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Cultural Consultation: A Model of Mental Health Service for Multicultural Societies
Case Report 1
A 21-year-old, recently married woman, newly arrived from India, was referred by an inpatient psychiatry team for anorexia nervosa and somatization unresponsive to treatment. The staff wondered whether they should stop visits from her mother, who was her only surviving relative and who brought food daily, because the girl seemed immature and “enmeshed.” During a series of consultation visits from a Hindi-speaking psychologist (conducted both with and without the presence of the referring team), it became clear that the girl was suffering from an undiagnosed medical problem that was duly investigated. Her physical pain was complicated by her distress over the fact that her new husband had absconded to another province after achieving immigration status. Further, he had kept a large dowry given by her mother, who came from a high-status family in her country of origin but who was now a factory worker. The consultation focused on supporting mother and daughter in dealing with multiple stressors that included feelings of shame and family dishonour. Identifying and explicitly acknowledging the social and cultural contexts of her distress allowed the inpatient treatment team to focus on treating the patient’s depression, on managing her pain, and on addressing the medical etiology of her somatic symptoms. Her mother’s continued support, manifested through the preparation of special foods, was acknowledged as important for her recovery.
Case Report 2
A 22-year-old man from the Caribbean, single and living with his parents, had a diagnosis of brief psychotic episode with symptoms of depression and anxiety. His family had decided to discontinue his neuroleptic medication and take him to the Caribbean to see a folk healer, and he was referred by his outpatient psychiatrist for assessment of treatment noncompliance. The referring psychiatrist adamantly opposed the family’s plan and feared that the patient would rapidly decompensate if taken off medication. The CCS arranged meetings with a psychologist from the Caribbean to allow the family to discuss their concerns. The family attributed the patient’s problem to tremendous pressures he had experienced through his involvement in a new religion that he had joined because of a girlfriend. They were not completely opposed to medication but hoped that traditional healing might help their son’s condition and that his extended family in the Caribbean would provide him with a safe environment and close supervision. After consultation, the referring psychiatrist was advised to adopt a more flexible position that allowed the family some control over treatment choice. The family agreed to have medication available for their son during the trip, should his condition deteriorate. The patient went to his country of origin and, following treatment by a healer, was greatly improved. His family maintained a strong alliance with the psychiatrist, marked by increased trust and willingness to return if their son’s symptoms recurred.
Case Report 3
A 50-year-old married man, a South Asian refugee claimant who had fled police torture without his family, was referred by his family practitioner and refugee clinic team, who were having difficulty understanding him and found him noncompliant with treatment. After 10 months of contacts, they remained unclear about his diagnosis. Further, the patient’s lawyer had missed the first hearing before the Immigration Review Board, resulting in a delay for his claim and subsequent deterioration in his condition. He related this story through an interpreter, apologizing repeatedly for his disorientation and memory lapses. He described chronic anxiety, insomnia, recurrent nightmares, and suicidal ideation. He wept as he spoke of the chronic pain and other symptoms he had experienced as sequelae of torture. He felt that his value as a man had been undermined because he had left his family behind to face an uncertain fate. Following the consultation, his antidepressant medication was increased and the issue of adherence to treatment was addressed by mobilizing additional support, including increased contact with a social worker, phone-call reminders, and the participation of religious leaders. The consultant reframed the patient’s predicament in the context of his strong spiritual and religious values, and his abandonment of the family was discussed as a choice that required the courage to take risks to safeguard his family’s future. As his attention was shifted to hope for his children and his own spiritual life, this patient was able to mobilize a more resilient response. The consultant first worked with the referring team alone, to discuss the case, and later with the patient present, to bridge the cultural barriers to understanding. A summary of the consultation was sent to the patient’s lawyer to support his upcoming refugee hearing.
