Adaptation des pratiques / accès aux services

Most models of mental health services have been developed in urban centres, with large populations and many specialized resources. Rural and remote communities pose challenges to these models for reasons of geography, social structure and culture. In Canada and other countries, rural and remote communities include a high proportion of Indigenous peoples, with important cultural differences from the urban population. In this chapter, we discuss the role of cultural consultation in providing mental health services for remote and rural communities, with an emphasis on the mental health of Indigenous peoples in Canada. The authors have worked as psychiatric consultants to First Nations and Inuit communities in Northern Quebec and draw from this experience and the work of the CCS to outline key issues for cultural consultation in this setting. The major social determinants of health and contextual factors that are distinctive for remote communities and Indigenous populations are reviewed. Models of service discussed include: onsite delivery of mental health services through collaborative care models; itinerant consultants; telepsychiatry; and satellite services. Mental health services for Indigenous communities need to be provided in culturally appropriate ways, both through supporting the use of traditional healing approaches and ensuring that mainstream mental health services are culturally safe and competent.

This chapter describes principles of collaborative care in mental health and how this model, based on strong partnership between primary care and mental health professionals, can be adapted to provide culturally sensitive services. The patient-centred model of collaborative care aims at decreasing barriers to accessing mental health care, which are particularly tangible for ethnocultural minorities and marginalized groups. It recognizes the major role played by primary care professionals in delivering mental health services and the benefit of comprehensive networks of professionals and community partners. The chapter discusses necessary conditions for implementing such initiatives, describes the benefits of multidisciplinarity, which goes beyond a medically centred model, and addresses issues of power. It then considers the adaptation of collaborative care to address the cultural specificities of communities. It reviews the recommendations of the Canadian Collaborative Mental Health Initiative (CCMHI) Toolkit for Ethnoculturally Diverse Populations and of the Canadian Collaboration for Immigrant and Refugee Health (CCIRH), and then focuses on two key areas identified by these recommendations: partnership with communities and awareness of historical and cultural specificities. The chapter then describes a youth mental health care project in a multiethnic neighbourhood to illustrate how collaborative care can be adapted to local constraints, while fostering attention to cultural diversity in mental health. Finally, the chapter addresses training methods appropriate to support collaborative care and proposes a continuing education program based on the synergy of seminars, supervisions, and didactic teaching.

Issues of gender, ethnicity, power and position not only influence the identity and social suffering of the patient, but shape the clinical encounter influencing therapeutic alliance, transference, countertransference and the process of assessment and treatment. This chapter uses case material from the work of South Asian cultural consultants to illustrate how the identity of the consultant influences clinical encounters with patients from the Indian subcontinent, with particular attention to gender and power issues. The cultural or racial similarities or differences in the identity of consultant and patient, or referring clinicians, raise complex issues encompassing institutional, familial, and individual dynamics. These issues may have positive effects on the clinical alliance, or create excessive ambivalence and negative responses that undermine therapeutic work. Mirroring of gender and power attributes can position the therapist as someone who shares vulnerabilities and strengths with minority patients. This can cause impediments to clinical work, with resistance, scotomas or excessive identifications. The intrapsychic, intra-familial and socio-political implications are explored using a case examples as well as reference to current literature on gender, migration and identity. As the cultural consultation strives to promote cultural safety as the primary basis of engagement, therapist and patient identity issues must be acknowledged and conflicting agendas of gender, power, ethnicity, as well as cultural dissonance and prejudice must be negotiated by consultants and clinical teams.

This chapter addresses cultural consultation in child psychiatry. The mental health needs of immigrant and refugee youth are outlined, and different models of mental health services for immigrant and refugee children and their families are described. The work of two transcultural child psychiatric teams, one in Canada and one in France, are presented in order to illustrate the practice of transcultural child psychiatry. The aim is to outline practical strategies for consultation and intervention, and also to show how specific institutional, social and political contexts influence how clinicians address issues associated with minority status and culture in their cultural consultation work. The chapter concludes with some reflections on how sociocultural context influences the practice of transcultural child psychiatry in these two models of care.

In this chapter, we describe the development, implementation and evaluation of the cultural consultation service (CCS). We begin with some background on the development of intercultural services in Montreal. The next section describes the rationale for the CCS approach and the steps involved in setting up the service. The third section provides an overview of the cases seen by the service in the first decade of its operation, including sources and reasons for referral, as well as socio-demographic and clinical characteristics. This provides a sense of the portfolio of cases from which vignettes are drawn throughout this book to illustrate key issues in cultural consultation. The remaining sections summarize findings from qualitative process and outcome evaluations of the service. The analysis of cases seen in the CCS and transcultural clinics indicates that access to mental health care varies widely by linguistic and cultural background. In a significant number of cases, language barriers and the cultural complexity of the cases had prevented adequate assessment in conventional mental health care settings. The CCS was able to provide clinical reassessment and redirection of treatment in a substantial proportion of cases and these interventions have been well received by referring clinicians. Although cultural consultations require substantial resources, in terms of specific expertise in cultural psychiatry as well as interpreters and culture brokers, the result of this intensive process is often a change in diagnosis and treatment plan with significant immediate and long-term consequences for patients’ functioning, use of services, as well as clinician satisfaction.

