, or for transfer of the patient for long-term treatment or case management. This may reflect not only the additional challenge posed by cultural difference but also the limited resources for mental health treatment available in the health care system as a whole. In several consultations, the referring clinician became inaccessible or stopped treating the patient, presumably on the assumption that the CCS would become responsible for the patient’s subsequent care. In some cases, when there was a clear need for long-term intervention and a good match of skills, the CCS staff or consultants did undertake ongoing treatment or continued to work as culture brokers. Mechanisms must be sought to support such work in a climate of constrained health care services and limited coverage of refugee claimants.
CCS staff benefited from a cohesive team that could absorb the impact of stories of massive trauma, conflicts of cultural values, diagnostic uncertainty, and limits of professional competence. However, cultural consultants or culture brokers were sometimes placed in difficult and opposing positions when called upon to balance the demands of developing an alliance with the patient based on cultural understanding while still negotiating the rules, norms, and standards of traditional psychiatric care. It was therefore fundamental to the consultation’s success that the consultant possess a high level of interpersonal skill.
The CCS actively promoted the use of professional interpreters in hospital and other mental health settings. The recommendation to use an interpreter was frequently made as part of a consultation but also as a phone intervention, even when a consultation was not pursued. Despite this, resistance to the use of interpreters persisted, with hospitals relying on family or housekeeping staff to interpret and using only a fraction of the budget allotted for interpreters by the regional health authority (48).
Conclusion: Implications for Training, Policy, and Research
Our experiences with the CCS have implications for training, health policy, and research. There is a need to increase awareness of cultural issues in mental health and corresponding clinical skills among primary care clinicians and social service workers, through in-service training. Specialized cultural consultation services can play a major role in educating clinicians and in developing innovative intervention strategies that can later be transferred to practitioners in primary care settings. The multiple perspectives, skills, and backgrounds represented in a culturally and professionally diverse team can facilitate critical analysis of conventional practices and case formulation and lead to creative intervention. This diversity can also sustain a cohesive, collegial group able to support consultants’ efforts to challenge systemic problems, including institutional racism.
There is a need to strengthen the training of mental health practitioners in concepts of culture and strategies for intercultural care (49). This training should recognize the value of clinicians’ own linguistic and cultural knowledge as added skills. There is a particular need to train mental health practitioners to work with interpreters (50). This should become standard, not only in graduate training programs in psychology, psychiatry, and family medicine residencies but also in the education of other mental health and social service professionals.
In turn, 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 (51). The role of interpreter is insufficient to address the exploration of cultural context and meaning essential for a cultural formulation. Consequently, there is also a need to develop the role of culture brokers, who can work closely with clinicians to mediate during clinical encounters (52). Culture brokers require formal training in mental health (53), ongoing supervision, development of formal assessment of competence, and a mechanism for remuneration. In parallel with this professional development, there is a need to support community services and to improve liaison with other mental health care professionals, so that appropriate resources to assist with the social care of patients can be identified.
The cases seen by the CCS clearly demonstrated the impact of cultural misunderstandings: incomplete assessments, incorrect diagnoses, inadequate or inappropriate treatment, and failed treatment alliances. These problems are costly, both in terms of increased service use and in terms of poor clinical outcomes. Directly measuring patient outcome would allow a more robust test of the value of the consultation service; however, there are many practical barriers to such an evaluation. For example, the diversity of the cases in terms of sociodemographic characteristics, diagnostic categories, and type of consultation request would require different measures of successful outcome. In addition, any measures would need to be translated into many languages and standardized for the patients’ variable level of education. Further, many consultations did not involve direct contact with patients and exerted their effects only through subsequent changes in the approach of clinicians and social service agencies over an extended period of time, making the timing of any evaluation problematic. Similar obstacles have been identified in efforts to evaluate the cost-effectiveness of psychiatric consultation in general hospitals (54). Some of these difficulties can be surmounted by accruing a larger patient cohort that can be subdivided into more homogeneous groups. In future research, we plan to assess the clinical outcomes and cost-effectiveness of this approach and identify specific clinical strategies useful in the consultative process.
Funding and Support
This project was supported by a financial contribution from the Health Transition Fund, Health Canada (QC424).
1. Details of the cases have been modified to protect patient anonymity.
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Manuscript received and accepted February 2003.
An earlier version of this paper was presented by the first author as an invited lecture at the Annual Meeting of the Canadian Psychiatric Association; November 17, 2001; Montreal (QC).
1. James McGill Professor and Director, Division of Social and Transcultural Psychiatry, McGill University, Montreal, Quebec; Director, Culture and Mental Health Research Unit, Sir Mortimer B Davis—Jewish General Hospital, Montreal, Quebec.
2. Assistant Professor, Division of Social and Transcultural Psychiatry, McGill University, Montreal, Quebec; Staff investigator, Culture and Mental Health Research Unit, Sir Mortimer B Davis—Jewish General Hospital, Montreal, Quebec.
3. Associate Professor, Division of Social and Transcultural Psychiatry, McGill University, Montreal, Quebec; Director, Child Day Treatment Centre, Department of Psychiatry, Sir Mortimer B Davis—Jewish General Hospital, Montreal, Quebec.
4. Postdoctoral Fellow, Division of Social and Transcultural Psychiatry, McGill University, Montreal, Quebec; Former Clincial Coordinator, Cultural Consultation Service, Sir Mortimer B Davis—Jewish General Hospital, Montreal, Quebec.
5. Faculty Lecturer, Division of Social and Transcultural Psychiatry, McGill University, Montreal, Quebec; Director, Cultural Consultation Service, Sir Mortimer B Davis—Jewish General Hospital, Montreal, Quebec.
Address for correspondence: Dr LJ Kirmayer, Culture and Mental Health Research Unit, Institute of Community and Family Psychiatry, 4333 Côte Ste Catherine Rd, Montreal, QC H3T 1E4
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