Challenges and advancements in providing access to mental

health services for diverse patients in Canada

Lola BendanaLola Bendanatranslations@multi-translations@multi-

languages.comlanguages.com

Prepared for: Scottish Universities Insight InstituteHeriot-Watt UniversityUniversity of StrathclydePsychiatry Unit, St John’s HospitalMental Welfare Commission for Scotland

April 9, 2015 - Glasgow

o Immigration in CanadaImmigration in Canadao Why Professional Interpreting Why Professional Interpreting

Services?Services?o Provision of ServicesProvision of Serviceso ChallengesChallengeso AdvancesAdvances

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Immigration in Canada

New patterns of immigration poses New patterns of immigration poses new challenges for the delivery of new challenges for the delivery of mental health services. mental health services.

For the first 100 years of Canada For the first 100 years of Canada being formed as a country, being formed as a country, immigration came from Europe.immigration came from Europe.

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Since the 1960’s there has been a shift Since the 1960’s there has been a shift in immigration sources.in immigration sources.

In Canada, the proportion of the In Canada, the proportion of the population that requires an interpreter population that requires an interpreter for health care is at least 1 in 50, and for health care is at least 1 in 50, and possibly much higher.possibly much higher.

Over 100 languages are spoken in main cities Toronto, Montreal, Vancouver

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Very diverse situation from province to province. Issues are accentuated in smaller communities.

Some communities are not well prepared for diverse immigrants.

Since 1990 Canada has accepted approximately 230,000 immigrants per year, mostly from countries where English is not the first language.

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Ontario is the most ethnically diverse Ontario is the most ethnically diverse province in Canada - its residents province in Canada - its residents speak more than 200 languages and speak more than 200 languages and dialects. dialects.

Over one quarter of the population has Over one quarter of the population has a mother tongue other than English or a mother tongue other than English or French (Statistics Canada, 2007).French (Statistics Canada, 2007).

Immigrants make up 41% of the Immigrants make up 41% of the population in the Toronto Central population in the Toronto Central Local Health Integration Network. Local Health Integration Network.

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Why Professional Interpreting Services?

Effective communication is crucial Effective communication is crucial to providing quality health care. to providing quality health care.

Qualified interpreters ensure that Qualified interpreters ensure that people who are not fluent in English people who are not fluent in English or French have fair access to high-or French have fair access to high-quality mental health services.quality mental health services.

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Language barriers pose limitations Language barriers pose limitations to informed consent, can delay to informed consent, can delay needed services, lead to needed services, lead to unnecessary testing, lengthen unnecessary testing, lengthen hospital stays, increase emergency hospital stays, increase emergency room use, interfere with follow-up room use, interfere with follow-up care and waste scarce resources by care and waste scarce resources by tying up health care providers' tying up health care providers' time. (TC LHIN, 2010). time. (TC LHIN, 2010).

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Interpreter services have particular Interpreter services have particular importance during mental health importance during mental health assessments and counselling assessments and counselling sessions. sessions.

Even when patients know basic Even when patients know basic English, their command of it may not English, their command of it may not be adequate to allow for mental be adequate to allow for mental health assessment or for detailed health assessment or for detailed information gathering, particularly information gathering, particularly when they are in distress.when they are in distress.

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Inadequate communication can have Inadequate communication can have significant clinical consequences, significant clinical consequences, including (Miletic et al, 2006):including (Miletic et al, 2006):ounderestimation or overestimation of underestimation or overestimation of the severity of mental health problemsthe severity of mental health problemsofailure to correctly identify the type of failure to correctly identify the type of mental health problems presentmental health problems presentodiagnosis of mental health problems diagnosis of mental health problems that are not present.that are not present.

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Provision of Services:

Canadian Universal healthcareoEqual access to mental health services to all

Mental Health Programs offered at:oFamily medicine clinicsoHospital Psychiatric departmentsoCommunity health centres, etc.

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Provision of Services:

ModalitiesoFace to FaceoVideo InterpretingoTelephone Interpreting

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Challenges:

Lack of culturally and linguistically appropriate mental health services further contributes to stigmatization and marginalization of ethno-racial/cultural communities exposing them to additional risks of developing mental health problems.

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Challenges:

oMistrust was identified by some studies as a major barrier to receipt of mental health services by racial and ethnic minorities

oVast spectrum of beliefs about mental health model and treatment

o i.e. susto

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Challenges:

oCulture divide –stigma o cultural barrier as important as linguistic

barrier

oPeople hesitant to ask for help

oLack of recognition of language as basic human right

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Challenges:

oLack of standard policy or processeso Wide difference in provision of services

through the country, hospitals that fully engaged only professional interpreters to those that still use the services of ad-hoc interpreters and family members

o Different training in different provinceso Smaller communities can’t fully abide by

national standardso Video/Telephone interpreting

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Challenges:

oFunding

oLack of knowledge of the health system and how it functions

oLack of understanding from families (partners in the care and treatment)

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Challenges:

oNew immigrants/refugeeso adaptation issueso job changeso family dynamics change - younger

members adapt bettero Financeso Discriminationo PTSD in case of refugeeso fear of psychiatry

Barriers identified by immigrants include:

ofear of speaking Englishosuspicion of authorityoisolation and sense of being an outsideroreliance on children to find accurate informationolack of familiarity with Canadian information sourcesocultural differencesoabsence of knowledge of how to ask for services

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Sample challengesSample challenges

Cognitive examinationsCognitive examinationsIn the performance of a cognitive examination, it is In the performance of a cognitive examination, it is important that the interpreter refrain from giving hints or important that the interpreter refrain from giving hints or extra instructions to the patient that may defeat the extra instructions to the patient that may defeat the purpose of the test. For example, the “serial sevens” test purpose of the test. For example, the “serial sevens” test is a test of concentration and memory. The exact is a test of concentration and memory. The exact instruction varies, but often it is "Take the number 100, instruction varies, but often it is "Take the number 100, subtract 7, and keep subtracting 7 until I say stop." If this subtract 7, and keep subtracting 7 until I say stop." If this statement is interpreted as “What is 100 minus seven? statement is interpreted as “What is 100 minus seven? [wait for answer] … Please minus seven again … minus [wait for answer] … Please minus seven again … minus seven again …,” the interpreter is essentially reminding seven again …,” the interpreter is essentially reminding the patient what to do and therefore limiting the ability of the patient what to do and therefore limiting the ability of the clinician to complete an accurate diagnosis.the clinician to complete an accurate diagnosis.

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Sample challengesSample challenges

Roma population:ooral language oconcept of timeo“getting them to understand procedures”oLack of engagement and participationoFeeling of being discriminated

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Sample challenges

Body language:oPatient not looking at doctors face could be misunderstoodoHead positioningoUse of silenceoSmile

AdvancementsProfessionalization processoDevelopment of the Canadian National Standards for Community Interpreting Services NSGCIS

oDevelopment of a standardized post-secondary training for interpreters in Ontario which is now available to other provinces online

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Advancements

Canadian Coalition and provincial coalitions such as the Nova Scotia Coalition and the Ontario Coalition for interpreting services

Recent creation of a multi tier-accreditation system for community interpreters in Ontario

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ConclusionLack of public awareness about mental health and stigma against linguistically diverse population suffering from mental illness are wide spread problems in Canada.

There have been several advancements over the last 20 years to provide better access to mental health services to linguistically diverse populations.

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Conclusion

In the future, the country needs to develop standardized policies to fully support patients from linguistically diverse communities so they have equal access to healthcare and public services.

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