Cultural diversity presents an important challenge for health care services in every society around the world. In this introductory chapter, we consider the changing meanings of culture and the ways in which different societies have responded to cultural diversity in mental health services. We show how these approaches reflect local patterns of migration and demography, ideologies of citizenship and theories of the place of culture in mental health. We outline the rationale and key principles of the cultural consultation approach: focusing on social and cultural contexts in assessment; recognizing the ubiquity of culture in the experience of patients and clinicians; understanding culture not simply as mental representations but as embodied and enacted; using systemic, interactional and self-reflexive views; emphasizing problems of power, position and communication; approaching culture and community as resources for healing, adaptation and recovery; and working within health care systems to foster change. We illustrate what culture adds to clinical care including diagnostic assessment and treatment through the contextual framing of psychiatric disorders. Social and cultural processes shape the mechanisms of disease, the symptoms of distress, and subsequent ways of coping or help-seeking. Systems of healing reflect cultural models of body, self and person that are grounded in distinctive ontologies or notions of what constitutes the individual and the world. Finally, we consider the importance of understanding culture and context for clinical empathy.

Cultural diversity is a global challenge for mental health services. The changing demography of communities requires rethinking approaches to cultural competence for health professionals and institutions. Cultural consultation is a way to improve the quality of mental health care by providing a nuanced understanding of the predicaments that prompt diverse clients to seek help, and the social contexts of their mental health problems, to guide clinical assessment and intervention.

Cultural Consultation explores the practice of cultural consultation as a strategy to improve the quality of mental health care for diverse populations. The contributors, who have worked together at an innovative clinical service, frame best practices in psychiatry clinical psychology, and social work in relation to empathy, human rights, and culturally responsive and ethically sound care. A detailed model of the process of cultural consultation, from initial intake, through assessment, to recommendations and referrals, provides guidelines for clinical practice. Expert contributors examine specialized settings (medical, psychiatric emergency, inpatient, social/legal services), populations (remote, indigenous, child and youth), and contextual issues in the care of people with a wide range of mental health problems. Numerous case examples, charts, and tools add depth for readers interested in developing similar services or enhancing existing practice. Among the key areas covered: 

• Working with interpreters and culture brokers.
• Family systems in cultural consultation.
• Gender, power, and ethnicity in cultural consultation.
• Consultation and mediation with racialized and marginalized communities.

Collaborative care and primary care consultation.

• Cultural consultation with refugees.

A unique guide to challenges and opportunities in contemporary practice, Cultural Consultation will be immediately useful for health care professionals, clinical psychologists, and cultural consultants and provide a versatile knowledge source for years to come.

Many migrants do not speak the official language of their host country. This linguistic gap has been found to be an important contributor to disparities in access to services and health outcomes. This study examined primary care mental health practitioners’ experiences with linguistic diversity. 113 practitioners in Montreal completed a self-report survey assessing their experiences working with allophones. About 40 % of practitioners frequently encountered difficulties working in mental health with allophone clients. Few resources were available, and calling on an interpreter was the most common practice. Interpreters were expected to play many roles, which went beyond basic language translation. There is a clear need for training of practitioners on how to work with different types of interpreters. Training should highlight the benefits and limitations of the different roles that interpreters can play in health care delivery and the differences in communication dynamics with each role.

