1. Responding to Client’s Mental Health Issues Soma Ganesan MD FRCP Clinical Professor of Psychiatry UBC Medical Director of Psychiatry VGH/UBCH Medical Director Vancouver Community Mental Health Services Physician Leader RVH

2. Service Barriers Frequent misdiagnosis Inappropriate use of interpreters and paraprofessionals Culturally inappropriate treatment methods NOT AVAILABLE NOT ACCESSIBLE NOT ACCEPTABLE

3. Cross Cultural Formulation Pre-Post migration factors which increase risk Impact of socio-political & cultural factors on diagnosis How culture affects perceptions of the cause of illness Socio-cultural factors affecting the development & onset Effects of culture on help- seeking patterns, treatment & response to care Service needs of “high- risk” groups such as torture victims, the elderly, children, adolescents & women Differentiating between immigrants & refugees & their respective problems

4. Periods of Elevated Risk First period  3 to 18 months after arrival Second period  3 to 5 years after migration

5. Relationship Between Complaint & Positive Findings ComplaintsPositive Findings Neurological86%22% Cardiopulmonary74%14% Gastrointestinal68%28% Urology34%4% Sex Organ54%16% Musculoskeletal92%

6. Questions to Elicit Client’s Explanatory Model What do you think has caused the problem? Why do you think it started when it did? What do you think your illness (or injury) does to you? How does it work? How severe is your illness? Will it have a long or short course? What kind of treatment do you think you should receive? What are the most important results you hope to receive from this treatment? What are the chief problems your illness has caused for you? What do you fear most about your illness?

7. Tips for Negotiating an Agreement Between Explanatory Models Approach this negotiation with an open mind, with an expectation of mutual learning Explore their understanding of the problem Explain your background and your understanding Utilize the metaphors of distress that they have used Acknowledge their model as an important source of understanding Work to identify areas of agreement, and to stress the strengths in the client’s situation Where discrepancies remain, discuss these

8. Important Factors in Planning Collaborative Primary/Mental Health Services for Ethnocultural Population Appropriate interpretation services Ongoing training for organizations and front-line staff Role of community for Immigrant settlement services Development of cultural competency training curriculum in professional training programs at academic centers Inclusion of Immigrant agencies in Federal, Provincial and Municipal as partners in service delivery system Explore role of diversity coordinator in community health centers No “cook book” model “bottom up research” and collaborative research should be encouraged

9. Key Lessons From The Literature Primary needs first (food, clothing, shelter, job) met prior to meeting Mental Health needs Safety and Trust Cultural competence of service providers Role of interpreters Lack of awareness of services by consumers and service providers Role of informal Mental Health system Population at risk = elderly, youth, single parent, victim of torture