These cases illustrate some of the complex issues addressed in cultural consultations. The CCS used a team of consultants with expertise in cultural psychiatry, as well as interpreters and culture brokers. This approach allowed the CCS to address the interplay of social, cultural, and systemic factors to produce more accurate diagnoses and to negotiate treatment plans that made sense to patients and to referring clinicians.
Service Development and Evaluation
We documented the process of setting up the service through periodic research meetings and semistructured interviews of key staff undertaken by a medical anthropologist. We also used various quantitative and qualitative methods to evaluate the first 100 cases seen. Quantitative evaluation of the service involved assessing the outcome of consultations in terms of the following: 1) types of cases referred and evaluated, 2) use of specific professional and community resources, 3) types of interventions and recommendations, 4) the consulting clinician’s satisfaction of with the service, and 5) the consulting clinician’s concordance with the recommended interventions. The qualitative component of the evaluation employed a participatory research model involving participant observation by a research anthropologist working in close collaboration with the team (20). We used a protocol to summarize case conferences and to interview both consultees and consultants. The following elements were documented: 1) the type of intercultural problems referred to the CCS, 2) the types of persons and institutions who use the CCS, 3) the types of cultural formulations and their influence on interventions, 4) the types of clinical and community recommendations proposed, 5) barriers to service implementation and how they were overcome, and 6) intrinsic and extrinsic factors that hindered or facilitated the implementation of CCS recommendations.
Service Development
The CCS was designed and implemented to provide the following: specific cultural information, links to community resources or to formal cultural psychiatric or psychological assessment, and recommendations for treatment. Referrals were accepted from health practitioners, community workers, schools, and other institutions—but only for patients that already had an identified primary care provider or case manager.
Core CCS personnel included 2 part-time psychiatrists, as well as psychologists, social workers, psychiatric nurses, medical anthropologists, and trainees from these disciplines and from family medicine. A full-time clinical psychologist acted as clinical coordinator and triaged all referred cases. The psychologist interviewed referring clinicians to determine the reasons for consultation and to identify the resource persons needed to conduct the evaluation (for example, interpreters, culture brokers, or clinicians with specific skills).
Two computerized databases were developed to facilitate the work. The first comprised available cultural consultants and culture brokers with specific linguistic, cultural, or clinical skills; the second listed community organizations and resources for specific ethnocultural communities or groups (such as refugees or people seeking asylum). The databases updated and expanded existing listings previously developed by the Multiculturalism Program and the Transcultural Child Psychiatry Service at the Montreal Children’s Hospital.
We prepared a handbook to guide consultants through the consultation process. Consultants were asked to use the “Outline for Cultural Formulation” in DSM-IV (21–23); an expanded version of the cultural formulation was prepared that emphasized issues related to migration, ethnic identity, family systems, and developmental issues.
We distributed a brochure describing the service and providing contact information to all registered psychiatrists and psychologists in the province of Quebec. Presentations to regional clinics and departments of psychiatry by CCS team members also increased awareness of the service and led to subsequent referrals. However, most clinicians requesting consultations had heard about the service through word of mouth.
We discussed cases during a weekly case conference. At that time, additional expertise could be brought in to assist with formulating the cultural dimensions of each case. This conference served as a training setting, built team cohesion, and provided an opportunity for quality control, in that the skill level and orientation of new consultants could be judged from the quality of their clinical presentation. A research anthropologist was a participant observer at the clinical case conferences and met subsequently with clinical staff to qualitatively evaluate the service.
Characteristics of Consultations
Over the initial 12-month period of operation, the CCS received 102 requests for consultation. Referrals came from the whole range of health and social service professionals based at hospitals, community clinics, and private offices. While most consultation requests concerned individuals, almost one-third involved couples. About 60% were women, 44% had only elementary school education, 9% had high school education, 47% had some college or university education, 65% were unemployed, 27% were Canadian citizens, 24% were landed immigrants, and 41% were refugees or asylum seekers. Four cases involved requests from organizations to discuss issues related to their work with a whole ethnocultural group or community.
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