On connait peu de choses sur la vie des immigrants sans papiers au Canada, et encore moins lorsqu’ il s’agit des jeunes. À partir d’ un terrain ethnographique, cette thèse examine les interactions complexes entre les politiques d’ immigration et les vies de jeunes migrants (14-20 ans) sans papiers, issus de pays latino-américains ou caribéens et vivant à Montréal. Cette thèse a deux objectifs principaux. Premièrement, à partir de l’étude des lois et décisions juridiques de la dernière décennie au Canada, cette thèse vise à explorer comment les politiques d’immigration construisent des jeunes migrants simultanément comme des Autres menaçants et comme des êtres vulnérables, leur enlevant ainsi leur voix. Ces politiques d’ exclusions sociales transforment dramatiquement la vie de ces jeunes en limitant les possibilités de leurs interactions quotidiennes et en restreignant leur accès à des services sociaux. Deuxièmement, à partir d’un terrain ethnographique réalisé auprès de jeunes migrants sans papiers, cette thèse a comme objectif de comprendre comment ces sujets réinterprètent activement leur position sociale subordonnée et affirment leur pouvoir d’agir. La thèse postule que la multiplicité des stratégies développées par les jeunes migrants pour faire face aux incertitudes et à la liminalité découlant de leur statut migratoire est ancré dans de complexes relations d’interdépendance et dans des sentiments ambivalents d’appartenance. Comme cette étude le montre, la vie de ces jeunes et les façons dont ils conçoivent leur existence ne devraient pas être interprétées comme des récits de victimisation ou de résistance. Les jeunes ont plutôt des façons multiples, complexes et parfois paradoxales de (re)prendre parole, en se situant de façon ambivalente et ambigüe comme étant “présents”. Ce n’est qu’à travers l’examen du pouvoir d’ agir et des appartenances ambivalentes des jeunes ainsi qu’à travers des recherches empiriques que nous pourrons améliorer notre capacité à répondre aux besoins des jeunes migrants sans papiers et comprendre l’impact des politiques migratoires sur leurs vies.

L’ouvrage s’adresse à tous ceux qui s’intéressent aux médecines traditionnelles, particulièrement au public marocain mais aussi ailleurs puisque il est situé, bien que brièvement, au sein d’un contexte global et en parallèle à d’autres notions comparables à la baraka au sein de d’autres peuples et religions. Une fenêtre sur un islam fort méconnu en Occident. En réussissant à dégager, au-delà de la quête du sens de la maladie et des soins, la quête du sens du monde, le livre contribue à un renouvellement et à un enrichissement de la connaissance de l’«islam populaire».

Une analyse de la participation des travailleurs aux mesures préventives a été réalisée dans le cadre dune étude portant sur la santé et la sécurité au travail (SST) dans les petites entreprises (PE) montréalaises de 10 à 50 employés embauchant des travailleurs immigrants. Comparativement aux travailleurs canadiens dorigine, les travailleurs immigrants bénéficiaient de moins de formations en SST et étaient moins enclins à identifier les risques, à déclarer leurs lésions lorsquils se blessaient et à participer aux enquêtes daccidents. Plusieurs ne portaient pas déquipement de protection même si lemployeur en fournissait un. De façon générale, les travailleurs immigrants méconnaissaient leurs droits et leurs obligations en matière de SST. Certaines PE, surtout celles dont les dirigeants étaient diplômés en gestion ou en SST, faisaient des efforts soutenus pour corriger cette méconnaissance par des activités de formation, des systèmes de compagnonnage entre collègues originaires des mêmes pays ou communicant dans la même langue, des actions pertinentes, mais souvent insuffisantes. Les PE qui tentaient de surmonter les écarts de compréhension culturelle et linguistique de la SST étaient plutôt des entreprises hétérogènes sur le plan des origines culturelles et des langues : les dirigeants étaient majoritairement canadiens, alors que les superviseurs et les employés étaient originaires de divers pays. Au contraire, dans les PE homogènes où les dirigeants, les superviseurs et les travailleurs provenaient des mêmes pays dorigine (ex : Liban, Inde, etc.), les problèmes de compréhension des mesures préventives de SST se posaient à tous les niveaux hiérarchiques.

With the increase in international mobility, healthcare systems should no longer be ignoring language barriers. In addition to the benefit of reducing long-term costs, immigrant-friendly organizations should be concerned with mitigating the way language barriers increase individuals social vulnerabilities and inequities in health care and health status. This paper reports the findings of a qualitative, exploratory study of the health literacy of 28 Francophone families living in a linguistic-minority situation in Canada. Analysis of interviews revealed that participants social vulnerability, mainly due to their limited social and informational networks, influenced the construction of family health literacy. Disparities in access to healthcare services could be decreased by having health professionals work in alliance with Francophone community groups and by hiring bilingual health professionals. Linguistic isolation and lack of knowledge about local cultural organizations among Francophone immigrants were two important findings of this study.

Bien que le travail avec interprète professionnel soit fortement recommandé dans les consultations médicales plurilingues, de nombreuses consultations sont réalisées en présence dinterprètes familiaux (membres de la famille). Cette étude compare la situation médicale avec interprètes professionnels et celle avec interprètes familiaux selon deux perspectives : 1) les conceptions que médecins et interprètes ont des rôles des interprètes dans la consultation médicale, 2) les implications des postures de linterprète par rapport à la voix du monde vécu (lifeworld) lorsque celle-ci apparaît dans la consultation. Les principaux rôles de linterprète rapportés par les participants à notre enquête sont celui de linterprète professionnel comme « traducteur effacé » et celui de linterprète familial comme « interlocuteur à part entière ». Lun et lautre ont une vision différente du message et du contexte du patient. Dans certains cas, leur apport favorise une négociation de sens, dans dautres cas, il bloque la communication entre le médecin et le patient. Une meilleure connaissance des implications des postures de linterprète sur la communication permet de faire des choix éclairés quant à ces postures.

Lanalyse comparée des regards et des pratiques des soignants en France et au Québec permet dinterroger lesidéaux portés par les modèles politiques dintégration des populations immigrées et dits « de gestion de ladiversité ». À partir de travaux empiriques menés à Montréal, Paris et SaintDenis de la Réunion, nous montronsque les regards que les professionnels de la santé portent sur les populations altérisées ethnicisées ou racisées comme les pratiques quils déploient à leur endroit restituent des tensions historiques mal contenues par lesidéologies politiques. Les regards et les pratiques soignantes sont autant de révélateurs de figures daltéritéhistoriquement construites visant toujours à maintenir alter pour mieux préserver ego. Ce constat met en évidencele fait suivant : que la différence soit niée (modèle républicain) ou quelle soit mise en avant (modèlemulticulturaliste), elle reste celle des autres. Autrement dit, la relation majoritaire/minoritaires reste impensée,seule la différence supposée des minoritaires justifie le questionnement des limites du modèle de lintégration à lafrançaise ou de celles du multiculturalisme canadien.

Grace est un nom fictif. Julien est un nom fictif. La famille ne vient pas du Cap-Vert. Certains détails ont été modifiés, d’autres (qui ne changent pas l’esprit du récit) ont même été ajoutés pour brouiller les pistes. Tout cela est nécessaire pour s’assurer que les personnes concernées soient protégées

Nyra, une jeune immigrante, a des idées suicidaires. Dans quelques jours, elle doit rejoindre sa famille et épouser son fiancé dans son pays d’origine, le Nyrabec (pays fictif). Elle est tiraillée entre sa peur qu’on lui fasse du mal si on apprend qu’elle a perdu sa virginité et, d’autre part, son désir de revoir les gens qu’elle aime.

Un animateur sportif raconte comment un jeune est sorti de l’équipe de basket avant même d’y entrer. Il revisite ses certitudes et grâce à une formation en animation, il va découvrir ses erreurs passées et cherche désormais à devenir un meilleur animateur pour aider les jeunes.

Dans ce récit, Danielle nous parle de la participation citoyenne à l’école publique, thème qui est au cœur des activités de l’organisme La Troisième Avenue

Une intervenante de Multi-Écoute se rappelle d’un de ses premiers suivis d’intervention psychosociale, à ses débuts, avec une jeune mère monoparentale immigrante.

Une intervenante de Relais Côte-des-Neiges nous raconte un événement durant l’un des ateliers de francisation que l’organisme propose. Un homme et une bénévole ont une altercation autour d’un sujet d’ordre religieux. Il faut alors rapidement intervenir pour ne pas laisser s’envenimer le conflit.

Drawing on knowledge of the historical evolution of health and social services in Quebec and Canadian studies on accessibility to healthcare for immigrants, this paper provides some reflections for initiating dialogue on this subject in relation to English-speaking ethnocultural and immigrant communities. A training tool designed to sensitize health and social service practitioners to barriers of access within a multiethnic context is also outlined as means of improving accessibility as well as the quality of care.

The universality of the health system in Canada is often emphasised to contrast the differences between the Canadian and American systems of access to care. However, changes in migration patterns and tightening of administrative procedures around undocumented persons are beginning to challenge this Canadian image. Currently, there is a lack of data to support the existence and the consequences of this shift. This pilot project documents health care professionals’ and community organisation workers’ perceptions of the problems faced by recent migrants in accessing health care, and the health consequences of such barriers. Results confirm the existence of numerous health care access problems for both completely undocumented migrants and legal migrants who fall into the cracks of the provincial and federal health systems. The data suggests that these barriers may have important unrecognised morbidity and mortality consequences, and that they are a source of severe stress and psychological distress. To protect recent immigrant families, there is a need not only to revise the articulation between the provincial and federal health mandates but also to address the strong societal perception linking universality of health care to the notion of citizenship. Further research is warranted on this emerging social problem, but the institutional sensitivity of these issues may constitute an obstacle to a more comprehensive understanding.

Le présent rapport a pour but de décrire les conditions et les étapes de réalisation d’un projet de formation. Ce projet de formation a pour objectif de développer chez les jeunes intervenants et les gestionnaires du CLSC Côte-des-Neiges et des organismes communautaires du quartier une compréhension commune et une réflexion critique du concept d’empowerment et de sa pertinence pour une pratique en milieu pluriethnique.